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Last year I wrote a piece called Understanding and Training Hip Flexion . The idea was to take a look at muscles of the hip and how these muscles function from a slightly different perspective. This process led me to continue to study the hip and how we look at this critical area.
One of the things I pride myself on is continuing to try to learn. Fortunately or unfortunately I feel like the more I learn the more I realize I don’t know. An area that has become of increasing interest to me, and to many others in the fields of performance enhancement and physical therapy, is the area of sports hernia. It seems like every week another athlete is having surgery for a ‘sports hernia”.
In order to begin to understand the concept of sports hernia, the first thing we need to do is attempt to describe a sports hernia. In the technical sense, the sports hernia is a tear in the lower abdominal wall in the inguinal area. Unlike a classic inguinal hernia there is rarely a significant tear that results in a bulge. Rather there is a gradual onset of pain in the lower abdominal area, usually beginning as groin pain.
In truth a number of different conditions fall under the umbrella of sports hernia. However, the most interesting thing about the sports hernia is that it almost always seems to begin as groin pain, not as abdominal pain. Most sports hernia sufferers, when interviewed or evaluated, will describe a groin injury that gradually progressed into a painful lower abdomen. This often-overlooked fact may be the real key to solving or understanding the problem.
Sports hernias are not traumatic. There is no singular incident but rather a gradual progression. What begins as a groin pain progresses into an abdominal pain. So in reality, the “sports hernia” may be secondary injury. In fact sports hernias may be the reaction of the abdominal muscles to a groin injury or more specifically the reaction of the abdominal muscles to a change in the mechanics of the hip joint.
The questions are why does the abdomen become effected and how? I have worked with athletes with “sports hernias ” in both high-level soccer (MLS) and high-level ice hockey (NCAA and NHL). In the summer of 2006 I participated in and coordinated the successful rehabilitation of two athletes who had sports hernia surgery. One was an NHL player, the other an NCAA Division 1 hockey player.
To backtrack a bit lets first examine the term “groin” or, the concept of a “groin pull”.
The groin area, as commonly described in sports and sports medicine, actually includes the muscles that flex the hip, the muscles that adduct the hip, and surprisingly some of the hip extensors. The term groin is really a garbage term or catch-all most often used to describe all of the adductors and flexors of the hip. This is where things begin to get interesting and, why the article is subtitled Understanding Adduction.
The adductor group is comprised of five muscles, the adductor magnus, gracilis, pectineus, adductor longus and adductor brevis. Because we have commonly been taught what I like to call origin-insertion anatomy we often visualize all of these muscles in their singular, uni-planar role as adductors. We tend to adopt a simplified view of adduction as a motion done purely in the frontal plane. However, my recent readings in Florence Kendalls Muscles -Testing and Function made me realize that like all things, nothing is as simple as it appears.
During the summer of 2006 I was lucky enough to enlist the assistance of an outstanding manual therapist, Dr Donnie Strack DPT ( currently Director of Sports Medicine for the NBA’s Oklahoma City Thunder). Donnie evaluated both players I was working with and found that each had significant soft tissue restrictions in the pectineus. In other words, they had at some point experienced a “groin pull” or adductor strain that was treated conventionally with ice/ rest etc.
Subsequently both players were allowed to return to play after symptoms had subsided but, neither player had received appropriate soft tissue work to this critical area. Dr Strack’s mentor, physical therapist Dr Dan Dyrek, uses the term “benign neglect” to describe the treatment of such injuries. The assumption is that an absence or decrease in symptoms is the same as healing.
What does this have to do with sports hernias or, the subtitle of this article Understanding Adduction?
Here is where it continues to get interesting. After reading Muscles- Testing and Function it became obvious that all of our adductor muscles have a secondary, multi-planar role. I was surprised to read that two of the adductors are also weak hip flexors. The pectineus (no surprise here) and the adductor brevis act to assist in hip flexion.
In other words they flex and adduct. As I sat reading, the lights came on pretty brightly in my little mind. Sports hernias are near epidemic in two sports, hockey and soccer.
What do hockey and soccer have in common? One very critical point. The recovery of the skating stride in hockey is a combination of hip flexion and adduction. What muscles do we envision being overworked and injured? Obviously those that both flex and adduct. Striking a soccer ball? You guessed it, flexion/ adduction combination. What do these adductor/ flexors also have in common? They insert just below the abdominals right in the area of the sports hernia.
