Sports Hernia Rehabilitation Protocol (Hip Groin)

This protocol outlines a comprehensive physical therapy rehabilitation program for individuals diagnosed with a sports hernia (athletic pubalgia or groin pain). This is a guideline and must be individualized based on the patient's specific presentation, pain levels, functional goals, and progress throughout rehabilitation. Close communication between the physical therapist, physician, and athlete is crucial for optimal outcomes.

Pathophysiology

The term "sports hernia" is a misnomer, as it doesn't typically involve a true hernia (protrusion of abdominal contents). Instead, it describes a constellation of injuries affecting the soft tissues of the groin region, particularly the abdominal wall musculature (obliques, transversus abdominis) and adductor muscles (longus, magnus, brevis). Common findings include tears or strains in these muscles, avulsions of the adductor tendons, pubic symphysis instability, and nerve entrapments (e.g., obturator or ilioinguinal nerve). Repetitive twisting, turning, cutting, and forceful hip flexion/extension movements, common in sports like soccer, hockey, and football, contribute to the development of this condition. Imbalances between the strong hip flexors and relatively weaker abdominal muscles can also predispose individuals to injury.

Phase I: Protection (Acute Phase - Weeks 1-2)

Goals: Reduce pain and inflammation, protect the injured tissues, and begin gentle range of motion (ROM) exercises.

• Pain Management:
  • Relative rest and activity modification. Avoid aggravating activities.
  • Cryotherapy (ice packs for 15-20 minutes, 3-4 times daily).
  • Modalities (e.g., electrical stimulation, ultrasound) may be considered to manage pain and inflammation.
  • Consider physician-prescribed pain medication or NSAIDs if needed.
• Range of Motion Exercises:
  • Gentle pain-free active assisted ROM exercises for hip flexion, extension, abduction, adduction, and rotation.
  • Focus on controlled movements within pain limits.
  • Examples: Heel slides, pendulum exercises, supine hip circles.
• Isometric Exercises:
  • Begin with gentle isometric contractions of the abdominal muscles (e.g., abdominal bracing) and adductor muscles (e.g., squeezing a ball between the knees).
  • Hold for 5-10 seconds, repeat 10-15 times.
  • Ensure pain-free execution.
• Core Activation:
  • Diaphragmatic breathing exercises to promote core stability.
  • Pelvic tilts to improve lumbopelvic control.
• Avoid: Activities that provoke pain, such as running, jumping, and resisted hip adduction or abdominal exercises.

Phase II: Loading (Subacute Phase - Weeks 3-6)

Goals: Restore normal ROM, improve strength and endurance of the core and hip muscles, and gradually increase functional activities.

• Progression of Exercises:
  • Progress ROM exercises to active ROM and then to gentle stretching (e.g., hip flexor stretch, adductor stretch).
  • Introduce resisted hip flexion, extension, abduction, and adduction exercises using resistance bands or light weights.
  • Begin with high repetitions (15-20) and low resistance, gradually increasing resistance as tolerated.
  • Examples: Hip bridges, clam shells, side-lying hip abduction, standing hip extension.
• Core Strengthening:
  • Progress isometric core exercises to dynamic core exercises, such as planks (starting with modified planks on knees), side planks, bird dogs, and dead bugs.
  • Focus on maintaining proper form and avoiding compensatory movements.
• Agility and Balance Training:
  • Begin with simple balance exercises, such as single-leg stance with eyes open and closed.
  • Progress to agility drills, such as cone drills and ladder drills, focusing on controlled movements and minimizing pain.
• Cardiovascular Conditioning:
  • Begin with low-impact activities, such as walking or cycling, gradually increasing intensity and duration as tolerated.
• Criteria to Advance:
  • Pain-free ROM in all planes of motion.
  • Good strength and endurance of the core and hip muscles.
  • Ability to perform functional activities without pain or increased symptoms.

Phase III: Return to Function (Weeks 7+)

Goals: Restore sport-specific function, improve power and agility, and prevent re-injury.

• Sport-Specific Training:
  • Gradually introduce sport-specific activities, such as running, jumping, cutting, and kicking, under controlled conditions.
  • Focus on proper technique and biomechanics to minimize stress on the groin region.
  • Progress from low-intensity to high-intensity activities as tolerated.
• Plyometric Training:
  • Begin with low-impact plyometric exercises, such as jumping jacks and skipping.
  • Progress to high-impact plyometric exercises, such as box jumps and depth jumps.
• Advanced Core and Hip Strengthening:
  • Continue to progress core and hip strengthening exercises, focusing on power and endurance.
  • Examples: Medicine ball throws, resisted rotation exercises, single-leg squats.
• Return to Sport Criteria:
  • Pain-free participation in all sport-specific activities.
  • Full ROM and strength in the core and hip muscles.
  • Ability to perform functional testing without pain or increased symptoms.
  • Physician clearance.
• Maintenance Program:
  • Continue with a regular exercise program to maintain strength, flexibility, and core stability.
  • Focus on proper technique and biomechanics to prevent re-injury.

Common Special Tests

• Adductor Squeeze Test: Patient supine with knees bent. Examiner places a fist between the knees and instructs the patient to squeeze. Pain indicates adductor involvement.
• Resisted Hip Flexion Test: Patient supine. Examiner resists hip flexion. Pain indicates iliopsoas or rectus abdominis involvement.
• FABER (Patrick's) Test: Patient supine, ankle of tested leg placed on opposite knee. Examiner stabilizes the opposite hip and applies gentle pressure to the tested knee. Pain in the hip or groin indicates hip joint pathology or sacroiliac joint dysfunction.
• Pelvic Compression/Distraction Test: Patient side-lying. Examiner applies a compression force across the pelvis or a distraction force through the iliac crests. Pain suggests sacroiliac joint dysfunction.
• Gilmore's Groin Assessment (specific to palpation of inguinal floor): This is a more complex assessment that requires specific training, involving palpation of the superficial inguinal ring and cremasteric reflex.

Disclaimer: This protocol is intended for informational purposes only and should not be considered a substitute for professional medical advice. Always consult with a qualified healthcare provider before starting any new exercise program.