Sports hernia: symptoms, diagnosis, treatment and recovery

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. A sports hernia, we've covered this at length in many different podcasts.

I still get a bunch of questions about it from clients that we see, especially a lot of the telehealth ones. But I get them a lot from the people we see in person too. And unfortunately, they haven't read the book that I put together. And so I will put that in the description for the podcast. It's a 50-page book, includes videos, et cetera, to help you guys understand better about what's going on. But I will cover a lot of these topics today. And then there's going to be things that you're not going to find in the book just because I never really wrote them. So the first thing, the questions that are popping up in the forums all over the place are what are the symptoms of a sports hernia?

Now, I would say that it is so hard to narrow this down for a lot of people because there is number one, number one, there is a very, I apologize, I'm still getting over a cough here. So my voice may cut out a few times. People keep thinking this is a hernia. We have endless YouTube videos on the topic about how they're different. Most of the time we do start our podcasts and YouTubes with, it is not a abdominal hernia. It has nothing to do with abdominal contents. If you can see a big bulge coming out, it is not a sports hernia. And unfortunately, what happened when someone made up the term sports hernia years and years ago is that they didn't know what it was and they just called it a sports hernia, which leads everyone to believe, rightfully so, that it's the same thing as a hernia.

It's like calling a part, like there's a fruit in a cactus called a prickly pear. It's not a pear, it's a fruit of a cactus. So it is very misleading, but if you are dealing with a hernia, which inguinal hernia, abdominal hernia, umbilical hernia, hiatal hernia, all these things are managed differently. So this podcast is not the correct fit for you. A sports hernia is an anterior chain injury, what we call an abdominal or core muscle injury. It does have a component of a adductor. And a lot of times there's a really big hip component too, which I'll discuss a little bit more today as well. But remember that you can have an injury all along this chain where the abdominal muscles go down and attach to the pubic bone and then go down into the adductor kind of within like a few inches from that attachment at the adductor.

And it's still classified as a support hernia. Now, is it abdominal injury? Is it an adductor tendinopathy? Is it an adductor tear? Like this is all like, this is where it all gets very confusing because if you do an image and the image shows nothing, how do we rightfully call it anything? If it's not a tendonitis, how do you call it a tendonitis? If there's no tear of the transverse cells fascia, which is stereotypically what we say the sports hernia is, and you don't see it, how can you call it that? But people are still getting that diagnosis. And I would call this like a low-level abdominal injury.

Also, it's called athletic pubalgia, sportsman hernia, Gilmore's groin, etc. And so probably the best way I can sum this up to you guys, at least for symptoms, is it's going to be in the groin. Many of you, not all of you, will have it at the pubic bone, the bone right above your private parts. Some of you will have an adductor component, which goes down into the inner part of the thigh and into, not way down the thigh, but it'll kind of go into the crease of the thigh, but kind of more in the leg. Some of you will have a lower abdominal component. It'll feel like it's kind of the lower part of the belly.

Some of you will have, actually, this is a genital component. And let's say about 25% of people will have, not necessarily pain, we're not calling it pain into the genital regions, but it's a tightness or an abnormality of feeling. Remember, there's many different reasons why you can't have any of these symptoms, especially some of the groin ones. Males out there, they may need to be checked by urologists and have an ultrasound performed to confirm there's nothing else big, bad, and scary happening. So it's up to you guys to, number one, understand here's the overall symptom collection that it could be.

I'll tell you, those are the locations, and I'll tell you the things that tend to bother here in a moment. But also, it's up to your responsibility to rule out other things that are not managed with rehab, exercise, and types of surgeries. I mean, there's endless things that it could be. So what it normally feels like in regards to provoking factors is usually running, sprinting tend to bother it. I've noticed people that are doing lunges, the back leg is usually the symptomatic one that starts to speak up to them. It can feel stiffness or tight or painful. It can oftentimes, there's a guy that I, a few people I met that they said, it feels like a storm that's brewing.

