Sports Hernia Rehab

Hip and groin injuries make up approximately 15% of all soccer injuries. This includes chronic, athletic groin pain or sports hernia, which makes up approximately 6% of athletic injuries. Several studies have found that 1/2 of all soccer players with groin pain lasting > 8 weeks likely have a sports hernia. This condition tends to be under-diagnosed in general, so that number could actually be higher.

The term “sports hernia” is a bit of a misnomer, because there is no true hernia or protrusion in the groin or abdominal wall. This condition has also been referred to as athletic groin pain, athletic pubalgia, core muscle injury (CMI), inguinal disruption, among many other names. However, sports hernia is still the most widely used and recognized name.

What exactly is a sports hernia?

Sports hernia is a chronic, overuse injury that typically affects both the lower abdominal muscles and the upper adductor (groin) muscles. The tendons and fibers of these muscles combine to form what is called the pubic aponeurosis. The vast majority of these injuries occur in soccer, football, and hockey players, whose sports require repetitive and rapid cutting and kicking. There is a higher prevalence in elite athletes compared to recreational.

Athletes will typically describe the pain as deeper, closer to the pubic bone, and more intense than a groin, hip flexor, or abdominal strain.
Sprinting, cutting, kicking, deep squatting, sneezing/coughing, and performing sit ups can all exacerbate pain.
If irritation is high, getting out of bed can even be painful.
It will typically only affect one side, though it can be present on both.

Doha Agreement - 4 types of chronic groin pain - sports hernia — https://bjsm.bmj.com/content/49/12/768

One of the hallmarks of this condition is that symptoms tend to improve temporarily with rest, however, when the athlete returns to activity, symptoms also return. Some athletes are able to continue playing with just dull pain, whereas for others the pain can eventually become so intense that they must stop all field training. It is very common for soccer players to have symptoms for 1-2 years before being diagnosed. These injuries rarely occur in isolation and athletes often have other hip, groin, pelvis, or core issues at the same time, which can make diagnosis even more challenging.

Anatomy Review

The transverse abdominis and internal oblique tendons combine, forming a sheath of connective tissue called the conjoined tendon. This tendon, combined with fibers from the rectus abdominis (6-pack muscle), external oblique and pyramidalis, attach to the pubis and the origin of the adductor muscles. The tendons and fibers of these muscles all combine to form what is called the pubic aponeurosis (or rectus abdominis/adductor aponeurosis). These injuries tend to occur in this very spot, where the adductor and rectus abdominis muscles attach onto the front of the pubic bone, although any or all of the previously mentioned tendons may be injured.

https://www.aspetar.com/Journal/upload/PDF/201992685418.pdf

Why do these injuries occur?

The rectus-adductor unit acts as a dynamic stabilizer of the pubic symphysis during high intensity activities, such as kicking or cutting. Weakness, overuse, or any other dysfunction of either tendon predisposes the other to injury as a result of the increased load. The extreme opposing strain on the muscles, particularly while kicking a soccer ball, leads to repetitive strain at the pubic aponeurosis.

The diagonal pattern in skating and cutting is very similar to kicking, with hip extension/abduction/external rotation, followed by a quick transition to hip flexion/adduction. The adductor longus experiences the most strain in the lengthened position and we must focus on strengthening in this position.

Risk Factors

- This is the #1 risk factor for most injuries.
- Decreased hip ROM increases motion and stress at the pubic symphysis, as well as stress to the lower abdominals, upper adductors, and back of the inguinal canal.
- Also adductor tightness/limited flexibility.
- Increased risk, especially with eccentric adductor/hip flexor weakness.
- The risk is much, much higher when the adductors are significantly weaker than the abductors (<80%).
- Some authors suggest that intense training of the lower extremities while neglecting the abdominals may contribute to pelvic imbalance and increase sports hernia risk.
- Anterior pelvic tilt may also be a factor as increased anterior tilt reduces hip internal rotation. Limited hip IR influences forces on the pelvis.
- The soccer season is much longer than most other sports. A shortened preseason can cause rapid changes in training volume and workload. This may be part of the reason why there’s a much higher incidence in soccer players.
- This condition is more common in elite athletes.

Gender Differences

This condition affects men far more frequently than women. Most authors estimate men are 10x more likely to have this condition, though more women have been diagnosed in recent years. This may be due to differences in pelvic anatomy as females tend to have a wider pelvis and different force vectors may play a role. It occurs more often in older, elite athletes as well.

How do you know if you have this condition?

Most athletes will have:

Complaints of deep groin/lower abdominal pain.
Pain with sprinting, cutting, sit-ups, or kicking. Relief with rest.
Pain with pressure on the upper groin tendon/lower abdominal tendons and where they attach to the pubic bone.

