How is a sports hernia, specifically an adductor longus tendon tear, managed?

Management of Adductor Longus Tendon Tear (Sports Hernia)

Initial conservative management with physical therapy and activity modification should be attempted for 6-12 weeks, but if symptoms persist in an active patient, surgical repair with adductor tenotomy is the definitive treatment that allows return to full athletic activity within 3-4 weeks. 1, 2, 3

Initial Conservative Management

• Begin with 6-12 weeks of conservative treatment including physical therapy focused on core strengthening, activity modification, and NSAIDs 1, 2
• Most athletes with sports hernias will have failed conservative therapy before surgical consideration 3
• The MRI findings in this case show focal tearing without significant retraction, which can initially be managed conservatively 1

Indications for Surgical Intervention

Surgery is indicated when:

• Conservative management fails after 6-12 weeks 1, 2, 3
• The patient is a competitive or professional athlete requiring return to high-level activity 1, 2, 3
• Persistent pain limits athletic performance or daily activities 1, 3

Surgical Technique

The optimal surgical approach combines:

• Suture repair of the posterior inguinal wall (herniorrhaphy) to address the fascial weakness 2, 4
• Adductor longus tenotomy to release the opposing vector forces on the pubic bone 2, 4, 3
• Rectus abdominis fascial release when there is concomitant rectus injury 2, 4

Surgical Approach Options

Two validated approaches exist:

1. Mini-open technique through a 4-cm incision with suture repair (no mesh) 2, 4

   • Preferred in young athletes to avoid mesh-related complications 2
   • Allows direct visualization and precise tenotomy 4

2. Laparoscopic totally extraperitoneal (TEP) repair with synthetic mesh and ipsilateral adductor tenotomy 3

   • Sensitivity of ultrasound for diagnosis is 95.42% with 100% specificity when confirmed laparoscopically 1
   • Success rate of 98.81% in returning athletes to full activity 1

Expected Outcomes

Return to full athletic activity:

• 21-28 days after laparoscopic repair with adductor tenotomy 3
• 30 days for assessment of pain resolution and functional outcome 1
• All patients in surgical series returned to their respective sports at high level, including professional status 2, 3

Important Considerations

Associated injuries are common:

• 21.52% of sports hernias have concomitant adductor longus tendon injuries 1
• 30.1% have contralateral defects discovered during laparoscopic exploration 1
• The small left inguinal hernia noted on this MRI should be addressed during surgical repair 1

Complications are minimal:

• Urinary retention (rare) 3
• Adductor brevis hematoma (rare, occurring months post-surgery) 3
• Recurrence rate is extremely low (1.19%) 1

Common Pitfalls

• Do not mistake this for a simple inguinal hernia - the adductor pathology must be addressed surgically for successful outcome 5
• MRI may be normal in 37% of cases despite clinical sports hernia, so diagnosis remains clinical with imaging confirmation 3
• Mesh repair alone without adductor tenotomy has inferior outcomes - the opposing vector forces must be released 2, 4, 3
• Avoid prolonged conservative management in competitive athletes - early surgical intervention (after 6-12 weeks of failed conservative care) prevents chronic disability 1, 2