It's not really painful. It's like a storm. There's usually not any tingliness or numbness. It just kind of hurts in those areas. Worse with twisting. Worse with kicking. First step out of the car, especially if it is your left leg and you're in America, that's the leg that leads out of the car, but it could be either hip. Putting on shoes, if you do it, standing. Putting on pants, if you do it, standing. Crossing your legs. Sitting crisscross applesauce. Sit-ups, crunches. And adductor work. Adductor work at the gym. Or leg lift, flutter kicks, things like that. It tends to bother people. And surprisingly, it does feel better at rest.

And then when you wait it out long enough, it seems like it goes away. And then a lot of times it comes back after it's been dormant for a month or two. And so that is a very common presentation with it. Again, it's up to you to make sure that you actually see a trained professional to rule some of these things out. Which brings us to the second question is, how is the support trine diagnosed? I always tell people to start with a good physical examination with an experienced healthcare provider with this condition. Now, I can tell you, I really don't deal with a ton of people with shoulder replacements.

I'm not an expert at post-operative shoulder replacements. So don't come to me for an exam for that. Don't come to any of us at a performance place. But there's a lot of providers out there who have never heard nor seen a sporternia or an abdominal injury or an adductor tendinopathy. And so ideally go to someone who can perform a good physical exam to rule in and out different diagnoses of that area. Some of you may be candidates for an MRI or an ultrasound to figure out if there's any actual tearing in ultrasound. Yes, there's a treatment type of ultrasound. There's a diagnostic musculoskeletal ultrasound, which can be used to figure out if there's tears in the area with some of the tissues.

As I mentioned, some people are going to have tears, some don't. You can also use an ultrasound to rule out the different types of actual hernias by bearing down. And an experienced sonographer can do this for you. So there's a great value in an ultrasound. My understanding is they're cheaper than MRIs. MRIs are actually not super expensive either, especially if you pay cash for them. And they, what we'd be looking for on that is mainly the bone marrow edema or the injury at the pubic bone. And so I've met tons of people over the years. We literally had thousands of people with diagnosed sporternias come into our facility and we see them telehealth.

And only a small fraction ever have positive MRI findings of bone marrow edema. And what we noticed is that a lot of these people actually have had an image early on within a month. Not everybody does. Usually people wait and see. And I do the same thing. I have an injury. I kind of wait and see. I turn my hamstring. It bruised a few months back. I didn't get an MRI for it. I knew what it was. I didn't detach it from the bone. It wasn't an abulsion. So it's like, why would I, unless I'm really worried about it, I think it's something super severe. Why would I do it? And so it's up to your healthcare provider to decide whether that's needed or not.

But you should be seeing them early on in your problem anyways. So the problem with like doing an image later on is the bone marrow edema is kind of like a fluid within the bone. Imagine like a soupy inside of the bone or like a bruise to the bone. Like eventually it heals itself. And then there's not really a lot of evidence to show that that was an injury. And to my understanding, and this is going to get a little bit more out of my room because remember I do the rehab part. I do the diagnostic part, but I don't do the surgical part. And so there's a cartilaginous plate on the front of the pubic bone that attaches.

So where the abdominal muscles attach, some of them, where the, some of the, the adductors attach to the area too. And then it can pull enough to where it kind of pulls it loose from the underlying bony attachment. And to my understanding, that's what leaves the remnant of the injury at the actual bone. And so that was those heart, those cases are a little bit harder. I still think they're, they're, we're able to manage them and it usually they go really well still, but it does provide a different flare on it because it's different. There's actually tissue deformity. There's, I don't want to call it damage, but it's like, there's a hamstring strain and there's a hamstring tear.

