Medial Groin and Hernia:

Sonographic Evaluation

Adam M. Pourcho DO

Swedish Sports Medicine

Disclosures

Hernia Eval Takes Practice: Fake it till you make it

Objectives

• Understand anatomy of medial hip and hernias

• Go over inguinal, direct, indirect, Spigelian, and “sports

hernia”

• Scanning protocols for each

Ways to illicit a Hernia

• 1. Bearing down(Valsalva)

– Try blowing on back of hand

• 2. Lifting shoulders

• 3. Bearing down while lifting shoulders

• 4. Coughing

• 5. Standing Evaluation

Femoral Triangle Anatomy

• Femoral Canal

– Femoral artery and vein

– Femoral Br.

Genitofemoral nrv

– lymph nodes

– Femoral nerve is

separate

• More common in

females

– Common post-pardum

Femoral Canal Scanning

n av

RT FC SAX MED

Femoral Hernia Valsalva: Normal

RT FC SAX MED

Femoral Hernia

RT FC LAX DISTRT FC SAX MED

Inguinal Canal Anatomy

• Deep and superficial rings

• Females

– Round ligament of Uterus

• Males

– Spermatic cord

– Testicular artery and vein

– Artery to Vas Deferens

– Pampiniform Plexus

– Genital br. Genitofemoral

Nrv

– Vas deferens

– Lymph

– Processus Vaginalis

– Autonomic nerves

Scanning for Direct/indirect hernias

a

v

RT FC SAX MED

Inguinal Canal Males vs Females

a

v

RT MALE IC SAX MEDRT FEM IC SAX MED

a v

Female Male

Finding Inferior Epigastric Arteries

RT IEA SAX MEDRT IEA SAX MED

RA

Inguinal Canal: Normal

RT IC SAX MED

SAX to IEA

Indirect Inguinal Hernia

SAX to IEALAX to IEA

Slides courtesy of Doug Hoffman, MD

Direct Inguinal Hernia

Slides courtesy of Doug Hoffman, MD

Spigelian Hernia

• Spigelian hernia (1-2% of all hernias) is the protrusion of

preperitoneal fat, peritoneal sac, or organ(s) through a congenital

or acquired defect in the spigelian aponeurosis

– the aponeurosis of the transverse abdominal muscle limited by

the linea semilunaris laterally and the lateral edge of the rectus

muscle medially

Skandalakis, PN. Et al. 2006

Scanning for Spigelian Hernia

RT ABD SAX MED

Spigelian Hernia

Slides courtesy of Doug Hoffman, MD

“Sports Hernia” / Athletic Pubalgia

• Its not athletic pubalgia

• Its not osteitis pubis/ pubic instability

• Its not adductor/gracillis tendinopathy

• Its not rectus abdominus or conjoint

tendinopathy

• Its not a hernia

• It is tranversalis diastasis with deformation

of the spermatic cord or round ligament

Scanning for “Sports Hernia”

• Pubic symphysis

• Adductor tendons

– Esp adductor longus

• Gracilis

• Rectus abdominus

aponeurosis/tendon

• Conjoint tendon

• Direct region

– Laxity of transversalis

fascia-Valsalva

Transversalis Fascia Insufficiency/ Direct region

Transversalis Fascia Insufficiency

Transversalis Fascia Insufficiency

Slides courtesy of Doug Hoffman, MD

Scanning for Medial Groin

RT MED HIP LAX PROX

L

B

M

PR

Adductor Longus Tear With Calcification

RT MED HIP LAX DIST

Adductor Longus and PF, and ICH Add Magnus tears

Obey, 2016

Distal and Proximal Adductor Longus Tear

RT MED HIP LAX DIST

Pubic Symphysis

RT LT

Pubic Symphysis

RT LT

Distal Rectus Abdominus

RT RA LAX DIST

Questions?

References

• The Athletic Hernia-A Systemic Review; Swan and Wolcott:Clinical Orthopaedics and Related

Research; 2006 455:78-87

• Sportsmen’s Groin-Diagnostic Approach and Treatment With the Minimal Repair Technique: A

Single-Center Uncontrolled Clinical Review; Muschaweck /Berger: Sports Health 2010 2:216-

220

• Santilli, O. L., et al. (2015). "Sports hernias: experience in a sports medicine center."Hernia.

• Steele, P., et al. (2004). "Surgery for posterior inguinal wall deficiency in athletes." J Sci Med

Sport 7(4): 415-421; discussion 422-413.

• Orchard, J. W., et al. (1998). "Groin pain associated with ultrasound finding of inguinal canal

posterior wall deficiency in Australian Rules footballers." Br J Sports Med 32(2):134-139.

• Hackney, R. G. (1993). "The sports hernia: a cause of chronic groin pain." Br J Sports Med

27(1): 58-62.

• Obey MR1, Broski SM2, Spinner RJ3, Collins MS2, Krych AJ4. Anatomy of the Adductor

Magnus Origin: Implications for Proximal Hamstring Injuries. Orthop J Sports Med. 2016

Jan 11;4(1):2325967115625055. doi: 10.1177/2325967115625055. eCollection 2016 Jan.