Sports Hernia: Nomenclature, Examination and Rehabilitation

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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)table

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.

Treatment
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.

img_7501Blog 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.

References

1.Ellsworth AA, Zoland MP, Tyler TF. Athletic pulbalgia and associated rehabilitation. Int J Sports Phys Ther. 2014;9(6):774–784. Accessed March 3, 2017.

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.

 

Movement of the Week: Tri-Planar Overhead Carry

This is an excerpt from a blog post I did for Daily Gaines:

The Overhead Carry is a well-known movement that can train overhead strength as well as shoulder and core stability. It can also be used as an assessment tool to help guide therapeutic and corrective interventions so that your athlete can continue to progress their overhead lifting safely. daily-gaines

Life and sport take place in 3 planes of motion, therefore training & mobility work should reflect that. Depending on the type of weighted modality, this movement can be biased for strength, stabilization or assessment. In the video below we use a med ball atop a flat hand and extended wrist to take a look at the athlete’s stability and mobility through all 3 planes. The ball is resting on the hand, so as form breaks down it will roll out of place or compensatory patterns will present themselves.

For the full blog post and more great sports performance content, check out DailyGaines.com

Visual Training: A Possible way to Enhance Baseball Performance

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By Tom Sutton, DPT Student

One important aspect of baseball, let alone sports is undoubtedly vision.  The input an athlete takes in while competing in a game or practice environment is paramount for peak performance. Having good hand-eye coordination and tracking skills to locate the ball as a batter or to accurately place the ball across the plate as a pitcher are just a few reasons why a baseball player needs good vision.

A recent study by Dimitrios Palidis and colleagues was conducted to evaluate the dynamic visual acuity (DVA) of 23 males on a high school baseball team in Vancouver, Canada. DVA is evaluated by two tests which are static-object (head rotation, with vision locked on a still object) and dynamic-object (head still with vision locked on moving target) fixation. This study was published in the Public Library of Science (PLOS) in February 2017.

Distinct Eye Movement Patterns Enhance Dynamic Visual Acuity
Dimitrios J. Palidis1, Pearson A. Wyder-Hodge1, Jolande Fooken1,2, Miriam Spering

Background
In a study by Palidis et al, the investigators tested whether or not there is a relationship between a high school baseball player’s eye movement kinematics and DVA performance. With both static and dynamic methods of testing DVA, static-object is used in a variety of practice settings and requires the athlete to utilize the vestibulo-ocular reflex (VOR) to maintain fixation on the object.(2)eye-study

Methods
The study consisted of 23 males on the same high school baseball team with an average of 19.5 years. The study was performed at the University of British Columbia (UBC) in Vancouver, Canada. The researchers reported that the baseball players had either normal or corrected-to-normal visual acuity and those who did not have normal acuity wore contact lenses or glasses during the study. The study tested dynamic visual acuity by using black Landolt-C rings (see figure 1) and had the athletes track the “gap” in the letter “C” as it was spinning and moving horizontally on the screen from left to right. The athlete then had to decide with 4 arrow keys whether the “gap” in the letter “C” was located in the top right, top left, bottom right or bottom left corner. The “C” on the screen moved at a constant speed of either 50 or 70 degrees per second with random speeds and movements every trial.(1) Every time the athlete was correct in guessing which the corner the “gap” of the “C” was located, the width of the gap would decrease. The static acuity test (see figure 2) was performed with a visual acuity chart with numbers that the athletes were instructed to read from top to bottom while rotating their head.
Figure 1: The Landolt-C Ring test evaluating dynamic object acuity.(1)
Figure 2: The static acuity test,(1) utilizing VOR.(2) The top numbers signified a visual acuity of 20/800 vision and the bottom numbers were indicative of 20/20 vision. (1)

Results
The study showed that when athletes used smooth pursuit to track the object during the test as opposed to using anticipatory saccadic movements, their perceptual performance improved and translated to better DVA. As reported by Paladis et al, players who utilized anticipatory saccadic movements showed less accuracy and acuity during the dynamic object test.

