Hernia: Inguinal Hernia Symptoms – A Runner’s Approach

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It was not that long ago, when someone heard about a hernia injury, the common assumption was grandpa had lifted a box from the attic that was too heavy. That type of hernia is no longer the only one in our vernacular, especially as more athletes of all ages are diagnosed with a sports hernia.  Turn on any game on television and you will likely hear about a team’s star player now sidelined because of a sports hernia. That same aliment may be the reason your weekend tennis or golf partner is now unavailable for the next few weeks.

Today, when the topic of hernias and runners is addressed – the focus is on a sports hernia.  Still, there are a number of different hernia types, and many of them can hinder runners of all ages and genders. This article focuses primarily on sports and inguinal hernias.

A sports hernia in particular will often cause runners, athletes or other active people to feel an achy, sometimes dull, pain in the groin and abdominal region.  While running, twisting or stretching, the pain of a sports hernia tends to become even sharper and more debilitating. So much so, the first recourse for many runners is to stop training entirely in order to find some comfort.

Even though avoiding workouts may help bring some level of well-being, every day movements can also trigger the pains of sports hernia which makes it important for runners to understand the complications of this injury.  The following information will help runners become more acquainted with sports hernias, symptoms, treatments, and preventive measures.

What is a Sports Hernia? 

A sports hernia is an overuse injury that leads to a weakened, strained, and sometimes torn wall of the lower abdomen. Overuse of the hip muscle can also cause this injury to occur.  Stress placed at the juncture between the muscles connecting the pubic bone and the hip abductor is usually the focal point of this painful injury.

Often there is no bulge associated with a sports hernia. An inguinal hernia is the type of hernia that most people immediately think of since there is usually a bulge in the abdomen, groin or scrotum. An inguinal hernia can also be acquired from rigorous athletic endeavors.  An inguinal hernia is when the intestine protrudes through a soft spot or a tear in the abdominal muscles. When this happen and the bulge appears, it will often hurt and/or create a burning sensation.

 

Sports hernias, being a soft tissue injury, don’t necessarily involve any muscle tears or always include any bulging points. However, a lack of treatment of a sports hernia could lead to an abdominal hernia or other negative ancillary effects in the groin/hip region. While all athletes are at risk of a sports hernia, the injury commonly occurs to those participating in a vigorous activity which causes quick planting of the feet and twisting of the core. Those most susceptible to this injury are soccer, football, baseball, tennis, hockey and basketball players.  That is why sports hernias are also referred to as Athletic Pubalgia, hockey hernia, Sportsman’s hernia, or Gilmore’s groin.  For runners, this type of hernia could come into play for those who run on trails and must quickly avoid branches, limbs or rocks.

Other Types of Hernias

By definition, a hernia is when fatty tissue or an organ squeezes through a weakened area in a surrounding muscle or fascia (connective tissue). The inguinal hernia, when the bladder or intestine protrudes through the abdominal wall, is the most common hernia. It is estimated that nearly 96% of hernias in the groin for men are of the inguinal variety. Men are eight times more likely to develop an inguinal hernia compared to women.

For females, the most common type of hernia is a femoral hernia. This hernia transpires when the intestine enters the canal carrying the femoral artery into the upper thigh. A femoral hernia, when the intestine is in front of the blood vessels, is known as a Velpeau hernia.  Women who have had children can also be afflicted by an umbilical hernia. An umbilical hernia is when a portion of the small intestine travels through the abdominal wall near the navel.  Similar to that is an incisional hernia which can occur when an intestine pushes through the abdominal wall near an area that was operated on in a previous time.

Another type of abdominal hernia is the Spigelian hernia, also known as lateral ventral hernia. A Spigelian hernia occurs along the semilunar line which causes a herniation between the muscles of the abdominal wall. These are rare and can be both acquired and congenital.  A hiatal hernia, while not normally associated with physical activity or running, is the result of the upper stomach squeezing through the hiatus, the opening in the diaphragm through which the esophagus passes.

