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Veiled Threat

Vol. 17 •Issue 1 • Page 19
In the Game

Veiled Threat

Sports hernias present a classic case of hide and seek.

How do you treat something that you don't know is there? Although the situation sounds like a trick question, a condition called the sports hernia is challenging the diagnostic skills of clinicians.

Groin injuries constitute approximately 5 percent of all athletic injuries.1-3 Treating these conditions can be frustrating for athletes and clinicians because it's difficult to completely resolve symptoms. Different clinical entities can cause groin pain, and sports hernias should be considered. Athletes with groin pain that doesn't respond to conservative treatment within 4 to 6 weeks should see a medical specialist to rule out a sports hernia or more serious medical problem.

A sports hernia, which can be called Gilmore's groin, athletic pubalgia, incipient hernia, posterior abdominal wall disruption (PAWD) or sportsmen's hernia, is a diagnosis of exclusion.2,4-6 One source describes the condition as a groin injury that can't be seen, palpated or effectively managed (conservatively) yet requires surgical repair to alleviate symptoms.1

From an anatomical perspective, a sports hernia is an inguinal canal disruption, which involves a tear of the distal attachments of the abdominal aponeuroses to the anterior pelvis.5 The specific structures involved include the aponeuroses of the external oblique, internal oblique and transverse abdominis muscles as they insert to the pelvis to form the posterior walls of the inguinal canal. The superficial ring of the inguinal ligament may also dilate and require surgical repair.1-3,7

However, a sports hernia doesn't present the characteristic bulge or positive cough reflex of its namesake cousin, the inguinal hernia. An inguinal hernia is a protrusion of abdominal contents through a weakness in the abdominal wall and crural orifices of the inguinal canal.5

To qualify as a sports hernia, the following symptoms may be present: persistent groin pain with athletic activity; no pain at rest or with Valsalva maneuver; unilateral pain when palpating the medial pubic area; unilateral or bilateral pain with resisted hip adduction; pain with abdominal contraction, such as a half sit-up; little or no response to conservative measures; and improvement with surgical intervention.

Understanding the mechanism of injury can also help clarify key characteristics of the condition. Most studies on sports hernias involve soccer and hockey players, due to their increased incidence of groin pain. But the condition can occur in any sport in which rapid changes in direction are part of the athlete's movement.2,8,9

Forceful and repetitive trunk rotation appears to be the most common mechanism of injury. However, 75 percent of afflicted athletes can recount an inciting incident. The abdominal tissues seem to be unable to withstand increases in intra-abdominal pressure from a resting pressure of 15 to 20 mm at rest, to 150 to 200 mmHg during sports participation. Muscle imbalances, such as tight hip flexors and weak abdominal muscles, may also lead to tissue fatigue and stress tears in inguinal structures.4

Symptoms of adductor strains most closely resemble those of sports hernias. In fact, athletes may have both injuries simultaneously. In a study testing the reliability of clinical tests for sports hernias, provocation tests included single and bilateral lower extremity hip adduction.10

Hemingway hypothesized that shear forces of the adductor group across the pubic symphysis may cause excessive stress at the post-inguinal wall.1 However, adductor strains in professional hockey players respond to an appropriate exercise regimen without surgery.11

Athletes often complain of symptoms for months before seeking treatment. Despite the time lapse, surgical repair methods are usually effective. Improving symptoms and function following surgery for sports hernias was rated excellent in 85 percent to 90 percent of studies reviewed.2,5,9,12

Post-surgery return to play often depends on a surgeon's technique. Was the repair laparoscopic or open? And did the surgeon suture the tears and reinforce them with polypropylene mesh?

A study by Hemingway examined recovery after surgery. He looked at changes in muscle strength and pain levels in 16 soccer athletes before and after open surgical repair of a posterior abdominal wall disruption. All surgeries were performed by the same physician, who used mesh to reinforce the post-wall repair.

Hemingway's athletes returned to play 6 weeks after surgery.4 Schuricht's laparoscopic repair using mesh returned soccer players to competition within 4 weeks.6 Other studies note return to play timetables between 9 weeks and 6 months.2,5,7

In preop testing, only 12.5 percent of Hemingway's subjects could perform adequate isometric abdominal contractions, such as pelvic tilts with the lower extremities abducted and externally rotated, indicating oblique weakness. Postoperatively, that number climbed to 96 percent. Oblique function was worst preoperatively and increased most postoperatively in these patients. Hemingway noted that rotational control of the pelvis appears to be the most important factor to prevent and rehab posterior abdominal wall deficiency.4

Another study of athletes with long-term groin pain revealed that an active program of isometric exercises and functional training was superior to a program of passive modalities in reducing pain and improving function.8

The goal of any sports rehab program is to return athletes to competition at a functional level equal to or better than their pre-injury status. But before you implement a rehab regimen for a surgically repaired sports hernia, consult with the referring surgeon about the type and extent of repair. Individual differences occur, and tissue healing varies by method.

Address all parameters of athletic movement including the hips, trunk, flexibility, muscle endurance, muscular power and trunk stability. And remember that progressing to full activity requires gradual stressing of repaired tissues. Determine the timing and progression of exercises by re-assessing the patient after previous treatments.

During the acute phase of rehab, athletes can use stationary bikes and treadmills to warm-up before exercising. Workouts should focus on trunk rotation and flexibility, submaximal hip adduction, and resistive hip flexion, abduction and extension. Applying modalities, such as ice, e-stim and laser therapy, during all phases of rehab can prevent post-exercise soreness.

