Sports hernia or pseudo sports hernia? Rehab for stubborn groin pain

I said, okay, so does it hurt you in any gym work? He's like, yeah, it hurts doing pull-ups. I said, your groin hurts when doing pull-ups? He's like, yeah. I'm like, huh, that's interesting. You know, at that point, I want to see him do a pull-up. And he dramatically extended, showed his ribs, and it was a mid-lumbar extension that occurred. And I know you know what people I'm talking about, and they're typically the people who are not strong enough to do a darn pull-up. 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.

And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. If this is your first time, welcome. Thanks for spending the next about 45 minutes to an hour with me in this one. There will not be a guest. It will be me by myself today, and we'll be talking about sports hernias. Sports hernias. So, if you're a patient, this is going to be one to format a little bit more for lay public or 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 think, I don't know if your guys' experience is the same as mine, but I think when people feel like they don't know what's going on or they feel like they're not in control or they feel like that they're not being taken care of appropriately, they tend to drop from care. And that's partly an issue with communication on our part of what we're trying to relay about what we're going to do with them to help them get them to feel better in return to this sport. So, this one is intended mainly for that. And so, this podcast is intended to blend the line between patient and provider. Kind of like we're all having a beer together and then we're, no one's really lacking in the conversation because we all kind of understand what's going on.

We're explaining what's going on. So, yes. So, we're going to go into sports hernias today or specifically groin pain. And with sports hernias, it is classified as a type of groin pain, but it's a mysterious one. Ooh. So, I thought I would try to break that down in a simple way today because I've had some really great experiences with sports hernias or classified as quote-unquote sports hernias. And I also 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. So, also, too, if this is your first time to the podcast, I tend to share a little bit about myself as the host.

So, I try to do that in a little bit of story about things I like, about things I don't like, or just things I observe anyway so you get to know me better. So, we'll get into that story right here and then we'll get right into the content, okay? So, one thing I've really wanted to do over the past couple years, which I don't know if I'm ever going to be able to do is, the thing that you see typically the spies do or people when they go over into a different country and they're like, you know what? I've got to make sure that I'm out of here. I've got to make sure no one knows I was here and I just want to burn this passport.

And so, everyone knows their passport's like gold. But I want to be in another country sometime and just go put my passport in a trash can 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 that I've done it. I want to tell people, hey, man, you ever burned your passport? And they're like, no, I never did it. You can't burn your passport. I'd say, I burned my passport. I literally burned my passport before. Just no regard. Just reckless. Reckless mofo. So, if you burned your passport before, tell me. Email me. Let's get on to the content.

All right. So, as we get into this content about, let's call this sports hernias today. Also, when I say sports hernia, I want you to think groin pain or even some stubborn adductor, high adductor strain. Because people tend to classify this kind of all in the same. But I think if we separated this, we'd kind of find that we're looking at the phenomena of like IT band syndrome, which is way overly diagnosed. People tend to think they have it very quickly. And it's oftentimes a lot of, it could be a lot of other things, which actually when you treat it with the right intention of the thing that it actually is, it resolves very quickly.

But when you go through and read about all the frustrated cases that people have through forums or specifically with IT band, God, you look up injuries in there, the injury part of the forums. So, you're going to see IT band all over the darn place. And it's just people commenting upon comment upon comment about what has not worked for them. And I would venture to say that they're probably doing the wrong thing. And so, sports hernias, it's interesting. When I wrote this massive article back in, it was, this was probably about, probably about four years ago now, I think. So, some of the data and research is going to be a little bit old since I didn't update this one yet.

I will plan on it soon, probably. So, I found that one of the major classifications of sports hernias or the definition, the best one, 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 groin-related activity or activity-related groin pain, meaning the person doesn't really have problems with day-to-day activity, typically, like walking downstairs or walking in particular is fine. But as soon as they start thinking about going back to their sport again, such as cutting, pivoting, sharp turns, and even increasing speed and so on, all of a sudden, they have these problems.

And so, activity-related. And I'll break these down into parts just as I kind of think about them, is that, to me, I think about the, when I recovered from my back injury back when I was in high school, I was 15 at the time, the first bout of rehab I went through was actually, it was very passive care approach. It was a lot of adjusting, it was a lot of tissue work, there was a lot of foam rolling, there was a lot of, a lot of rest, honestly. And not to say I didn't feel better, I felt better and I could do day-to-day stuff without a problem very quickly, they did a good job with that. But I never really developed the tools that I needed within my body to integrate back into sport.

Because, I'm not kidding, I'm not even joking, the literal first pitch of the first game back in my very first at-bat, first swing, I missed the ball. And I hurt my back again, had to come out of the game. I mean, that's pretty, that's pretty, I think, indicative that I was not set up for success on this thing. Because I had already had at least, I think a month, month and a half, two months of no symptoms, you know. And so, when you think about this phenomenon of chronic activity-related groin pain, what if I kept going back over and over and over again, just to try to see if I could swing. And every time I triggered it.

But in between times, there was lots of deconditioning or rest period. So, this chronic activity-related groin pain, to me, is a little bit skewed. Because how do we know that these people have had actual, let's say, and then we have this definition of conservative therapy. What is conservative therapy, you know. And so, there's a big, broad category in there that when I, again, 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. And then I could have swung again. And it could have hurt again. And it could have been, again, a failed conservative therapy.

