Sports Hernia Success Therapy And Treatment Suggestion62 Minutes - Apr 17, 2019
I've done some podcasting and writing on the topic of sports hernias in the past but I feel the need to update the information I've released.
Over the past few years I've learned more about sports hernias and my success rate for groin pain has really skyrocketed. Allow me to share what I thought to be true about sports hernia (and other types of groin pain) via podcast today.
“I said okay, does it hurt doing any gym work? He was like, yeah during pull-ups. I was like your groin hurts when doing pull-ups? Huh, that’s interesting. At that point, I wanted to see him do a pull-up. He dramatically extended and showed his ribs and it was a mid lumbar extension that occurred. I know you know what people I’m talking about and they\'re typically people who are not strong enough to do a darn pull-up.”
If you\'re a patient, this is laid out a little bit more for the lay public for your consumption. For practitioners, this is intended to give to your patients as a teaching tool to help them understand what’s going on in their body and to really help them understand what’s going to happen with them because I don\'t know if you guys’ experience is the same as mine, but I think when people feel like they don\'t know what’s going on or not in control or feel like they\'re not being taken care of appropriately, they tend to drop from care. It’s partly with communication on our part of what we are trying to relay of what we are going to do with them to help them to feel better and return to their sport ... this is the main intention of this one.
Sports hernias are classified as a type of groin pain, but it’s a mysterious one. I am going to break down this in a simple way because I have had great experiences with sports hernia or what is classified as a “sports hernia” and I wrote a massive article on it back in the day, so I do get a lot of questions about sports hernias as well because that one ranks pretty well.
Personal Story: One thing I have really wanted to do over the last couple of years which I don\'t know if I’m ever going to be able to is the thing you typically see the spies do where people go over into a different country and they\'re like, “I’m gonna make sure I’m out here and no one knows I was here and just burn this passport.” So everyone knows their passport is like gold, but I want to be in another country sometime and just go put my passport in a trashcan and light it on fire, and just know that I’m going to be able to get back, but I want to know that I could do it. I want to know I’ve done it. I want to tell people, “Hey man ... you ever burned your passport?” They’d be like, “No, you can\'t burn your passport.” I’d say, “I burned my passport. I literally burned it. Just no regard ... just reckless. Mo-fu ... So if you have burned your passport before, tell me, you know me ...
When I say sports hernia, I want you to think groin pain or some stubborn high adductor strain. People tend to classify this all kind of the same, but I think if we separated this, I think we would find we are looking at the phenomenon of IT band syndrome, which is WAY overly diagnosed. People tend to think they have it very quickly and oftentimes it could be a lot of other things, which actually if you treat it with the right intention of the thing it actually is, it resolves very quickly, but when you go through and read about all the frustrated cases people have through forums or specifically if you look up IT band injuries, in those parts of the forum, you\'re going to see IT band all over the place. People comment upon comment about what has NOT worked for them. I would venture to say they\'re probably doing the wrong thing.
It’s interesting, when I wrote that massive article about 4 years ago now I think, the research and data is going to be a little bit old since I didn\'t update this one yet, but I will plan on that soon probably ... So I found that one of the major classifications of sports hernia is the best definition was “the phenomena of chronic activity-related groin pain that is unresponsive to conservative therapy and significantly improves with surgical repair.”
Think about that--that’s an interesting statement because it is chronic activity-related groin pain meaning the person does not really have problems with day-to-day activity typically like walking down stairs or walking in particular is fine, but as soon as they start thinking about going back to the sport again such as pivoting, cutting, sharp turns, and increase in speeds and so on, suddenly they have these problems, so activity related ... I will break these down into parts as I think about them.
When I think back and was recovering from a back injury when I was in high school and was 15 at the time, the first bout of rehab I went through was a very passive care approach; a lot of adjusting, lot of tissue work, foam-rolling, lot of rest honestly, and not to say I did not feel better because I did feel better and I could do day-to-day activity without a problem very quickly and they did a good job with that BUT I never really developed the tools I needed within my body to integrate back into sports. I’m not even joking ... the literal first pitch of the first game back at bat at my very first swing, I missed the ball and hurt my back and had to come out of the game ...
So that’s pretty indicative that I was not set up for success for this thing because I had at least 2 months of no symptoms. When you think about this phenomenon of activity-related groin pain, what if I had kept going back over and over again just to try to see if I could swing and every time I triggered it? It between times, there was a lot of deconditioning and rest period.
So this chronically activity-related groin pain to me is a little bit skewed because how do we know these people have had actual conservative therapy? What is conservative therapy? So there’s a big, broad category that I when I went through my back issue the first time; the first bout could have been considered conservative therapy and I could have gone back to them again, then I could have swang again, and it could have hurt again, and again a failed conservative therapy.
I eventually went to someone who done a more well-rounded job, a more complete approach, where we did a lot of strength conditioning, lot of anti-rotational work, lot of building of the hips, and making the body overall resilient. We did passive therapies too or things that modify pain and I think I was playing again 2 weeks again after that, at least swinging a bat.
So I think building things up to challenge them within the sport is the thing we might be missing in here, so it’s interesting to see if it responds well to conservative therapy or that sports hernias do not typically respond well to conservative therapy.
The last part of that is significant improvement happens after surgical repair.
