First phase (first 2 weeks)
Second phase (from 3rd week)
Third phase (from 6th week to return to run)
Static adduction against ball placed between feet lying supine
Leg abduction and adduction exercises performed in side lying
Slow jogging
• Slow running at easy pace
• Can progress if no pain
Static adduction against ball placed between knees when lying supine
Low-back extension exercises prone over end of couch
Straight sprints
• 100 m sprints at increasing speed and repetition
• Can progress if no pain
Abdominal sit-up both in straightforward direction and in oblique direction
One-leg weight pulling abduction/adduction standing
Cutting
• Sport-specific sprints involving change of directions
Combined abdominal sit-up and hip flexion, starting from supine position and with ball between knees
Abdominal sit-up both in straightforward direction and in oblique direction
Balance training on wobble board
One-leg coordination exercise with flexing and extending knee and swinging arms in same rhythm
One-foot exercises on sliding board, with parallel feet as well as with 90° angle between feet
Training in sideways motion on a mini-skateboard
Balance training on wobble board and skating movements on sliding board
The first step of the conservative treatment is focused on inflammation and pain control. We can use anti-inflammatory drugs, instrumental and manual therapy. Pharmacotherapy consists of systemic administration or local injection of NSAIDs, corticosteroids and, recently, platelet-derived growth factor (PDGF) [6].
Heat therapy with resistive to capacitive system, laser therapy and electrical therapy can be really useful in order to decrease local swelling and inflammation and to reduce pain acting on nociceptor’s membrane and the nervous fibres by the modulation of the painful stimulus and its transmission. Extracorporeal shockwave therapy can also facilitate tendon enthesis healing and regeneration due to the stimulation of nitric oxide and growth factor production and stem cell proliferation, migration and differentiation. Physical therapy is recommended as the first-line treatment after a period of rest or restricted activity [11]. In the acute phase, we can use postural balance techniques through global and site-specific stretching, mechanical and proprioceptive orthotic insoles and global postural re-education. Improving the hip ROM, specifically internal and external rotation, has been proposed as a possible method to reduce stress across the pubic symphysis and the surrounding structures [12]. Muscular imbalance between abdominal and hip muscles may contribute to mechanical overload and loss of functional stability of the groin [1]. Hip adductors are essential stabilizers of the pelvis together with gluteus, hamstrings and abdominal muscles in sport activities like running, pivoting and kicking [13]. Thus, it may be possible that improving control and strengthening of these muscles [14] may restore the function of the groin region [5]. Decontracting massotherapy is useful to relax and stretch adductors and abdominal muscles. A correct application of neuromuscular taping can detent tendon insertions, promote muscle relaxation and protect the muscle-tendon unit from overstretching. In the early stages, active exercise therapy involves isometric strengthening of abdominal and adductor muscles in the gym or in the warm water of a therapeutic swimming pool. In the subacute phase, muscle strengthening is increased by introduction of concentric and eccentric exercises and cardiovascular reconditioning. Core stability exercises should be introduced as soon as possible and consist of the contextual and synergic activation of abdomen, adductor and lumbar muscles. Finally, running is gradually started at first on a treadmill, proceeding with free aerobic run at increasing speed. The last rehabilitation step will be focused on the return to sport [7]. Learning preventive postural, eccentric and plyometric exercises is important during and after the return-to-sport phase in order to maintain a good stretch of the posterior and adductor chain, as well as a global balance between agonist and antagonist muscle groups [6].
18.3 Conservative Management of Sport Hernia
Sport hernia is defined as a weakness of the posterior inguinal wall without a clinically palpable hernia, which results from injury of muscular and/or fascial attachment to the anterior pubis bone [15]. Tears associated with an athletic pubalgia may involve the transversalis fascia at the posterior inguinal wall, the insertion of the distal rectus abdominis, the conjoined tendon and the external oblique aponeurosis [15]. The hallmark symptom is a severe lower abdominal, pubic or groin pain with exertion that improves with rest but typically returns upon resumption of sport-related activities. Pain is usually deeper, more proximal and more intense than an adductor or rectus abdominis strain. It is common to find a point tenderness near the lower abdominal insertion at the pubic tubercle that can involve the adductor longus tendon origin as well.