But I eventually went to someone who did a more well-rounded job, I'd say, a more complete approach, where we did a lot of strength conditioning, a lot of anti-rotational work, a lot of building of the hips, and making the body overall resilient. We did do passive therapies, too, or things to modify pain. And I was, I think I was playing in, like, two weeks again after that, like, at least swinging a bat. And 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 that it responds well to conservative therapy. And, or that sports hernias typically don't respond well to conservative therapy.

And the last part of that is significant improvement usually happens after surgical repair. Now, I haven't done, back when I wrote this article, I did more detailed, I did more detailed research on what the actual surgical interventions were. I don't typically talk to people about surgical interventions because most of the time under my care, they usually get better. Like, I'm not trying to be cocky, but they typically get better. So, I don't really have to have this conversation very often. So, it's not, doesn't happen very often. But it's interesting that there have been a couple cases, and this is kind of taken out of the McGill book, is where you have the virtual surgery.

And I've mentioned this to a couple people. And they were kind of, I don't want to say they weren't reluctant of doing things, but they weren't serious about doing things in regards to what was asked of them. And so, the virtual surgery approach is acting like you've 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's going on, they, all of a sudden, people tend to listen a little bit more. And it makes it real. And they might have to take time off work, right?

They might have to take time away from the activity that they kept going back to challenge their body in and couldn't keep it together. So, I think the surgery part is a little bit skewed in here, too, because how do we know they didn't actually improve based upon their overall ability to comply to what's asked of them, or at least really good, I don't know, we should separate conservative care with amazing care, or like top-notch care. Because I think when, remember that back in the day when Adrian Peterson had that accelerated return to play after his ACL injury, football player? And everyone's like, wow, how did you do that?

You know, and all of a sudden, they go into like a conservative, quote-unquote, 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 like your deconditioning type of approach and pain modulation approach, kind of what they did with me the first time. And so, I think there's a big category in there in regards to conservative care. And I also think there's a little bit of a skewedness to the surgical repair and that nature. But for the most part, I tend to think these people with sports hernias, so if you have a sports hernia, I think your body's more resilient than you think.

And I think that if you're not responding, you're probably not doing the right thing yet. And in my experience, people that we tend to find the right thing on, which it might take one time, it might take a handful of times to really figure out what's going on with you because you're unique. You're a unique individual. You're a unique person. And you have unique tendencies and everything else. So, not everyone is exactly standard, but there's good starting points to most people. And so, once we find that out, you should feel much better within, I think, a couple weeks or at least in my experience.

And I'm not saying 100% better. I'm talking about being able to see that there's an improvement, being able to see that there's a significant change. And so, 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 chill. So, they're different things in my opinion. So, what I thought we'd do today to start with is I would go over, first, I wrote an article called The 12 Truths About Sports Hernias, which I thought was I can definitely clean up a little bit here. So, I haven't read it in years.

So, if I run into something that I'll clean up, then I will. And I thought as we go over this, I can go over some cases that I've done with people and how they've fared, how they've improved, and just some things that make you kind of think, you know. I will also go through the things that I use, theory and some application of how I scale things in the office for people based upon the things that I find, okay. So, as we go into the first truth here is that sports hernias, they say, often happen with cutting, pivoting, kicking, and sharp turns. Usually things you see in soccer, football, tennis, and rugby.

And I tend to think that the change of direction things, we can also kind of blend with those non-traumatic ACL injuries. So, I would guess in theory that the people that have non-traumatic ACL injuries, such as usually girls, basketball, soccer, things of that nature, and they're usually an overload theory. And because if it's trauma, it makes sense they've been hit and they have the unhappy triad, they call it, where they just had a poor stroke of luck. But with the landing with the ACL and the changing of direction, I think we have to consider there's a possibility that there's kind of some commingling of what's going on here, just to break down in a different area.

So, I've seen this in runners as well. I've seen this in, I didn't put hockey players on here, but I've seen it in hockey players as well. And just to open up the category, I've seen groin pain on a lot of people. I've seen groin pain on dancers. I've seen tight adductors or chronic adductor issues on dancers. So, I've seen a lot of these issues on different people. So, let's not classify this as only these four sports. Next, I put down that sports hernias can be, truth number two, is that no one really has to hit you. You don't have to fall. You don't have to hear a pop. And which this typically means that there's a slow progression occurring, a biomechanical progression occurring, that in my theory, makes it preventable.

Truth number three. Symptoms can oftentimes radiate into the upper thigh, or what you guys might say, like the groin area, or even like radiate down a little bit to the inner part of the knee. And, again, this is, in my experience, a lot of times it's a radiation of symptom. And I will get into a case later of a guy who came in who had, he had adductor issues, or a chronic adductor strain, quote-unquote. Negative imaging. No one can find a thing. And so I would venture to say it's probably not really an adductor issue in regards to structure of the muscle. It's more of a radiation or referred pain or a response in the muscle based upon what else has happened a little bit higher.

And so if this is tough to understand for you, it's typically people tend to get the idea of the heart attack. It's like everyone kind of knows, like, you have an elephant sitting on your chest, you're starting to sweat, you have radiating arm pain, and you're wondering, huh, what's going on? I think I might have a heart attack. You know, and then you tell someone you have a heart attack. And no one tends to talk about the arm symptom. And even can go into the face sometime. And so no one tends to treat the arm symptom. And when you do treat the arm system, guess what happens? Not good things, right?

