Rehabilitation and Return to Activity Following Sports Hernia Surgery


Adductor stretching
Sumo squats
Side lunges
Kneeling pelvic tilts

Strengthening program

Ball squeezes (legs bent to legs straight)
  Different ball sizes
Concentric adduction with weight against gravity
Adduction in standing on cable column or elastic resistance
Seated adduction machine
Standing with involved foot on sliding board moving in sagittal plane
Bilateral adduction on sliding board moving in frontal plane (i.e., bilateral adduction simultaneously)
Unilateral lunges with reciprocal arm movements

Sports-specific training

On ice kneeling adductor pull together
Standing resisted stride lengths on cable column to simulate skating
Slide skating
Cable column crossover pulls

Clinical Goal

Adduction strength at least 80 % of the abduction strength

The injuries were tracked over the course of the two seasons. In the present study there were three adductor strains which all occurred in game situations for an incidence of 0.71 adductor strains per 1,000 player-game exposures. Adductor strains accounted for approximately 2 % of all injuries. In contrast, there were 11 adductor strains and an incidence of 3.2 adductor strains per 1,000 player-game exposures in the previous two seasons prior to the intervention. In these prior two seasons, adductor strains accounted for approximately 8 % of all injuries. This incidence was also significantly lower than that reported by Lorentzon et al. [16] who found adductor strains to be 10 % of all injuries. Of the three players who sustained adductor strains, none had sustained a previous adductor strain on the same side. One player had bilateral adductor strains at different times during the first season. These data demonstrate that a therapeutic intervention of strengthening the adductor muscle group can be an effective method in preventing adductor strains in professional ice hockey players.

Despite the identification of risk factors and strengthening the intervention for ice hockey players, adductor strains continue to occur in all sports [23]. The high incidence of recurrent strains could be due to incomplete rehabilitation or inadequate time for complete tissue repair. Hömlich et al. [9] demonstrated that a passive physical therapy program of massage, stretching, and modalities were ineffective in treating chronic groin strains. By contrast, an 8–12-week active strengthening program consisting of progressive resistive adduction and abduction exercises, balance training, abdominal strengthening, and skating movements on a slide board proved more effective in treating chronic groin strains. An increased emphasis on strengthening exercises may reduce the recurrence rate of groin strains. An adductor muscle strain injury program progressing the athlete through the phases of healing has been developed by Tyler et al. [13] and anecdotally seems to be effective.

As seen in Table 17.2, this type of treatment regime combines modalities and passive treatment immediately, followed by an active training program emphasizing eccentric resistive exercise. This method of rehabilitation program has been supported throughout the literature [23, 24].

Table 17.2
Adductor strain post-injury program

Phase I (acute)

RICE (rest, ice, compression, and elevation) for first ~48 h after injury
Submaximal isometric adduction with knees bent → with knees straight progressing to maximal isometric adduction, pain-free
Hip passive range of motion (PROM) in pain-free range
Nonweight-bearing hip progressive resistive exercises (PREs) without weight in anti-gravity position (all except abduction), pain-free, low-load, high-repetition exercise
Upper body and trunk strengthening
Contralateral LE strengthening
Flexibility program for noninvolved muscles
Bilateral balance board

Clinical milestone

Concentric adduction against gravity without pain

Phase II (subacute)

Sumo squats
Single limb stance
Concentric adduction with weight against gravity
Standing with involved foot on sliding board moving in frontal plane
Adduction in standing on cable column or Thera-band
Seated adduction machine
Bilateral adduction on sliding board moving in frontal plane (i.e., bilateral adduction simultaneously)
Unilateral lunges (sagittal) with reciprocal arm movements
Multiplane trunk tilting
Balance board squats with throwbacks
General Flexibility Program

Clinical milestone

Involved lower extremity PROM equal to that of the uninvolved side and involved adductor strength at least 75 % that of the ipsilateral abductors

Phase III (sports-specific training)

Phase II exercises with increase in load, intensity, speed, and volume
Standing resisted stride lengths on cable column to simulate skating
Slide board
On ice kneeling adductor pull together
Lunges (in all planes)
Correct or modify ice skating technique

Clinical milestone

Adduction strength at least 90–100 % of the abduction strength and involved muscle strength equal to that of the contralateral side