As rehab progresses to the subacute stage, you can introduce biking, swimming or walking at a comfortable pace for a warm-up. Exercises should attempt to increase trunk, hip and lower extremity flexibility, and build strength. Consider prescribing sets of double knee lifts, curl-ups and oblique curls in hook-lying position, Sumo squats, dumbbell deadlifts, isometric push-ups, and chops/lifts with a cable column. Increase reps and weights as tolerated.

Dedicate the final phase of rehab to advanced strengthening and return-to-play regimens. Warm-ups should include jogging at a moderate speed; exercises should refine trunk, hip and lower extremity flexibility. Common workouts involve progressive sets of medicine ball rotational throws, oblique sit-ups, front planks, side planks, dead lifts, side lifts, chops/lifts with a cable column, power cleans/presses, kettlebell double arm swings, and push-ups. Athletes should also progress to full-speed sprinting and acceleration drills.

If you return an athlete to any competition without improving or restoring his ability to generate power–specifically, trunk rotation–rehab is incomplete.

Traditional resistance exercises, such as dead lifts, squats and power cleans, can increase core stability and abdominal strength.13 Use lighter weights for these exercises at the beginning of a program.

Proprioceptive neuromuscular facilitation patterns with cable column resistance involve multiple sets of 8 to 12 reps, with weights progressing from 15 lbs. to 75 lbs. or more. If an athlete has no increased abdominal soreness, you can steadily add weight. But frequently assess the ability of repaired tissues to withstand increased loads.

Awareness among athletes and sports medicine professionals is validating the sports hernia as a legitimate–albeit challenging–diagnosis. Once you pinpoint the problem and surgery is performed, rehab of repaired sports hernias has a high success rate. The key is to understand the mechanism of injury so rehab can address deficits and accommodate sport-specific demands.

For references go to and click on the references toolbar.

Gary Shiffman, PT, ATC, CSCS, is director of the Millennium P.T. Clinic at the Velocity Sports Performance Center in Mahwah, N.J. He can be reached at Rich Campbell, ATC, CSCS, and Sean Donellan, ATC, CSCS, contributed to this article.

Following a Rehab Regimen for Sports Hernias

The goal of rehabilitation for a sports hernia is to return athletes to competition at a functional level equal to or better than pre-injury status. Applying the following program can achieve this aspiration. In each of these phases, you should use modalities such as ice, electrical stimulation and lasers to prevent post-exercise soreness.

Acute Phase

Warm up on a stationary bicycle and walk on a treadmill for 5 to 20 minutes, as tolerated.

  • Ball roll-ins on a fitness ball. Perform 20 to 50 repetitions.

  • Trunk rotation in supine with lower extremities on a fitness ball. Control rotation through abdominal contraction. Work both sides and progress to full range of motion.

  • Submaximal hip adduction in supine with pillow or soccer ball at knees. Hold 10 for 5 seconds. Progress to maximal isometric contraction.

  • Resistive hip flexion/abduction/extension following straight leg raise protocol. Perform 2 sets of 12 in each direction.

  • Work on passive stretching of all hip motions to optimal levels, including internal and external rotation.

  • Work trunk flexibility with forward leans, press-ups and side bends. Hold for 30 seconds or to tolerance.

    Subacute Phase

    Warm up with biking, swimming or walking at a comfortable pace for 5 to 20 minutes.

  • Work on trunk, hip and lower extremity flexibility through all motions.

  • Double knee lifts with short arc. Progress to 5 sets of 10 to 15 reps.

  • Curl-ups in hook-lying position with hands sliding toward knees, and with the head and chest lifted. Perform 15 to 50 reps.

  • Oblique curls in hook-lying position with hands reaching toward opposite corner. Perform 15 to 50 reps on each side.

  • Sumo squats/dumbbell dead lifts. Perform 5 sets of 5 reps. Progress from 20 lbs. to 50 lbs.

  • Side dumbbell lifts. Perform 5 sets of 5 reps. Progress from 10 lbs. to 50 lbs.

  • Isometric push-ups. Hold 6 "up" positions for 10 seconds each.

  • Proprioceptive neuromuscular facilitation chop/lift with a cable column. Perform 2 sets of 8 to 12 reps in each direction on each side. Increase weight as tolerated.

    Return-to-Play Phase

    Warm up with jogging at a moderate speed.

  • Work trunk, hips and lower extremity flexibility through all motions.

  • Medicine ball rotational throws. Perform 20 on each side. Progress from a 2-lb. ball to a 12-lb. ball.

  • Fitness ball oblique sit-ups. Perform 2 sets of 30 reps on each side.

  • Front planks with trunk supported on forearms. Hold 10 for 10 seconds. Progress to 30-second holds.

  • Side planks with trunk supported unilaterally. Hold 10 for 10 seconds. Progress to 30-second holds.

  • Dead lifts. Perform 5 reps maximum. Progress from 50 lbs. to optimal levels.

  • Side lifts. Perform 5 reps. Progress from 15 lbs. to optimal levels.

  • Chop/lift with cable column. Increase weight as tolerated.

  • Power cleans/presses

  • Kettlebell double arm swings. Perform 5 sets of 10 reps. Progress from small (18 lbs.) to large (up to 70 lbs.) kettlebells.

  • Progress to full-speed drills practicing sprinting and acceleration.

  • Slide board for hockey players. Progress from 3 to 5 1-minute intervals.

  • Push-ups and T push-ups

    –Gary Shiffman, PT, ATC, CSCS


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