Sports hernia and athletic pubalgia: do's and don'ts for 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. We're covering sports hernias or athletic pubalgia today, which is basically pubic pain with athletes.

There's a lot of people who have come to our office for this condition, and they're very frustrated about, they say, the lack of information available to them publicly on the internet, at the doctor's office, whatever have you. I think I've heard that comment, I don't know how many times, and so just like in one of the other podcasts, I went back to listen, watch, read some of the information that's public and see if I can find anything that's worthwhile. And I've been surprised how many I've found. I wanted to share just a few today. One is a research article called The Epidemiology Analysis of 240 Patients with Athletic Pubalgia.

This one was on PubMed. And there's another one, a podcast, that was by the Sports Medicine Research Rundown, Episode 3. It's called Athletic Pubalgia Sports Hernia with Dr. Mark Zoland. I thought it was fantastic, and it gave me some good insight of what happens in the operating room. They actually go that far. Again, I've met a lot of people who have successfully recovered from an injury without surgery, but there is a time and place. And especially if you think that you're there, I think going to that podcast will give you a little bit more insight about some of the complexities and also the considerations associated to surgery.

And I know probably a lot of people watch the news and look at the accelerated timelines of the return for some of the professional athletes who have had surgical repairs and things like this. And I'll say, at least for recreational public, if you were my brother or my father, I would tell you let's not do that. And mainly because we're not getting paid to pay the recreational sport. There's no need to rush things. There's a tissue healing timeline that does occur, and we just want to make sure that things go extremely well. There's no money on the line. That would be my at least takeaway from the accelerated programs.

But let's get into a few things here on the podcast. We're going to cover some of the things that I thought were great resources in that podcast with Dr. Mark Zoland. I'll also cover the symptoms that I thought were fun with the study that I mentioned earlier. It'll be in the show notes. And also cover a lot of do's and don'ts, at least that I've come across with managing people with sports herniers or athletic pubalgia. So let's first cover some of the information found in the epidemiology study with 250 patients with athletic pubalgia. They ranged between ages of 14 to 75. Most of them were running or soccer as the most prevalent sports.

And the reason I actually think these percentages will be interesting because I know a lot of the clients that we see, they say, well, I'm dealing with problems when I do this. Is that normal? And I kind of stop and say, yeah, it's pretty common. Not normal, but extremely common. Because I don't want them to believe that it's acceptable to be that way. But it's extremely common with people of this condition. So if these resonate with you, I really urge you to just to consider that these, the mechanics associated to your problem are similar to other people with the same problem. So they're going to have similarities to it.

You may have slight variance on what you feel just because they're different. I mean, remember, these are percentages, so not everybody feels them. But I think probably the most common things that I see, which is not in the study, is that they have pain with a resisted adductor test. And that's something you can do on your own where you put your fist between your knees and you squeeze. But also like a sit-up test from like a bed. You just sit up. Sometimes they resist the sit-up. But when they're in the clinic to test it, I'd say well over 75% of people have one or if or maybe both of those two.

So these are the slight variation ones. Sorry, 53% trained or played soccer three or more days a week. That's important to note. There are people who are non-athletic who tend to believe they have this condition as well. But remember, there may be other reasons for your groin or lower abdominal pain too. There's many different reasons or adductor. So 24% of patients had pain when changing directions, such as running one way across the field and then changing it to the other. 23% had pain with kicking, 22% during sprinting and speed training. That's one of the clients that I worked with. That was the last thing to go with him.

He could do everything else. But a dead-out sprint was a little bit challenging to him. But he eventually got that back too. 70% during long runs, 14% during jumping, and 13% with sexual intercourse. Interesting, right? Pretty much everybody, 80% had inguinal region, adductor muscles, and pubic, like the actual pubic bone, like midline, were their main sites of pain. Which basically means that some of you had not those locations too. So everybody's got their own little flair on things. As I mentioned earlier, I said and skimmed down the study. So the test involving adductor contraction against resistance, that was 77.6%.

People were positive, so I was pretty dead on with that. And also simultaneous hip and abdominal flexion against resistance. So basically, like a sit-up test, 76% were positive. So that's pretty, pretty common. You can almost gamble on that thing right there. And it's interesting that confirmation of a clinical diagnosis took more than six months for a lot of these people. I think, personally, I think it's too long. There is, there are simple ways for a practitioner, a skilled examiner to figure out what you have. You don't necessarily need an MRI to figure out exactly what you have either. But they do cover some findings that you may have with your MRI in the other podcast that I mentioned with Dr. Zoland about that bone marrow edema and finds it may indicate that you actually have a larger injury because everybody's a little bit different too.