And so if you tend to treat this adductor issue, and you keep chasing this symptom of tight muscle or scar tissue or adhesions, and that's the only thing that you're addressing, then there's a possibility you're missing the boat. And just to make sure that I'm retracting this a little bit, is that if you have had work on these areas and it improved your groin pain, you might be in the grouping that actually needs it, okay? I'm not saying that this theory that 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 van issue, and I say that foam rolling might not be a thing for you, and you're like, hey, man, foam rolling is my bro.

Foam rolling works for me. Cool. Works for you. Great. Like, I'm not talking to you. I'm talking to the other 50% of the people or more that it didn't work for. And so if it was going to respond to a foam roller or some other type of technique that you're using that is addressing that one part of the symptom, then it probably would work in just like everything else I'm talking about today. It's probably going to work in a couple weeks. Or at least significantly. And so if that's working for you, great. Amazing. If it's not, think about jumping ship on that and trying something different, okay?

The fifth truth about sports hernias is that it's really hard for patients to pinpoint. And I've had this quite a few times on people. I'm like, can you put one finger on the area of symptom? And they can't do it. They chase the darn thing around. And a lot of times they will refer up into the puic bone. They'll say it's tender up in here. And so they can usually find a spot in and around there. But it's hard to find within the adductor area. It's hard to find within the belly area. So they have trouble describing it. And some people even say that there's a tightness in the testicular area. So it's interesting that there's this diffuse type of symptom pattern there.

So it's going to be hard for people to pinpoint down. Don't worry if that's you. You're not alone. You still fall in the category of the things that we're going to be talking about today. Truth number six. I guess I jumped the gun on this one. Sometimes people feel a tight or numbness into the testicular area or the scrotum. And so this is a pretty classic one. I think, though, that if there's a numbness, that this is probably a neurological-based aspect, too. And I had a case recently that he had this symptom. And it was freaking him out. And there was some 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 then it took him probably the course of about four or five days after to really work on stuff on his own to where he can say it was safely gone. And so just consider that if there's a numbness in the feeling of tightness, not necessarily tightness, but the feeling of tightness, we might be looking at a neurological-based thing. And I think this is actually one of the areas where we're missing the boat on sports hernias, honestly. Truth number seven about sports hernias is that we have some AKAs. So if you've been reading around and you're like, I don't know which one I have, then, well, this is probably all of them.

You have Gilmore's groin. You have athletic pubalgia. And you have sportsman hernia. Sports hernia, truth number eight. The top four diagnoses that can be confused with is a real hernia, direct or indirect, hip joint pathology, osteitis pubis, and adductor longus dysfunction. I think I would probably throw in there a couple more things now is that although hip joint pathology is very broad, I'd say I really commonly find femoral acetabular impingement on there within the area of the actual symptom. Or, sorry, on the side of the symptom if it's a unilateral one. But also, too, it's nice to see just overall just from an observational standpoint.

When you watch patients, if you're a patient, your doctor 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 you had chronic plantar fasciitis on the right side. Maybe you had a past sciatica on the other side, you know. And so those are things to be considered of. But as you go through imaging on 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.

They see, well, the adductor is normal. Oh, the pubic bone is normal. The hip joint is normal. There's no actual hernia. Well, maybe it's a sports hernia. Maybe I should get a musculoskeletal ultrasound thing. And so as you start to investigate things, the funny thing is you're going to find a lot of these are negative. So 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. They're not dynamic in nature. They don't move. Now, truth nine is we get into musculoskeletal ultrasound, which is a type of imaging which is not a treatment.

Okay, so ultrasound, yes, there is a treatment, but there's an image, which is think about looking at babies in the womb. So this is probably one of the better ones to confirm, actually, if you're actually dealing with the aponeurosis or the issue within the classification of a sports hernia or you're dealing with something else or you're looking at maybe there's no symptom or, sorry, there's no structural damage at all. Now you're wondering what the hell is it at all, right? And so an ultrasound is a really nice way to non-invasively, there's no radiation, go in there and just check it out. I used to do these a little bit more often in my office personally, but there's a couple people around who are really good.

If you're in Southern California area, Mike Jablon, that's J-A-B-L-O-N. He is currently, I think he does it in Santa Ana 1 area, but also up in the valley, up and towards L.A. Also, Michael Meng is really good in San Diego area. So if you're looking for them, I've had Mike Jablon on a couple times. Michael Meng is amazing. They're both really good. So if you're looking to confirm it, those are the guys that I would suggest go to in the local area because they are honest, they're 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? And they're like, eh, there's something there, but I don't really think it's really a sports hernia. Because they've had more reps in it than I am, so I typically refer those out to them. Let's get on to truth number 10. Now this section I wrote again actually about probably six months ago, and I made it real simple, but I could rewrite this whole section even more. But in this one I want to say that rehab can be really slow, really frustrating, and super uneventful if you actually have a sports hernia. And I know it's a bummer, but it's kind of the progression of the thing.

That's where you see that classification at the top that I talked about. But the great thing is that actually if you have a skilled diagnostician, if you have someone who can really dig into all of the aspects of your injury and what triggers it and seeing what can improve it right then and there, trial and error. What if you're in there and all of a sudden the groin pain or the groin symptom just went away? And you might be thinking, well, it hurts when I cut and turn. Well, then cut and turn, and we'll see what can reduce it right then and there. Because it can happen. And so in those classifications, if you found someone to really dig into your case, there's a strong possibility that you've been working with a pseudo sports hernia or a false one.

