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Understanding Noninguinal Abdominal Hernias in the Athlete

Cabry, Robert J. Jr MD; Thorell, Erik DO; Heck, Keith DO; Hong, Eugene MD; Berkson, David MD

doi: 10.1249/JSR.0000000000000036
Chest and Abdominal Conditions

Abdominal hernias are common with over 20 million hernia repairs performed worldwide. Inguinal hernias are the most common type of hernia. Inguinal and sports hernia have been discussed at length in recent literature, and therefore, they will not be addressed in this article. The noninguinal hernias are much less common but do occur, and knowledge of these hernias is important when assessing the athlete with abdominal pain. Approximately 25% of abdominal wall hernias are noninguinal, and new data show the order of frequency as umbilical, epigastric, incisional, femoral, and all others (i.e., Spigelian, obturator, traumatic). Return-to-play guidelines need to be tailored to the athlete and the needs of their sport. Using guidelines similar to abdominal strain injuries can be a starting point for the treatment plan. Laparoscopic repair is becoming more popular because of safety and efficacy, and it may lead to a more rapid return to play.

Drexel University College of Medicine, Philadelphia, PA

Address for correspondence: Robert J. Cabry Jr, MD, Drexel University College of Medicine, Philadelphia, PA 19127; E-mail:

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Abdominal hernias are common with over 20 million hernia repairs performed worldwide. Inguinal hernias are the most common type of hernia. Inguinal and sports hernia have been discussed at length in recent literature, and therefore, they will not be addressed in this article. The noninguinal hernias are much less common but do occur, and knowledge of these hernias is important when assessing the athlete with abdominal pain. Approximately 25% of abdominal wall hernias are noninguinal, and new data show the order of frequency as umbilical, epigastric, incisional, femoral, and all others (i.e., Spigelian, obturator, traumatic). Hiatal hernia is a different type of abdominal hernia involving the diaphragm; in athletes with symptomatic esophageal reflux or poorly controlled exercise-induced asthma, hiatal hernia is an important diagnosis to consider.

Abdominal pain can occur anywhere from the chest to the groin, and almost every athlete will complain of it at some point. The pain may present in many ways, but a thorough history, physical examination, and close follow-up will help prevent a delay in the diagnosis. Commonly used radiologic studies can provide significant information. Plain radiographs can show intestinal gas outside the abdomen. Dynamic changes in position and intra-abdominal pressure can have a higher yield. Contrast computed tomography (CT) scanning with oral and intravenous contrast may help to identify the elusive hernias.

Any condition that inhibits wound healing or weakens the connective tissue will make an athlete susceptible to the development of a hernia or worsening of an existing hernia. Conditions such as infection, obesity, smoking, performance-enhancing drugs, malnutrition, fractured sutures, poor technique, and connective tissue disorders all can play a role. Understanding these less common abdominal hernias and how to manage the athlete once diagnosed may significantly reduce the recovery time of the athlete and reduce the risk of complications.

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Umbilical Hernia

Adult umbilical hernias are usually not the result of persistent infantile hernias but rather close to 90% develop due to increasing intra-abdominal pressure (26). The hernia occurs by gradual weakening of the cicatricial tissue that closes the umbilical ring. Bordering the umbilical canal is the umbilical fascia posteriorly, the linea alba anteriorly, and the medial edges of the rectus sheaths on each side (26). Predisposing factors to developing an umbilical hernia as an adult include obesity, multiple pregnancies, and physical strain.

Paraumbilical hernia (PUH) is another entity to consider when evaluating patients. Most PUHs are acquired secondary to surgical procedures, particularly secondary to laparoscopic port placement with subsequent conditions such as pregnancy, peritoneal dialysis, ascites, and obesity causing increased intra-abdominal pressure leading to herniation of abdominal viscera.

Umbilical hernias in both the infantile and adult categories are typically asymptomatic; it is very rare in this country that they may become incarcerated, requiring emergent surgical intervention (47). The diagnosis is primarily clinical, and consideration for other underlying disease states should be made in infants found to have an umbilical hernia when appropriate. Adults typically present with an asymptomatic bulge at the umbilicus most commonly seen in the fifth and sixth decade of life (40). Many studies have shown the incidence of adult hernias to be more common in women. However a recent study out of the UK showed that men underwent more than twice as many umbilical hernia repairs than did women (11).