Now back when I did this article, I did more detailed research on what the actual interventions (surgical) were and I don\'t typically talk to people about surgical interventions, because most of the time under my care, they usually get better. I’m not trying to be cocky, but they typically get better, so I don\'t have to have this conversation really often, so it does not happen very often. It’s interesting that there have been a couple of cases and this is kind of taken out of a McGill book, is where you have the virtual surgery. I have mentioned this to a couple of people and they were kind of ... I don\'t want to say reluctant on doing things, but they were not serious about doing things in regards to what was asked of them.
The virtual approach is acting like you have had a surgery and just doing what is asked of you after the surgery because all of a sudden after you have yourself cut into and something kind of placed in there like a mesh or whatever is going on, all of a sudden people tend to listen a little bit more; it makes it real. They might have to take time off work, right? They might have to take time off the activity that they kept going back to challenge their body in and could not keep it together, so I think the surgery part is a little bit skewed too because how we do know that they did not actually improve based on their overall ability to comply to what is asked of them or at least really good.
Let’s separate conservative care with amazing or top-notch care because remember back in the day when Adrian Peterson had that accelerated return to play after his ACL injury? Everyone was like, “How did he do that!” Then all of a sudden they went into a “conservative” therapy and they don\'t have the same result and I think because there’s a lot of other things going on there--there’s a lot more than just the deconditioning-type approach and pain modulation approach (kind of what they did with me the first time). I think there is a big category in there in regards to conservative care and I think a little bit of skewness with the surgical repair, but for the most part, I tend to think these people with sports hernia ... if you think you have a sports hernia, I think you\'re body is more resilient than you think. I think if you\'re not responding, you\'re probably not doing the right thing yet.
In my experience, the people we tend to find the right thing on, which it might take one time, maybe a handful of times to really figure out what’s going on with you because you\'re unique, a unique individual and person, and you have unique tendencies and everything else, so not everyone is exactly standard, but there’s good starting points to most people, so once we find that out, you should feel much better within a couple of weeks or at least in my experience. I’m not saying a hundred percent better ... I’m talking about being able to tell there is an improvement, a significant change. I think there’s a difference of seeing significant change with keeping some activity in play versus seeing significant change with going ahead and watching Netflix and being chill, so there’s different things in my opinion.
First off, I read an article called The 12 Truths About Sports Hernias which I thought I could clean up a little bit here, so I have not read it years, so if I run into something I clean up then I will. As we go over this, I thought I would run over some cases I have done with people and how they fared, how they have improved, and just some things that make you think. I will also go through the things I used, theory and some application of how I scale things in the office for people based upon the things I find.
So the first truth here is “sports hernia often happen with cutting, pivoting, kicking, sharp turns.” These are things you usually see in soccer, football, tennis, and rugby. I tend to think the change of direction thing we can kind of blend with non-traumatic ACL injuries, so I would guess in theory is that the people who have non-traumatic ACL injuries such as basketball, soccer, things of that nature and they are usually in the overload theory, because if it’s trauma, it makes sense they have been hit and they have the “unhappy triad” they call it where they just had a poor stroke of luck, but with the landing of the ACL and changing of direction, I think we have to consider there is a possibility of co-mingling of what’s going on here just to break down a different area. I’ve seen this in runners as well. I didn\'t put hockey players, but I have seen it in hockey players as well. Just to open up the category ... I’ve seen a lot of groin pain on a lot of people. I’ve seen it on dancers, tight adductors or issues of a chronic nature on dancers, so I’ve seen a lot of these issues on a lot of different people, so let’s not classify this only as these 4 sports.
Next, sports hernias truth #2 is “no one really has to hit you, you don\'t have to fall, you don\'t have to hear a pop,” and what this typically means is there is a slow biomechanical progression occurring that in my theory makes it preventable.
Truth #3 “symptoms can often radiate into the upper thigh” or as some of you guys might say “in the upper groin area” or radiate down a little bit to the inner part of the knee. Again this is in my experience, and a lot of times it’s a radiation of symptom. I will get into a case later of a guy who came in and he had adductor issues or “chronic adductor strain” negative imaging ... no one could find a thing ... and so I would venture to say it was not really an adductor issue in regards to structure of the muscle, more of a radiation or referred pain or response in the muscle based on what else has happened a little bit higher. If that’s tough to understand for you, it’s typically that people tend to get the idea of a heart attack ... it’s like everyone knows you “have an elephant sitting on your chest, starting to sweat, radiating arm pain, and you\'re wondering what’s going on ... I think I might be having a heart attack,” and then you tell someone and then you have a heart attack, but no one tends to talk about the arm symptom and it can even go into the face sometimes and no one tends to treat the arm symptom. When you treat the arm symptom, guess what happens? Not good things, right? So if you tend to treat an adductor issue and you keep chasing the symptom of tight muscle or scar tissue or adhesions, and that’s the only thing you\'re addressing, there’s a possibility you\'re missing the boat.
Just to make sure I’m retracting on this a little bit ... if you have had work on these areas and it improved the groin pain, you might be in the grouping that actually needs it. I’m not saying this theory I’m using today is used for everybody ... it’s for people who are the non-responders to the typical things.
Just like I’ve said in the past, if you have an IT band issue and that foam-rolling might not be the thing for you, and you\'re like, “Hey man, foam-rolling is my bro. It works for me.” Cool, it works for you ... great ... I’m not talking to you. I’m talking to the other 50% of the people or more that it did NOT work for.
So if it was going to respond to a foam roller or some other type of technique you\'re using that is addressing that one part of the symptom, then it probably would work in everything else that I’m talking about today. It would probably work in a couple of weeks or at least significantly, so if that’s working for you great, amazing. If not, think about jumping ship on that and trying something different.