And so although that you may have read a lot of things on the internet or someone else has told you that you had a sports hernia, you might not. And so earlier I mentioned that hip impingement, hip flexor tendonitis, light 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 so you're kind of at a loss of what you can do. I remember I had a teacher call one time and they said they, I mean, they had, they typically teachers have good insurance.

I mean, better insurance. I'm not going to say any insurance is good right now, but they're better than most. And they're like, I don't know what to do. I'm a teacher. I make like, I think they said like 40, 50 grand a year. I can't pay for the procedure and my insurance won't cover it. I can't get through this. What do I do? And so I know it's frustrating to people, but I think if you spend some time with someone who really knows what they're doing and it takes the time with you and digs into what you have, I think you'll be pleasantly surprised to figure out that actually your options are not just surgical route anyways.

And so all you really need is a little bit of TLC and some direction. And so I tell my patients that come on the phone anyways that the new people are like, well, what's the first exam include? I'm like, well, you know how like your internet doesn't work and you call up the place and they say, well, let's troubleshoot it. Is it plugged in? And you say, yes. Good. Is the green light on? Yes. Is the yellow plug in there? No. Okay, let's do that. You know, and they plug it in. You figure out, lo and behold, this thing works. I mean, it doesn't have to be extremely technical in regards to testing.

We do rule in, rule out a bunch of things, but for the most part, we're figuring out what works for your body. And hopefully, I mean, I've only had a few cases over the course the last couple of years where I couldn't figure out what turned them on and off, you know, in regards to their symptoms. And it's scary when you can't because if we're really looking at, if we're musculoskeletal people, doctors helping out people with musculoskeletal problems, and you're looking at someone who doesn't have a musculoskeletal problem, then what are you looking at? You know, how are you going to apply a musculoskeletal biomechanical correction if you don't have a direction to it?

So we're troubleshooters just like everybody else. And so patients, when you're listening to this, is that your doctor 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 your 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 also spend, they should be catching up.

And so I tend to spend an hour and a half, an hour and 15, or at least an hour with all my new people because I want to figure this thing out. And throughout the entire thing, we do what we call a trial and error process or better, worse, same. And so when they go and show me symptomatic movements or postures or positions, then I make a correction or a suggestion and I say better, worse, or same. And so I'm looking for a mechanical route in there that I can help them out with. And so just to keep in the confines of this truth 10 is that if you have a sport journey, it's going to be very slow and frustrating, but hanging there, the bodies are really resilient.

But don't immediately classify yourself as having a sport journey because most of the time you don't. I would say a strong 75% of the time of the people that I see don't have that, but they think they do. And they're following the typical route of the sport journey, which is very frustrating. So, yeah, go in and see someone who knows what they're doing and feels confident about guiding you out of the whole situation. Sport journey is truth number 11. Rehab may include, and I will rewrite this one at some point to make it more specific because I went off of what was found in research at that time.

So, six to eight weeks of modified play. I think originally I said, quote unquote, rest. So, I had to change that already. Pain modifying modalities. So, ice, heat, stem. I personally, in clinic, don't use any of those. I do have an e-stem machine, but only a couple people request it and do it because they ask for it. But I typically don't use them. I have good results without. Sports massage or deep tissue work. I have done this more frequently in the past with people, and I do tend to address it, usually about treatments four to five in, mainly because I want to see you first if there's a movement-based, biomechanical unloading that we can do first.

Core endurance-based exercise is critical. I do use that a lot. Breathing exercises for inter-adominal pressure will help recalibrate your inter-adominal 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. That's the squat, deadlift, push, pull, and carry. Our Dan John fundamentals. Unilateral training with anti-rotational considerations. Yes, as you can see, all these things, the later ones, I think 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 the athlete. We just want to keep their head in the game enough to not completely decondition them overall. Like, let's say we have a football quarterback and he can't use his shoulder or his legs or his feet or anything. It doesn't mean he's not watching game tape, so there's still stuff going on. Gradual 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'll talk about those as we go through in this podcast still. Truth number 10 is surgery is recommended if rehab is unsuccessful.

And that one, there is a whole section in the article about that. Now, on to the newer part here, and these are the things I'll probably update the article with. Now, the thing that I commonly see with these people is that they tend to have what we call a spinal hinge around the mid-lumbar area. And if you don't know what this looks like is they tend to have a little bit of a gully in there or a sag that really doesn't have the complete ability to resist rotation when challenged. And I believe that's what's happening with this fatigue-based anti-rotational trigger that they're having or this change of direction trigger.

And so I tend to say that the solution is that we're building up endurance within the area, and then we're trying to improve the ability of the hips to do the hinging movements. And I've mentioned this in a couple podcasts that I've been interviewed recently with is that I think the idea of the push-pull squat carry hinge has been not – honestly, not a lot of people, patients know it. They need to know it. And I try to position it as an exit plan to my care for people. But I think they forget actually what I'm asking is because I probably don't say hip that often, but I mention the hip a lot. So I literally do mean the hip hinge, the hip hinge, not a spinal hinge.