In the case of infantile umbilical hernias, 95% of defects <1 cm in size close spontaneously by the age of 5 years (33). For those hernias that do not progress to spontaneous closure, surgical intervention is recommended. Surgical methods may involve either a primary closure of the defect by approximation of the edges of the defect and suture placement or placement of mesh prosthesis to aid in the hernia repair (9). The choice of closure is primarily dependent on the size of defect, with defects 1 cm or less lending themselves to primary closure (9).

PUH should be addressed promptly as this condition has a particularly high morbidity and mortality rate secondary to the typically narrow neck of the hernia and consequent high likelihood of incarceration, strangulation, and need for emergent surgical intervention (3).

With most congenital umbilical hernias being resolved either spontaneously or surgically prior to 5 years of age, there is a reduced likelihood of encountering this entity as a source of complaints in athletic populations. Consideration must still be given for acquired umbilical hernias particularly in athletic disciplines causing increased abdominal pressure (such as powerlifting for which case reports exist describing a variety of abdominal wall hernias) (14). Athletes should, under these circumstances, be recommended to undergo hernia repair to prevent progressive worsening of the hernia and to avoid potential adverse events such as strangulation and incarceration. Abdominal binders may aid in preventing certain hernias; however the increased intra-abdominal pressure seems likely to exploit other weakness within the abdominal cavity. Regarding return-to-play guidelines, it would seem prudent to place strain limits for 2 to 3 wk postoperatively as general current surgical guidelines recommend (6). Patient-guided symptomatic governance also should be stressed to avoid adverse outcomes and potential recurrence of hernia.

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Epigastric Hernia

Epigastric hernias are a type of ventral hernia. These hernias are relatively uncommon and make up only a small percentage. Epigastric hernias are located inferior to the xiphoid process and superior to the umbilicus. They are defined as protrusions through a weakened linea alba. The contents of these protrusions consist mainly of preperitoneal fat. The etiology of these hernias has been the subject of debate. A congenital defect in the linea alba was thought to be the main cause. However increases in intra-abdominal pressure may play a role, and according to a study in the Annals of the Royal College of Surgeons of England, “As straining and coughing constitute the main etiological factors in males, their hernias are often epigastric (1).” Many athletes experience constant straining during workout routines, thus raising intra-abdominal pressure and placing them at risk from epigastric hernias. Most are relatively small and could occur as multiples.

Symptoms of an epigastric hernia can range anywhere from being asymptomatic to severe pain secondary to strangulation. Common symptoms include epigastric discomfort that may or may not worsen with eating, may radiate to the back, or may cause nausea and vomiting. Lying in a supine position may relieve the symptoms secondary to gravity reducing the hernia contents. Given these signs and symptoms, one should think of other diagnostic possibilities such as peptic ulcer disease, pancreatitis, acute cholecystitis, or lipoma.

Diagnosis is made by physical examination and imaging. On physical examination, an epigastric hernia may not be apparent if performing an abdominal examination in the supine position. If suspicious of an epigastric hernia, it is best to examine the patient in the standing position and run the hands down the linea alba to appreciate any protrusions. Epigastric hernias differ from diastasis recti, which is a separation of the right and left rectus abdominis at the linea alba. Diastasis recti, common in infants and those with multiple pregnancies, do not contain any hernia contents. Most are treated conservatively with core exercises, and surgery is rarely necessary. To help confirm an epigastric hernia, the imaging modalities of choice would be ultrasound or CT.

Most, if not all, epigastric hernias should be corrected surgically. Smaller hernias have a propensity to strangulate, and larger hernias can cause a significant cosmetic concern. Epigastric hernia repair carries a 10% to 20% recurrence rate (51). There is no consensus surgical procedure among surgeons to correct epigastric hernias; however it is thought that a tension-free repair with primary closure provides the most optimal result. Readmission rates for open versus laparoscopic repair of umbilical and epigastric hernias are 3.6% and 1.5%, respectively, at 30 d (26). Given these facts, if any athlete exhibits signs and symptoms of an epigastric hernia, it likely needs to be repaired. Laparoscopic surgery would be the preferred surgical technique allowing decreased hospital stay and quicker return to play.