The fifth truth about sports hernias is “it’s really hard for patients to pinpoint.” I’ve had this quite a few times on people and been like, “can you put one finger on the area of the symptom?” They can\'t do it. They chase it around and a lot of times, they will refer up into the pubic bone and say, “It’s tender up in here,” and they can usually find the spot in or around there, but it’s hard to find within the adductor area, hard to find within the belly area, so they have trouble describing it. Some people even say there’s a tightness in the testicular area, so it’s interesting there’s a diffuse type of symptom pattern there. It’s going to be hard to pinpoint down, but don\'t worry if that’s you, you\'re not alone. You still fall into the category of things we’re going to be talking about.
Truth #6 and I jumped the gun on this one ... sometimes people “feel a tight or numbness into the testicular area or scrotum.” This is a pretty classic one. I think though if there is a numbness, this could be a neurologically based aspect too. I had a case recently that he had this symptom and it was freakin’ him out. There was a groin symptom as well and he thought he had a sports hernia and so we were able to reduce this in about one session, but it took about the course of 4 or 5 days after for him to be able to work on stuff on his own to where he could say it was safely gone. So just consider if there’s a numbness and feeling of tightness, not necessarily tightness, but the feeling of tightness, we might be looking at a neurologically based thing and I think this is one of the areas where we are missing the boat on sports hernias honestly.
Truth #7 is we have some “AKAs” so if you have been reading and you\'re not sure which one you have, then well this is probably all of them ... you have Gilmore’s groin, athletic pubalgia, and sportsman hernia.
Truth #8 ... the top four diagnoses that it can be confused with are: a real hernia (direct/indirect), a hip joint pathology, osteitis pubis, and adductor longus dysfunction. I think I would probably throw in there a couple more things is that although hip joint pathology is very broad, I would say you really commonly find femoral acetabular impingement on there within the area of the actual side of the symptom or on the side if it’s a unilateral one, but also too, it’s nice to see just from an observational standpoint of when you watch patients (and if you\'re a patient, your doc should be watching you move) and when you sit and squat and move and it becomes very apparent that you\'re loading that side of the body of the symptom, then there’s a possibility that we have something else which created it longer term, maybe you had a past ACL injury on the right side, maybe chronic plantar fasciitis on the right side, maybe a past sciatica on the other side, so those are things to be considerate of, but as you go through imagingo and these things, a lot of people do get imaging on these because they\'re very frustrated about not being able to solve their condition or someone can\'t identify what’s going on with them. The adductors are normal, the pubic bone is normal, the hip joint is normal and there’s no actual hernia. Well, maybe it’s a sports hernia, maybe I should get a musculoskeletal ultrasound thing. So when you start to investigate things, the funny thing is you\'re going to find a lot of these are negative. You will find some positive actual issues when you get to the musculoskeletal ultrasound, but a lot of your classic imaging like x-rays and MRIs are going to miss these things because they\'re not dynamic in nature; they don\'t move.
With Truth #9 we get into musculoskeletal ultrasound which is a type of imaging, not a treatment. So ultrasound, yes there is a treatment, but there’s an image. Just think about looking at babies in the womb. This is probably one of the better ones to confirm if you\'re actually dealing with an aponeurosis or the issue within the classification of a sports hernia or you\'re dealing with something else or maybe you\'re looking at there is no structural damage at all and then you\'re wondering what the hell is it at all, right?
So an ultrasound is a really nice way to non-invasively, no radiation going there and just checking it out. I used to do these a little bit more in my office personally but there’s a couple of people around who are really good. If you are in the southern California area, Mike Jabalon, currently I think he’s at Santa Ana area but also up in the Valley towards LA. Also Michael Mangus is really good in San Diego. So if you\'re looking for them; I’ve had Mike Jabalon on a couple of times and Michael is also amazing and both really good. If you\'re looking to confirm it, I suggest you go to the local area because they\'re honest and legit, and if you\'re under my care at least they can relay information back to me and we have a rapport already so ... we know what we’re looking for and I can ask him beyond reasonable doubt and say “Look, do you think it’s really that?” They\'re like, “Ah, there’s something there, but I don\'t really think it’s a sport hernia, so ... “ Because they have had more reps in it than I am, so I typically refer it out to them.
Truth #10: With this section I wrote about 6 months ago and made it real simple, but I could rewrite this whole section even more, but in this one, I want to say rehab can be really slow, frustrating, and super uneventful if you actually have a sports hernia. I know it’s a bummer, but it’s kind of the progression of the thing and that’s where you see that classification at the top I talked about. The great thing is that if you have a skilled diagnostician, someone who can really dig into all of the aspects of your injury, what triggers it, and seeing what can improve right then and there, trial and error. What if you\'re in there and all of a sudden the groin symptom just went away? You’re going to think it hurts when I cut and turn. Well, then cut and turn and let’s see what can reduce it right then and there. Because it can happen.
In those classifications if you have really found someone to dig into your case, there is a strong possibility that you have been working with a pseudo sports hernia or a false one. Although, you may have read a lot of things on the internet or someone else told you had a sports hernia, you might not.
Earlier I mentioned hip impingement, hip flexor tendonitis, nerve impingement, disc injuries; there’s a lot of other things that can create this pseudo sports hernia which is really frustrating to people because again you have negative imaging. Insurance companies “word of mouth” will not tend to pay for the procedure and you\'re kind of at a loss of what you can do.