All of these hernias are painful and must be addressed by a doctor to prevent further damage. If the hernia is not able to be pushed in, the contents of the hernia will be trapped in the abdominal wall and be considered incarcerated in that area. This incarcerated hernia runs the risk of becoming strangulated, which cuts off the blood flow to the trapped tissue. A strangulated hernia must be immediately attended to by a physician since it can be life-threatening.

Symptoms of a Sports Hernia

The most common symptom of a sports hernia is the reoccurring presence of aching pain in the lower abdominal region or groin during physical activity. The triggers of the pain are usually felt during lifting, cutting or twisting movements.

For runners, this painful sensation came be triggered with the impact of the foot on a loose surface. It can also be felt by runners during pre and post-run stretching routines.  Discomfort during sit-ups intensifies the pain of a sports hernia. These types of symptoms often make it difficult to distinguish a sports hernia from an abdominal strain or a groin pull. As for pain, a sports hernia can often be as painful as or even more painful than an inguinal hernia.

If the pain tends to be centralized to just one side of the body, it should be an indicator of a sports hernia instead of another broader based lower-core aliment. For men, pain can be experienced in both or just one testicle.  Rest may alleviate these symptoms but once running is resumed, if a sports hernia is present, they will return.

Breakdown of Symptoms:

  • Pain in lower abdomen or groin
  • Pain for men in one or both testicles
  • Pain in usually one side of the lower trunk region
  • Increased pain during workouts that often include twisting, lifting or cutting
  • Lingering pain while rolling over or sitting up
  • Pain that continues to increase during workouts and subsides during periods of rest

 

 

Causes

There is no scientific determination about the exact causes of a sports hernia. However, the common theory is it results from the overuse of lower abdominal and thigh muscles.   When this area is weakened it can become prone to injury from repetitive and quick movements such as sprinting, twisting, kicking or bending. It is not just overuse of this area which could cause injuries, but improper training or stretching as well.

Essentially all the moving and twisting of the abdominal area can foster an imbalance of the pubic bones and the pubic symphysis (joint between the two pubic bones) that stresses the back wall of the inguinal canal. When there is a disturbance of the inguinal canal, it can lead to muscles, tendons and ligaments pulling away from the pubic bone.

It is estimated that men are  ten times more likely to experience a sports hernia than women. Besides the athletic overuse of the abdominal area, other causes for sports hernias can include age associated degeneration of the muscles and bones, previous medical exploration in the area and birth related defects in the groin and thighs.

Breakdown of Causes:

  • Overuse of abdominal muscles
  • Repetitive and quick movements within a weakened abdominal/groin area
  • Short periods of strenuous actives without consistent exercise or stretching
  • Soft tissues found in the lower abdomen and pubic area are torn or injured

 

Diagnostic Practices

The first step for a runner or athlete suffering these symptoms is to have a physical exam conducted by a doctor.  Likely the doctor will have the patient do some physical activities such as sit-ups, trunk twists, and resistance stretching. For those suffering a sports hernia, this exam is often a painful doctor’s visit.

The next diagnostic step for a sports hernia is an X-ray, ultrasound, CT or MRI to look for injuries to the bone, nerves and soft tissue. An MRI tends to be the best practice since it is an effective tool to use to identify soft tissue tears. In some cases a doctor may perform a bone scan to rule out other possible causes.

 

Breakdown of Diagnostic Practices:

  • Physical exam with focus on injured area
  • Perform exercises and stretches for the doctor
  • MRI to examine possible soft tissue injury


Treatment

Nonsurgical Treatment

The initial move a doctor will take is to have the athlete go on an extended period of rest from running and other athletic endeavors. Commonly the rest period will be between 7-10 days and be accompanied by ice and compression applied to the focal point of pain.  Aspirin and ibuprofen are effective in treating the pain and inflammation of minor, less severe sports hernias.

Once the rest period is completed, the doctor will often recommend physical therapy (that can be done at home) and a rigorous stretching routine. The exercises will look to improve strength and flexibility of the inner thigh and abdominal muscles.  Some of the best stretches that assist with the hips and abdomens include: Side Bends, Lunge Stretches and Sitting Groin Stretches.   Those taking the physical therapy treatment route often see improvements within 4 to 6 weeks.