Given the dearth of studies on epigastric hernias, a return-to-work or return-to-play timeframe is at the discretion and clinical judgment of the physician. To provide guidance on a return-to-work protocol, we may be able to learn from studies on abdominal muscle strains in high-level athletes. In a study of National Hockey League (NHL) players, abdominal strains cost a player an average of 11 games lost (16). Eleven games in an NHL schedule equates to approximately 3 to 4 wk. Also, according to the British Journal of Sports Medicine, tennis players with rectus abdominis strains took on average 4 to 5 wk to return to play (29).These studies may provide insight into the body’s physiology and serve as guidance in determining a return-to-play protocol.

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Incisional Hernia

Incisional hernias are hernias occurring at or in close proximity to previous incisional sites in the abdomen. Approximately 90% of all incisional hernias occur in the midline of the abdomen and relatively infrequently in other locations corresponding to the infrequency of operative approaches used in these areas (10). Generally, closure with sutures has proven inadequate as a durable closure in the vast majority of patients. This is due to the frequent existence of other comorbid conditions contributing to eventual failure of this method including obesity, smoking, chronic obstructive pulmonary disease, and advanced age (9). Of all ventral abdominal surgeries performed, 2% to 20% of patients will develop an incisional hernia as a postoperative complication (22). With approximately 4 million abdominal surgeries being performed each year this is a considerable number of patients having significant postoperative complications requiring subsequent intervention (41).

Individuals with incisional hernia will commonly present with a painless bulge in the abdomen usually at the site of prior surgery though hernias may form in close proximity to the incisional site where there has been fascial weakening from suture placement (41,30). Typically pain is not present early on though some patients may report pain with episodes of vigorous exertion or lifting activity prior to appearance of the bulge (30). Greater than 50% of incisional hernias present within 2 years of the primary surgery but they may appear up to 10 years thereafter as well (30,7). As time progresses these hernias enlarge and have a tendency to become symptomatic, particularly with movement, straining, and coughing. Red flags of which to be mindful are fever, bilious vomiting, obstipation, and severe pain associated with incarceration or strangulation of intestinal structures requiring emergent surgical intervention. In obese patients or individuals who have had multiple abdominal surgeries clinical diagnosis of incisional hernia can be difficult. In these populations abdominal CT, ultrasonography, and contrast gastrointestinal studies may be employed to diagnose hernias (13,42,52). If still unclear clinically and imaging studies are equivocal laparoscopy can be used as a final diagnostic tool. Other physical findings such as diastasis recti and abdominal wall laxity secondary to nerve injuries seen in spinal conditions may further complicate the abdominal examination.

After establishing the diagnosis of incisional hernia surgical repair is recommended unless comorbid conditions exist precluding the patient from undergoing the procedure. The main objective is to prevent progression, enlargement and potential incarceration or strangulation of the hernia. Furthermore avoiding morbidity associated with incisional hernia as well as a more complex surgery as the defect enlarges generally leads to better outcomes for the patient. Though controversy currently exists as to the best method of incisional hernia repair most recommendations advocate the use of prosthetic mesh placement (30). Defects ≤2 cm in diameter at the widest point may be repaired by primary closure (5). Larger defects should use prosthetic mesh for hernia repair as this method for closure has a reported recurrence rate of less than 5% (30).

To avoid future complications, incisional hernias should be repaired at the earliest opportunity. In accordance with most abdominal hernia surgeries, recommendations for activity postoperatively vary greatly from brief to long conservative periods of inactivity. Return-to-play decisions should take into consideration the size of the repaired defect as well as the symptomatic composite of the patient. For small defects 2 to 3 wk of recovery avoiding overtly strenuous activity may be sufficient whereas larger defects may require longer periods of limited activity (6). Additionally, certain methods of incisional hernia repair may be worth considering avoiding. The retro-rectus mesh placement would appear to be a source of postsurgical pain in athletes as more than 10% of patients had pain postoperatively with movement due to the mesh pulling during movement at the lateral edge of the mesh fixation points (47). Patient-guided symptomatic governance should be stressed also to avoid adverse outcomes and potential recurrence of hernia.