They're, they're very different. Timelines are different. Considerations of what we would give the person in the beginning for rehab and exercise and clearance to move are very different too. So people who have the cartilaginous injury or the bony injury, that's, it's just a different bucket we put them in for rehab. But again, you wouldn't really find that unless you did the image pretty early on the process. But I would start with a physical exam. I, I would say at least see your healthcare provided within like a week or so. And, and if you don't know who to go to, just ask if they've ever dealt with an injury like that.

I, I do it all the time. If I have work done on my house, I say, I have termites. Have you dealt with that before? You know, and just see what they say. And if they seem wishy-washy about it, say, do you know anyone who does? By the way, if you guys don't already know, we do have telehealth as well. So if you guys want to talk to us, me, Dawne Costantino or Mandy, you can, and just go to the description or our contact below in the, in the podcast player. 714-502-4243 or to p2sportcare.com. We got a bunch of references there for you. So I think doing an examination is first and foremost important. Now for a quick pause before we keep going.

Hey everybody, it's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working, and we also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity. The link's in the description. It only takes a few minutes to fill out the form.

Okay, back to the show. Question number three, treatment options available for a sports hernia. Well, I think rehabilitation and modification of activity or lifestyle is a big part. Yeah, there's people who need surgery, but if you listen to some of the references of the surgeons out there, they'll say that, you know, most people aren't surgical candidates, so it's a wait-and-see rehab type of scenario first, surgery's last resort as we always say, but in our heads sometimes we think it's first. And the people who have done surgeries really early out there, usually they're professional athletes because they can't really wait and see if they're going to get better because they're an asset, they're a commodity.

And so there's a timeline that has to make sure that you buy by a different timeline. But most people, I like to see how they fare with about a month of rehabilitation. Six weeks is pretty fair. Not to say that they'll always be 100% at that point, but they should be reasonably getting better. I did a bunch of podcasts recently about my hamstring tear. Timelines are super important. I know it's a tear because it actually bruised. That's a distinguishing factor. If it was a strain, it would not bruise. And so I know at that point I probably got about four to six weeks of some recovery. I can do rehabilitation at that time.

I can work around the tissue. I wouldn't challenge the tissue more than maybe isometrics for a little bit of time. So something like an adductor one. I probably wouldn't do a bunch of Copenhagens on day one. I probably wouldn't do a bunch of sit-ups on day one. But I'd probably do side planks and I'd probably do glute bridges and I would probably do some deadlifting. I may not do the lunge because that bothers me, right? And I may end up doing some other version of like a modified squat. There's tons of things that people can do. I was actually jogging within one week from the hamstring injury but not sprinting.

So you need to make sure that you're paying attention to things that bother you. So treatment options is rehabilitation, yeah, it's really important. Rest or strategic rest, not provoking the issue knowingly is really important. But also lifestyle factors. Like you have to understand that like most people don't get this way in an accident. say it's just an incident that happens but it's accumulation of what they've been subjecting their body to. Some of you may notice that like this happens after doing a long spurt of soccer when you haven't played soccer in a while or you played weekly soccer or two times a week soccer and all of a sudden you did a couple tournaments.

So there's a big burst of work oftentimes that leads into this type of thing. Or there's an older injury such as hip impingement or some type of old hip condition that this laying there dormant which is putting a necessary workload in the area. I've discussed this in my other podcast about talking about grading muscle injuries. If it doesn't bruise it's a strain. If it's a strain if it's mainly in the two categories it's actually four but two are the only ones that people ever show up for in people's clinics. Number one is what we call a referred strain. Referred strain is where the muscle feels strained but there's no tissue damage because remember it's a strain.

It's under the level of actually having an imaging finding. And so a good example of this that most people are familiar with is it feels like my hamstring's tight but my back hurts and I have rip and leg pain which is sciatica. Another example of referred pain is hey my arm hurts left arm but my chest hurts too. It's a heart attack. So referred pain happens with organs as well as spinal conditions. And so the groin issues or lower abdominal issues actually can be referred from parts of the spine or some of the cutaneous nerves of the that go around the abdominal region. The second category which most people come in with is called underutilization or overuse type of scenario.