Here are 5 tests you can perform by yourself. If 2 or more of these increase your symptoms AND you’ve had symptoms with activity > 8 weeks, it is very likely you have this condition.

Squeeze test/Resisted hip adduction at 0, 45, and/or 90 degrees of hip flexion.
Hollow body hold.
Resisted crunches.
Combine squeeze test and resisted crunches. This allows us to further stress the area from above and below at the same time.
Resisted hip flexion with external rotation.

Resisted adduction/squeeze test is almost always painful, but this does not confirm the presence of sports hernia by itself. If this is not painful, you probably don’t have this condition.

This diagnosis can be confirmed with MRI, though this is often not necessary.

Do you need surgery?

Nearly all medical providers recommend at least 2-3 months of good rehab before considering surgery, and even longer for recreational athletes (if rehab does not begin in a timely manner, it can easily take 6 months for the athlete to fully return to sport without pain, though they may be able to return sooner with pain). However, surgery does have very high success rates with around 90% of athletes returning to sport within 2 months. Many professional footballers will opt for surgery as a result. Looking at the research over the past decade, surgery has had better return to sport rates compared to rehab only.

Unfortunately many of these older studies fail to specify what the rehab actually consisted of and are limited by poor research methodology. Many of the passive treatments described are outdated and we know athletes require progressive increases in loading in order to return to sport. Many of these studies did not perform any direct adductor or hip flexor strengthening, and there was very little focus on plyometrics, hip mobility interventions, core stability, and progressive return to sport activities. We are starting to see more and more studies, with several published over the past 3-4 years, showing much better recovery and return to sport rates with progressive strength training of the hips and core along with sport specific activities.

If you are a professional or collegiate athlete with a confirmed diagnosis and a short timeline before an important competition (world cup, champions league, playoffs, etc), surgery may be an appropriate option, allowing a relatively quick return to sport. If this is not the case, I would recommend at least 3-6 months of high quality rehab for most other athletes. If this is ultimately unsuccessful, I would schedule a consultation with a surgeon who specializes in this condition. Keep in mind every case is unique and not all recoveries will follow the same timeline.

I do believe we can do a better job preventing and rehabbing this injury with more deliberate programming, and I think we will continue to see more research in support of rehab first in the next few years.

Rehab and return to play

One of the most frustrating things about this injury is that a full recovery may take several months or longer, even if you just stopped playing recently. That being said, we do want to ramp up the intensity fairly quickly after the initial break from playing. Resting too much can lengthen the recovery time and ultimately increase the risk of re-injury.

We want to continue training at the highest possible level while still modifying as needed based on symptoms and phase of recovery. The progression is going to look different for each player. Some players may be able to return to straight, high speed running while isolated adductor strengthening remains painful. Another player may be able to squat or deadlift close to their 1 rep max, while kicking and cutting are painful. Running, kicking, and strengthening exercises should begin at a low intensity with little or no pain, and gradually progress in both load and velocity. You may be able to progress much quicker with some exercises than others.

Timeline

Most players will undergo 2-3 months of rehab before returning to sport, and it may even take up to 6 months before they return to their pre-injured state. Some players will return earlier than this, but they will often still have deficits. If this condition is not addressed appropriately it can easily take over 6 months to recover from.

Phase 1 (0-6 weeks)

Goals for this phase:

Control pain and protect injury
Regain flexibility if limited
- Need to focus on multi-planar mobility.
Begin exercises with little to no pain allowed at this stage
- We want to strengthen the hip flexors, adductors, extensors, and improve core stability.
- Exercises that focus on the rectus abdominis 6-pack muscles (think crunches/leg lifts), tend to be more painful initially. Oblique and transverse abdominis ex’s may be less painful in this stage.
- Adductor strengthening with minimal pain.

Should you stop running?

If you’re having a lot of pain, you may want to completely stop running for 1-2 weeks. You can still continue other training. I would not rest longer than that if possible. However, you want to at least be walking and performing daily activities with little or no pain before you start jogging again.

How do you know when to progress strengthening?

Wollin et al recommends using the 5-second squeeze test to determine when more aggressive strengthening can begin. Pain should be less than 5/10 with this test and ideally <3/10 with exercises.

Copenhagen 5 second squeeze test. — https://bjsm.bmj.com/content/51/7/594

Warm up and mobility

If there is decreased adductor flexibility, lengthening the tendon can help rebalance forces at the pelvis. Adding manual therapy/massage to the groin muscles can help with this.

Some researchers have recommended not stretching the adductors as it may irritate the pelvis at the insertion. However, if the ROM is limited we need to increase it somehow, whether that’s stretching, soft tissue work, or eccentric strengthening. You should try to keep the stretching painfree. In my experience, stretching one side at a time is typically tolerated better than stretching both sides at once (frog stretch, happy baby, etc.)