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Femoral Hernia

A femoral hernia is the protrusion of a peritoneal sac through the femoral canal, posterior and inferior to the inguinal ligament. Contents of the hernia sac may be preperitoneal fat, omentum, small bowel, or other structures. Due to the narrow neck typical of femoral hernias, they have a high tendency to become incarcerated leading to the need for emergent surgery. They account for approximately one-third of all groin hernias in women but only 2% of groin hernias in men (15). In men with femoral hernia, about 50% also present with an associated direct inguinal hernia, whereas this is only the case in roughly 3% of female patients (50). Recurrence rate after femoral hernia repair is only 2% (50). Unfortunately reportedly 36% of cases of femoral hernia in a recent large prospective study were operated on emergently due to incarceration compared to only 5% of inguinal hernias presenting in this manner (12). This statistic accordingly corresponds to a 10-fold risk of mortality associated with acutely presenting femoral hernias (53). There are also several subtypes of femoral hernia that have been described in the literature, including de Garengeot and Littre hernias. De Garengeot hernias contain the appendix and occur in 0.8% of femoral hernia, and Littre hernia contains a Meckel’s diverticulum and is also uncommon (38).

Evaluation for femoral hernia is important in the setting of groin pain but should be considered also in the setting of abdominal complaints. Notoriously asymptomatic until strangulation or incarceration occurs, this can be challenging on routine general examination. Thus colicky abdominal pain and signs of intestinal obstruction should prompt evaluation for femoral hernia as these are frequently part of the presentation with symptoms in the femoral region often being absent (15). When present, they will appear as a bulge below the inguinal ligament. However, on occasion, it may present over the inguinal canal due to cephalad ascension, but the hernia sac still exits through the femoral canal. Classically femoral hernias are small, nonreducible bulges and mildly painful when present (53). Due to the challenging nature of the diagnosis of femoral hernia, employing imaging diagnostic tools is frequently necessary. Ultrasound, magnetic resonance imaging (MRI), and CT have all been shown to be highly accurate in diagnosing femoral hernia with ultrasound having demonstrated sensitivity and specificity of 100% in 2 recent studies (47). Although the efficacy of diagnostic use of ultrasound is highly operator dependent, it should be used preferentially over MRI and CT due to wide availability, low cost, and reduced radiation burden compared to the other modalities. Should these studies be equivocal, laparoscopic evaluation may be considered as a final diagnostic tool.

Femoral hernia, unlike many other hernias, should be urgently referred for prompt surgical repair to avoid the potential for strangulation or incarceration. Femoral hernia repair consists of reduction of the hernia with examination of the contents for viability due to the frequent presence of incarceration. Certain cases also may need further incisional measures to reduce the hernia contents prior to closure of the defect. Generally, repair of the defect consists of primary closure with nonabsorbable sutures using the Cooper’s ligament or iliopubic tract to lend firm support for the repair (15). Mesh prostheses also can be used to close the defect, but in the case of compromised sections of bowel, this is contraindicated due to the risk of infection (50).

Detecting femoral hernia to avoid the need for emergent surgical intervention is very important not only in the general population but also perhaps even more so in athletic populations. Particularly due to the fact that most femoral hernias are not easily reducible or completely nonreducible, the risk of traumatization and the consequent sequelae, especially in the setting of contact sports, makes thorough evaluation and prompt management of this condition imperative. Consideration should be given to individuals complaining of abdominal pain without a clear underlying reason as strangulated femoral hernias commonly present in this fashion. Regarding return-to-play guidelines, it would seem prudent to place strain limits for 2 to 3 wk postoperatively as general current surgical guidelines recommend (6). Patient-guided symptomatic governance should be stressed also to avoid adverse outcomes and potential recurrence of hernia.