Applicability and Conclusion
Have you ever noticed when watching a baseball game, the pitcher may squint as he is trying to see the signals given by the catcher? Sunlight is one thing, but when this happens during a night game, this may cause some viewers to wonder. In this case, the catcher may have highlighted marks on their hands and fingers to make it easier for the pitcher to see the calls made before he makes his pitch. If the pitcher is having trouble seeing the signs by the catcher, this may warrant a visit to the optometrist.

There are a few different ways to apply visual evaluation and training to a clinical setting before seeing an optometrist. A clinician or trainer can test an athlete’s vision with the static-object test using an acuity chart. Additionally, to further evaluate or enhance an athlete’s ability on the field, it may be prudent to find out what their dominant eye is. Although it is an older study from 2006, Shneor et al found that the dominant eye of given individual processes visual information better and faster and additionally takes over primary visual processing as seen in tests such as bionocular rivalry and hole-in-the-card.(3) Additional ways to test to see what the athlete’s dominant eye is, more can been seen here.

Utilizing computer-based tests to help facilitate better tracking skills and VOR training can be useful ways to assess an athlete’s visual ability and acuity to enhance their skill set and take their game to the next level. As suggested by Deveau et al, eye movement exercises can be a great intervention in an athlete’s training program. (4)

img_7501Blog 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.

References

Dimitrios J. Palidis DJ, Wyder-Hodge PA, Fooken J, Spering M. Distinct eye movement patterns enhance dynamic visual acuity. PLOS ONE. 2017;12(2):e0172061. doi:10.1371/journal.pone.0172061.
Demer JL, Crane BT, Tian JR, Wiest G. New tests of vestibular function. Ann N Y Acad Sci. 2001; 942: 428–445. PMID: 11710482
Shneor E, Hochstein S. Eye dominance effects in feature search. Vision Research. 2017;46(25):4258–4269. doi:10.1016/j.visres.2006.08.006
Deveau J, Ozer DJ, Seitz AR. Improved vision and on-field performance in baseball through perceptual learning. Curr Biol 2014; 24:R146–R147. doi: 10.1016/j.cub.2014.01.004

Femoral Acetabular Impingement: Kira

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Early in the year I had a hip injury and I couldn’t dance for a few months. Thanks to Chris and Catz I am back dancing with my team and am headed with them to compete at USA Nationals in a few weeks.

-Kira

Movement of the Week: Med Ball Pitching Step Up

Building strength in the stride leg of a pitcher is essential for developing a stable balanced support as the arm and body aggressively enter the acceleration and deceleration phases of throwing.  The arm reaches its highest velocity and greatest range of motion during these two phases, so it’s critical for the pitcher to land on a solid, stable base.  This is a task specific a drill that can be added to a traditional strength training routine for building stride leg strength while rotating and weight shifting  from back to front and right to left.

The Relationship Between Rotator Cuff Weakness & UCL Tears

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By Tom Sutton, DPT Student

The following is a study that was published in International Journal of Sports Medicine that researched the relationship between the strength of the rotator cuff and ulnar collateral ligament (UCL) tears. There are a variety of reasons why baseball players of all ages, from youth to the majors, injure their arms. The results of this study found that baseball players who had a torn UCL had deficits in strength of the rotator cuff vs. players with a healthy UCL.

This study shows that it is very important to make sure the baseball player, whether a position player or pitcher, has adequate strength of the rotator cuff musculature. Muscles can act as dynamic stabilizers and ligaments only prevent unwanted movement. With that, a strengthening program for the rotator cuff may play a role in preventing UCL tears in baseball players.

BASEBALL PLAYERS WITH ULNAR COLLATERAL LIGAMENT TEARS DEMONSTRATE DECREASED ROTATOR CUFF STRENGTH COMPARED TO HEALTHY CONTROLS   Garrison JC, Johnston C, Conway JEGarrison JC, Johnston C, Conway JE

In a study performed by Garrison et al, the investigators researched the possible relationship of ulnar collateral ligament (UCL) tears in baseball players with deficits in rotator cuff muscular strength. The study consisted of 33 players who had been diagnosed with a UCL tear and 33 players that were healthy and without UCL tears. All participants were not exclusively pitchers, as both groups were matched by position. All participants had baseball experience at the high school and/or collegiate level and volunteered for the study.ijspt

The hypothesis of the study stated that baseball players with a torn UCL would have decreased isometric strength in external rotation (ER) and internal rotation (IR) at 0 degrees glenohumeral (GH) abduction. All participants’ strength was evaluated on both throwing and non-throwing arms.