I remember I had a teacher call one time and typically teachers have good insurance ... I mean better insurance; I’m not going to say any insurance is good right now but they are better than most. They\'re like, “I don\'t know what to do. I’m a teacher. I make like 40 or 50 grand a year. I can\'t pay for the procedure and my insurance won\'t cover it. I cannot get through this what do I do?” I know it’s frustrating with people but if you spend time with someone who really knows what they\'re doing and take the time with you and digs into what you have, I think you will be pleasantly surprised that your options are not just surgical anyway, so all you need is a little TLC and some direction.
I tell my patients (the new people) the ones that are like “What’s the first exam include?” I’m like, “Well, it’s how like your internet does not work and you call up the place and they say let’s troubleshoot it. Is it plugged in? Yes. Good. Is the green light on? Yes. Is the yellow plug in there? No. Okay, let’s do that. They plug it in and you figure out low and behold this thing works.”
It does not have to be extremely technical in regards to testing because we rule in and out a bunch of things, but for the most part, we’re figuring out what works for your body and hopefully, I have only had a few cases over the course of the last couple of years where I could not figure out what turned them on and off regarding their symptoms. It’s scary when you can\'t. Because if we’re musculoskeletal people and doctors helping out people with musculoskeletal problems and you\'re looking at someone who does not have a musculoskeletal problem, then what are you looking at? How are you going to apply a musculoskeletal biomechanical correction if there’s not a direction to it, so we’re troubleshooters just like everybody else.
So patients, when you\'re listening to this, doctors should probably spend more than a half hour with you honestly if they\'re going to figure out what’s going on with you. Because a lot of times, what you tell them, history, as well as the activities and specific movements, postures, loads, and so on that actually trigger or cause symptoms or make them better then they\'re not taking enough time to really troubleshoot your condition or if they do take that quick of a time, that’s okay, but the next time they should be catching up.
I tend to spend 1-1/2 hours or an hour 15 minutes or at least an hour with all my new people because I want to figure this thing out. Throughout the entire thing we do a trial-and-error process or better, worse, same, and so when they go and show me symptomatic movements, postures or positions, then I make a correction or suggestion and I say better, worse, or same. So I’m looking for a mechanical route that I can help them out with. So just to keep it in the confines of this truth 10 is that if you have a sports hernia, it’s going to be frustrating, but hang in there, the body is really resilient, but don\'t immediately classify yourself as having a sports hernia because most of the time ... you don\'t.
I would say a strong 75% of the time of the people I see, don\'t have that, but they think they do. They\'re following the typical route of a sports hernia, which is very frustrating, so yeah ... go and see someone who knows what they\'re doing and feels confident about guiding you out of the whole situation.
Sports hernia truth #11: Rehab may include (and I will rewrite this one at some point to make it more specific because I was going off what research was found at that time) 6-8 weeks modified play. I think originally I said, “rest” and so I’ve changed that already; pain modifying modalities (ice, heat, stim). I personally in clinic don\'t use any of those. I do have an e-stim machine, but only a couple of people request it and we do it because they ask for it, but I typically don\'t use it and I have good results without.
Sports massage or deep tissue work--I have done these more frequently with people in the past and I do tend to address it usually about 4-5 treatments in, mainly because I want to see if there is a movement-based biomechanical unloading that we can do first.
Core endurance-based exercise is critical and I do use that a lot. Breathing exercises for intraabdominal pressure will help recalibrate your intraabdominal pressure and help solidify the area that is the pain-generating structure.
Progressive hip strengthening exercises, hip mobility exercises, corrective and gradual loading of movement patterns which are squats, deadlift, push-pull and carry, Dan John fundamentals, unilateral training with antirotational considerations ... so as you can see all things (the later ones) I was more specific and I wrote them later.
Graded exposure to sports specific movements ... remember we don\'t want to decondition the person or athlete; we want to keep their head in the game enough to not completely decondition them overall. Like a football QB who can\'t use his shoulder or legs or feet or anything so that does not mean he’s not watching game tapes, so there’s still stuff going on. So gradually return to play with at-home progressive rehab.
So I think there’s a lot of things I can build in on that and I will talk about that as we go through in this podcast.
Truth #12: Surgery is recommended if rehab is unsuccessful and that one, there’s a whole section in the article about that.
Now onto the newer part and these are things I will probably update the article with. The things I commonly see with these people are they tend to have what is called a spinal hinge, around the mid lumbar area, and if you don\'t know what this looks like, they tend to have a little bit of a gully or sag that really does not have the complete ability to resist rotation when challenged and I believe that is what’s happening with this fatigue-based anti-rotational trigger that they\'re having or this change of direction trigger. So I tend to say that the solution is we are building up endurance within the area and then we’re trying to improve the ability of the hips to do the hinging movements.
I’ve mentioned that in a couple of podcasts that I have been interviewed in recently with and I think the idea of the push-pull squat carry hinge has been ... not a lot of patients know it and they need to. I try to position that as an exit plan to my care for people, but I think they forget actually what I’m asking. Because I probably don\'t say “hip” that often but I mention the hip a lot, so I literally do the mean the hip hinge, not a spinal hinge.
When we’re looking at deadlifting, it’s an opportunity to really ingrain the movement of the hip hinge, so when we have people with these symptoms of the sports hernia, really looking at what I tend to find are the areas that are triggered in their symptoms such as the groin area. Let’s say iliohypogastric, we are looking at the genitofemoral nerve, or lateral femoral cutaneous nerve, we’re looking at the saphenous contribution; we’re looking at all those ones that are a more high-lumbar contribution and so the inability to control rotation at the mid lumbar area is actually interesting. I’ve seen it quite a few times on these cases where I’ve cued them in a unique way to them and it’s immediately taken their symptoms away.