I really hate the term overuse because it insinuates that you just did too much but really why did the other side not react that same way? So you did the same amount of running and sprinting maybe you did kicking more on this leg but for a lot of scenarios we find out actually the person feels that they feel on the leg that's not the kicking leg. So I hate to call it an overuse injury but it's more underutilization because this tissue is working harder and becomes strained and starts to speak up when it's compensating for other ones the glute max is really an important one poor core support especially if you don't have the ability to generate good intra-abdominal pressure is another good one to look at and this is what your rehab specialist's job is is to figure out where the deficiencies are where the range of motion deficiencies may be if they are at all and give you strategic suggestions about what to do about it.

Doing a hip stretch for a hip that's completely fine with range of motion is kind of a waste of time. Doing core exercises when you actually have strong core kind of a waste of time but if you are not deadlifting how can you reasonably have hip strength? Hip strength helps out with this condition and it's a good preventative measure so that's something I may start with with that person but for other people who are deadlifting fine and feel no problems with it I may not even tackle that but I think so there's many different ways to rehab it surgery yeah you could do it if you really were trying to jump the gun I don't think it's a good idea for most people there's injectables that are done or we call like regenerative therapies like your PRPs and prolotherapies and so on I'm not sure if these really have a lot of evidence to suggest that they work don't quote me on that one but I haven't seen anything super compelling but if I was in the right scenario I would probably do it too but I would not discount the value of having soft tissue mobilization a structured rehabilitation program and actually doing the hard work you didn't get this way in accident like there's a deficiency elsewhere most of the time question number four is how long does it take their sports hernias to typically recover well usually people are jogging within like a couple weeks sprinting I would give them a good like six weeks to eight weeks to get fully back into what they want to do it may take a little bit longer but most of the time we encourage people to get back on the field and be active as soon as possible which brings us to the last question which is is there any complication to have it not treated yeah depression is probably the biggest one and lifestyle change like different trajectory of life there I've met so many people over the years that I wish they would just let me help them a little longer and show them that their body is actually capable there's people in their 30s and 40s and often times will get this they do the yes I'm just too old for that type of scenario you know what's the die hard type of type of situation and but I've met tons of people who they actually do the right rehabilitation and then re-engaging in activity and they're like I feel better than I have in years even though I had that problem yeah I was sucked when I had it I was kind of out for like a couple months but overall in the grand scheme of things their life is so much better because now they're going to have an extra 10 to 20 years of physical activity and sport that they like when the other person said ah I'm just too old for that and then all of a sudden they start having bad habits their social circle changes they don't see their sport or teammates anymore and it's just a different scenario and so I can totally see how this happens I'm not I'm not trying to say that like it wouldn't happen to me I had a hamstring injury like I had mentioned before and I still attend the games because I can feel that actually my my Fridays and Sundays which I that's where I usually play baseball I didn't feel satisfied I was actually running less I more willing to go get a drink with friends so more drinking involved and so there's there social circles change habits change and then if you push that out 10 years what version of you are you looking at I personally think it's better to be at least a little limited in your sport and be more physically active so your overall healthy body you have better lifestyle you have better social circles than somebody who's just giving up and not even being like a 75% version of their past athletic self if it does come to that I'm not saying that most people can't get back to full recovery they can but even if you didn't would you rather be 75% in a little limited but also being a better version of you or would you rather be the other version so I think depression lifestyle change is the biggest danger with things like the tissue always heals whether it be at your timeline or not I have known people have had it for years and years and I think it's probably because they're unknowingly provoking it but overall like people do get better if anything in today's episode resonated with you visit the link in your podcast player there you'll find any free resource that we mentioned in the show any guest links and a link for a free discovery call with us we're licensed to work with our outdoor active people via telehealth across many states in the US at this point in fact we cover almost half of the population in the US and we add more states every year thanks for listening subscribe to the show and we'll see you in the next one