Here are some drills I like to use to improve hip adductor and flexor mobility.

As mentioned previously, limited hip rotation can also contribute to this condition. Here are some drills to help gain hip rotation mobility to reduce stress on the pelvis.

Core exercises

Strengthening the obliques and transverse abdominis specifically helps to increase pelvic stability by counteracting the adductor contractions. Several studies have found athletes with chronic groin pain tend to have delayed deep abdominal firing and decreased muscle thickness compared to healthy athletes. Exercises more focused on the rectus abdominis should also be introduced when pain free.

Hip adductors/groin

Stress on the adductors is highest in the backswing when kicking, along with any sudden/unplanned cutting movements. As the speed of these increases, so does adductor stress. We need to get these muscles long and strong to better handle this stress, and then gradually start increasing speed with the exercises.

This muscle group is highly active on both sides when kicking, stabilizing the pelvis and performing the actual kicking movement. It is important to work both sides with all exercises.

Try to perform most of these exercises with minimal pain. The Copenhagen adductor exercise can be very painful initially and may need to be introduced at a later point. This exercise should be introduced as soon as tolerated though due to large increases in eccentric adductor strength and flexibility.

One note on ball squeeze exercises. You may see these recommended by some providers, but in my experience they can be quite painful and really offer minimal strengthening benefits. I find this is more useful as a return to sport test.

Hip flexors

Increasing strength in the hip flexors can help reduce some of the load on the adductors during kicking. We find these muscles often become weak and painful in athletes with chronic groin pain. The adductor longus is a hip flexor when the hip is extended (backswing of a shot). When this muscle becomes injured it contributes less to hip flexion, forcing the hip flexors to become overworked.

Hip extensors

Compound exercises

Single leg movements may be tolerated better than double leg initially. With lunges and split squats we want to gradually increase the depth and move the feet further apart, as well as work various widths and angles. Deadlifts tend to stress this region less than squats and may be introduced earlier. Squatting progression should look something like this:

Goblet squats -> Hack squats -> Front squats -> Box squats -> Back squats

Pausing and controlling the motion at the bottom of the squat can be very beneficial to start strengthening the adductors in a more lengthened position.

Phase 2 (6-12 weeks)

Goals for this phase:

Continue to monitor pain response
Continue working on mobility, strength and stability.
Begin slow and heavy loading and gradually build up to faster movements when you can perform without pain or compensation.

Many athletes will feel fine when performing slower activities, but when speed increases the pain returns.

Begin plyometrics and sprinting.

Running progression

Slow jog -> Side steps and backpedaling -> Running with change of direction -> Sprinting -> Full speed cutting/change of direction.

Jogging should begin in phase 1. Some athletes may progress faster with running than with exercises and vice versa.

Start field drills

Basic passing, dribbling, and juggling. Once you are able to sprint, begin practicing shooting. Gradually increase velocity and distance with all of these. There is more stretch and stress on the adductors with harder shots so we need to build back up to this.

Full power shots and full speed dribbling will likely be two of the last things to improve.

Return to play

We want to gradually return to training at this point, starting with 30 minutes of individual training and progressing to 90 minutes of team training over several weeks. You should complete at least 1 week of full training before playing full matches. Note that your strength and performance may not be back to normal for several months or more after returning to sport. It is important to continue these strengthening exercises 2-3 days per week to help prevent any setbacks.

Criteria for full return to sport

No pain with palpation of adductors or lower abs
Pain free sit up and ball squeeze at 0, 45, and 90 degrees.

Painful squeeze test is typically one of the last things to resolve.
Fairly good indicator if you are ready to return to sport.

No pain with groin stretch.
No pain with passing, shooting, cutting, and running.
3x6+ Copenhagen adduction pain free

Key takeaways

It may take 3-6 months or longer to fully recover from this injury.
Your exercise program should be focused on pain free strengthening of the lower abdominal musculature, adductor muscles, and muscles that stabilize the pelvis.
You may be able to progress much quicker with some exercises than others.
This injury most often occurs in sports requiring repetitive cutting or kicking at high speeds, such as soccer, hockey, and football.
- As a result, we need to gradually increase the velocity with our exercises to prepare for return to sport.
Continue to work on improving or maintaining strength and flexibility after you fully recover and return to sport.

Post Surgical Protocol

At the professional level, athletes will often be cleared to return to sport 6-8 weeks after surgery. This article does not address post-surgical rehab specifically, but here are two post-op protocols if you are interested in learning more. Please consult with your surgeon and rehab professional before beginning any post-op rehab.

Mass General

IJSPT

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Phase 2 (6-12 weeks)

MCL Sprain Rehab

Lateral Ankle Sprain Rehab