Guess what else? The remaining three adductors are extensor/ adductors. Adductor magnus, adductor longus and gracilis aid in adduction but, by virtue of their position of insertion on the pelvis aid in extension of the hip.
The Etiology of the Sports Hernia
Two muscles get overworked, the pectineus and adductor brevis. A strain occurs. Rehab is often inadequate. The location of the strain makes soft tissue work difficult. In fact many athletic trainers, particularly if gender lines are involved, are reluctant to perform soft tissue work in the high adductors. Soft tissue work can also be neglected due to time constraints or skill constraints.
If rehabilitative exercise is performed, the focus is on frontal plane adduction, which does not directly address the unique function of the injured muscles. In frontal plane adduction the long adductors can substitute and “hide” the issue with the flexor/ adductors. Wraps and elastic devices are often used to mask symptoms and/or to decrease pain. The result of this process of “benign neglect” is an eventual tear of the abdominal wall secondary to a groin strain in the pectineus or adductor brevis.
Here’s where the AT/ PT crowd gets mad at me. Currently, the only therapists I use for my athletes or clients are manual therapists. I am lucky enough to have a long time relationship with Dr. Dan Dyrek probably the greatest physical therapist you have never heard of. Dan is a genius and a master of soft tissue. His entire business revolves around soft tissue mobilization. I have never seen a modality besides the human hand used.
Adding Dr Donnie Strack to his practice allowed us increased access to outstanding treatment. This is the solution. If you are an athletic trainer or a physical therapist develop your soft tissue evaluation and treatment skills. Most athletic trainers and physical therapists don’t do massage in this country because it’s too hard and not cost effective. This has to change to stem the tide of sports hernias. I am lucky to have found two excellent massage therapists, Ellen Spicuzza and Joanie Gauthier. With this team approach we can keep athletes healthy or, get athletes healthy.
If you are reading this and are an athlete with a lower abdominal issue find a good manual therapist. This is not easy. They are few and far between. Surgery may help but, it will not be the entire answer. Resolution of scar tissue is the final piece of the puzzle. You need to get to the original source of the injury and deal with it. This can only be done by a soft tissue professional.
Discussion (added post initial publication)
Many in the medical world will disagree with my thoughts. Truth is, I don’t really care. I have discussed the sports hernia phenomenon with numerous well-respected colleagues and have gleaned a few theories. One of my conversations with renowned physical therapist Gray Cook yielded this gem. Cook theorizes that most athletes would do as well without surgery as with surgery if they would actually take time and rehab. The surgery is almost a method of forced rest that allows healing.
Another thought comes from Pete Freisen, former Athletic Trainer for the Carolina Hurricanes of the NHL. Pete thinks that a large predisposing factor in ice hockey athletes is that many hockey players stretch the adductors but, not the hip flexors. The adductors are easy to self-stretch while the hip flexors require either great concentration or the assistance of a partner. The result is often athletes that have great frontal plane mobility at the hip with limitations in the sagittal plane. You basically have one large degree of freedom and one limited one.
Think of the forces on the hip capsule and lower abdominal wall when you think of excessive abduction but a big block in extension. If you think of this mechanically it makes sense. The discrepancy of hip ROM probably sets these athletes up for an abdominal tear and potentially for labral damage. Freisen has actually stated that he would rather have tight athletes or loose athletes but not athletes that are tight in one plane but loose in another. Cook would define this as an assymettry. In Cook’s Functional Movement Screen research asymmetry was a greater prediction of injury than a symmetrical restriction. Asymmetrical range of motion at the hip may be another precursor to sports hernia.
An additional area of concern in sports hernia is hip internal rotation. Most of the athletes who experience a sports hernia seem to lack hip internal rotation ( a transverse plane deficit). The consensus seems to be that just as we have misunderstood the role of the adductors, our athletes in an attempt to be healthier may be over-lengthening the wrong muscles ( adductors in the frontal plane) and leaving other muscles ( hip flexors and hip external rotators) critically short.
The result is a hip that lacks extension and internal rotation but, has great ROM in conventional frontal plane adduction. This forces the pelvis to move in compensation and, stress to be shifted to the lower abdominal wall. The result is an eventual sports hernia.
Part two of this article will deal with prevention and rehab following sports hernia.
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