And so when we're looking at deadlifting is an opportunity to really ingrain the movement of the hip hinge. And so when we have people with these symptoms of the sporternia, really looking at – I tend to find that the areas that are triggered in their symptoms, such as the groin area, let's say ileohypogastric, we're looking at the genitofemoral nerve, we're looking at the lateral femoral cutaneous nerve, we're looking at the saphenous contributions, we're looking at all those ones that are kind of more of a high lumbar contribution. And so that inability to control rotation at the mid-lumbar area is actually interesting.

And 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. And so when we're building the hip hinge, we need to make sure that we're keeping that – the cuing of solidifying the torso 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, is I tend to improve intra-abdominal pressure or abdominal bracing of the DNS and the McGill model. And I think those are different skill sets. I think people need to understand bracing or the hard brace.

It's really hard to breathe when you're doing a hard brace. And 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, their breathing is happening, okay? Just like I'm here podcasting and speaking with you guys, then I'm also bracing and breathing at the same time. And as I start to increase my brace, I can't really breathe and speak as well. And it's hard to take a breath. So when we use our low-level brace via intra-abdominal pressure, then we can have a low-level stabilization even with athletic movements.

And so 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. I'm going to butcher this one because I looked at it years ago. But for the most part, passive, that they were looking at hip flexor, sorry, ability to extend the hip and being able to keep it over time, basically. Long-term improvement, I believe. And so there was passive stretching. There was active stretching, and then there was ball socket dissociation, I think. I know there's passive and ball socket dissociation, or as we say, stiffen the beer keg and move the dolly, or as I say anyways, the dolly being the hips.

And ball socket just killed it. And so I would suggest a ball socket in this with people. And so what does this look like, really? And so I tend to give people the analogy of the beer keg, like I just mentioned. And the beer keg is the torso area. We have the front of the beer keg, we have the side, we have the back, we have the top, the bottom, and it also has 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're going into a bendy sport where you have to bend backwards, or even in tennis, you tend to distort the keg, or in baseball, you tend to distort the keg a little bit.

It's okay as long as the keg has enough resiliency to not break. And so that beer keg there is, I think it's easy to build, easy to build with groundwork. And so in the past, I had people do crawling to kind of start with this, where they're using the floor as a feedback and bracing tool. And they're doing it long enough to where they're having to have some stabilization in the spine, in that mid-lumbar area, and I'll cue them into it. And I'll say, look, this area right here, I'll draw their attention to it, and I'll put something there, and I'll say, don't move this object, you know, a yoga block, a cup of water, whatever the hell, you know.

And if they can't do it crawling, then you've got to scale it back, maybe into a buttress plank. You just take an arm or a leg away. If they can't do that, you go to the knees. If you can't do that, I go down to like a DNS crawling, I don't know the months. I've been to one DNS course, the foundation ones. I have no idea the months, and I don't have a baby, so I don't know. But let's just say we're armly crawling. And so that's a little bit more controllable. And when I teach people this, I tend to say that your ground contact matters. And when you're working on a crawl, I start them crawling backwards because I want them to push with their hands to get the abdominal wall start to working because a lot of these people are a little bit more extended at that area, like I said.

And so I just want to make sure there's good abdominal co-contractions because if there's not, we're not really doing anything productive, I think, in the long term for these people. It might be nice and fun to crawl on the ground, but really not working on what I want them to work on. And so when they really don't succeed, I give them more ground contact points. And I also decrease the amount of moving. I make it more of a frozen position. And now they're just holding it for 5 to 10 seconds. So I tend to use that with beer keg stuff, but also things like hanging on a bar, you know, moving the legs and not even doing pull-ups, just stiffening up like your human punching bag and then moving your legs.

That's still stiffening the torso while you're moving the socket. So those are, I tend to like to have people get into an anti-rotational work in the long run, 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, number one, can they turn the floor? Number two is I try to incorporate the beer keg in the thing, in the movement. So I give them a goat bag 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.

So if no one's seen the goat bag, you throw a kettlebell into their belly. Sorry, don't throw it. You hand it to them and then they pull into their belly. And the thing is, their belly's not going to lose because if they do, they're going to squish their guts out of their mouth. And so this intra-abdominal pressure is kept constant or at least at a low level while they're turning the floor, standing up, sitting down, standing up, sitting down, or pushing the pockets backwards and standing up and so on. And 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, though, these people that have some type of anterior hip pain or groin pain, so they won't always tolerate a squat really well, so I start them in a high hinge. And so it's important to realize that the hinge, again, is if you call it a deadlift, and if you 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 haven't played a sport before, or if you have, rather, the universal athletic position is the one that you typically are waiting for a ball on, or it's when you're shuffling to the side, you're in that.

When you're a shortstop waiting for a ball, you're in that. When you're at bat, you're in that. So the universal athletic position, it stands. So we want to get people to an athletic position while they can still keep intra-abdominal pressure as we, again, build the beer keg and start the engine. And so you can take them to deadlifting, all that kind of stuff, but, again, we are, 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. Sometimes the ground's slipping and so on. And so you have to bring these variables into play in a scaled approach.

And so I typically like, again, to start just giving them the idea with the two-legged hinge, then we start to scale it to the sport. And I like to use the hip as the, I like to use the Koichi work. If you haven't seen, Koichi is really great with rotational and lateral squats was the main thing I got out of this thing. Or rotational and lateral movements of the hip. Or being able to press the ground, press the floor away, like you're changing direction quickly. So it was interesting to see when I went through his workshop that when people say, well, you have to have the knees over the second toe when you're squatting, that's the way to do it, you know.