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Traumatic Abdominal Wall Hernia

Traumatic abdominal wall hernia (TAWH) is defined as the presence of intact skin at the site of the herniation and the absence of any hernia at the site prior to the trauma (21). Despite the high prevalence of blunt abdominal trauma, TAWH is rare. When there is a delay in diagnosis, TAWH is associated with significant morbidity and mortality (21). Although a motor vehicle accident is the most common cause, consider TAWH when athletes, playing high-impact sports, present with localized pain after direct abdominal trauma. The hernia occurs as a result of a shearing force associated with increased abdominal pressure. More than 70% of the documented cases presented immediately. The differential includes rectus and abdominal wall hematomas.

TAWH has been classified into three categories: small defects caused by impact against blunt objects such as handle bars (handle bar hernia); large defects sustained during motor vehicle accidents; and rarely, intra-abdominal bowel herniation associated with a deceleration injury (54). Although TAWH can occur anywhere in the abdomen, it is most commonly seen in the lower quadrants, just lateral to the rectus sheath (36). Extra-abdominal injuries associated with TAWH include pelvic, lumbar, and proximal femur fractures, implying significant transmission of kinetic energy to the body (25). The “handle bar” hernias have a low incidence of intra-abdominal bowel injuries.

The diagnosis can often be difficult. The disruption may not be evident on physical examination, and the incarcerated bowel loop may be contained with minimal signs of peritonitis. A CT scan may help to make the diagnosis, but a lateral or oblique x-ray may show a gas-filled loop outside the abdominal cavity (4). Once confirmed, TAWH is typically repaired with laparotomy and double layer suture repair using nonabsorbable sutures. Laparoscopic repairs are typically reserved for the “handle bar” hernia.

Recovery and return to play will be dependent on the type of repair and whether there has been other intra-abdominal trauma. The laparoscopic repair will be the best scenario for quick return to sport. Without additional trauma, the recovery is 2 to 3 wk after laparoscopic repair and slow progression from there.

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Obturator Hernia

An obturator hernia is uncommon (0.05% to 1.4%) but can be a significant cause of intestinal obstruction. An obturator hernia is an abdominal wall hernia in which abdominal content protrudes through the obturator foramen. It is much more common in women than in men because of the differences in anatomy. It often presents as a bowel obstruction. A delay in the diagnosis leads to high morbidity and mortality. It is more commonly encountered in emaciated, multiparous Asian elderly women (20). The middle-aged, thin, malnourished female athlete also must be considered at risk. Adolescent cases have been documented as well. Degradation of the body fat within the obturator canal is a possible contributing factor (37). Women have a six-fold greater risk, likely due to the wider pelvis and more triangular obturator canal. Other risk factors include chronic constipation, COPD, and kyphoscoliosis. Herniation is more common on the right side by as much as 60%, and this is thought to be due to protection by the sigmoid colon on the left (17,35). Three stages of obturator herniation have been described. The first two stages are typically asymptomatic and found on operative exploration. The third stage is the entrance of an organ into the canal accompanied by the onset of symptoms (19).

More than 90% of patients will present with an intestinal obstruction. One-third of the patients have intermittent symptoms. Because the symptoms can mimic pain of hip pathology, the diagnosis can be significantly delayed. There are three important signs to remember specific to an obturator hernia. First is obturator neuralgia that commonly presents with pain in the medial thigh (28). Flexion of the thigh relieves the pain, and extension, abduction, and internal rotation worsen it (27). Second is the Howship–Romberg sign, characterized by pain extending down the inner thigh to the knee. This can be overlooked because it mimics pain referred from the hip and the patient gets referred to orthopedics. The third sign is the Hannington-Kiff sign. This is characterized by absence of the adductor thigh reflex (23). The adductor reflex is elicited by tapping over either medial epicondyle causing the adductor muscles of the hip to contract, moving the leg inward. Reduction or absence of the adductor reflex and intact ipsilateral intact patellar reflex can indicate compression of the obturator nerve.

The radiologic study of choice is the CT scan. If there is a high index of suspicion, the CT scan is nearly 100% accurate. Because many patients have intermittent symptoms and the diagnosis is often delayed until complete bowel obstruction, CT of the abdomen and pelvis is strongly recommended.

