Sports Hernia Rehabilitation Protocol

This rehabilitation protocol provides a guideline for physical therapists managing patients diagnosed with a sports hernia (athletic pubalgia). It is crucial to tailor the protocol to the individual patient's specific needs, pain levels, functional limitations, and surgical findings (if applicable). Close communication with the referring physician is essential throughout the rehabilitation process.

Pathophysiology

A sports hernia is not a true hernia. It's characterized by chronic groin pain due to injury to the soft tissues of the lower abdomen or groin area. This often involves strains or tears of the muscles, tendons, or ligaments in the lower abdominal wall, particularly where these structures attach to the pubic bone. Common structures involved include the rectus abdominis, adductor muscles (especially adductor longus), and the transversalis fascia. The condition often results from repetitive twisting, turning, and sprinting movements, leading to an imbalance between the strong hip adductors and the weaker abdominal muscles. Nerve entrapment, particularly of the ilioinguinal or genitofemoral nerves, can contribute to pain.

Phase I: Protection and Pain Management (Weeks 1-3)

Goals: Decrease pain and inflammation, protect injured tissues, initiate gentle muscle activation, and restore basic range of motion.

• Activity Modification: Complete rest from aggravating activities. Avoid activities that provoke pain, such as running, jumping, kicking, and resisted hip adduction/abdominal exercises.
• Pain Management:
  • Cryotherapy: Apply ice packs for 15-20 minutes every 2-3 hours to reduce pain and inflammation.
  • Pharmacological Management: Encourage adherence to prescribed pain medication as directed by the physician (e.g., NSAIDs).
  • Gentle Soft Tissue Mobilization: Address muscle spasm and trigger points in the adductors, abdominals, and hip flexors.
• Range of Motion (ROM):
  • Gentle hip ROM exercises in pain-free ranges (flexion, extension, abduction, adduction, internal and external rotation).
  • Pelvic tilts and gentle trunk rotation exercises.
• Muscle Activation:
  • Isometric adductor squeezes (gentle contraction against resistance without movement). Hold for 5 seconds, repeat 10-15 times.
  • Isometric abdominal contractions (drawing the navel towards the spine). Hold for 5 seconds, repeat 10-15 times.
  • Gluteal sets (squeezing the glutes). Hold for 5 seconds, repeat 10-15 times.
• Education: Educate the patient on proper posture, body mechanics, and activity modification techniques. Emphasize the importance of avoiding activities that provoke pain.

Phase II: Progressive Loading and Strengthening (Weeks 4-8)

Goals: Gradually increase muscle strength and endurance, improve core stability, and begin to reintroduce low-impact activities.

• Progressive Strengthening:
  • Adductor strengthening: TheraBand adduction, seated adductor machine (light resistance), standing hip adduction.
  • Abdominal strengthening: Modified crunches, pelvic bridging, dead bugs, side planks (progressing to full planks). Emphasize proper form and core engagement.
  • Hip flexor strengthening: TheraBand hip flexion, standing hip flexion.
  • Gluteal strengthening: Hip thrusts, single-leg glute bridges, clam shells, monster walks.
• Core Stability Exercises:
  • Progress from static core exercises (e.g., planks) to dynamic core exercises (e.g., bird dog, Pallof press).
  • Focus on maintaining a neutral spine during all exercises.
• Low-Impact Aerobic Exercise:
  • Begin with walking, cycling, or elliptical training. Gradually increase the duration and intensity as tolerated.
  • Avoid activities that provoke groin pain.
• Proprioceptive Training:
  • Single-leg stance exercises on stable and unstable surfaces.
  • Balance board or wobble board exercises.
• Flexibility: Continue stretching exercises for hip flexors, adductors, hamstrings, and abdominals.

Phase III: Return to Function (Weeks 9-12+)

Goals: Restore sport-specific skills, improve power and agility, and prepare for return to full activity.

• Sport-Specific Training:
  • Gradually reintroduce sport-specific movements, such as running, jumping, cutting, and kicking.
  • Focus on proper technique and biomechanics.
  • Monitor for pain and adjust the program accordingly.
• Plyometric Training:
  • Begin with low-impact plyometrics (e.g., jump rope, box jumps) and progress to high-impact plyometrics (e.g., single-leg hops, depth jumps).
  • Ensure proper landing mechanics to minimize stress on the groin.
• Agility Training:
  • Cone drills, shuttle runs, and agility ladder drills.
  • Focus on quick changes of direction and maintaining balance.
• Strength and Power Development:
  • Continue to progress strengthening exercises with increased resistance and volume.
  • Incorporate power exercises, such as Olympic lifts or medicine ball throws.
• Gradual Return to Sport:
  • Gradually increase the duration and intensity of training sessions.
  • Monitor for any signs of pain or recurrence.
• Maintenance Program: Develop a long-term maintenance program to prevent recurrence of the injury. This should include regular stretching, strengthening, and core stability exercises.

Common Special Tests

These tests can help to identify the source of groin pain and rule out other potential diagnoses.

• resisted hip adduction test: With the patient supine, the therapist resists hip adduction. A positive test is pain in the groin.
• resisted abdominal crunch test: Patient performs a crunch while the therapist resists. Pain in the groin constitutes a positive test.
• Palpation: Palpation of the pubic symphysis, adductor tendons, and abdominal muscles to identify areas of tenderness.
• FABER test (Patrick's test): Evaluates for hip joint pathology.
• Scour Test: Evaluates for hip joint pathology.
• Adductor Squeeze Test: With the patient supine and knees bent, the therapist squeezes a ball between the patient's knees. Pain in the groin indicates a positive test.

Disclaimer: This protocol is intended as a general guideline and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.