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Looking at Rugby Players’ Groins!

Watching Johnny May score 3 tries in under half an hour against France recently really emphasised the importance of all the training and conditioning that is required to make a world class athlete. The speed, power, strength and agility that he showed, with such sporting devastation, was the end result of hard work, not only from him, but also of all of his “backroom” team. They will have worked hard to ensure that he was physically ready, with opposing muscle groups balanced and ready to respond with blistering acceleration (for his first try), power and strength (throughout the game), and a lightning fast change of direction (for his second try). Despite all the careful preparation injuries can still occur. One area of potential weakness in sportsmen is the “groin”, or inguinal region. This is the area where the abdominal muscles meet the leg muscles and it is subjected to huge stresses and strain during a gain. If the forces that are produced cannot be matched by the strength of the muscles, then the groin muscles can tear. This is, fundamentally how the condition of Gilmore’s Groin (also known as a groin disruption, or a sportsman’s hernia) occurs.

The condition was first recognised, and successfully treated, by the London surgeon Jerry Gilmore in 1980. He operated on a small series of 3 professional (association) footballers, none of whom had been able to play because of severe groin pain. All of them subsequently returned to top flight football.  During the surgery he was able to see the way that the muscles had been torn and was able to restore the normal anatomy of the groin, allowing them to return to their sport. Despite that fact that the condition is sometimes called a sportsman’s hernia, they do not, in fact have a hernia. With a hernia there is a definite hole in the muscles of the groin allowing the intestines to poke through. With a Gilmore’s Groin there is no defect, but the muscles have been pulled away from their normal positions so that the abdomen and leg are “disconnected”, it is a complex musculoskeletal disruption. Since 1980 over 9000 cases have been seen at The Gilmore Groin and Hernia Clinic, 108 Harley Street, and over 50000 operations performed. The operation is successful in 90% of professional soccer players and 86 English league clubs have referred players, whilst many have come from other parts of the UK and abroad. Over 2000 professional sportsmen have undergone surgery with more than 400 internationals from 35 countries, including world cup wining rugby players. In rugby it tends to be the kickers and the wingers who are potentially more prone to problems, but we have also seen it in forwards.

To understand Gilmore’s Groin, it is helpful to think about the anatomy of the groin. The muscles of the wall of the abdomen may be pictured in 3 layers.  The outer layer (the external oblique) runs at about 45 degrees downwards and inwards. The middle layer (the internal oblique) runs at 45 degrees upwards and inwards. The inner layer (the transversus abdominus) runs straight across. Towards the middle all these muscle fuse together into a common tendon (the conjoined tendon) and are fixed to the pelvis in the middle (the pubic tubercle). In men the external oblique has an archway in it through which the blood vessels and nerves go down into the testicle, along with the vas deferens. When the groin is torn this archway opens up and becomes much wider. There are also tears in the muscle around the archway. The internal oblique is pulled up and away from the pelvis, allowing the unsupported transversus abdominus to become loose and floppy. In women this archway is much smaller, so tears are less common.

Sufferers get a fairly characteristic set of symptoms including pain with running, twisting, turning and kicking. After playing sport they are stiff and sore and this is often much worse the next day. Rising from a low position (for example getting out of bed, or in and out of a car) and coughing and sneezing make the pain worse. Only a third of patients can remember a specific injury, usually involving overstretching.

The diagnosis depends on taking an accurate history and performing a thorough examination. In order to feel the muscles at the back of the groin it is necessary to push a finger up into the scrotum, something which is always uncomfortable, but in the presence of a groin tear it is possible to feel the dilated archway in the outer layer of muscle along with the tears. It is also possible to feel the loose inner layer that is exposed because the middle layer has been pulled up and away. It may be an understatement to say that examination on the affected side is more uncomfortable than on the normal side! An MRI scan, and the involvement of an experienced musculoskeletal radiologist are fundamental, and an MRI scan will show changes of groin disruption in 80% of cases. Ultrasound scans can sometimes be helpful, but only if performed by an experienced radiologist. The presence of a posterior wall “bulge” on ultrasound seems to be quite a common finding and is not particularly helpful in making the diagnosis.

The surgical technique involves exploring the muscles of the groin, identifying the muscle tears and stitching the muscles back into their normal positions. In the classical repair the muscles were repaired with dissolvable sutures with a single supporting layer of a thick nylon, permanent, stitch. A structured rehabilitation programme is a fundamental part of the treatment and a multidisciplinary approach increases the chance of a full recovery. The method developed by Jerry Gilmore has stood the test of time as the definitive method of surgical repair for the condition that carries his name.

Whilst the fundamental principles of the original operation from the 1980s remain, two distinct modifications are now incorporated. Firstly, the stitch used for the reinforcing darn is now much thinner and will also dissolve, although it lasts for around 3 months. The importance of the original nylon darn in the standard repair is well recognised in that it provides immediate strength that persists as the non-permanent sutures dissolve at around 2 weeks. Without this layer there is the risk that the repair breaks down around this time. By replacing the nylon suture with a longer lasting but still dissolvable, “PDS” darn the aim is the produce less tissue reaction, and therefore less discomfort, allowing more rapid rehabilitation, but still supporting the repair as the muscle heal fully. A further, important, modification had been inguinal ligament “tenolysis”. In many suffers there is an element of pubic bone stress injury (previously known as osteitis pubis). It is likely that this is secondary to the groin disruption causing tension at the pubic tubercle. Division of the inguinal ligament reduces this stress and contributes to the relief of the symptoms.

Successful treatment depends on accurate realignment of the groin muscles in each layer. The whole length of the groin muscles needs to be exposed to allow a proper repair to be carried out in all the layers. This means that an incision of about 5cm (2 inches) is made. The full repair cannot be done with keyhole surgery as it does not allow full exposure of all the muscle layers. Following surgery there is a rehabilitation programme that must be followed over the next 4 to 6 weeks. The use of a “mesh” has no place in the repair of Gilmore’s Groin.

Surgery is required in sportsmen who are unable to play their sport, or in cases that have not responded to physiotherapy. Gilmore’s Groin is most commonly seen in footballers, but is also seen in rugby (union and league), athletics, racquets sports, cricket and hockey as well as those undertaking general fitness training for other sports. Correct assessment, diagnosis and treatment means that the vast majority can return to their normal activity between 4 and 8 weeks after their operation.

Following surgery, a structured rehabilitation programme is essential and progresses through 4 overlapping phases: mobility, flexibility and strength before resuming sport specific training. The input of a physiotherapist is always to be welcomed and, in fact, at 108 Harley Street we have established a multidisciplinary team that includes groin surgeons, sports and exercise consultants, orthopaedic surgeons, specialist anaesthetists, physiotherapists, musculoskeletal radiologists and pain specialists as well as specialist nurses to ensure that all of our patients get the highest quality treatment.

About the author

Mr Simon Marsh

Mr Simon Marsh

Consultant Surgeon & Surgical Director
Gilmore Groin and Hernia Clinic
108 Harley Street

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