EARLY REHAB FOR ANTERIOR LUMBO-PELVIC-HIP IINJURIES

Sports Hernia, Abdominal Strain, Osteitis Pubis, Adductor Strain...

These injuries have many labels and present differently in each individual but if your injured player doesn't warrant surgical intervention, the principles behind exercise intervention generally stay the same.

Where I think most rehab protocols miss the boat is in the reductionist approach to targeting specific tissues. In the grand scheme of things, I believe the tissue injured is often the least important. Because if the predisposing faulty movement patterns and strength deficits don't return to "normal" year after year he or she will likely suffer any of the following: an adductor longus strain, osteitis pubis, a rectus femoris strain, a sports hernia and so on.

Unfortunately, it becomes a never-ending cycle.

Granted, "contemporary" treatment generally consists of any or all of the following:

• Soft tissue release of the symptomatic region until the athlete reports decreased pain
• E-stim to the symptomatic region until the athlete reports decreased pain
• Corticosteroid injection into the symptomatic region then the athlete reports decreased pain
• Wall squats with a ball between valgus knees with little long-term improvement
• etc

But ultimately, the athlete never recovers 100%. Sometimes the athlete just ends up sitting out for more than a year until retirement then 2 years later finally "feels" better, and other times it simply spirals negatively into a vicious cycle and subsequently succumbs to several "failed" surgeries/repairs.

I don't think they're a lost cause and I truly believe that this really isn't an "orthopaedic" issue. Especially if your athlete is one that is willing to do whatever it takes physically to get better.

In no particular order, some of the things I look for below the pelvis initially are:

• Adductor length and quality
• Quadriceps length and quality
• Lateral hip stabilizer tone and quality
• Posterior hip capsule mobility

From a core integrity standpoint, I generally look for:

• Expiratory position ability of the lower rib cage
• Breathing pattern
• Abdominal tissue quality
• Cylindrical muscle activity
• Compensatory muscle activity in the "core"
• Ability to engage instantaneously

Once I have the big picture in mind, it is more than reasonable to restore tissue quality and tone. Especially in relatively nagging or recurrent cases, having a good manual therapist in your network do some hands on work would be valuable.

To assess, I think scouring the hip is a good place to start. A report of "pinching" is common in the anterior hip region so "cleaning up" the anterior-lateral hip is a nice way to regain mobility. My preference is via trigger point therapy with gentle passive movement.

Next, I generally want to see what the FABER test (Hip Flexion-Abduction-External Rotation) tells me. If the athlete reports a "pull" or tightness, I generally utilize a combination of Active Release Technique, Post Isometric Relaxation and the FAT Tool to the adductor region.

A manual Posterior-Anterior challenge (at 90 degrees of hip flexion in supine) of the hip will tell me if more posterior capsule hip mobility is needed and the Multi-Segmental Extension Top Tier from the SFMA I generally perform early on will let me know if I have to go after the paraspinals.  Trigger point therapy generally works well to relax the paraspinals but sometimes Active Release is necessary.

Every now and again, the presence of a tendinopathy will warrant some IASTM but I'd say this is rare. But all in all and as I said earlier, I want to make sure that nothing is holding me back once the athlete is on the floor.

I think often many of these injuries result from compensatory mechanisms. Compensatory whereby the body robs Peter (the muscles inferior/superior to the pelvis) to pay Paul (the opposite side of the Pelvis). And as a result, tissue overload.

So I generally start with a scaled back version of the Kolar Dying Bug to isolate and wind down the hip and/or groin musculature if necessary. I like this as a starting point because this provides the athlete with a base level of TL junction and core stability.

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Several key points with this exercise:

• The wall push is the help the athlete achieve expiratory position (if they can't get it on their own, passive positioning or balloon breathing may be warranted)
• 360 degrees of cylindrical muscle activity is paramount
• This includes the ability to pressurize the lower lateral abdominal region just medial to the ASIS
• The hips are both passively (not shown) and actively rotated internally and externally to make sure that they're free and easy. Again, we don't want compensatory muscle activity here so it is important to keep the hips loose

Once they can demonstrate the ability to isolate free hips, you can progress them into the standard Kolar Dying Bug.

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Key Points:

• I like kicking the hips out over dropping the heels but ultimately you have to find the most appropriate exercise along the regression/progression continuum
• Reverse Russian Pyramids work best in my opinion, either holding for time (10 seconds) with respiratory control and optimal cylindrical activity or better yet, counting down breath cycles.
• If they can't get cylindrical activity either in this exercise or the one above, tennis balls or a weight belt may help with indirect cueing (see below).

Aside from achieving stability on their back, the athlete must also stabilize on all fours. The Kneeling Plank Walkout is a decent choice here.

Points with the Kneeling Plank Walkout

• I've been using this more lately as opposed to Quadruped Rockback RNT, because, sometimes the athlete will report pinching in the hips with the latter. That said, if compensatory activity is absent, I have no issues with Q-ped Rockbacks.
• It's important to ensure rib cage positioning here as well as maximizing hip translation. You don't want lumbar extension here. This is an anti-extension exercise so make sure you watch for it...sweat the small stuff!
• Reverse Russian Pyramids will be a common theme throughout

Ipsilateral patterns progress to contralateral patterns as per DNS so depending on whether I need to improve hip control or that of the lumbo-pelvic-hip complex, I try to choose the most appropriate intervention.

For hip control, I like Single Leg Glute Bridge vs the Wall Progressions:

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Key Points:

• Because I want to ensure core control, I'll start with "vs the Wall" versions if necessary. And "if necessary" means most of the time in this population
• The version you see above is the Single Leg Glute Bridge but you can start with Double Leg Bridge into Single Leg Hold with Miniband, Single Leg Bridge with Miniband, Cook Hip Lift or other.

Valslides are staples when working with athletes suffering from these injuries and are key to improving lumbo-pelvic-hip control when on all fours. Make sure you attack each hip in both their supporting and stepping limb functions as if there's anything we've learned from recurrent ACL injuries, it's that far too often we forget about the "good" leg.

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Valslide Hip Stability Points:

• Control, control, control.
• Just in case, make sure you fully emphasize control in this exercise. Better yet, make sure you do so with every exercise, but especially this one.
• The neck and the thoraco-scapulo-humeral regions are important here, as in everywhere, so don't forget to centrate
• Underdo the range of translation in this exercise and make sure they nail it. It's easy to go awry here, so again, sweat the small stuff

Now as you can see, these are exercises you can integrate into the early phases of rehab but ultimately, you'll need to progress them into more upright positions. I may or may not, post upright progressions sometime down the road but for these athletes, I find that squatting with a ball between an athlete's legs is far too commonly prescribed. With the information Tyler et al prescribed several years ago, I do think med ball holds can be worked into a strength and conditioning program but in rehab, the above exercises may be better alternatives.

I hope this article gives you some ideas when it comes to rehabbing athletes with these injuries that plague two of our sport, but if there's anything you can take away it's this...

...being diligent and meticulous with motor control will go a long way.