Rehabilitation is usually the first option in treating a nonathlete patient with a diagnosis of sport hernia because evidence suggests poor surgical outcomes in these cases [16]. Moreover most physicians agree that a conservative treatment should be in many cases the first option even in athletes [15]. The current literature shows significant improvement after 6–8 weeks of physical therapy intervention [17]. The duration of the rehabilitation process depends on the nature of the injury, the level of preinjury performance of the athlete and the length of time before the athlete is expected to return to play [15]. The diagnosis of sport hernia usually implicates several weeks of rest and a gradually return to sports activities, depending on the single patient’s injury history.
First of all, the conservative treatment consists in pain control and reduction of swelling and inflammatory reaction. The patient should be able to move and conduct daily activities with little to no pain present. We can use oral anti-inflammatory drugs, physical agents or local injections in order to accelerate the reduction of symptoms. The rehabilitation treatment is mainly based on the association of exercise therapy and manual therapy. It has been shown that the use of these two treatments in combination allows achieving better results than using exercise therapy alone, with a faster return to sport [10]. Manual therapy works by improving soft tissue and fascia restrictions, reducing the viscoelastic stiffness in the adductor muscles and mechanical loads on the pubic bone. It also seems that manual therapy can influence core stability: the manipulation of the sacroiliac joint can enhance abdominal muscles function, improving the feedforward action of transversus abdominis muscle. Those techniques include soft tissue manipulation of the lumbar and hip regions, mobilization of the pelvis, sacroiliac and hip joints, neuromuscular re-education and manual stretching [10]. The main part of the conservative treatment is based on a customized and progressive exercise therapy programme that aims to minimize pre-existing risk factors and compensatory strategies, implement core stabilization and maintain good motor control around the pelvis. Safe progression through the various stages of the rehabilitation programme requires strict monitoring using objective tests and measures like the adductor squeeze test (Fig. 18.1) and the hip range of motion.
Fig. 18.1
Adductor squeeze test: pain provocation by isometric hip adduction. It can be performed at 0° (on the right), 30° (on the left), 45° and 90° hip flexion. It is possible to quantify the adductor strength during this test through pressure values measurement (mmHg), using a simple sphygmomanometer pre-inflated to 10 mmHg [18]
All interventions address specific objective impairments found during the physical examination, including muscle length deficits, strength imbalances and joint hypo-mobility. In fact these impairments may have led to, or been the result of, the sports hernia injury.
Clinical assessment of core stability, and identification of hip muscular compensation and imbalance are crucial. Treatment should target strengthening and neuromuscular re-education regarding timing and recruitment patterns during functional motion. In the early phase, the patient can perform a sequence of submaximal isometric contraction of hip abductors, adductors, flexors and extensors. Core stability exercises begin with static contraction of the deep core muscles and an initial emphasis on correct activation. These exercises are progressed by adding single-leg activities in stable positions and, subsequently, in unstable positions, incorporating external perturbation in order to improve proprioception and kinesthetic awareness [19]. Functional strength training includes a pattern of bilateral squat to single-leg squat and lunge, adding direction to lunge in the final stages. Dynamic stabilization of the pelvic ring is the central goal [20]. Active stretching of the spine and lower extremities to ensure the preservation of flexibility and full range of motion should be added. Joint range of motion of the hips and lumbar spine is expected to be optimal prior the return to sport.
The final step of the rehabilitation programme of all athletes with groin pain syndrome is the return to sport phase. Once completed this step, the athlete is expected to return to full competitive sport. This phase should begin with a gradual return to running; the player may start with a short run every 2 days improving gradually under supervision. Clinical criteria to start a safe return to running should be pain-free adductor squeeze test, minimal adductor guarding (i.e. spasm of the adductor muscles on passive hip abduction), pain-free pubic symphysis shear test into extension (feel for hypermobile pubic symphysis while shearing vertically through anterior superior iliac spines) and pain-free fast walking [20]. Running is progressed into straight-line speed, changing direction and then accelerative drills. Finally it can be introduced the sport-specific training on the field. Physicians and trainers typically allow the return to play once the athlete has no pain with sport-specific activities like sprinting and cutting and he can complete an abdominal curl-up and bilateral straight-leg raise/hip flexion without symptoms.
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