Return to Play from Sports Hernia

1. Return to Play from Sports Hernia By Tad Leusch MS ATC

2. Quick Overview of Sports Hernias • Sports hernias are different from other hernias in that they are not easily identified by an exam or imaging technology. They may only show up as groin pain that occurs during physical activity and disappears during inactivity. A tear in the Transversus abdominis is responsible for this hernia.

4. What are the symptoms of a sports hernia? • A sports hernia typically begins with a slow onset of aching pain in the lower abdominal region. Symptoms may include: • Pain in the lower abdomen • Pain in the groin • Pain in the testicle • Typically the symptoms are exacerbated with • Running • Cutting • Bending forward • Sports hernias are found in many types of athletes most commonly • Hockey players • Football players • Soccer players

5. How is a sports hernia diagnosed? • There are no diagnostic tests that can be used to detect a sports hernia. The diagnosis is made by the patient's history and physical examination. Other tests may be performed to rule out other causes of groin pain.

6. What is the treatment of a sports hernia? • Conservative Treatment • Ice • Rest • Anti-inflammatory medications • Physical Therapy • Surgery • Involves a patch of mesh-like material, held in place with surgical tacks. • Rehabilitation from surgery for a sports hernia usually takes about eight weeks.

7. Subject • Male • 21 year old • D1 College football player • Position: Cornerback • Demands of position: Linear running to explosive change of direction movements, backpedaling and opening of hips to change direction

8. History • Symptoms began approximately 1 year prior to August 2008 surgery date • Reported to the athletic training room following practice • Stated he felt a pop in his right groin during practice • No bulge was noted • No bruising was noted • Strength was 4/5 • ROM was equal compared bilaterally

9. Conservative Management • Athlete was allowed to return to play and continue normal weight training schedule • During this time he was receiving treatment for his pain which included: • Heat • Modalities (estim and ultrasound) • Stretching of the groin, hip flexor, abdominals, piriformis • Soft tissue release techniques including: • Foam rolling of leg and pelvic girdle • Softball rolling over involved side hip flexor and groin and well as piriformis • Strengthening exercises such as: • 4 way hip movements(adduction, abduction, flexion and extension) • Seated internal and external hip rotation with theraband • Ball squeezes with leg lifts • Swiss ball core strengthening exercises

10. Post Season Status • With conservative management, athlete was able to participate in all activities but felt limited due to pain • During the 4 week winter break period, athlete was instructed to go home and rest • If he felt his pain decrease, he was instructed to begin straight ahead jogging in order to maintain a level of fitness

11. Progress following 4 weeks of rest • When athlete return to campus, he stated that he was almost pain free • A slow return to play progression was initiated which included: • Progression of linear running which went well • Progression of explosive cutting drill during which pain returned which halted progression • Athlete was re-examined in March at which time an MRI was obtained • No hip pathology noted • Received a cortical steroid injection at the pubis symphysis which provide some relief

12. With the relief of pain following injection, running progression was initiated again • Athlete was able to achieve about 75-80 percent of speed before pain returned • Even with a significant amount of rest, anytime athlete would state his symptoms were decreasing and activity was ramped up, pain would return • This patterned continue on through the summer until athlete was unable to participate in any of the team workouts

13. Chief Complaints that Lead to Surgery • After approximately 1 year of conservative treatment, athlete was not able to fully engage in all activities • Pain became localized in the right groin area • Pain with squatting • Pain in lower abdominal area with core strengthening • Pain with explosive change of direction movements • Athlete was re-examined by the team physician and it was determined that he needed to be referred to Dr. Brad Pierce, a recognized surgeon that deals with sports hernias

14. Rehabilitation following Sports Hernia Repair • Research in this area is sparse • Protocol is very open • Generally speaking return to full activity is projected at 6 weeks • Typically we have been able to progress athletes back to full activity by 10-12 weeks

15. Surgeons Protocol for Rehabilitation • Straight line physical activity only for first 3 weeks • Start out with low impact exercises • By week 3 athlete should be back to jogging and running • Re-introduction of sporting activities between week 4 and 6 • Continue core strengthening and flexibility treatments

16. First 10 days following surgery • Athlete was seen approximately 3 days following surgery • Athlete was in noticeable pain upon entering the athletic training room • Walked with a slightly forward hunch due to pain • Initial treatment consisted of ice to control pain • After approximately 10 days following surgery, athlete was able to walk with normal gait and mild pain

17. 2-3 weeks Post Op • Week 2 athlete was able to walk on treadmill for 10 minutes • Exercises consisted of: • Isometric core strengthening • Gentle abdominal stretching • Ice following rehabilitation session • Week 3 • Pace was increased on treadmill but still at a walking pace • Progression of core strengthening • Body weight movement such as • Lunges • Side lunges • At week 4 athlete began to notice an increase in pain • Activity level was decreased until pain subsided: approximately 2 weeks

18. Weeks 4-7 • After pain subsided, athlete resumed progression of exercises • Core strengthening and machine upper body exercises which did not create a valsalva maneuver • Body weight movements progressed into movements with weight • Lunges • Squats • Side lunges • After approximately 4 weeks, athlete was able to transition to weight room activities

19. Weeks 8-9 • At week 8 athlete began running progression • Week 8 linear progression • 55 yard running (jogging to running) • Cross Field’s • Build ups • Week 9 Add in slow tempo change of direction • Box drill • 90 degree cutting drills • X pattern drills

20. Weeks 10-12 • Week 10 • Weeks 10 was a progression of tempo during linear and change of direction exercises • Begin to incorporate position specific drills • Week 11 • Continue drills from week 10 • Add reactionary change of direction movements • Week 12, athlete was given a recovery week

21. Weeks 13-16 • At week 13, athlete was allowed to progress into football practice activities • Individual drills for first 2 practices • Individual drills and 7on7 • Individual drills, 7on7, and 1on1 • No limitations by the middle of the 16th week

22. Why Twice As Long • Increase in pain during week 4 • Demands of the sport • Mentality of the athlete • As a Sports Medicine Staff we try to account for • Amount of whole body de-conditioning an athlete may have • Make sure that the athlete can tolerate activity level • Make sure not to rush return which may lead to other injuries