Now, improvement tends to happen with rest almost with everybody that I've met. And that's probably the reason why it takes six months for people to actually get a diagnosis because they rested, as most people do, which is a good idea. And then they go back to activity and returns. And honestly, a lot of athletes that I've met just ignore it. They, a lot of them get frustrated about not getting a correct diagnosis or not going away with excessive rest and just coming back week after week, month after month. And they get, they, they tend to, some of them get frustrated and they just tend to just keep playing on it.

I spoke with someone before that he said he's been playing on it for two years. He just realized it wasn't going away. So why, why even bother? It turned into a chronic issue. Some people though, I've noticed they actually tend to give up on their activity. This happens pretty frequently in recreational sports. They end up getting the idea that they're just too old for the sport or it's not worth the hassle or some of that nature. I've, I've met a lot of people who can actually fare very well through age with the right amount of repetition and the right amount of physical activity during the week with recreational sports.

So I, I don't want you guys to think that that is, that you're ever going to get too old for your sport. I'm not, I don't know what your sport is, but I venture to say many of the sports that, that I feel like people get too old for. There's, there's a retracted version for it. There is like tennis becomes pickleball. Baseball can become softball. And there's also upper leagues where people can actually play different skill levels or different speeds. So there's many different ways to keep yourself in the sport without just acting like you are too old for that. But I totally get it that people get frustrated that it, that it start keeps coming back and it's not worth it just coming back with a vengeance.

Now, as I understand, many of the professional athletes will have more surgical needs sooner. And this will mainly come down to the urgency they need to get back in. As I've talked about earlier, I really urge you guys to not attempt to rush the process. Think of it in your head that where it's going to take probably six months to really fully get back to full speed. It may be a little bit sooner, especially based upon what type of injury or what type of tissue actually damaged, if damaged at all. If your MRI is negative, it's probably going to be a lot faster than six months. But part of that six month, too, we have to consider the graded exposure or the buildup that you actually have to do to excel in your sport again versus just going all out.

And this takes us into some of our rehabilitation tips that I think I've learned over time to be generally true, but everybody is a little bit different. Do work everything but the adductor. And I guess I should reword that because the do's and don'ts don't always make 100% sense. But when you boil it down, don't isolate the adductor. I can't tell you how many people that I've met where they come in and they're pretty frustrated about how working their adductor is always painful. And they feel like they need to be challenging their adductor because they have to feel that the tissue involved is, quote unquote, working.

This isn't the only injury I've noticed this happen with. It's like the phenomenon of if you don't feel the tissue that's bothersome or the area that is your injury working in the exercise and the exercise isn't working. That's not completely correct. And there's many ways where you can actually get around the injury versus just challenge the tissue, which is irritated. Maybe it's a better idea just to relax that tissue and not necessarily challenge it, especially in the early stages of the rest. And maybe even post-op as well. But there's a lot of things that you can do to work around the tissue, which I'll get into a little bit later as well.

But ideally, don't pick exercises which isolate the adductor. Maybe later, later on it would be a good idea. But typically that's a compensation which you're already good at. So try not to challenge the tissue that is already good at compensating. Hey everyone, it's Sebastian. I'm going to hijack the show just for a second here to tell you about an opportunity that we have called the Discovery Session. A lot of people over the years have reached out to us from our YouTube channel because we have 150,000 YouTube subscribers at this point in time. Probably more by the time you're listening to this.

And we have a lot of people listen to this show and read our articles online. They're frustrated. People are frustrated about not being able to get back to full activity. They're frustrated they can't really trust their body. They're frustrated that they have not found any long-term answers or things to make them happy. And so we're here to help. We may not be the ones to actually help you and we're okay with that. But we're hoping that if you are able to speak with us that we can maybe give you some insight of things that you potentially haven't tried yet. And if we know people, we'll suggest those people too.

So if you want to take advantage of the Discovery Session, all you need to do is go to p2sportscare.com and find the Book Now button. It's all in there. We have virtual or in-person options. You can go to the show notes for this show and find a link that will directly connect you to us. Or you can call us, 714-502-4243. We'd love to help you the best that we can and we're always here to serve. Now back to the show. Next is don't try to isolate the abdominal wall either. And I mainly mean this by not trying to challenge an isolated section of the abdominal wall. Like trying to challenge the lower abs or the rectus or the oblique.

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. In my experience, there are other things that help out with anti-extension. And anti-extension or anterior chain, part of the anterior chain's job, like if you're diving or if you're kicking a ball. And by the way, the mechanics associated to a sports hernia or athletic pubialgia is trunk hyperextension as well as some leg movement. So the trunk hyperextension is in there. And ideally, you can try to challenge that by not trying to isolate those tissues. Let me rephrase that. You're always going to have activity of some of the tissues which may have some irritation to them.