So when we’re building the hip hinge, we need to make sure we’re keeping the cueing of solidifying the torse in play or else the hinge will become ingrained at the spine, not the hips. Now, what I tend to go through on these people just as a rough idea, I tend to improve intraabdominal pressure or abdominal bracing of the DNS in the McGill model. I think those are different skill sets that I think people need to understand. Bracing or the hard brace ... it’s really hard to breathe when you\'re doing a hard brace. I’m okay with teaching a hard brace because people are going to be able to decrease their symptoms with it, but also too, when they get into a game situation, the breathing is happening. Feels like I’m here podcasting with you guys and I’m also bracing and breathing at the same time. As I start to increase my brace, I can\'t really breathe and speak as well. It’s hard to take a breath. So when we use the low-level brace of intraabdominal pressure, then we can have a low-level stabilization with athletic movements.
After that, we’re looking at the ball-socket dissociation as a general principle and this goes for shoulder and hip and that was taken from a study that I think was done in the McGill lab ... but I’m going to butcher this one because I looked at it years ago, but for the most part, they were looking at the ability to extend the hip and being able to keep it over time basically, long-term improvement I believe, and so it was passive stretching. There was active stretching and ball-socket dissociation ... I think.... I know there was passive and ball-socket dissociation or as we say “stiffen the beer keg and move the dollie” the dollie being the hips and the ball-socket just killed it.
I would suggest a ball-socket in this with people. So what does this look like really? I tend to give people the analogy of the beer keg that I just mentioned. The beer keg is the torso area; we have the front of the beer keg with the side, back, top and bottom and also pressure on the inside, and so it’s really resilient and if you don\'t dent the thing, then it’s even more resilient; however, if you go into a bendy sport where you have to bend backwards or even in tennis, you tend to distort the keg or with baseball you tend to distort the keg a little bit, but it’s okay as long as the keg has enough resiliency to not break.
So that beer keg is easy to build on with ground work. So in the past I had people do crawling to kind of start with this where they are using the floor as a feedback in bracing tool and they\'re doing it long enough where you\'re having to have some stabilization in the spine in that mid lumbar area and I will cue them into it. I will say after drawing their attention to that area, I will put something there and say “don’t move this object,” like a yoga block, a cup of water, whatever ... If they can\'t do it crawling, then you have to scale it back maybe into a buttress plank. You just take an arm or leg away and if they can\'t do that, go to the knees. If they can\'t do that, I go down into a DNS crawling (I’ve been to courses and I have no idea of the months and I don\'t have a baby so I don\'t know) but let’s just say we’re army crawling. That’s a little bit more controllable and when I teach people this, I tend to say that “you\'re ground contact matters” and when we’re working on a crawl, I have them crawling backwards because I want them to push with their hands to give the abdominal wall a chance to start working because a lot of these people are a little bit more extended at the area. I just want to make sure that there’s good abdominal co-contraction because if there’s not, we’re not really doing anything productive in the long term for these people. It might be nice and fun to crawl on the ground, but we’re really not working on what I want them to work on.
When they really don\'t succeed I really give them more ground contact points. I also decrease the amount of moving and make it more of a frozen position and now there just holding it for 5 to 10 seconds. I tend to use that with beer keg stuff, but also things like hanging on a bar, moving the legs, and not enough doing pull-ups just stiffening up like you\'re a human punching bag and they\'re moving the legs because that’s still stiffening the torso while you\'re moving the socket.
I tend to like to have people get into anti-rotational work in the long term which is foot-on-ground and it’s more application to the actual sport, but I tend to build the engine first. Typically with engine building or people who like to extend like that, I like to start with #1 Can they turn the floor? #2 I try to incorporate the beer keg in the movement so I give them a go back from the Dan John library to keep their pressure in the abdominal wall or inside the torso area at least at a fundamental level or foundational level as they build the hinge.
If no one has the book Goat Bag you hand a kettlebell into their belly, they pull it to them, and they pull it into their belly and the good thing their belly is not going to lose because if they do, they\'re going to squish their guts out of their mouth, so this intraabdominal pressure is kept constant or at least a low level while their turning the floor, sitting down, standing up, sitting down, standing up, sitting down, or pushing the pocket backwards and standing up and so on.
So I don\'t really care which one they do; I tend to teach the hinge first, but if they want to squat, great, by all means. Typically all of these people who have some type of anterior hip or groin pain they will not always tolerate a squat really well, so I start them in a high hinge. So it’s important to realize that with a hip hinge, if you call it a deadlift and they have experience with deadlifting, they will go into a deadlift depth. I’m not asking for them to go into a deadlift really; I’m getting them to push their hips back into the universal athletic position.
If you have played a sport before, the universal athletic position is the one that you typically waiting for the ball on or it’s when you\'re shuffling to the side ... when you\'re a shortstop waiting for the ball, you\'re in that. At bat, you\'re in that. So the universal athletic position stands so we want to get people to an athletic position where they can still keep intraabdominal pressure as we build the beer keg and start the engine. So you can take them into deadlifting and all that kind of stuff, but again as athletes, we are single-sided people. We are propelling, turning, changing direction, typically we don\'t have a good solid ground contact as we’re doing that and the ground is slipping and so on. So we have to bring the variables into play in a scaled approach.
