What is the recommended treatment for a patient with chronic left hip pain and an MRI-confirmed sports hernia (adductor longus tendon tear) without significant hip joint abnormalities?

Treatment for Sports Hernia (Adductor Longus Tendon Tear)

Initial conservative management with physical therapy should be attempted first, but if symptoms persist beyond 2.5 months despite conservative treatment, surgical repair with adductor longus tenotomy is the definitive treatment that allows return to competitive sports in the majority of athletes. 1, 2

Initial Conservative Management

• Begin with a trial of conservative treatment including rest, physical therapy, and activity modification 3, 2
• Conservative treatment should be attempted for at least 2.5 months before considering surgical intervention 2
• Diagnostic and therapeutic injections are safe and useful tools for confirming the location of pain and providing short-term pain control 4

Indications for Surgical Intervention

• Surgery is indicated when there is a history of long-standing pain (>2.5 months) at the origin of the adductor longus muscle that is refractory to conservative treatment 2
• The MRI findings in this case confirm focal tearing of the adductor longus tendon from the symphysis pubis without significant retraction, which is consistent with a sports hernia 3, 1

Surgical Approach

• Suture herniorrhaphy with adductor longus tenotomy is the recommended surgical technique 1

• The procedure involves:

  • A 4-cm incision approach 1
  • Fascial release of the rectus abdominis 1
  • Adductor longus tenotomy to relieve opposing vector forces on the pubic bone 1
  • Suture repair to reinforce the inguinal floor (avoiding mesh in young athletes) 1

• Laparoscopic TAPP repair is an alternative approach with excellent outcomes (98.81% success rate) 3

Expected Outcomes

• All patients in surgical series returned to their respective sports and regained high-level performance, including professional status 1
• Mean return to same sport: 6.6 weeks 2
• Mean return to competitive sports: 14 weeks 2
• Long-term functional results are good, with all patients improved or symptom-free at 35-month follow-up 2
• 75% (12/16) of athletes returned to full athletic activity at the same competitive level 2

Important Clinical Considerations

• Sports hernias are often associated with adductor muscle strains (10.92% of adductor strains have concurrent sports hernias), suggesting a common mechanism of injury 3
• In 21.52% of sports hernia cases, ultrasound detects concomitant adductor longus tendon injuries 3
• The incidental left inguinal hernia noted on this patient's MRI should be addressed during surgical repair if intervention is pursued 3
• Some decreased muscle strength may occur post-tenotomy but does not appear to influence sports participation 2

Common Pitfalls to Avoid

• Do not mistake an adductor longus tendon rupture for an incarcerated inguinal hernia - both can present with acute groin pain and a palpable mass 5
• Failing to recognize that the pain is activity-related and originates from the adductor insertion rather than the hip joint itself 4
• Proceeding with prolonged conservative management beyond 2.5-3 months when symptoms are clearly refractory 2