By Tom Sutton, DPT Student
With every sport that athletes take part in including football, hockey and baseball, it is no surprise that many different types of injuries come about. One injury in particular, that is typically given a general diagnosis of “sports hernia,” involves groin and abdominal pain. According to a study carried out by Ellsworth et al in the International Journal of Sports Physical Therapy, sports hernia could encompass many symptoms and it is important for the practicing clinician to understand their patient’s presentation when treating them. This would of course include performing a thorough subjective examination as well as objective tests and measures. Although there is research in the current literature that discusses what rehabilitative measures should be taken in physical therapy for hernia-type injuries, Ellsworth examines more specific diagnoses beyond the catch-all term of sports hernia and compares conservative treatment vs. operative management.
Athletic Pupalgia vs. Inguinal Disruption
Per Ellsworth, sports hernia is not solely limited to the athletic patient population and can be better described as either athletic pubalgia and inguinal disruption. Athletic pubalgia conveys “separation of the more medial common aponeurosis from the pubis,”(2) and can likely involve tendinopathy of the hip adductors. This term is reportedly the replacement term for sports hernia per Kachingwe.(3) Possible mechanisms of injury include agility type movements involving sharp cuts, turns and twists as well as high-intensity planting of the foot in the ground, “repetitive kicking and lateral motion.” (4) Kachingwe outlines the five signs that are indicative of athletic pubalgia that should be heeded in the clinical setting on Table 1.(3)
Inguinal disruption is an umbrella term for pain syndromes that relate to an injury of soft tissue in the inguinal area. Sheen has suggested through his research that there are 5 possible signs of inguinal disruption and reports that 3 out of 5 increase the likelihood of an inguinal disruption diagnosis. The signs are as follows, per Sheen et al: (5)
1. Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon.”(5)
2. Palpable tenderness over the deep inguinal ring.”(5)
3. Pain and/or dilation of the external ring with no obvious hernia evident.”(5)
4. Pain at the origin of the adductor longus tendon.”(5)
5. Dull, diffuse pain in the groin, often radiating to the perineum and inner thigh or across the mid-line.”(5)
Screening & Diagnosis
Keep in mind, differential diagnosis is especially important for these types of injuries because sports hernia can mimic other conditions such as hip impingement, stress fracture and labral tears.(6) When screening for an inguinal disruption may consist of having the patient perform resisted sit ups and adductor squeezes which will likely show muscle weakness.(5) Gilmore reports that having the patient alternate between utilizing the Val Salva maneuver and breathing properly along with palpation of the transversalis fascia can reveal possible findings of inguinal disruption.(1) From an imaging standpoint, the standard appears to be magnetic resonance imaging (MRI) which is coming out with increased literature supporting its use in diagnosing core injuries.(1) The British Hernia Society in 2014 reported that there are two findings on an MRI that should be observed: bone marrow edema noted in the pubis and changes observed in the anterior capsule, adductor longus and rectus abdominis.(2) The MRI will show the degree of disruption present in the patient and may serve as a guide as to whether or not the patient will require surgery.
The first line of defense for injuries typically involves conservative treatment before resorting to surgical procedures. According to Ellsworth, there is little evidence in the current literature that fully support conservative management for hernia-type injuries.(1) However there are reported studies that demonstrated patients showing improvement after a rehabilitative program following 6-8 weeks.(1) Like all injuries, there are guidelines and protocols that can be heeded and examined before initiating an exercise program, but the fabric and makeup of a patient’s program should ultimately be determined based on their presentation. Non-operative treatment would consist of essential pillars such as strength, balance and flexibility. It would include activation, strengthening and coordination of the core and hip musculature, soft tissue techniques and neuromuscular re-education.(1) Ellsworth provides a week-to-week protocol that can guide a clinician’s treatment of a patient with athletic pubalgia or inguinal disruption. The protocol for conservative treatment vs. operative rehabilitation differ for imperative reasons such as facilitating healing and controlling swelling. The protocols for conservative treatment and operative management can be accessed here.
Closing Thoughts and Applicability
To apply what has been discussed in a clinical setting, it is important to understand that a patient’s complaints of “groin pain” may be more serious. This is especially true if the patient does not respond well to conservative treatment. Of course, during the examination it is paramount to observe the area affected, perform inspection and palpation. As for exercise, there are numerous possibilities for the patient’s individual program, as long as it is proportionate to their progress. Achieving the goals of optimal strength, range of motion and coordination following a groin injury or post-surgical procedure are focuses of treatment. Being familiar with the protocols and knowing that they are to be guidelines only. Not every patient will fit the protocol perfectly. Once determined what specific diagnosis the patient has, it will be very important starting the patient on a great exercise program to instill changes moving forward, like any other injury.
Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.
2.Sheen AJ, Stephenson BM, Lloyd, DM, et al. Treatment of the Sportsman’s groin: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2013. doi: 10.1136/bjsports-2013-092872.
3.Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (Sports Hernia): A case series. J Ortho Sports Phys Ther. 2008;38(12):768-781.
4.Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg. 2005;55(4):393-396.
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A,
5. Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M: ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014, 48 (14): 1079-1087. 10.1136/bjsports-2013-092872.
6. Kaar, MD S. Sports Hernia. Sports MD. http://www.sportsmd.com/hip-thigh-injuries/sports-hernia-athletic-pubalgia/. Accessed March 3, 2017.