Treatment and Prevention of Sports Hernia
I have struggled with the enigma of sports hernia for years, always looking for the cure or at least a clue to prevention. In my work with hockey players, experience has taught me that the key to preventing sports hernias is specific soft tissue treatment to the adductor muscles, the abdominal aponeurosis, and the hip flexors. In addition, working in conjunction with a strength and conditioning coach is imperative for permanent resolution of this complex problem.
The following are some factors I consider when treating athletes demonstrating symptoms that suggest a sports hernia.
* I hypothesize that the adductors transfer force through the pubic symphysis with abduction and external rotation of the hip and trunk rotation to the contralateral side (as in a slap shot). This can cause a tearing of the abdominal aponeurosis when the adductor longus is lacking elasticity due to adhesions, fibrosis, or spasm. Since there is no tendon or ligament that connects these muscles, I look to Thomas Myers for an explanation. In discussing the Functional Front Line (FFL), he states, “These fibers form a fascial continuity with the abdominal aponeurosis that links the external oblique and the rectus abdominis muscles, and the line passes essentially along the outer edge of the oblique fascia to the pubis. Passing through the pubic bone and fibrocartilage of the pubic symphysis via a mechanical link, we emerge on the other side with the substantial tendon of the adductor longus.” (Anatomy Trains, pg.18). The pectinius and the adductor group muscles are partially involved. The adductor longus is the strongest hip flexor and develops the most adhesions.
*As a precursor to the adductor problems, the shorting of the psoas and decreased hip extension is the true source of problems in the adductor muscles, including the pectinius. Myers gives insight as to why the pectinius is related to psoas shorting thereby limiting hip extension. “On the medial side, we could follow the pectineus from the lesser trochanter over to the iliopectineal ridge. From here, with the connecting fascia of the lacunar ligament and only a slight change in direction, we can pick up the psoas minor (which is expressed as a muscle in about 51% of the population but is expressed as a fascial band in nearly 100%). The psoas minor runs on top of the fascia of the psoas major to insert, or reach its upper station, at the 12th thoracic.” (Anatomy Trains, pg. 206). Treatment of the psoas is a protocol I use on every athlete I treat, especially hockey players. Sarhmann emphasizes the importance of psoas lengthening and hip extension in normal gait. (Diagnosis and Treatment of Movement Impairment Syndromes, pg.26).
* Another factor often contributing to sports hernias is a lack of internal rotation of the hip. This is due to shorting of the external rotators of the hip that is initially caused by the shortened psoas and is also associated with a shortened and tight adductor longus muscle. If the hip moves into extension and is restricted or unable to move into full extension (due to shortened hip flexors), the athlete will externally rotate the hip to get additional range of motion. This chronic repetitive motion of external rotation causes eventual spasm of the external hip rotators, specifically the piriformis, superior & inferior gemmeli, quadratus femoris, and obturator internus. The gluteus medius is also frequently involved.
* Related to treating sports hernia is the importance of treatment to the obturator externus muscle. This shortened muscle will feel like a tight groin muscle but there is no relief from stretching or treatment to the adductor muscles. While skating, it feels like a sharp pain after full hip extension when first pulling the leg forward. The pain is usually relieved with ARTâ protocols in one or 2 sessions. Untreated the pain is debilitating.
*I find that hockey players who have tight adductors usually have adhesions and palpatory tenderness in the abdominal aponeurosis. Treating the pyramidalis muscle relieves symptoms in the abdominal aponeurosis. Early treatment to this area is successful in prevention of sports hernias. Many times the athlete will not know he has pain or restrictions in this area until it is palpated.
I have more than 20 years experience treating athletes and recognize that treating sports hernias is a humbling experience. I want to use every possible tool I can find to improve my treatment success. My work with Sean Skahan, of the Anaheim Ducks, has really helped. Integrating soft tissue treatment with strength and conditioning is certainly the direction most professional sports teams are moving.
All of the soft tissue treatment I use is Active Release Techniques (ART, activerelease.com). Please note that: the opinions expressed in this article are not the opinion of ART or Dr. Michael Leahy, the inventor. I will not go into a long explanation of ART except that there is simply nothing that compares to the results that ART provides. If you are interested in working with an ARTâ practitioner, be certain to use only certified practitioners with current credentials, which can be found at activerelease.com. I have been an ART provider for 14 years and continue to go to seminars simply because I learn new and better ways to treat injuries like sports hernias. I suggest you find an experienced ART provider and get some treatment yourself. I can assure you that you will benefit from the treatment and you will see how you can help the athletes you work with in a new way.
