Sports hernia rehab in a high school track athlete

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it's Sebastian, your co-host with the Restoring Human Movement podcast. Thanks for joining me in the Movement Movement. If it's your first time on the show, welcome. We have lots of other podcasts on various different topics, such as hips and groins and low backs and sciaticas and even upper body conditions. Today, we're going to do a case presentation about a young female athlete, a high school track athlete who suffered with what they were diagnosed as a sports hernia.

A sports hernia, for those of you who are not aware of what it is, it is a really bad name for an abdominal or anterior chain injury. Now we're trying to get them to be called more of athletic pubalgia, which is groin pain or lower abdominal pain with an athlete, or it's going to be more called a core injury. The trouble is that the sports hernia by name was named a long time ago when there was a doctor. I don't know the name of the doctor, but they basically thought these people had hernias, but there was no evidence of a hernia. A hernia is when the abdominal contents comes out of the abdominal cavity or through the muscular layer, and they actually can be seen on images or felt by a medical practitioner.

So these people had groin pain, but they didn't really have any evidence of a hernia. But he thought it was a hernia, so he called it a sports hernia, which leads to the huge misunderstanding of the public of thinking that hernias and sports hernias are the same thing and they're completely different. So we see tons of people with it. This young female athlete came in with groin pain and a little bit of lower abdominal pain, more so associated with sprinting. She can run slow. She can walk. She could squat down. There was a little bit of pain at the bottom of the squat and also things in the gym tend to bother her, such as she was back squatting with her strength coach, rear foot elevated split squats also bothered her, which is also called Bulgarian split squats, but deadlifting was fine.

She had a little bit of back pain with deadlifting in the past, but overall it was nothing that she was really concerned about. I tested her on day one. She actually had an old knee injury, actually. I think it was actually a part of what's going on now, and I'll talk about that a little bit further as we go forward because the old injuries actually do tend to matter about how the load or the workload goes up the chain. Now, she had two positive tests or orthopedic tests for the sports hernia. The ones that are most commonly used is a resisted sit-up and a resisted hip flexion test on the side of involvement.

So what that looks like is do a partial sit-up for me, bring your knee towards your chest, resist me. So it was positive on that, reduplicated her groin or lower abdominal pain. I say lower groin, lower abdominal because she had a little bit of both. She had pain into like the area where the adductor muscle is attached into the pubic bone, and she also had a little bit into her lower abdominal area, which was baffling to, some of the other healthcare providers she's seen. She'd seen her PCP doctor. She'd also seen a local physical therapist who wasn't quite sure what it was and admittedly said that they weren't really sure what to do with it anymore.

I think she had gone through about like, it was about like a month and a half worth of care. Nothing has really changed. So the other test that was positive was a, imagine laying on your back, your feet are fully extended, your knees are extended, and you put a ball between your feet and then push against the ball. That reduplicated her groin pain as well. And those two tests are positive on about 77% of the people they say with sports hernias, but I've also seen them with people with what we call pseudo sports hernias, which is lower abdominal pain or groin pain that was referred from the lower back too, which is actually more common than you think.

So now we can get into a little bit of what the rehab looked like on her, the things that she could or couldn't do and the things that we actually took away. But before we do, just to let you guys know, we do offer consultations that are very affordable. You can call us at 714-502-4243 or email us info at p2sportscare.com. If you don't choose to work with us via our telehealth or in person, that's okay. Just know that we do have templated programs that I've put together on sports hernias and it's going to be in the link description. Take a look at that. It includes about eight times two. So 16, I think it's 16 or 12 weeks that I actually put on there and made it a little bit ago.

But it's all the exercises and stretches that we tend to use with people with this type of condition. So normally the first thing that I have people do with a sports hernia is I inform them of the things they shouldn't be doing. Because without fail, most people who have a sports hernia tend to be doing ab and adductor exercises too soon in their recovery. And it just feels, feels bad. And so the problem when they do this is they oftentimes think, well, I'm working the muscle or the tissue that's aggravated. So it must be a good thing. But the problem is they always feel worse afterwards. And sometimes during it, they feel terrible as well.

So I always tell them, let's not do that for now. The keyword is for now, because later we can, we need and will be putting those back in at a more opportunistic time when the tissue has healed itself. Now, the second thing is I let them know if they are possibly a surgical case or not. For people who don't have any images, I try to rehab them first. And also the ones that don't have any urgency involved or financial urgency involved, such as they're not a professional athlete. I won't push them towards sports hernia surgery so soon. There's endless references that say that rehabilitation is the best bet for a lot of people.

And if they don't get better with rehabilitation, structured rehabilitation, they may be more of a candidate for surgery or things like PR, PR injections into the pubic symphysis region. But to go that way, that way and lean that way in the beginning is, I think, a huge problem. So I informed them what their options are. So I chose to rehab this person. I told them the things they shouldn't be doing for a little bit, but also told them the things they should be doing. I think the easiest route to take with people is to establish what we call intra-abdominal pressure or better, better diaphragmatic breathing is step one, better intra-abdominal pressure, which is step two, which can all be done on the same day.

And I sent them home with those exercises to develop those skill sets. The problem is that a lot of these people get into this situation because either, number one, they have an old injury, which I'll talk about the knee in a moment, or they have poor internal pressure, which is basically poor core support. So their abdominal tissues and their adductor are basically part of the same sling. It's called the anterior chain. And they work extra to compensate for poor internal core pressure or poor core support. And because it's working so hard, it can develop an injury, which can also lead into some type of tear or fray or something like that as well.