And again, if you had torn the tissue off the bone, if you're post-surgical, like this is all maybe a different conversation. But you can work something like intra-abdominal pressure, which I've covered in my other podcast. There are therapists or trainers who know how to do this with you, and it's a coaching style. The exercise itself kind of doesn't really matter, but there's exercises that can help out to bias intra-abdominal pressure. And so if I was diving on my belly to a base, part of the things that slow me down from lumbar hyperextension is going to be part of my pecs, my anterior wall, which is going to be my rectus abdominis, my oblique, my transverse abdominis, even like my hip flexors will.

Even my rectus femoris will. There's a lot of things that do, but the internal pressure inside your abdominal wall is a big player in that, and it's overlooked all the time. So the exercises are not as important as in how you get coached through them, which will make the experience of the exercise painful, and that's not really the point. The next thing that you can do is challenge the posterior chain of the body. So the area that got irritated in the first place is part of the anterior chain, so sometimes things like planks or anything in the plank family may be a little bit too painful to do.

And so you can isolate the other things, like the posterior chain and even the lateral chain, which comes into frontal plane movement, which I can cover a little bit later. But the posterior chain, there are maybe regressed exercises first you can start with, with like bridges or banded bridges. Maybe even simple ones like clamshells can be helpful. It doesn't mean you can't work the low back musculature as well. It doesn't mean you can't work the hamstrings and the calves and so on. There's endless muscles that you can probably work, but if you focus on posterior chain exercises, ideally compound ones, then you'll actually be ahead of the curve without letting your body decondition as you're waiting for the sensitivity or the damage to the tissue to heal itself.

Next is don't feed the compensation. Feeding the compensation can look like, it can happen in more than just adductor and ab exercises, which I put, why I put this in a whole, its own category. I remember having a kid where he had, he had lower abdominal pain and he felt it when he did pull-ups. And so he's like, can I do pull-ups? And yeah, you could do pull-ups, but maybe we do it in a way that's not really painful. Moving his feet into a different position, tucking his knees to his chest, building more internal pressure at before he did it, not going so fast, not kipping, not doing butterfly ones.

There's endless ways where we can modify this, or do we even have to use the pull-up at all? We can use something like some other type of overhead pull-down, like a single-arm one, which requires a little bit more stability requirements since you have to stabilize or else the band will pull you over. But there's other things that you can do. So don't feed the compensation and the exercise that bothers it, even if it's not just an abdominal or adductor exercise. If it hurts you or it feels like it's isolating the area that already works a lot, then don't feed the compensation. Try a different version of the exercise.

Change the implement or the item that you're working out with, or get coached. That's a pretty simple solution as well. Next is you can challenge the frontal plane. This is something that I have been doing more recently with people. There's exercises, which most weight training exercises are going to be sagittal forward backward plane movement with stability requirements in the frontal and transverse plane. Something like a split squat or a lunge is an example of this. You're still in a sagittal plane force-producing movement, but the other ones are stabilizers. So you can change that a little bit into something like a lateral squat, not a caustic squat, but a lateral squat can do that, or even a rotational squat can do it as well.

There's regress versions like wall wedges and cross-over wedges that you can probably do too. There is adductor activity in there as well, but you're producing force in the frontal plane. I think I've realized over the years that treatment for conditions can be sometimes really simple if you do what feels good a little bit more, like increase the dosage. Like it seems really simple to say, but it's really not wrong, you know. When you get back into activity, make sure you grade the exposure. Don't do things too fast, you know, just too much too soon. Sometimes when it hurts to bend a joint into one position, like low back injuries actually respond really well to McKenzie protocols where it hurts to bend forward, you bend it backwards, they feel better.

You know, very quickly sometimes. And sometimes there's a loading challenge where loading in the sagittal plane, like they bend forward, they feel it. They bend backwards, they feel it. They deadlift, they feel it. They split squat, they feel it. That's all sagittal plane loading. And you can try frontal plane loading, not frontal plane stability. Frontal plane loading, and it feels better. I had a person just recently that had some adductor pain, and we did frontal plane loading. We did some heavier versions because he's had it for a little bit of time, and he felt fantastic the next day. You know, not perfect, but he's going to build this into his program.

It's something that he needs to expose his body to over time. Next thing to not do is return too fast, too soon. I did just talk about this. I guess I rushed to it. But when people feel good, or when they rest excessively, and then they return to activity, the problem is sometimes that they went back too soon. I know that this happens with games. Games are a finite time. There's X amount of play or reps associated to it. I know that I don't play soccer. I don't play hockey, so I play baseball. And that's what I can really, like, might come from is that when you show up to the game as a recreational athlete and you don't have any more pitchers, you get thrown in there and you end up pitching too much.

