Mike Boyle – Understanding Sports Hernia’s Webinar
Salepage : Mike Boyle – Understanding Sports Hernia’s Webinar
Boyle, Michael
Understanding and Training Hip Flexion was a piece I wrote last year. The objective was to take a look at hip muscles and how they operate from a little different angle. This method inspired me to continue researching the hip and how we see this vital location.
One of my accomplishments is that I am always trying to learn new things. Fortunately or unfortunately, I get the impression that the more I study, the more I discover I don’t know. Sports hernia is a topic that has piqued my attention, as well as that of many others in the disciplines of performance improvement and physical therapy. It seems like every week another athlete is undergoing surgery for a ‘sports hernia”.
To begin to comprehend the notion of a sports hernia, we must first attempt to explain one. A sports hernia is technically defined as a tear in the lower abdominal wall in the inguinal region. In contrast to a conventional inguinal hernia, there is almost never a major rip that results in a bulge. Rather, discomfort in the lower abdomen area begins gradually, generally as groin pain.
In reality, sports hernia refers to a variety of various conditions. The most intriguing aspect of a sports hernia is that it nearly always appears to begin as groin discomfort rather than stomach pain. When questioned or examined, most sports hernia patients would describe a groin injury that eventually evolved into a painful lower abdominal. This frequently neglected truth may hold the key to addressing or comprehending the situation.
Sports hernias are not painful. There is no single occurrence, but rather a series of events. What starts as groin pain develops into stomach ache. As a result, the “sports hernia” might be a subsequent injury. In reality, sports hernias may be the result of the abdominal muscles’ reaction to a groin injury, or more precisely, the abdominal muscles’ reaction to a change in the mechanics of the hip joint.
The questions include why and how the abdomen is affected. I’ve dealt with sportsmen with “sports hernias” in both professional soccer (MLS) and ice hockey (NHL) (NCAA and NHL). I participated in and oversaw the successful recovery of two athletes who underwent sports hernia surgery in the summer of 2006. The first was an NHL player, while the second was an NCAA Division 1 hockey player.
Let’s take a step back and look at the term “groin” and the notion of a “groin pull” first.
The groin region, as it is generally defined in athletics and sports medicine, contains the muscles that flex the hip, adduct the hip, and, unexpectedly, certain hip extensors. The term groin is a catch-all phrase that is commonly used to designate all of the hip adductors and flexors. This is where things start to get interesting, and why the title of the post is Understanding Adduction.
Adductor magnus, gracilis, pectineus, adductor longus, and adductor brevis are the five muscles that make up the adductor group. We frequently see all of these muscles in their solitary, uni-planar capacity as adductors because we have been taught what I like to call origin-insertion anatomy. We often think of adduction as a motion that occurs just in the frontal plane. My recent readings in Florence Kendall’s Muscles -Testing and Function, on the other hand, made me understand that nothing is as easy as it looks.
During the summer of 2006, I was fortunate enough to obtain the help of an exceptional manual therapist, Dr. Donnie Strack DPT (now the Director of Sports Medicine for the NBA’s Oklahoma City Thunder). Donnie assessed both of the guys I was working with and discovered that they both had major soft tissue constraints in the pectineus. In other words, they had a “groin pull” or adductor strain that had been treated normally with ice/rest, etc.
Both players were eventually cleared to return to play after their symptoms subsided, but neither had received the necessary soft tissue work in this critical area. Dr. Dan Dyrek, a physical therapist, uses the term “benign neglect” to describe the treatment of such injuries. The assumption is that the absence or reduction of symptoms equates to healing.
What does this have to do with sports hernias or, as the article’s subtitle suggests, Understanding Adduction?
This is where things start to get interesting. It became clear after reading Muscles- Testing and Function that all of our adductor muscles serve a secondary, multi-planar function. Two of the adductors are also weak hip flexors, which surprised me. The pectineus and adductor brevis work together to help with hip flexion.
They flex and adduct, in other words. As I sat reading, the lights in my head began to shine brightly. Hernias in sports are nearly epidemic in two sports: hockey and soccer.
What are the similarities between hockey and soccer? One very important point. In hockey, the recovery of the skating stride is a combination of hip flexion and adduction. What muscles do we envision being overworked and injured? Obviously those that both flex and adduct. Striking a soccer ball? You guessed it, flexion/ adduction combination. What do these adductor/ flexors also have in common? They insert just below the abdominals right in the area of the sports hernia.