When the diagnosis is unclear, an abdominal laparotomy is preferred. If the preoperative diagnosis is confirmed, the retropubic, obturator, and inguinal approaches all provide good results (49). In the nonemergent confirmed cases, laparoscopy is becoming more popular. The totally extraperitoneal approach, using mesh to seal the hernia from outside the perineum, was shown to be safe in men with obturator hernias (42). This also would allow a more rapid recovery and return to sport. The athlete can start light aerobics and light weight training within 2 wk. Obturator hernias are relatively rare but carry high morbidity and mortality if the diagnosis is delayed. The index of suspicion should be high in an elderly, malnourished female athlete presenting with intermittent lower abdominal and groin pain.

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Spigelian Hernia

Spigelian hernias occur through a narrow congenital or acquired defect in the anterior abdominal wall at the aponeurosis of the transversus abdominis. This hernia is known also as a spontaneous lateral ventral hernia. It is a rare hernia making up 1% to 2% of all hernias. These hernias lie in the “spigelian hernia belt,” a 6-cm-wide zone above the interspinal plane (44). This zone crosses the abdomen transversely just below the umbilicus. Defects in the aponeurosis of the transversus abdominis in adults are associated with increased abdominal pressure such as in cases of obesity and pregnancy. In pediatric cases, this defect is mostly congenital.

The spigelian hernia starts as a protrusion through an opening in the transverse abdominal aponeurosis. It often continues through the aponeurosis of the internal oblique and positions behind the strong external oblique (44). There are other documented scenarios, but this partial abdominal wall hernia can be difficult to diagnose.

Symptoms may vary from anterior lateral abdominal pain to a lump in the abdominal wall. It is often worsened by upright positions and valsalva and relieved by rest especially lying supine. The physical examination can be difficult because of the positioning of the hernia between the internal and external obliques. A high index of suspicion is needed, and ultrasound or CT scan can make the diagnosis. Once the diagnosis is made, surgical repair is necessary due to a high risk of incarceration (43).

The surgeon’s preference often dictates the approach, but recent debate has been on open repair and mesh fixation. This approach is complicated by recurrence and the development of chronic pain. A recent article showed that, in 84 cases over 9 years, laparoscopic repair led to 0% recurrences and very low morbidity (45).

Laparoscopic repair for the athlete is ideal. They can start light aerobic workouts in a week, light weight training at 2 wk, and heavy lifting in 4 wk with progression back to activity from there.

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Lumbar Hernia

Lumbar hernias are a rare type of hernia that causes a protrusion of extraperitoneal and peritoneal contents through a weakened posterior abdominal wall. The contents may include preperitoneal fat, bowel, stomach, kidneys, or ureters. The potential consequences of these hernias are evident by the organ systems involved. Only 300 cases of lumbar hernias are documented (32). Lumbar hernias are categorized as being congenital or acquired, as well as according to their specific location. Acquired lumbar hernias account for 80% of all lumbar hernias. Location of lumbar hernias can be subdivided into superior lumbar hernias (Grynfeltt-Lesshaft), inferior lumbar hernias (Petit), and diffuse lumbar hernias. Grynfeltt-Lesshaft hernia is the most common type. Anatomically the area forms a triangle with the medial border being the quadratus lumborum, internal oblique laterally, twelfth rib superiorly, and transversalis fascia serving as the floor. The area of weakness occurs at the transversalis fascia where it is not covered by the external oblique. The triangle of Petit consist of the iliac crest inferiorly, latissimus dorsi posteriorly, external oblique laterally, and erector spinae medially.

Those at risk from acquired lumbar hernias are those who engage in strenuous physical activity, who have muscular dystrophy, who have local wound infections, whose age is increasing, who have trauma to the surrounding area, and who have retroperitoneal hematomas. Also those who have had nephrectomies are at increased risk. Several professional athletes in the recent past have undergone nephrectomies. Signs and symptoms may vary. Some patients may be asymptomatic, while others may have strangulation of an organ system mentioned previously. Patients may experience signs of bowel obstruction such as nausea, vomiting, and pain. Patients also may experience colicky pain, urinary retention, and hematuria if the genitourinary system has herniated. Also patients may experience a bulge in the posterolateral aspect of their back. It is important to know a differential for a mass in this location. Other diagnostic possibilities include lipoma, fibroma, abscess, hematoma, and renal cell carcinoma. Given that strenuous physical activity is a risk factor for lumbar hernias, we should include lumbar hernia high in our differential of back masses, along with hematomas, in our athletes who participate in contact sports.