 

Medication Treatment for Comfort Used in Hernia Cases

The doctors who often diagnose hernias range from pediatricians, general family practitioners and internists.  If surgery is needed, that will be done by a general surgeon. In the case of an umbilical hernia, an OBGYN will likely be involved.  Whatever the doctor’s specialty, he or she is first going to recommend ice and rest to patients as the initial steps. These old-time remedies will hopefully bring some pain relief and recovery.

A surgical belt or a truss can be worn to help stabilize the midsection and create support around the bulge. Something like a truss is a short term solution and not a long term remedy. Some doctors will tell their patients to wear a truss in preparation of a surgery.  A truss or surgical belt is available at any drug store or pharmacy.

Unfortunately there is no magic pill that will cure a hernia but a doctor may prescribe a powerful cough medicine or stool softeners to prevent unwanted movement, tension and pressure in the abdomen and groin areas. An increased consumption of water and high-fiber food before and after the onset of a hernia will also help prevent and ease the pain associated with hernias.

When a hiatal hernia is involved, doctors will have patients take antacids to deal with stomach acid. Over-the-counter products like Tums, Rolaids and Maalox tend to provide some passing relief. If even more reduction of stomach acid is needed, then comes the Zantac, Pepcid and Tagamet. Those can be followed by stronger medicines such as Prilosec and Prefaced.

Medications
Credit Source: By Christine Dela Cerna –

According to the Mayo Clinic there are some reports – not supported by any clinical research – of alternative health professionals curing hiatal hernias by gently pushing the stomach back into its normal area under the diaphragm. No surgery, just manipulation and calculated pressure. This method is of course not recommended within the health community.

For those suffering more significant hernias where it pushes the highest level of pain boundaries, doctors will sometimes prescribe narcotics to the ease the suffering. The use of narcotics is almost universal after hernia surgery to combat postoperative discomfort.

There can be a wide range of narcotics used in hernia cases including acetaminophen with codeine, Vicodin, and Lorcet. Opioids like hydrocodone and oxycodone could be necessary also.

Of course these narcotics will ease the pain (remember hernia surgeries tend to be the most common surgeries conducted) but they do come with side effects.  Some side effects like nausea, vomiting and dizziness will play a role and could be detrimental in the healing process for those coming off a hernia surgery. The same holds true when opioids, that can cause constipation, are used to relieve the pain.

It is imperative for hernia patients to inform their doctors of any side effects history with narcotics.  The use of narcotic should only be needed for 2-3 days following surgery (unless there is a unique situation that may expand the time frame to 1 week). After that time, Tylenol or aspirin should be enough to handle any residual pain.  It is common to be back at work in slightly less than a week’s time following an abdominal hernia surgery.

Surgical Treatment

If physical therapy is not enough, or for a competitive athlete who wants to miss as little time as possible, surgery is the best option to treat a sports hernia. Those who undergo a surgical procedure for a sports hernia are typically healed within 6 to 12 weeks and are able to resume their regular sports activity without any complications.

According to the American Orthopaedic Society for Sports Medicine, 90 percent of those who get hernia surgery are able to return to sports activity. Operations for sports hernias can be conducted by the use of local, regional or general anesthesia. Also, doctors could perform an open operation or laparoscopic procedure with the implementation of a mesh piece. The open procedure allows the doctor the opportunity to evaluate and repair any damaged nerves, muscles or tissue. In this scenario, the insertion of a mesh into the injured area is not needed. Mesh is associated with laparoscopic procedure conducted under general anesthesia. The thin, pliable mesh inserted by the surgeon repairs the injured area and helps support the inguinal canal and floor.  The incision required to conduct this surgery is usually 4-5 centimeters in length.


Mesh used for a hernia surgery

In some cases the doctor may do an inguinal neurectomy where a small nerve in the groin area is cut.  Following this surgery, a patient will be prescribed strict rest and relaxation for at least one week. In the second week, patients will start with a light rehab that includes 20 minutes of walking on a treadmill. After three weeks and a checkup visit with the doctor, the patient will be given a wider rehab routine.