Guess what else? The remaining three adductors are extensor/ adductors. Adductor magnus, adductor longus and gracilis aid in adduction but, by virtue of their position of insertion on the pelvis aid in extension of the hip.
The Etiology of the Sports Hernia
Two muscles get overworked, the pectineus and adductor brevis. A strain occurs. Rehab is often inadequate. The location of the strain makes soft tissue work difficult. In fact many athletic trainers, particularly if gender lines are involved, are reluctant to perform soft tissue work in the high adductors. Soft tissue work can also be neglected due to time constraints or skill constraints.
If rehabilitative exercise is performed, the focus is on frontal plane adduction, which does not directly address the unique function of the injured muscles. In frontal plane adduction the long adductors can substitute and “hide” the issue with the flexor/ adductors. Wraps and elastic devices are often used to mask symptoms and/or to decrease pain. The result of this process of “benign neglect” is an eventual tear of the abdominal wall secondary to a groin strain in the pectineus or adductor brevis.
Here’s where the AT/ PT crowd gets mad at me. Currently, the only therapists I use for my athletes or clients are manual therapists. I am lucky enough to have a long time relationship with Dr. Dan Dyrek probably the greatest physical therapist you have never heard of. Dan is a genius and a master of soft tissue. His entire business revolves around soft tissue mobilization. I have never seen a modality besides the human hand used.
Adding Dr Donnie Strack to his practice allowed us increased access to outstanding treatment. This is the solution. If you are an athletic trainer or a physical therapist develop your soft tissue evaluation and treatment skills. Most athletic trainers and physical therapists don’t do massage in this country because it’s too hard and not cost effective. This has to change to stem the tide of sports hernias. I am lucky to have found two excellent massage therapists, Ellen Spicuzza and Joanie Gauthier. With this team approach we can keep athletes healthy or, get athletes healthy.
If you are reading this and are an athlete with a lower abdominal issue find a good manual therapist. This is not easy. They are few and far between. Surgery may help but, it will not be the entire answer. Resolution of scar tissue is the final piece of the puzzle. You need to get to the original source of the injury and deal with it. This can only be done by a soft tissue professional.
Discussion (added post initial publication) (added post initial publication)
Many in the medical world will disagree with my thoughts. Truth is, I don’t really care. I have discussed the sports hernia phenomenon with numerous well-respected colleagues and have gleaned a few theories. One of my conversations with renowned physical therapist Gray Cook yielded this gem. Cook theorizes that most athletes would do as well without surgery as with surgery if they would actually take time and rehab. The surgery is almost a method of forced rest that allows healing.
Another thought comes from Pete Freisen, former Athletic Trainer for the Carolina Hurricanes of the NHL. Pete thinks that a large predisposing factor in ice hockey athletes is that many hockey players stretch the adductors but, not the hip flexors. The adductors are easy to self-stretch while the hip flexors require either great concentration or the assistance of a partner. The result is often athletes that have great frontal plane mobility at the hip with limitations in the sagittal plane. You basically have one large degree of freedom and one limited one.
Think of the forces on the hip capsule and lower abdominal wall when you think of excessive abduction but a big block in extension. If you think of this mechanically it makes sense. The discrepancy of hip ROM probably sets these athletes up for an abdominal tear and potentially for labral damage. Freisen has actually stated that he would rather have tight athletes or loose athletes but not athletes that are tight in one plane but loose in another. Cook would define this as an assymettry. In Cook’s Functional Movement Screen research asymmetry was a greater prediction of injury than a symmetrical restriction. Asymmetrical range of motion at the hip may be another precursor to sports hernia.
An additional area of concern in sports hernia is hip internal rotation. Most of the athletes who experience a sports hernia seem to lack hip internal rotation ( a transverse plane deficit) ( a transverse plane deficit). The consensus seems to be that just as we have misunderstood the role of the adductors, our athletes in an attempt to be healthier may be over-lengthening the wrong muscles ( adductors in the frontal plane) and leaving other muscles ( hip flexors and hip external rotators) critically short.
The result is a hip that lacks extension and internal rotation but, has great ROM in conventional frontal plane adduction. This forces the pelvis to move in compensation and, stress to be shifted to the lower abdominal wall. The result is an eventual sports hernia.
Part two of this article will deal with prevention and rehab following sports hernia.