Diagnosis of a lumbar hernia is a combination of clinical signs and symptoms along with CT scan. History should note a patient’s risk factors for possible lumbar hernia. Physical examination may show an obvious deformity in the posterolateral back. CT, the gold standard imaging modality, is used to help delineate muscles, fascia, and organ systems to confirm a hernia. According to the American Journal of Roentgenology, CT is the only radiograph method necessary for diagnosis of lumbar hernias (2). Also it states that a normal CT of this region in symptomatic patient enables the physician to confidently exclude a lumbar hernia (2). Moreover when clinical suspicion points toward a lumbar hernia, CT would be appropriate to confirm diagnosis.

Any patient presenting with a confirmed lumbar hernia will likely need to have it surgically corrected. As mentioned earlier, there have only been 300 documented cases of lumbar hernias. Therefore most surgeons are vastly inexperienced in correcting these hernias. Given this vast inexperience, many surgeons have different techniques. The question of whether to perform laparoscopic surgery versus open is controversial. Some believe that for small- to moderate-sized lumbar hernias, laparoscopy may be the procedure of choice, and large hernias are better served with open surgery (32). Also the rarity of lumbar hernias makes it difficult to predict recurrence. However according to one study, diffuse lumbar hernias had a recurrence rate of 43% (31). Having a diffuse hernia, hernia larger than 16 cm, and a history of muscular dystrophy are risk factors for recurrence. It is very difficult to ascertain a time to return to work or play with lumbar hernias. According to a study documenting a specific laparoscopic surgical technique, patients with lumbar hernias returned to work in 2 wk (24). While this appears to be a relative quick recovery, one needs to take into account a patient or athlete’s workload and formulate a sound clinical return-to-play protocol. Also in a study of baseball players with oblique injuries, pitchers averaged 35 d on persons with disability list while position players averaged 26 d (10). It should be at the discretion of the providing physician and surgeon to apply these studies with sound clinical judgment for a return-to-play protocol.

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Hiatal Hernia

Hiatal hernias are a prolapse of stomach contents into the diaphragm. The two types of hiatal hernias seen are a sliding hernia and a paraesophageal hernia. Sliding hiatal hernias involve the ascension of the gastroesophageal junction along with the proximal stomach through the diaphragmatic esophageal hiatus. Paraesophageal hernias are prolapsing of the stomach fundus into the diaphragm just lateral to the hiatus. The most common of these hiatal hernias are the sliding hernias. The prevalence of hiatal hernias in the general population is 0.5%, and it is thought that 30% of the population has a hiatal hernia (46). The primary underlying cause of these hernias is secondary to degeneration of the phrenoesophageal ligament as we age. However there is belief that increases in intra-abdominal pressure in those who are pregnant, those who are obese, and those who are powerlifters may be risk factors for developing hiatal hernias.

Clinically most hiatal hernias are asymptomatic. If symptomatic, patients experience gastroesophageal reflux disease-like symptoms. Rare complications include esophageal strictures, ulceration, Barrett’s esophagus, or gastric strangulation. Diagnosis is typically confirmed by barium swallow. Other means to confirm diagnosis includes esophagogastroduodenoscopy, CT scan, and ultrasound. In a study in Academic Radiology, patients with hiatal hernias underwent ultrasound examination as well as CT to compare the diameter of the hiatal hernias. The study found that the diameters found on ultrasound were nearly identical to the diameters found on CT scan (8). Therefore ultrasound may be a valuable diagnostic tool while limiting the amount of exposure to radiation.