Some competitive runners may be tempted to bypass the treadmill for a light run on the road or trails; however this would be a significant mistake. The treadmill early in the rehab process is needed to help alleviate any resistance in order to assist in the healing process. If there is still pain after the initial surgery, another procedure may be needed. Next would be an adductor tenotomy when the doctor cuts the tendon that connects the inner thigh muscles to the pubis. This cut tendon then will heal at a longer length and should release tension and increase range of motion.

Symptoms, causes and treatment for an inguinal hernia

The main symptom of the inguinal hernia is the aforementioned bulge in the groin or scrotum. The bulge will feel like a round lump. The appearance of the bulge from the time of the specific injury can vary from over months, weeks or days. Once the bulge appears, it does not always have to be painful.  A person suffering from an inguinal hernia may feel tugging or burning near the bulge, and find comfort from these symptoms by lying down. Intestinal problems resulting from the hernia may cause vomiting and nausea.

Most inguinal hernias happen because an opening in the muscle wall does not close as it should prior to birth. This leads to a weak area in the belly muscle that can eventually (could happen right after birth to much later in life) be the spot where tissue pushes through and bulges out.  Overweight people are at high risk of getting an inguinal hernia. Other causes include lifting, coughing and straining. Pregnant women may encounter this hernia because of the pressure on the belly wall.  The hernia repair for an inguinal hernia can also include both rehabilitation and surgery. The surgical option also commonly employs the insertion of a mesh to the injured area.


Implanted mesh used during inguinal hernia surgey

William Macewen, a Scottish physician who lived from 1864-1924, is considered the pioneer of hernia surgeries. He was immortalized after he conducted the Macewen’s operation which is considered the first cure used for an inguinal hernia.

 

Prevention

A runner can find relief from a mild sports hernia with a combination of rest, ice, aspirin/ibuprofen, and stretching rehab. However, if those techniques don’t help, it is imperative to stop with a running program and make an appointment for an exam. The best way to prevent a surgical procedure for a mild sports hernia is to see a doctor before the condition worsens and more muscles, tendons and tissues are impacted. Keep these techniques in mind to prevent future occurrences of a sports hernia.

  1. Pre-run workouts: Any pre-run workouts should include hamstring stretches, abdominal stretches, planking and bridging. Don’t forget to also do self-massage (or self myofacial release) on troubled or tender areas in the abdomen or groin. You can use a foam roller, tennis ball, lacrosse ball or massage stick to help release the knotted area.

Here are some bridging exercises to use to help prevent a sports hernia or when rehabbing from one.

  • Pillar Bridge. Start on the stomach with forearms on floor under chest. Push forearms away from chest so that only your feet and forearms are on the ground and hold for a prescribed amount of time. The goal of the Pillar Bridge is push the neck and sternum as far from the forearms as possible with a tight stomach.
  • Pillar Bridge Lateral. This time the person is lying on a side with the forearm on the ground under the shoulder, with feet split. Here keep your body in a straight line and your elbow under your shoulder, push your hip off the ground, creating a straight line from ankle to shoulder and keeping your head in line with your spine.

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Pillar Bridge                                                                       Pillar Bridge Lateral

  1. Be Dynamic: A warm-up routine should also include dynamic and moving stretches. Here are some dynamic stretches to regularly include during warm-ups.
    • Hand Walks. Begin this in the standing position then bend over at waist and walk hands out into a pushup position. While keeping the knees straight, walk toes toward hands until the stretch is felt. Walk hands back out and repeat.
    • Glute Bridge – Single Leg. Begin on the floor; face up, right knee bent to 90 degrees with heel on ground, left leg held to chest. Fire your right glute to bridge hips to sky so weight is supported only by the right heel and shoulders. Hold, and return to start position. Do this for a certain amount of repetitions then switch legs.
    • Inverted Hamstring. Begin standing on one leg with arms raised to 90 degrees and shoulder blades pinched together. Then bend over at waist and kick opposite heel to sky. When the stretch is felt, stand and step back with other foot and repeat for prescribed number of repetitions.


Inverted Hamstring Stretch

  1. Kegel Exercises: Kegel exercises should be done for both men and women. Yes, men should do these as well. Pelvic floor exercises for men can also help with urinary and erectile issues.  Kegel exercises for men and women are ways to support pelvic organs (urethra, bladder, bowel) and keep them in place.