So it's hard to manage your return activity or your workload in that fashion because other people are dependent upon you. Another way to scale this is perhaps do more practicing during the week for the activity that you're going to do anyways on Sunday or Saturday or so on. If you have multiple games a week, maybe just require your coach to know that you're only going to play 15 minutes of the game versus an hour. And this is actually better than taking the whole time off, in my opinion, because you still have the skill acquisition or the dribbling skills if you're playing soccer. You still expose your body to some of the loads and reps associated with the sport so you won't get frustrated when you come back and you're not hitting baseballs.

So there's a lot of benefits to it. And I think adding a little bit over time is the real deal. I know that people that I've worked with with various different types of conditions that are workout people, not sport people, workout people, they go to a class and they stay an hour and they say, well, hurt during the hour. I say, you could have just stayed 30 minutes. You don't need to stay the whole hour. So you can always scale that back a little bit and you think about like, how many reps did I do this week? How many reps did I do last week? Is there a big jump or not? Same thing month to month.

Next is you want to restore, do restore movement and strengthen areas around the injury. There's been endless suggestions in research with people with sports hernias, athletic pubial, chronic groin pain, low back pain, knee stuff, that the hip tends to be limited in range of motion or strength in all of those conditions. In my opinion, all these conditions are similar in probably the mechanics originally if you looked early enough. All of these essentially are power leaks. They're areas that are required to work too much, if not related to trauma, due to a lack of activity or strength or capacity of another area.

The hip is so powerful. The hip has so much movement. And it's limited in a lot of people, probably not because they sit all day, but because they've had an old injury. If you compare side to side, you'll see that one side is severely limited versus another, but it doesn't hurt. And you'll even notice that when they don't have symptoms of a sports hernia or low back or knee, you'll just notice it's not painful, but it's limited. Or if you test it on a dynamometer, it's weak. Like, there's things that you can improve here to improve your ability to get back into your sport and actually excel without having this reoccurring flare-up.

Like, that's the madness with this, is that, like, a lot of our attention as a healthcare industry, we're focused on what is generating the symptom. And that is important. You know, you have to know what generates a symptom, especially if there's something like bone marrow edema or there's actually been a significant injury to the pubic bone or other things attaching to it. But if it's not, like, if there's nothing really big there, you kind of just make sure that it's not a surgical case and you need to manage the workload. You have to make sure the workload to the area is less because you've improved function of the area that's deficient.

If you only take care of the symptom, the symptom generator, and not the area that is limited, creating the compensation, it's going to come back sooner than you think. And it may not always come back as a sports hernia. It may come back as a back injury or a knee one or a hamstring strain. Essentially, it goes to the area of least resistance or where the dam is the weakest. So it's the work going through your body when you're playing the sport or even lifting a weight. So it finds the area of the weakest link, and that becomes the diagnosis. So in this example, so say I had limitations of hip range of motion, which is very common with a lot of people.

One side, let's just say, old injury there. It doesn't hurt anymore. I'm not addressing it. Now I have a sports hernia. Well, in this case, there was too much load at the pubic bone, right? And so it could have easily gone to the low back, creating a disc injury, or it could have gone to the knee. Why did it go to one versus another? I don't really have that answer. I'm sure there's someone else who can speak to that nature. But I think chasing around the power leaks is so frustrating. I would rather you just address the thing that's not doing the work sooner than later, because it's harder to recover the strength.

If you have limitations in range and you let it go too long, at some point, adaptation occurs. I was talking to a trainer today, actually, and I think this would be a good thing to eventually end on. As I was talking to the trainer, and we were discussing adaptation, essentially. And how there should be certain things taught in high school, you know, like how to eat better, you know, like eat well and you'll live well. Learning how to manage your finances. And then, as an overall theme, adaptation. What does adaptation mean? Well, like you didn't wake up overweight. Like that was an adaptation because of habits, all right?

If you don't use your legs because you are, like, say you're not able to because you're on crutches, the bones will weaken. The muscles will weaken. This is adaptation in either direction. If you're in the sun and you get tanner, that is an adaptation. These are all adaptations. And so, essentially, if we think about what we want for ourselves and our lives and our athletic endeavors, and just for your sanity, like, why is your condition right now this adaptation? Why did this happen? It's an adaptation from something. So, think back of what your habits, your old injuries, and it'll be, other than trauma, I think for a lot of people, you dig down deep enough.

It's no surprise how we got here. All we can do now is figure out how to get out of it and be responsible with finding out what or why it happened in the first place. And I would almost guarantee that it's something that happened a long time ago that is now exposing itself as a power leak in the area where you have the symptom. 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 U.S. at this point.

In fact, we cover almost half of the population in the U.S., and we add more states every year. Thanks for listening. Subscribe to the show, and we'll see you in the next one.