And so when you get into a single-legged squat, all of a sudden that changes a little bit, you know. And all of a sudden when you're in a single-foot stance and change the 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 opposing direction of how you're going. And so if your knee's not in the middle of that, then it's going to be really hard to do. So building the ability to do that can, it can present many different forms. So I won't go too much into that because honestly when it gets into anti-rotational work or change of direction drills and power and speed, I typically like to refer them out to someone who's got a better skill set than me.

And so 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. Usually, and they've had a good result, let me disclaimer that, then they'd be a good person for this client to work with. Because I think the problem, at least in my experience, is that when people come in to see me for a condition, my responsibility is 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 they're not doing their homework well, then this relapse might occur.

I don't want it to occur, so I might as well hand them off to somebody else. And I tend to realize that when people come in to see me, maybe I do this to them, maybe 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, right? And so the focal point of working with their coach is that to get the work done. Their focal point of coming to me is to troubleshoot a symptom. And so I think that 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 certain thing that's occurring, you know?

They're searching for it. And it's normal. And 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 fare 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 their movements they're looking to do again in their sport, okay? Because if not, they can, again, this is a chronic activity-related symptom. So if you want to keep having it, then just completely avoid the things that you've been doing or completely avoid the things that trigger it.

So 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. So before I jump too far with these things, let me just talk about a couple cases really quickly about how this played together with me. And it was an interesting one. I think the first one where I really started to realize that mid-lumbar contribution was, 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 coming with a strain. They're like, oh, it's just not shown on the MRI, but it's a strain. And so I talked to him about a strength conditioning. I said, look, what are you doing? What do you like doing? And he's like, well, I like doing pull-ups. I said, okay, so does it hurt doing any gym work? He's like, yeah, it hurts doing pull-ups. I said, your groin hurts when doing pull-ups? He's like, yeah. I'm like, huh, that's interesting. At that point, I want to see him do a pull-up. And he dramatically extended, showed his ribs, and it was a mid-lumbar extension that occurred. And I know you know what people I'm talking about, and they're typically the people who are not strong enough to do a darn pull-up, or they don't have the, or to do a pull-up with good form.

And so I don't have a problem with a couple 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 mid-lumbar extension, then maybe that's not the thing you want to do. And so after talking to him about what else he did, and I said, do you squat? He said, no. I said, do you hinge? He said, no. I said, do you push? He said, yeah, because every high school boy pushes. Do you carry? No. So there's three missing parts in there. And what we actually found with this case, 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 offloading the other side, or sorry, he was offloading the side of the symptom. So we loaded the side. His symptoms went away. And day one, he can change direction. He still had an issue with decelerating from top speed. He can run to top speed, but decelerating he couldn't do. And we ran in the parking lot to show this. And then I showed that. I said, can you act like someone's punching you in the belly when you're slowing too? Make sure that there's tension in your belly when you're slowing. That decreased the symptom. And so over the course of time, I worked with him here and there. And then so one thing, when we finally got into hinging, I saw that, look, he just doesn't, like he's probably the least flexible boy I've ever seen in my life in regards to like his lower body.

And most people think that, well, you know, this is just the way I am. I'm just not very flexible. My parents aren't flexible and so on. And so he kept rounding at the back when he was hinging, even like really high, even like pinpull style. That would be his initial point of movement. And so I said, look, let's just try these. You know, let's just try this other thing. So we did some end ridge loading and extension of the spine. And that took his symptoms away completely. Funny, one of his symptom generators was putting his shoe on the morning. He would do it standing and he would do it with a low back round.

And so we can put him to that position on his back without having a symptom as long as we took the lumbar round out of it. So we treated him as a disc-related protocol for a little while. Sorry, not a little while, a week. He was to do everything as a flexion intolerant disc was. He came back, he said he was 90% better. Amazing, right? It's pretty cool. And 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. And so we're working on the same type of protocol that I mentioned above.

We're building the beer keg and we're building the engine and we're going to build ability to change direction. And so that was a really good case where it was interesting to see. And actually, not until a couple weeks ago did I really think when I saw someone else do a pull-up, I said, huh, that mid-lumbar extension really makes sense now with that one case. So I still learn as I go. The second one, this will be a real quick one, is I had a runner with inner arch pain decrease while holding breath while running. It didn't hurt to sprint. It hurt to jog. Think about that again. So we have runners that typically tend to extend and fall apart at the end of a run, especially when they're exhausted.

And so now we have the rotation happening at the mid-lumbar area a lot of times. And so holding the breath builds the keg's pressure with inside, or at least momentarily for the test, and it decreases their symptoms. So think about that. What would you do with that person? Then we had a dancer with groin symptoms into the front, right around the inguinal, is that an inguinal canal, inguinal crease, inguinal ligament. There you go. As well as adductor pain that went down the inner thigh all the way to the knee. And so she was a unilateral complaint. Everybody else before has been a unilateral complaint too.