I typically like, again, to just start giving the idea with the two-legged hinge and we start to scale it to the sport. I like to use the Koichi work; if you haven\'t seen Koichi, he’s really great with rotational and lateral squats was the main thing I got out of his thing or rotational and lateral movements of the hip or being able to press the ground or push the floor away like you\'re changing direction quickly, so it was interesting to see when I went through his workshop when they said you have to the knees over the second toe when you\'re squatting and that’s the way to do it. So when you get into a single-legged squat, that changes a little bit. All of a sudden when you\'re in a single-foot stance and changing direction to the left or to the right, that changes a little bit too. So it’s all about the vector of force and you\'re pushing in the direction of how you\'re going. So if your knee is not in the middle of that night, it’s going to be really hard to do.
So building the ability to do that can present many different forms, so I won\'t go too much into that because obviously when it gets into anti-rotational work or change of direction drills and power and speed, I typically like to refer those out to someone who has better skill set than me. Usually a strength conditioning coach is pretty darn good if you have a good relationship with one and they tend to work with soccer players and usually have a good result (let me disclaimer that) and they would be a good person for this client to work with.
In my experience, I think the problem is when people come to see me for a condition, it is my responsibility to get them out of the symptom and start to build them up into a level where I can reasonably hand them off and get them to do their homework, but if they\'re not doing their homework or doing it well, then a relapse might occur. I don\'t want it to recur, so I might as well hand them off to somebody else. I tend to realize when people come to see me, and maybe I do it to them or they do it to themselves, but they tend to talk about their aches and pains a little bit more than they would if they go to their yoga class or to their trainer.
So the focal point of working with their coach is to get the work done. The focal point of coming to me is to troubleshoot a symptom, so I think in that setting it’s a little bit harder to get away from what is important that day because they might be fixating on a single thing that’s occurring; they\'re searching for it and that’s normal. I tend to think if we can get them to someone who has a better framework for that type of management in that part of their care, then they might fair better because they have to have the venom to create an anti-venom. They have to be exposed to these movements to be able to tolerate the movements they\'re looking to do again in their sport. Because if not, this is a chronic activity-related symptom, so if you want to keep having then completely avoid the things you have been doing or completely avoid the things that trigger it. At some point, you have to expose yourself to it and create an anti-venom and that’s where the strength conditioning coach really comes into play really well here.
Before I dump too far with these things, let me talk about a couple of cases really quickly about how these play together with me ... it’s an interesting one. I think the first one where I really started to realize there was a mid lumbar contribution was and I think I’ve talked about this case in the past and I knew from the get-go on this kid that his symptom was not of the adductor and he had multiple MRIs that showed that it was a negative adductor strain, but people kept calling it a “strain” and just not showing them the MRI but saying it was a “strain” and so I talked to him about his strength conditioning and said “Look, what are you doing?” He’s like, “I like doing pull-ups.” I said, “Okay, does it hurt doing any gym work?” He’s like, “Yeah, it hurts doing pull-ups.” I said, “Your groin hurts doing pull-ups?” He’s like, “Yeah.” I’m like, “Huh, that’s interesting.” At that point I wanted to see him do a pull-up.
So he dramatically extended and showed his ribs and there was a mid lumbar extension that occurred. I know you know what people I’m talking about ... they\'re typically people who are not darn strong enough to do a pull-up or to do a pull-up with good form. So I don\'t have a problem with a couple of crappy pull-ups here and there, but doing repetitive crappy pull-ups when you\'re under a symptom of lumbar extension, then maybe that’s a thing you don\'t want to do.
So after talking to him about what else he did, he didn\'t squat, he didn\'t hinge, but I asked if he pushed and he told me “yes” because every high school boy pushes. I asked if he carried and he said “no” and so there’s three missing parts in there and what we actually found with this case because it was interesting because in the beginning I found that there was a neurological contribution to him as well as a frontal plane deficiency; he was off-loading the side of the symptom, so he loaded the side with the symptoms and the symptoms went away in day one and he could change direction. He still had an issue with decelerating from top speed; he could run to top speed, but decelerating he could not do and we ran in the parking lot. I asked if he could act like someone was punching him in the belly when he was slowing down and make sure there was tension in the belly when he was slowing down and that decreased the symptom.
Over the course of time, I worked with him here and there, so one thing ... when we finally got into hinging and he’s probably the least flexible boy I’ve ever seen in my life in regards to his lower body. Most people think “that’s just the way I am and I’m just not really flexible, my parents are not flexible,” and so on ...
So he kept rounding at the back when he was hinging even like really high, even like pinpoint style and that would be his initial point of movement, so I said, “Let’s just try this other thing,” so we just did some end-ridge loading and extension of the spine and that took his symptoms away completely.
Funny thing is that one of his symptom generators were putting his shoe on in the morning. He would do it standing and he would do it with a low back round and so we could put him in that position on his back without having the symptom as long as the lumbar round was taken out of it. So we treated him as a disk-related protocol for a week. He was to do everything as a flexion intolerant disk was and he came back and said he was 90% better. Amazing, right? Pretty cool.
So over the course of time what we need to do with this kind of case is that we need to improve the ability of the hips to function within deeper ranges because if not, his lumbar hinge is going to come back. So we’re working on the same type of protocol that I mentioned above; we’re building the beer keg and building the engine and we’re going to build the ability to change direction, so that was a really good case and it was interesting to see and actually not until a couple of weeks ago when I saw someone else do a pull-up, I said, “Huh, that lumbar extension really makes sense now with that one case,” so I still learn as I go.
