Sporcu Fıtığı ve Pubalji
Özet
Sporcu fıtığı ve pubalji, özellikle futbol ve buz hokeyi gibi alt karın ile uyluk kaslarının yoğun kullanımını gerektiren sporlarda görülen, kasık bölgesindeki yumuşak doku yaralanmalarından kaynaklı kronik bir ağrı sendromudur. Gilmore tarafından 1990’ların başında tanımlanan bu durum hakkında literatürde net bir konsensüs bulunmamakta, patogenezi ve ağrının tam anatomik kaynağı tartışılmaktadır. En yaygın hipotez, ani hareketlerin kasıkta yarattığı gerilimin fasya transversalis gibi yapılarda zayıflık veya yırtığa yol açmasıdır. Hastaların %85'inde posterior inguinal duvar zayıflığı saptanır. Teşhiste kapsamlı fizik muayene, MRG ve ultrasonografi kullanılırken, İngiliz Fıtık Derneği’nin belirlediği beş klinik kriterden en az üçünün varlığı tanı için şarttır. Tedavide ilk adım 3-6 ay süren istirahat, ilaç ve fiziksel rehabilitasyonu içeren konservatif yöntemlerdir. Bu süreçten fayda görmeyen kronik vakalarda ise cerrahi müdahale devreye girer. Operatif tedavide, kasık kanalı defektlerini onarmayı ve gerilimi azaltmayı amaçlayan açık meshsiz (Bassini, Gilmore, minimal tamir) veya meshli (açık/laparoskopik TAPP, TEP) farklı ameliyat teknikleri uygulanmaktadır. Her iki yaklaşımın da kendine özgü avantajları bulunmakla birlikte, hastaların normal hayata dönüş hızı laparoskopik onarımlarda daha yüksektir.
Sports hernia and athletic pubalgia represent a chronic pain syndrome in the groin area resulting from soft tissue injuries, frequently observed in sports that demand intensive utilization of the lower abdominal and proximal thigh muscles, such as soccer and ice hockey. Initially defined by Gilmore in the early 1990s, there remains no clear consensus in literature regarding this condition, and debates persist concerning its pathogenesis and the precise anatomical source of pain. The most widely accepted hypothesis is that increased tension from twisting, turning, and kicking causes weakness or tearing in groin structures, with posterior inguinal wall (transversalis fascia) deficiency detected in 85% of patients. Diagnosis relies on comprehensive physical examination, MRI, and ultrasonography, requiring at least three out of five clinical criteria defined by the British Hernia Society. Initial management is conservative, encompassing rest, non-steroidal anti-inflammatory drugs, and physical rehabilitation lasting three to six months. For chronic cases unresponsive to conservative treatment, surgical intervention becomes necessary. Operative treatment employs various open mesh-free (modified Bassini, Gilmore, minimal repair) or mesh-based (open or laparoscopic TAPP/TEP) techniques aiming to reinforce inguinal canal defects and alleviate tension, with laparoscopic approaches demonstrating faster return to daily activities.
Referanslar
Renström PA, Peterson L. Groin injuries in athletes. British Journal of Sports Medicine. 1980 Mar;14(1):30.
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, De Beaux A, Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I. ‘Treatment of the Sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. British journal of sports medicine. 2014 Jul 1;48(14):1079-87.
Litwin DE, Sneider EB, McEnaney PM, Busconi BD. Athletic pubalgia (sports hernia). Clinics in sports medicine. 2011 Apr 1;30(2):417-34.
Hackney RG. The sports hernia: a cause of chronic groin pain. British journal of sports medicine. 1993 Mar 1;27(1):58-62.
Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, Long JN, Jorge I, Garth WP, Vasconez LO. Athletic pubalgia: definition and surgical treatment. Annals of plastic surgery. 2005 Oct 1;55(4):393-6.
LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003 Jun;7(2):68-71.
Swan Jr KG, Wolcott M. The athletic hernia: a systematic review. Clinical Orthopaedics and Related Research®. 2007 Feb 1;455:78-87.
Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett JR WE. Abdominal musculature abnormalities as a cause of groin pain in athletes: inguinal hernias and pubalgia. The American journal of sports medicine. 1991 May;19(3):239-42.
Albers SL, Spritzer CE, Garrett Jr WE, Meyers WC. MR findings in athletes with pubalgia. Skeletal radiology. 2001 May;30(5):270-7.
Kumar A, Doran J, Batt ME, Nguyen-Van-Tam JS, Beckingham IJ. Results of inguinal canal repair in athletes with sports hernia. Journal of the Royal College of Surgeons of Edinburgh. 2002 Jun 1;47(3):561-5.
Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. The American journal of sports medicine. 2000 Jan;28(1):2-8.
Malycha P, Lovell G. INGUINAL SURGERY IN ATHLETES WITH CHRONIC GROIN PAIN: THE ‘SPORTSMAN'S’HERNIA. Australian and New Zealand Journal of Surgery. 1992 Feb;62(2):123-5.
Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011 Feb 1;27(2):252-69.