I do have a bilateral one coming up. And dancers, interesting, is they tend to, they're coached into a hide their butt, tuck their butt, flare their rib type of appearance, if I'm getting this right. And so it was interesting to teach hinging to her. Because, again, I like to do this, this is my rough systems. I look at beer keg stuff, and I look at engine work in the hips. And so we started with the engine work. I should have started with the beer keg, but I didn't. I started with the engine work. And so just teaching her how to turn the floor, turn her cheeks on, and decrease the amount of valgus collapse, and probably answer tilt at the same time, or build a buffer to this.

It decreased her symptoms pretty significantly there. But then I'm like, you know what? You don't carry. Let's just try carrying. I had her carry it, lit her symptoms up, and I saw her walking kind of like a duck. And I said, okay, so let's push the hips forward under your body a little bit, and then walk like your businessman, walking through an airport in a tight suit. And she's like, oh, that makes it even worse. And so I had to ask Allie, which I've had on the podcast before. She was in office. She works with dancers. I said, what would you tell a dancer to get rid of that mid-lumbar extension thing?

She said, hide your ribs. And it was an internal cue. She said she doesn't like using it, but it really resonates well with dancers. So she hit her ribs. She said, huh, all my symptoms went away. And so we went back into the hinge again, as well as her squatting. Her squatting was painful at the time. And she said, huh, it doesn't hurt anymore. And so she eventually went into her plie, grand plie. She said, oh, this hurts right here. And so we said, hide the ribs. She said, huh, it went away. And so this is an example of someone being cued into the movement that is a triggering one. And so I had to explain to her, I said, look, we're building your hinge.

We're building the hinge and taking this duck thing away, not because we're not saying that 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 a symptom generator away for now. And so, again, example, she could have been classified as a sports hernia, but she probably wasn't. This next guy, he was a hockey player. He actually had testicular tightness, he said. He was kind of freaking out about it. He was on one side. And when they called, actually, I said, look, just to let you know, I'm not going to be, you've already been checked for a hernia and you've already had an image, so I'm not going to be checking in there because I know how it was when you go in for physicals, it's like a barrier for entry is someone's going to make me drop trowel.

So, I said, look, I'm not even going to have to do that. If I do have to do that, then I'll send you to somebody else, okay? And so, what we found with him is that we can decrease his symptoms by doing what we call dynamic for bears. He landed on his back, he put his leg in a figure four, he said, yeah, that's my symptom in the groin, the adductor, and I feel a little bit into the testicular area. And so, I had him, I actually pushed my hand into his belly area, I said, fight my hand, don't let me, don't let me push your guts out. And so, he fought it and he's like, oh, it went away. And so, we used that same principle we talked about before.

For him, I started him into a low DNS position, kind of like a low, like baby crawling, but reaching for stuff type of thing. And I really cued him to push his pubic bone into the floor, to dent 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 into a buttressing plank and we built the hinge. Squatting was painful, so we built the hinge. Eventually, we came back to the squat about a week later, but after about a week, he had 75% improvement in symptoms. He can go and play hockey. Two weeks from initial date, he was able to play hockey.

He still had symptoms when reaching for the puck. And I would imagine reaching for the puck, they were increasing the moment arm on the spine when his hips have to stay behind with the skates. So there was still a little bit of work to do in there, but for the most part, doing really well. So again, he would have been a classic as your population, probably your age grouping in your symptom pattern of a sports hernia, which was a pseudosports hernia as well. Mid-lumbar and neurological contribution on that one, I believe. The last one, it was a runner with bilateral tenderness in the pubic bone.

This one, it was interesting to see that I don't know the end results of this case because he lived a long ways away, but we talked on occasion about this, and he ran a lot of miles, let me put it that way. And I said, look, can I see your squatting and so on? And I started with him originally with just tissue work around the area, and he said it helped, so we continued for a couple times. And I said, let me see your squatting and hinging, and he wasn't really extremely receptive of doing the movement stuff because he drove a long ways to get the tissue work, so I completely understand that. And so I saw squatting and hinging, it was not good.

And so I would venture to say that if we had improved on some of that and built the hip's ability to be the hinge versus the spine, as well as having that abdominal extension, which we can equate to say, well, there's a chronic eccentric tugging on the anterior abdominal wall of the pubic bone that could generate the sports training symptom or even the finding, then I think if we had worked on that, I think it would have been much better. So those are just examples of the cases, but interesting, I went to a Michael Shot Clock course recently for clinical neurodynamics, and we did some mid-lumbar neurological testing as well as some treatments.

And it was interesting that he said that of some of the things that he's found neurological-based is that some of those mid-lumbar contributions, he's found some more sinister pathology than he ever thought. You know, spinal tumors, or I think he mentioned some type of female parts issues. And so there was things in there, he said, that he wouldn't mind imaging these people just to see, just to make sure there's nothing going on there before really treating them extensively. So I never even thought about that, but now I do. So those mid-lumbar contributions are probably something I would image a little bit more in the future, especially if they're not responding.

And I actually had someone a couple years back who had a pathology in the spine that we wanted to know about that was also too, it was a intermedial thigh type of presentation. So it's interesting, you got to make sure to roll out all your red flags, but sometimes your red flags won't tell you what's going on because those things are a little bit more silent, you know? And so I think, I know when people come in to see me with this pseudo sports hernia, they've had imaging and so on. I know they've had imaging of the hip and so on, but I really like them to have imaging of the spine. And can you get an image done if you're a patient?