The second one is (and this will be a quick one) I had a runner with inner arch pain, decreased while holding breath while running. It didn\'t hurt to sprint, it hurt to jog. Think about that again ... So typically we have runners extend and fall apart at the end of a run, especially when they\'re exhausted, so we have the tension happening at the mid lumbar area a lot of times, so holding the breath builds the keg pressure with inside (at least momentarily for the test) and it decreased their symptoms. So think about it, what would you do with that person?
Then we had a dancer with groin symptoms into the front, right around the inguinal canal/crease/ligament, as well as adductor pain that went down the inner thigh all the way to the knee. She was a unilateral complaint--everyone else was a unilateral complaint before too and I do have a bilateral one coming up--and dancers, interesting, they tend to be coached into a hide/tuck the butt, floater rib type appearance (if I’m getting this right) and it was interesting to teach hinging to her because this is my rough system ... I look at beer keg stuff and engine work in the hips.
So we started with the engine work; I should have started with the beer keg, but I didn\'t, so just teaching her how to turn the floor, turn her cheeks on, and decrease the amount of valgus collapse and probably anterior tilt, or build a buffer to this, it decreased her symptoms pretty significantly there, but then I’m like, “You don\'t carry, let’s try carry.” I had her carry and it lit her symptoms up and I had her walk kind of like a duck. I said, “Okay, push the hips forward under your body a little bit and then walk like a businessman working through an airport in a tight suit.” She was like, “Oh, that makes it even worse.”
So I had to ask Ally who I have had on the podcast before and I asked her what she would tell a dancer to get rid of that mid lumbar extension thing and she said, “Hide your ribs.” It was a cue. She said she did not like using that but it really resonates well with dancers. So she hid her ribs and she said, “Huh, all of my symptoms went away.”
So we went back into the hinge again, as well as squatting because that was painful at that time. She said, “Huh, it does not hurt anymore.” So then she went into her plie and she said, “Oh! That hurts right here,” so I said, “Hide the ribs.” She said, “Huh, it went away.” So this is an example of someone being cued into the movement that is a triggering one, so I did explain to her that we were building her hinge and taking this duck thing away not because saying you can\'t do this and dance ever again because you guys are contortionists, but we’re doing it because we’re trying to build resiliency for those movements as well as take a little bit of symptom generator away for now. Again, she could have been classified as a sports hernia, but she probably was not.
Next I had a hockey player who had testicular tightness and he was kind of freaking out about it. It was on one side and when they called actually I said “You’ve already been checked for a hernia and you have already had an image and I’m not checking in there.” Because I know how it was when you went in for a physical; it’s like a barrier for entry is someone is going to make me “drop trou” and so I said, “Look, I’m not going to have to do that. If I do have to do that, then I’ll send you to somebody else.”
What we found with him is that we can decrease his symptoms by having him do what we call dynamic [48:53:6] while lying on his back, he put his leg in a figure 4 and he said, “Yeah, that’s my symptom in the groin, in the adductor, I feel a little bit into the testicular area.” So I actually pushed my hand into his belly area and said, “Fight my hand. Push your guts out.” He fought it and said, “Huh, it went away.” So we used that same principal we talked about before. I started him in a low DNS position, like baby crawling but reaching for stuff type thing, and I really cued him to push his pubic bone into the floor and he bent the floor, as well as I took some videos to make him aware of that mid lumbar extension and rotation he was having. We eventually got him up into a buttressing plank. Squatting was painful so we built the hinge. Eventually we came back to the squat a week later, but after about a week, he had 75% improvement in symptoms, but he could play hockey two weeks from the initial date he was able to play hockey. He still had symptoms when reaching for the puck. I would imagine reaching for the puck and increasing the moment on the spine when his hips had to stay behind with his skates, so ... there was still a little bit of work to do in there, but for the most part, he was doing really well.
So again, he would have been the classic population, age grouping in your symptom pattern of a sports hernia, which was a pseudo sports hernia as well--mid lumbar and neurological contribution on that one I believe.
The last one was a runner with bilateral tenderness in the pubic bone. This one was interesting to see but I don\'t know the end result of this case because he lived a long way away, but we talked on occasion about this and he had ran a lot of miles, put it that way. I asked him “Can I see your squatting and so on?” I started with him just tissue work around the area and he said it helped so we continued a couple of times and I said “Let me see your squatting and hinging and he was not really extremely receptive of doing the movements and stuff because he drove a long way to get the tissue work, so I completely understand that.
So I started hinging and squatting and it was not good. So I would venture to say that if we had improved on that and built the hip ability to be the hinge versus the spine, as well as having that abdominal extension, which can equate to say there’s a chronic eccentric tugging on the anterior abdominal wall of the pubic bone that could generate the sports hernia symptom or even the finding, but I think if we would have worked on that, I think we would have been much better.
Those are just examples of some cases, but interesting, I went to a Michael Shacklock course recently for clinical neurodynamics and we did some mid lumbar dynamic neurological testing, as well as some treatments. It was interesting that some of the things he has found neurological based is that some of those mid lumbar contributions he has found some more sinister pathology than he ever thought; spinal tumors, or I think he mentioned some type of female parts issues and so there were things in there that he would not mind imaging these people just to see and make sure there was nothing going on there before we were treating them extensively, so I had never really thought about that, but now I do.
Those mid lumbar contributions I would probably image something a little bit more in the future, especially if they are not responding and actually had someone a couple of years back who had a pathology in the spine that we wanted to know about that was also too, it was an anterior medial thigh type of presentation, so it’s interesting and you have to make sure you rule out all your red flags, but sometimes the red flags won\'t tell you what’s going on because those things are a little more silent.