In closing, the study demonstrated that the group of players with a torn UCL showed a great decrease in strength on the throwing and non-throwing arm in both ER and IR when compared to the healthy control group.

img_7501  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.

Movement of the Week: Pitching Lateral Speed Lunge

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This movement is part of a pitching deceleration series. Pitchers need to be able to decelerate not only their arm but their entire body. I like to use this not only for deceleration but also for training: foot placement, coordination, hip/shoulder disassociation and agility.

How it’s done:

Hold a pair of lighter dumbbells at shoulder height in 90 degrees of external rotation.  Shuffle once to the side and open up towards the shuffle direction leading with the foot followed by the hip, trunk and finally allow the opposite arm to fall across the body in a pitching motion. The key is allowing the arm to fall, this should not be an active throw, it should be a faster but controlled fall. The trunk should hinge forward at the hip over a flexed knee and ankle. Keep the opposite arm up in an externally rotated position, reverse the motion and repeat in the opposite direction.

Standing Multi-Plane Core Stability

Dead Bugs, Bird Dogs, Bridges & Plank variations are a great place to start a core stability routine.  The problem is that we don’t live our lives on a table.  Once the core musculature is activated and we can move our limbs while stabilizing our spine in a safe gravity reduced position its time to get off the table and introduce gravity and resistance.  This routine is a nice place to start because the majority of these movements are isometric at the spine yet they are able to introduce stability in 3 stances and 3 planes.  This is the environment that most of us live and play in.  The upper extremities do the majority of the movement while the spine and core musculature need to respond the increasing demands created by the changing lever arms of the band resistance.  This routine works well as a second step to traditional core stability movements because it complies with post-op restrictions and provides a more challenging environment where safety is still a priority.

Movement of the Week: Band Resisted Lunge + Reach

This is a more advanced version of a standing core stability series I take many of my lumbar patients through. I like this for clients with hip & pelvic stability issues as well as for athletes having difficulty controlling frontal plane knee forces during lunge tasks. The purpose of these movements is to maintain posture through the ankles, knees, hips, trunk and shoulders while performing a single plane movement and resisting isometric multi-plane forces applied by the horizontal pull of the band as the lever arm.

How it’s done:

Start with the hands against the body and take a fencing lunge forward, once the lunge posture is stable reach the hands forward or overhead. Make sure the hands go straight forward or straight upwards and there is no deviation towards or away from the pull of the band, then reverse the sequence back to the starting position. After the desired number of reps turn and face the opposite direction and repeat.

Movement flaws can easily be observed from side and front views, look for over compensation strategies as well. Modifications can be made by changing the band resistance or shortening the lever arm by remaining in the starting position with the hands close to the body during the entire task.

Below are a few additional variations:

1. Overhead Stick Reach: This makes it easier to get overhead, sometimes clients have difficulty getting overhead witch the narrow grip.

2. Long Arm Rotational Lunge +  Reach:  This is a more advanced version of the rotational lunge + reach movement. The longer lever arm intensifies the rotational core demand.

There are many other variations, feel free to share some of yours with me in the comments.

ACL Reconstruction: Kyle

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Thank you so much for helping me through my recovery. Lacrosse tryouts went well and I made the varsity team again, and I have been back to playing lacrosse cobrassince just before the new year. My knee feels excellent, and if not back to full health it is at least 99%.  It is crazy to me to think that about 8 months ago I was barely able to crutch around and couldn’t do a leg lift, and I can’t believe how far I’ve come. In addition to making varsity, I have been coaching and attended a tournament, and I really cannot stress enough how good it feels after so long away from the sport. I have loyolaattached pictures of me in a tournament last weekend, and I hope they show how helpful you were in my recovery. Thank you so much, I could not have done it without you and hopefully I can find a time to swing by CATZ soon to say thanks in person.

Sincerely,
Kyle