Sports Hernia

Athletic Pubalgia, also referred to as “Sports Hernia,” “Gilmore Groin,” “Sportsman’s Hernia,” or “Groin Disruption,” has been used to define a particular injury in the groin area, but lacks a universal definition [25, 26]. Typically, this injury is believed to be multifaceted and can occur with a twisting motion exacerbated by planting the foot at high speeds, sudden sharp changes in direction, repetitive kicking, and lateral side to side motion [2527]. Injury usually results from disruption of the muscular components and/or fascial attachments to the pubis area [2830]. Diagnosis is often made with an accurate history and physical exam, and confirmed or rebutted with diagnostic imaging. A current investigator, Dr. Mark Zolan MD, at Lenox Hill Hospital in NYC is investigating the diagnostic accuracy of MRI imaging while the patient holds a Valsala maneuver to detect a tear of the posterior wall of the inguinal canal. Pain is often described as chronic, with point tenderness near the lower abdominal insertion, pubic tubercle, and can involve the adductor longus tendon origin as well [25, 30]. A typical physical exam will often reveal overall pelvic weakness with palpable tenderness over the pubic tubercle. The patient will often experience increased symptoms when asked to perform a resisted sit-up, and the abdominal area pushes outward upon execution of this movement. In addition, the patient may present with adductor and hip flexor weakness and overall pelvic instability [25]. Upon completion of a gait analysis, dysfunction can often be noted with the movement of the pelvis and femoral alignment of the lower extremities. The hallmark complaint of athletic pubalgia is a “deep” groin or lower abdominal pain with exertion. This pain tends to be deeper and more intense than an adductor or iliopsoas strain and is ipsilateral in nature. According to Kachingwe et al. [30] there are five signs that are indicative of a sports hernia: (1) a subjective complaint of deep groin/lower abdominal pain, (2) the pain is exacerbated with increased exertion such as sprinting, cutting, and sit-up and is relieved with rest, (3) palpable tenderness over the pubic ramus at the insertion of the rectus abdominus and/or conjoined tendon, (4) pain with resisted hip adduction at 0°, 45°, and/or 90° of hip flexion, and (5) pain with resisted abdominal curl up.

Nonoperative Treatment of Sports Hernia

Nonoperative treatment of sports hernia is often advocated as the first type of intervention for treatment. There is little evidence and few research papers support the effectiveness of conservative care; however, the majority of studies that have been conducted showed significant improvement after 6–8 weeks of physical therapy intervention [30, 31]. With little evidence to guide clinicians with the differential diagnosis and effective treatment of patients with athletic pubalgia or “sports hernias,” management of this condition has been diverse. While this lack of evidence-based research may not seem like a problem with nonoperative treatment, Table 17.3 reveals various pathological injuries that may present with similar signs and symptoms with overlapping findings upon exam and evaluation [28, 30, 32].

Table 17.3
Differential diagnosis

Differential diagnosis of groin pain

Hip-associated causes

Pubic-symphyseal causes

Inflammatory causes

Traumatic causes and stress fractures

Developmental causes

Neurological causes

Referred pain

Neoplastic causes

Differential diagnosis is important to ensure that the main cause or affliction is not being overlooked and the proper treatment is being administered. There is also the possibility of coexisting injuries, where more than one affliction causes groin pain, making it difficult to establish which injury is the main contributor to the pain and which is secondary. In fact, Larson et al. [33] found that when an athlete had a sports hernia and an intra-articular hip surgery concomitantly the success rate was much better than performing surgery on just one of the pathologies. Typically the patient has experienced these symptoms for months if not longer by the time a diagnosis of athletic pubalgia is determined. Given that the majority of cases of athletic pubalgia are insidious onset, determining the mechanism of injury is difficult and the patient may experience periods of improvement and episodic exacerbations making long-term success sometimes difficult. The main commonality of this injury is typically due to increased repetitive torque on the pubic symphysis during aggressive abduction/adduction of the thigh. This motion can lead to disruption of the aponeurosis of the rectus abdominis and the adductor longus tendon [1, 2, 28].

Rehabilitation can be performed on its own or coupled with steroid injections of the pubic symphysis or the adductor tendon origins, anti-inflammatories, and rest from activity. Clinical assessment of core stability, hip strength and flexibility, and identification of muscular compensation and imbalances are crucial [32]. Treatment should target strengthening and neuromuscular reeducation regarding timing and recruitment patterns during functional motion in addition to manual therapy techniques to manage soft tissue and fascial restrictions [31]. A comprehensive rehabilitation program to develop coordination and strength of the hip adductors, flexors, internal rotators, extensors, core stabilizers and lumbopelvic spinal musculature is important for an effective recovery. Table 17.4 is a list of examples of core and proprioceptive exercises to include in the beginning stages of a rehabilitation program.

Table 17.4
Lower abdominal and core exercises

Examples of beginner lower abdominal and core exercises

Posterior pelvic tilts with completion of exhalation

Posterior pelvic tilts with exhalation and bridging

Front and side planks with exhalation and maintaining pelvic neutral

Examples of proprioceptive exercises

Balance on unstable surface maintaining pelvic neutral (progress from double leg to single leg stance)

Balance on unstable surface while throwing and catching a ball (progress from double leg to single leg stance)

Balance on unstable surface using a BodyBlade® (progress from double leg to single leg stance)

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Mar 26, 2017 | Posted by in SPORT MEDICINE | Comments Off on Rehabilitation and Return to Activity Following Sports Hernia Surgery
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