Van Veen RN, de Baat P, Heijboer MP, Kazemier G, Punt BJ, Dwarkasing RS, Bonjer HJ, van Eijck CH. Successful endoscopic treatment of chronic groin pain in athletes. Surgical endoscopy. 2007 Feb;21(2):189-93.
Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic groin pain in athletes. Medical Journal of Australia. 1991 Nov;155(10):674-7.
Susmallian1abef S, Ezri2acd T, Elis1bfg M, Warters3eg R, Charuzi1abc I, Muggia-Sullam1e M. Laparoscopic repair of ‘sportsman’s hernia’in soccer players as treatment of chronic inguinal pain. Med Sci Monit. 2004;10(2):54.
Kesek P, Ekberg O, Westlin N. Herniographic findings in athletes with unclear groin pain. Acta Radiologica. 2002 Jan 1;43(6):603-8.
Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011 Jun 1;27(6):768-75.
Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. American journal of roentgenology. 2006 Nov;187(5):1168-78.
Steele P, Annear P, Grove JR. Surgery for posterior inguinal wall deficiency in athletes. J Sci Med Sport 2004;7:415–21; discussion 422–3.
Kingston JA, Jegatheeswaran S, Macutkiewicz C, Campanelli G, Lloyd DM, Sheen AJ. A European survey on the aetiology, investigation and management of the “sportsman’s groin”. Hernia. 2014 Dec;18(6):803-10.
Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, Krogsgaard K. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. The Lancet. 1999 Feb 6;353(9151):439-43.
Machotka Z, Kumar S, Perraton LG. A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes. BMC Sports Science, Medicine and Rehabilitation. 2009 Dec;1(1):1-0.
Almeida MO, Silva BN, Andriolo RB, Atallah ÁN, Peccin MS. Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain. Cochrane database of systematic reviews. 2013(6).
Jansen JA, Mens JM, Backx FJ, Kolfschoten N, Stam HJ. Treatment of longstanding groin pain in athletes: a systematic review. Scandinavian journal of medicine & science in sports. 2008 Jun;18(3):263-74.
Weir A, Jansen JA, Van de Port IG, Van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Manual therapy. 2011 Apr 1;16(2):148-54.
Ellsworth AA, Zoland MP, Tyler TF. Athletic pubalgia and associated rehabilitation. International journal of sports physical therapy. 2014 Nov;9(6):774.
Comin J, Obaid H, Lammers G, Moore J, Wotherspoon M, Connell D. Radiofrequency denervation of the inguinal ligament for the treatment of ‘Sportsman's Hernia’: a pilot study. British Journal of Sports Medicine. 2013 Apr 1;47(6):380-6.
A. Hamid MS, Yusof A, Mohamed Ali MR. Platelet-rich plasma (PRP) for acute muscle injury: a systematic review. PloS one. 2014 Feb 28;9(2):e90538.
Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic literature review. British journal of sports medicine. 2008 Dec 1;42(12):954-64.
King E, Ward J, Small L, Falvey E, Franklyn-Miller A. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. British Journal of Sports Medicine. 2015 Nov 1;49(22):1447-51.
Moyen B, Mainetti E, Sansone V, Pedotti E. Surgical treatment of pubic pain refractory to conservative treatment. Italian Journal of Orthopaedics and Traumatology. 1993 Jan 1;19(1):43-9.
Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clinics in sports medicine. 1998 Oct 1;17(4):787-93.
Economopoulos KJ, Milewski MD, Hanks JB, Hart JM, Diduch DR. Sports hernia treatment: modified bassini versus minimal repair. Sports Health. 2013 Sep;5(5):463-9.
Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic groin pain in athletes. Medical Journal of Australia. 1991 Nov;155(10):674-7.
Dojčinović B, Šebečić B, Starešinić M, Janković S, Japjec M, Čuljak V. Surgical treatment of chronic groin pain in athletes. International orthopaedics. 2012 Nov;36(11):2361-5.
Muschaweck U, Berger L. Minimal repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia. 2010 Feb;14(1):27-33.
Preskitt JT. Sports hernia: the experience of Baylor University Medical Center at Dallas. InBaylor University Medical Center Proceedings 2011 Apr 1 (Vol. 24, No. 2, pp. 89-91). Taylor & Francis.
Irshad K, Feldman LS, Lavoie C, Lacroix VJ, Mulder DS, Brown RA. Operative management of “hockey groin syndrome”: 12 years of experience in National Hockey League players. Surgery. 2001 Oct 1;130(4):759-66.
Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, Long JN, Jorge I, Garth WP, Vasconez LO. Athletic pubalgia: definition and surgical treatment. Annals of plastic surgery. 2005 Oct 1;55(4):393-6.
Edelman DS, Selesnick H. “Sports” hernia: treatment with biologic mesh (Surgisis). Surgical Endoscopy And Other Interventional Techniques. 2006 Jun;20(6):971-3.
Lloyd DM, Sutton CD, Altafa A, Fareed K, Bloxham L, Spencer L, Garcea G. Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall: a new approach for the management of chronic groin pain. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2008 Aug 1;18(4):363-8.