I know when people come in to see with this pseudo sports hernia and they have had imaging and so on, I know they have had imaging of the hip and so on, but I really like for them to have imaging in the spine. Can you get an image done if your a patient? Yeah, sure. Like more information is good information. Even if those things are negative, it’s still very telling, so I’m okay with you getting it. Like you can get every image you want, I do not care. You might be subjected to some radiation with some of them, but just know if your image is negative, that does not mean like someone like me or someone listening to this podcast can\'t help you. A lot of times, there are loading issues of your body tissues are not necessarily issues with your body structure or something torn, frayed, or so on, there’s other stuff to it.
Can you go see an ortho, neurologist, or family practitioner, or PT, or chiro? Sure, whatever. You can see whoever you want. I tell people the more opinions you have, the better. You might not want to take everybody’s opinion, but it’s nice to see what everyone says. I think it’s important to see the way they say it too. You want to see some confidence in what they say, so I have told people who have been unsure about their progress in the past ... by all means, I would love to have someone else take a look at you, but when you have questions or concerns I want you to talk to me about it and we can figure out what’s the best route for you. Not because I will know better than the other guy, but I tell them in advance that I’m willing to take the time. Like you\'re paying me for guidance and you paid me a lot of money in the front to guide you, so allow me to do that for you whether it be in or out of my care and by the way, if my care does not make a big dent in your symptoms within a couple of weeks, we need to be talking anyway.
I’m a strong believer in if what you\'re doing is not doing anything for you, ditch it. I will tell people straight up, “look if what I’m doing is not working for you too, tell me, and then ditch me.” But jumping from provider to provider without really having any guidance is not a good recipe either because we all start from the beginning on you.
So if you have been told you have a sports hernia, please work with someone who will test and challenge you within the examination. The history is great and hearing your concern is great and spending time with you is great, but they have to be able to turn your symptoms on and off like a switch. If they can\'t, they need to spend a little bit more time with you. Unless we have an actual route to take on you or at least have some feedback from you over the week to see that we are progressing in the right direction, we need that feedback from you and if we don\'t hear that we’re doing right or wrong, it’s hard to make a judgement call. So I’ve told people in the past, “Look, I’m testing a theory on you. You don\'t have a symptom right now and I’m testing a theory on you.” Please test the theory and if you end up getting worse that confirms the theory that I suggested something poorly and that helps me recommend as we go forward because I’m gathering data points.
Expect to work with your doctor for at least a month or so to figure out what’s going on. Again, we might pick the wrong thing sometimes, but does not mean the wrong thing is not still non-productive information. Don\'t jump doc to doc or you\'re going to be very frustrated and I can almost guarantee it, just go with someone who is honest and caring and willing to take time with you, and also, someone who is honest enough to know when they don\'t know what’s going on with you.
Expect a positive result I like to say within one week, but I like to give myself a buffer and let’s just say two weeks. Just make sure what you\'re doing is working for you. Many times, I will anyway ... ask you to test out your abilities and keep certain aspects of your sport within play while the region is recovering. The rest of you has nothing wrong with you and so if we go into that push, pull, carry, squat, hinge thing and if one of them hurts, we do the other four. If you\'re a soccer player and sprinting or changing direction hurts but you can still do little footwork drills, do footwork drills. If you want to watch game tape, do game tape. I’m pretty sure every athlete will say, “Well, if I spent a month in bed and just eating Doritos,” they\'re probably going to say “it’s harmful to me. It won\'t make me more conditioned.” Make yourself conditioned, but with stuff you can do and ask your practitioner to help you out to find what those are.
Most people and just general observation ... most people can walk, swim with a pool buoy, because we have to eliminate that mid lumbar hinge, resistance train, and they can do stuff in their normal life. Typically when I cue people to run again, I ask them to sprint first and like I said with those other people above, sprinting a lot of times, is not symptomatic, decelerating it will and losing tension it will, so I might ask you to do certain things that are going to seem scary, but when you\'re working with me, I tempted to reduce your risk. I’m not going to lie, I’ve missed it sometimes, but also too, I’ve hit it a lot.
So work with someone who is willing to explain the risk-reward with you. If you do not return back to sprinting at some point, you will not return to your sport. If you don\'t want to return to your sport, that’s fine, you don\'t have to sprint ever again, but if you\'re looking to then we need to work on doing that with you and a lot of times, in my opinion, people tend to respond well with high tension work with sprinting first before doing long, slow distance and this goes for distance runners as well.
In closing, I do believe that rising water raises all ships. There’s a lot of people out there doing really terrible care or lacklustre care out there that we just need to help them improve their skill set. I always feel like I sound very cocky when I say that, and I can honestly say that about 5 years ago, I would say my treatment was lacklustre. I was doing okay, but I could have done way better and I could not open Pandora’s box until someone suggested it to me, so please use my podcasts as Pandora’s box for somebody and let’s get some really amazing providers out there to make sure when your mom or dad has a problem living in Kentucky that they have someone to go to, because I guarantee you\'re going to find someone one day who needs help who is not around you and not everyone is able to fly in and you want to be able to trust the person you\'re sending them to is doing the right work, so let’s help build up the professions now, so we can have a lot of people doing really, really good work.
By the way, if you think I’m missing the boat on something, please email me. I would love to keep learning more.
As always, leave people better than how you found them. If you\'re dating, date an Eagle Scout. Exciting stuff coming in the next few podcasts, so tune in. Talk to you guys next time.
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