Yeah, sure. Like more information is good information. And 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 that if your image is negative, it doesn't mean that someone like me or someone listening to this podcast can't help you because a lot of times they're loading issues of your body's tissues. They're not necessarily issues with your body's structure or something torn or frayed or so on. There's other stuff to it. Can you go see your ortho or neurologist or family practitioner or physical therapist or chiropractor?

Sure. Whatever. You can see whoever you want. You know, like I tell people the more opinions you have, the better. Like you might not want to take everybody's opinion, but it's nice to see what everyone says. And I think it's important to see the way they say it too. You want to see some confidence in what they say. And so I've told people that have been unsure about their progress in the past, by all means, like 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 then we can figure out what's the best route for you.

Not because maybe I'll know better than the other guy, but I tell them in advance 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 doesn't make a big dent in your symptoms within a couple weeks, we need to be talking anyways. So, and I'm a strong believer that if what you're doing is not doing anything for you, ditch it. And I tell people straight up, I say, look, if what I'm doing doesn't work for you two, tell me and then ditch me.

Okay? 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've been told you have a sports hernia, please work with someone who will test and challenge you within the examination. Okay? The history is great and hearing your concerns 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 just need to spend a little bit more time with you. Okay? And 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're progressing in the right direction, I mean, so we need that feedback from you.

If we don't hear that we're doing right or wrong, it's hard to make a judgment call. And so I've told people in the past, I say, look, I'm testing a theory on you. You don't have a symptom right now. I'm testing a theory on you. Please test the theory. If you end up getting worse, that confirms the theory is, well, it confirms that I did, that I suggested something poorly and that helps me recommend as we go forward. I'm gathering data. We're 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 it doesn't mean the wrong thing is not still nonproductive information.

So don't jump doc to doc. If you do, then you're going to be very frustrated. I can almost guarantee it. Just go with someone who is honest and caring and willing to take time with you and who is also honest enough to know when they don't know what is going on with you. Expect to have a positive result within, I'd say, I would like to say one week, but I like to give myself a buffer. Let's just say two. So just make sure that what you're doing is working for you. Many times, I will, anyways, ask you to test out your abilities and to keep certain aspects of your sport within play while the region is recovering.

The rest of you, there's nothing wrong with you. Okay? And so if we go into that push-pull-carry squat hinge thing, if one of them hurts, we do the other four. If you're a soccer player and sprinting and changing direction hurts, but you can still do a little footwork drills, do footwork drills. If you want to watch game tape, do game tape. If you think that, I'm pretty sure every athlete will say, well, if I spent a month in bed and just eating Doritos is going to be harmful to, they're probably going to say it's harmful to me, so 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 in general observation, most can walk. Most can swim with a pull buoy because we've got to eliminate that mid-lumbar hinge. They can resistance train and they can do stuff within normal life. And typically, when I click 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 will when they lose tension, it will. So, I might ask you to do certain things that are going to seem scary but at least when you're working with me, I've attempted 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's willing to explain your risk-reward with you. Alright? If you do not return back to sprinting at some point, you will not return to your sport. Alright? 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 people in my opinion tend to respond well to high tension work with sprinting first before doing long slow distance and this goes for distance runners as well. Hope you guys liked the podcast today and the format and if you have not already, please subscribe and review.

If you are liking what I have to say, please share this podcast with a friend, a colleague, someone who's experienced a sports hernia or just someone who needs to keep updated on their information. I'm included in that, okay? And so, I'll plea with you, okay? As a listener, if you've heard more than five podcasts, please share. Because producing these podcasts is, I think I've said it a couple times, they're challenging. I do them weekly. I'm here on my off days doing them and I have to really search and find to get line up times for people to interview and really share their information with us.

And so, I know a couple people who have ended their podcasts and I'm not saying that it's on the horizon for me, but for people who typically end their podcasts, I believe it's because they're not finding that there's good feedback or that there's people listening in general. So, they want to know that people are listening and that there's a reason for their passion. And so, I like doing this, but even some of my favorite TV shows like Mayor of Children, went 12 seasons and it stopped and I wish it never stopped. But, please contribute to this forum. You're part of the movement movement, okay?

So, please share this, share it with as many colleagues as you can. I'm trying to improve the reach of this podcast to help our profession and that will go for obviously movement providers. Let's just say ATCs, strength coaches, PTs and DCs. I'm not just talking DCs. I want us to rise to the top and see more people. And I really do believe that rising water raises all ships. There's enough people out there for us all to work with and there's enough people doing really terrible care or very lackluster care throughout there that we just need to help them improve their skill set. And, I know I sound, I always feel like I sound very cocky when I say that.

And, and I can honestly say about five years ago I would say that my treatment was lackluster. Okay? I was doing okay but I could have done way better. And I didn't open Pandora's box until someone suggested it to me. So, please use this podcast as Pandora's box for somebody. And let's get some really amazing providers out there to make sure that when your mom or your dad has a problem living in Kentucky that they have someone to go to. Because, I guarantee that you're going to find someone one day who needs help who's not around you. And, not everyone's able to fly in and you want to be able to trust that the person you're going to send 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. And by the way, if you think I'm missing the boat on something, please email me. Alright? I would love to keep learning more. As always, leave people a button on how you found them and if you're dating, dating Eagle Scout. Exciting stuff coming in the next few podcasts. Tune in. Talk to you guys next week.