So most of the time, the issue is that those tissues aren't weak, which is why we remove some of the exercises early on in the program. You'll see that in some of the free content that we have on YouTube, which is linked into the description as well. And you'll see it within our online programs too. Now, what I like to do first is to try to get the hip range of motion normal. If it is abnormal, we do something called a diagonal sit, which is a great glute facilitation exercise. And usually within the second week, we try to do ab wall priming, as long as it doesn't duplicate the person's symptoms.

A good choice that we tend to go with first is something called a three-month prone. This is from a dynamic neuromuscular stabilization discipline. It's a type of rehabilitation, or we use something like a hard style plank, but it's an isometric non-moving core exercise that usually is okay for a lot of people after week two or after at least not after the first week of having the onset of injury or having like a flare-up with it. And then we can move into more advanced core exercises later. Also doing a deep squat isometric is usually okay for them. Some people with hip impingement complications don't tolerate the deep squat.

Some do. So what I have them do usually is I have them unweighted, isometric. I put them in a doorway. So we call this a door jam. Squat, hold. And we do it to mainly increase the activity of the quads. So we've already done one exercise to increase the activity of the glutes, glute max specifically. We've done one to increase activity of the abdominal wall, which is going to be a three-month prone or hard style plank. And then we also do one to do increase the activity or prime the quad muscles, which is going to mean isometric hold. All these things are usually about 30 seconds or so. Sometimes they're 10 based upon the person's ability to hold it or levels of pain.

But some people can hold it for quite a bit of time. And we absolutely tank them. We absolutely tank them. Probably the second mistake that most people make when they're trying to recover from something like this is they don't actually go to full maximum contraction of the tissue that's not injured. If the quad is okay, we need to crush that thing. And it's easier to do it with an isometric and it's safer to do it. And we can do that as early as day one a lot of times. So I did these three exercises with this girl and she actually had a normalization of those two positive tests of the resisted sit-up test and the squeeze in the ball test in that same day.

I worked with her for about three weeks. It was not perfect every single time I saw her. She had a little bit of flare-ups here and there because she tried to sprint. I told her she shouldn't. She did try to sprint, but it's probably too soon. But we should add it back in around the three to four week mark. But she can certainly do other things. She can weight train. We're going to remove rear-foot elevated split squats or Bulgarian split squats. We're also going to remove the back squats and replace them with goblet squats because those are more tolerable for her type of condition. And if deadlifting didn't bother her, so I kept her deadlifting.

I actually elevated the, I had her do it on a safety bar, sorry, a squat safety bars on the sides so that she didn't have to go quite as deep because it hurt her back originally. So we don't really necessarily need that. So what my plan is, is to continue to manage her as it's, we're in track season. So I can't fully put her out, but I do anticipate some flare-ups. It's completely normal to have it. It doesn't mean she went back to square one, but I want to continually manage her on a weekly basis and make sure that she's doing the right things and that she's not being scared out of doing the correct things as well.

I see a ton of times where people actually start to add in the wrong things at the wrong times or adding things too soon. And they have a flare-up just from adding the wrong things in. So part of management, other than just treatment of doing things and giving, showing her things to do is one thing. Management is making sure that the person actually does the things that are appropriate at the timetable that it seemed to be done. And that's what I'm planning on doing with her for about six to eight weeks or so, at least getting her through the season. And then we have a little bit more time in the summertime to take some extra gambles.

Now, this is a methodology that I use with a lot of people with this type of condition. I'd love to say everybody's exactly the same. They're not. But I think it's very sad that people will suffer through this condition for months or years. I've met people who have had this for literally two or three years, and they keep searching for things on YouTube. They keep searching for self-help things, or they have not found a healthcare provider who's experiencing working with something like this to actually get good advice. I've heard many references on this over the years is that people will oftentimes, with various different trades, stock trading, with woodworking, with rehabilitation, they will almost always meet their goals.

You will take this pain away. But the problem is, is they fail to realize that the taking the guidance of somebody who's already done it many times before, it puts them back. And so the term that I've heard used many times, I really like it, is using a skilled person or a skilled template or a template created by someone who with education about what's going on is a cheat code. If you want to do things faster, use a cheat code. So if you want to do it and you're okay with it being slow, do it on your own. That's okay. I've done my own woodworking. I've done my own countertops. I'm okay with the results, but I was also very slow at doing it.

So if you're looking for help with this and you want to make sure that you're accelerating your process to get back into your game faster, just reach out to us or at the very least, take advantage of our structured online programs that we have. We do have a lot of free information on YouTube. You guys have probably found it by now. It's okay to have that. I do like that. Those are all good things. But I think is probably what you're finding even with sometimes with podcasts and all the other social media things out there is that there's no structure. The problem is that YouTube does not provide structure and context to the problem.

We make endless videos on sports hernias that are completely free, but even the virtual sports hernia one that we have on there, which is, I think it's an excellent program for people who are looking at doing a surgery for it and, or, or it's actually a very fresh brand new injury. That's a perfect thing to start out with. Like it just happened yesterday. Yeah, go ahead and do it. But if you've been dealing with this for like three months or so, or like three years, why would you start on a virtual surgery program? It's, it's, it would be a complete waste of time. And I've had plenty of people who have reached out and saying, look, I've done, I see this virtual surgery.

I've had it for like five years. Do you think I can, do you think I should do that? You can, but I'd be lying if I said there wasn't a more structured approach and something's going to get you there faster, which is literally just doing it with someone who can curate a program, which is going to be one-on-one attention. And that's just the way it is. So I don't want to badger you guys with like the details of that, but I think everybody does know if you want, if you want help, that's going to be the fastest way to get to your goals. And we're always here for you. 714-502-4243 or email us info at p2sportscare.com.

But we will have other tons of free information going forward about sports hernias. And we actually have a great PDF on our channel as well. I will put links to everything, including the free PDF in the description for this podcast. And I hope to see you guys next time.