Athletes who engage in activities that involve consistent valsalva maneuvers and increased intra-abdominal pressure may have a higher incidence of hiatal hernias. These include powerlifters and athletes who engage in heavy lifting as part of their training regime. This is thought to be related to pressure overload. A study in the Journal of Clinical Gastroenterology in 1999 by Smith et al. (46) compared eight powerlifters and seven nonlifters who were relatively the same size and age. The study found that 88% of powerlifters demonstrated hiatal hernias on fluoroscopy while the nonlifter group had 0%. Of those powerlifters with the hiatal hernia, half admitted to reflux symptoms during exercise (46). The authors concluded that hiatal hernias in this population were secondary to pressure overload, not necessarily degeneration of the phrenoesophageal ligament. Also more evidence that pressure overload can cause a hiatal hernia and GERD symptoms comes from a study in the Journal of Clinical Investigation in 1961, in which Nagler and Spiro (34) assessed heartburn in late pregnancy. In this study, manometric values and indirect measures of reflux were recorded in three patient groups. These groups included nonpregnant females, pregnant patients without reflux symptoms, and pregnant patients with reflux symptoms. The results showed that nonpregnant females did not have esophageal pressure changes while the pregnant patients exhibited elevated esophageal pressure gradients, leading the authors to conclude that increased intra-abdominal pressure is a contributing risk factor for GERD (34). One limitation of this study was that imaging to look for a hiatal hernia was not performed secondary to possible barium teratogenicity.

The vast majority of those with hiatal hernias are asymptomatic. If symptomatic, patients may experience vague chest discomfort, belching, burping, retrosternal burning, chronic cough, and sensation of food being stuck behind the chest. Those who are symptomatic tend to do well with medical management, such as proton pump inhibitors (PPI), H-2 blockers, and lifestyle modifications. However if medical management fails to control symptoms, then anti-reflux surgery is a last resort option. It is important to have general knowledge of surgical options for antireflux surgery. Different approaches include open surgery through either the thoracic cavity or abdominal cavity. The open approach is much more invasive. Another approach, which is employed much more commonly today, is laparoscopic surgery. According to Fullum et al. (18), length of hospitalization and mortality were significantly reduced after laparoscopic hiatal hernia repair as compared with the open approach. Given this information, athletes would benefit from laparoscopic surgery for a quicker return to play.

As mentioned, hiatal hernias are typically asymptomatic. If our high-risk athletes, such as powerlifters and football players, experience symptoms of reflux that may be attributable to a hiatal hernia, they can be easily treated with PPIs, H-2 blockers, and lifestyle modifications. When treated medically, athletes may return to play right away. Indications for surgical intervention include those who have failed medical management and have persistent symptoms, and those with uncontrolled exercise-induced asthma secondary to a hiatal hernia not controlled medically. In clinical practice, those who undergo laparoscopic surgery typically spend 1 to 3 d in the hospital and can return to activities about 2 to 3 wk postoperatively. If undergoing open surgery, patients typically spend 2 to 5 d in the hospital, and return to activities is longer at 4 to 6 wk. Athletes should work closely with their physician and athletic trainer to develop a graduated sport-specific rehabilitation program prior to fully returning to their respective sport.

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Abdominal hernias are important causes of abdominal pain in the athlete. Most sports physicians are comfortable evaluating the inguinal hernia. The abdominal hernias discussed here are presented in different ways but have several similar risk factors. Physical straining and obesity in athletes such as powerlifters and football linemen put them at risk from various abdominal hernias. High-impact sports can lead to TAWHs as the athletes become bigger and faster. The obturator hernia, also known as “the little old lady hernia,” must be considered in the older, anorexic female distance runner with unexplained hip and groin pain. These diagnoses can be challenging for even the experienced provider. Close follow-up, a high index of suspicion, and further testing when the athlete is not responding to traditional treatment will help make an early diagnosis. Some of these hernias, if unrecognized or treatment is delayed, may go on to incarceration and even strangulation of abdominal organs, greatly increasing the athlete’s morbidity and mortality.

Return-to-play guidelines need to be tailored to the athlete and the needs of their sport. Using guidelines similar to abdominal strain injuries can be a starting point for the treatment plan. Laparoscopic repair is becoming more popular because of safety and efficacy, and it may lead to a more rapid return to play.

The authors declare no conflicts of interest and do not have any financial disclosures.

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