In order to start with Kegels, both men and women need to identify their pubococcygeal (PC) muscles. These PC muscles can be identified while urinating. When urinating, stop the process and you feel these PC muscles tightening. The workout of these PC muscles is done by contracting and holding them for about 10 to 20 seconds per set. Repeat this for at least 10 times in a row multiple times throughout the day. Just like any exercise gradually increase the number of contractions and the amount of time.

Don’t hold your breath during these Kegel exercises and try not to tighten your abdomen or thigh muscles.

  1. Work the Core: You should include in a running workout different exercises aimed at strengthening the abductor muscles. Here are some ways to work on the abductor muscles
    1. Shallow knee bends. Bend your knees a quarter of the way down to seated. Make sure your knees are aligned with your big toes.
    2. Leg lifts. Lying on one side, bend the knee closest to the ground to 90 degrees and lift the other leg straight up toward the ceiling. Do 10 reps on each side. Then bend the knee closest to the ceiling and straighten the other leg, lifting it up toward the ceiling.
    3. Side steps. Include a few minutes of a grapevine into your workout.


Grapevine

                    4. Standing leg swings. Begin by facing a wall/pole with your hand reached out for balance, and swing one leg side to side. Be sure to use muscles to     do this (not just momentum), trying to keep the hips square to the wall/pole.

 

 
Standing Leg Swings

 

  1. Keep on Pace: Avoid dramatic fluctuations of the intensity within your overall running regimen. Sudden increases in your training level may be the instigator that turns weakened muscles or tissues into a sports hernia. Never increase training intensity, duration, and frequency by more than 10 percent a week.
  2. Be Flexible: Yoga and Pilates will improve a runner’s flexibility and balance. Increased flexibility will help prevent awkward twisting movements – what is widely considered a root cause of a sports hernia. Muscle balance will help create tissue loading which then builds tissue tolerance.
  3. Don’t be Weighted Down: A runner’s weight is something that constantly must be monitored. Any sudden weight changes that result from periods of inactivity or injury will add stress to the joints and muscles near the abdomen and groin.
  4. Give it a Rest: Taking a day off or at least occasionally downsizing a workout or run could be the remedy to heal weakened abdominal muscles. A sports hernia is an overuse injury so a runner must always be cognizant of not overusing the abdominal and groin areas to the point of injury.


Conclusion

A sports hernia is a painful and gradual injury that arises from stress placed on weakened abdominal and groin muscles. A hernia of this variety can be easily treated and not take a runner too far off a regular routine. However, if not treated properly at first it can worsen to the point where surgery is needed to implant a mesh into the injured area. Understanding the early signs of a sports hernia is vital to limiting its effect. With the information presented in this article, you should be able to identify the symptoms of a sports hernia, and prevent it from becoming a serious injury.

Keep your eye out for any lingering abdominal or groin issues and keep on running!

These are the sources cited in this article with additional information on a sports hernia. While these are reputable sources with information from medical professionals, you should not take the information in this article as professional medical advice. Consult a doctor before trying anything listed in this article.

 

 

Sources

  1. Staff Writer, Sports Hernia , American Academy of Orthopaedic Surgeons, May 05, 2017
  2. Brown, Jim, Sports Hernia 101, Exos Knowledge, Jun 23, 2017
  3. William Brown, MD, Sports Hernia Symptoms When Running, , Sports Physiotherapist , Jun 23, 2017
  4. Brown, William, MD, Sports Hernia Surgery An Effective Treatment, Sports Hernia.com, May 05, 2017
  5. Caucci, Desirea, Preventing the Dreaded Sports Hernia, , Philly.com, Jun 23, 2017
  6. Howard, Dan, Sports Hernia & Running, AZ Central, May 05, 2017
  7. Staff Writer, Sports Hernia , Johns Hopkins, May 10, 2017
  8. Mayo Clinic Staff, Inguinal Hernia, Mayo Clinic, May 10, 2017
  9. Staff Writer, Understanding Hernia -- the Basics, Wed MD, May 09, 2017
  10. Web MD Staff, Common Types of Hernias - Topic Overview, Web MD, May 05, 2017