NON-SURGICAL TREATMENT OF A PROFESSIONAL HOCKEY PLAYER WITH THE SIGNS AND SYMPTOMS OF SPORTS HERNIA: A CASE REPORT
Abstract
Study Design:
Case Report
Background:
Injury or weakness of lower abdominal attachments and the posterior inguinal wall can be symptoms of a “sports hernia” and an underlying source of groin pain. Although several authors note conservative treatment as the initial step in the management of this condition, very little has been written on the specific description of non-surgical measures. Most published articles favoring operative care describe poor results related to conservative management; however they fail to report what treatment techniques comprise non-operative management.
Case Presentation:
The subject of this case report is a professional ice hockey player who sustained an abdominal injury in a game, which was diagnosed as a sports hernia. Following the injury, structured conservative treatment emphasized core control and stability with progressive peripheral demand challenges. Intrinsic core control emphasis continued throughout the treatment progression and during the functional training prior to return to sport.
Outcome:
The player completed his recovery with return to full competition seven weeks post injury, and continues to compete in the NHL seven years later.
Discussion:
Surgical intervention has been shown to be effective in the treatment of the “sports hernia.” However it is the authors’ opinion that conservative care emphasizing evaluation of intrinsic core muscular deficits and rehabilitation directed at addressing these deficits is an appropriate option, and should be considered prior to surgical intervention.
BACKGROUND
Groin pain is a common complaint in athletics and a source of frustration for many athletes and clinicians alike. The incidence has been reported as high as 5% of all athletic injuries1 and often is poorly understood due to its potential complexity of etiologies. In a survey of hockey related injuries, the groin accounted for 15% of all injuries leading to lost competition time.2 In addition to basic adductor muscle strains, several other structures and conditions have been identified as possible contributors to groin pain/dysfunction. Osteoarthritis of the hip,3 labral tears and femeroacetabular impingement,4 osteitis pubis,5,6 stress fractures of the pubic ramus and femoral neck,7 various nerve entrapments (including genitofemoral,8ilioinguinal,7,9,10 lateral femoral cutaneous,7,8 and obturator nerves7,11,12) iliopsoas strains and bursitis,7,13and intrapelvic pathology are included in a partial list of possible causes. One of the most difficult causes of chronic groin pain to identify is a combination of signs and symptoms referred to as the sports hernia.14,15,16
Hackney14 defined the “sports hernia” as “a weakness of the posterior inguinal wall resulting in an occult (medial) hernia”,14,15,17,18 but recently this definition has expanded to more broadly include injuries to the abdominal wall and supporting musculature (Figure 1). Some authors have noted a correlation between the sports hernia with other muscular injuries about the pelvis, most commonly injuries of the adductors.17,18,19It has also been suggested that this injury occurs bilaterally14,19 and is related to kinematics of the trunk, pelvis and lower extremities. The prevalence of this injury has been shown to be higher in sports that involve cutting, pivoting, and quick powerful changes in direction such as soccer, ice hockey and football.17,18,19 In one report sports hernia was noted to be the underlying cause in as high as 50% of athletes with chronic groin pain.20
Abdominal Anatomical Diagram (Used with permission of Mark Combs, Aurora, CO).
Subjective histories involving the onset of groin pain vary depending on the activity of the athlete and the circumstances surrounding the injury. Injury can occur from a specific incident usually associated with cutting and planting of the lower extremities at speed or with contact activities.17,19 However most often groin pain is of a chronic nature,8,14,17,18,20,21,22,23,24 occurring insidiously and is related to repetitive stresses incurred across the pelvis and associated muscular attachments.14,17,18 Common subjective symptoms may include pain with strenuous activity, resolution of or minimal pain with rest, and unilateral or bilateral inguinal and adductor pain.18,19
Objective clinical findings rarely include a palpable hernia.19,25,26 However, palpation can include tenderness of the lower abdominal/inguinal ligament region,15,18,19,25,26 pubic tubercle,14,15,18,25 pubic symphysis,14,19,27 and the adductor muscles of the thigh.15,18,19 In addition, pain may be elicited with stretch of the adductors, resisted hip adduction, and the sit-up maneuver, due to contraction of the rectus abdominis.15,19 Hölmich et al28 evaluated the intra-observer and inter-observer reliability of nine examination tests for groin pain among four experienced clinicians. These included: strength testing of hip adduction, strength testing of the psoas muscle, strength testing of abdominals (rectus abdominis and obliques), palpation of the adductor longus at the pubic bone, palpation of the pubic symphysis, palpation of the rectus abdominis at the pubic bone, palpation of the psoas muscle, passive adductor stretching, and iliopsoas muscle length testing. The percentage of intra-observer agreement was over 90 for all tests except the resisted psoas muscle test (85%). Likewise, the resisted psoas muscle test was the only test that showed poor reproducibility and low inter-observer agreement. No determination was made in the study by Hölmich et al regarding the number of tests necessary to indicate a positive diagnosis of a sports hernia. In 2000, Meyers et al19 published a study reporting the physical findings of 157 patients (140 male, 17 female) prior to pelvic floor repair. Palpation results proved to be somewhat variable, with 35% of this sample demonstrating pain with palpation of the proximal adductor longus tendon and insertion, 9% with pain of the pubic symphysis, and only 7% with palpable tenderness of the lower abdominal and inguinal regions. Of significance in Meyer’s study were the findings in which resisted adduction produced pain in 88% of this population, while resisted sit-ups produced pain in only 46% of this group.
Previously, diagnostic imaging was reported to be inconclusive in the identification of the sports hernia.19,26 Several authors noted magnetic resonance imaging (MRI) to be effective for ruling out underlying and associated pathology, but that it offered no significant findings in patients with the diagnosis of a sports hernia.17,23,29,30 More recent authors suggest improved imaging techniques utilizing a large field-of-view magnetic resonance (MR) survey of the pelvis, in combination with high-resolution MR of the pubic region to be an effective tool for evaluating athletes with the potential diagnosis of sports hernia.31,32 These protocols are noted to have improved accuracy in identification of adductor tendon and abdominal injury.33 It is suggested that greater understanding of musculoskeletal anatomy of the pubic region offered by these MR image findings, and specific patterns of pathology associated with athletic pubalgia may aide in the identification of the sports hernia.33,34,35
With the lack of objective findings demonstrated using diagnostic methods such as radiographs, ultrasound, and computerized tomography (CT), the definitive diagnosis of a sports hernia has proven difficult without surgical exploration. Diagnosis most often is achieved following the exclusion of other potential pathology.36 After other potential sources of groin pain have been eliminated, focus can turn to the classic symptoms described by athletes with sports hernia. These symptoms can include a subjective complaint of groin and/or abdominal pain, pain which increases with activity and subsides with rest, tenderness over the pubic ramus/lateral border of the rectus abdominis/conjoined tendon, pain with resisted hip adduction, and pain with resisted abdominal curl-up.37 Unfortunately these symptoms exist with numerous other pathologies and the most accurate diagnostic method is surgical exploration and identification.
Treatment options have typically included conservative methods such as modalities, physical therapy, and anti-inflammatory medication, followed by surgical repair when non-operative treatment fails. While numerous authors have reported exceptional success rates following surgical repair of the “sports hernia”,18,19,21,26,35,38,39 little has been published regarding conservative treatment of this pathology. Several authors report surgical treatment of patients who did not respond to conservative measures,24,26,39,40,41 however those reports fail to specify the non-surgical measures incorporated prior to the surgical procedure, vaguely referring to them as rest and physical therapy. While several authors suggest noninvasive treatment as an initial alternative to surgery,22,42 others state this to be ineffective.19,26,43
In a recent case report, six collegiate athletes were diagnosed with a sports hernia using five classic signs and symptoms which the authors referred to as the “cluster of five”. These include: complaints of deep groin/lower abdominal pain, exacerbation of pain with sports activity which is relieved by rest, tenderness with palpation of the pubic ramus, pain with resisted hip adduction, and pain with resisted sit-up test.37 Of these athletes, three of the individuals were treated non-surgically and three surgically. While postoperative results were favorable for the surgical cases, the non-surgical patients did not have a long-term follow-up to adequately evaluate the effectiveness of the conservative treatment option used.
To the knowledge of the authors, no literature has been published describing the long-term follow up of the athlete with a non-surgically treated sports hernia. The purpose of this case report is to describe the non-surgical management of a professional athlete with the characteristic signs and symptoms of a sports hernia.
CASE DESCRIPTION
At the time of injury, the subject was a 26-year-old ice hockey player who had played in the NHL for 4 years. No history of groin or abdominal injury was noted prior to this incident. The injury occurred during the second period of an NHL contest. The player was turning to his left with weight on both skates when he was pushed abruptly in the back by an opponent (Figure 2). During contact, the player’s trunk was forced into extension followed by right hip abduction and extension as his weight was transferred to his left skate (Figure 3). Following the forcible contact from the opponent, the subject’s trunk and upper body moved into flexion as he struggled to recover and maintain his balance. The player reported experiencing an immediate sharp pain in the lower abdomen and right groin region during contact. He was unable to complete the rest of the game because of the acute pain and disability associated with the injury.
Player Position Prior to Injury (Used with permission of Mark Combs, Aurora, CO).
Player Position at Impact/During Injury (Used with permission of Mark Combs, Aurora, CO).
Upon evaluation the following day, the athlete reported significant right lower abdominal and groin discomfort with all activity including ADL’s such as basic trunk mobility of rolling in bed, sit to stand, and walking. The athlete was observed ambulating in a protected, flexed-trunk posture with difficulty moving from sitting to supine. No effusion or ecchymosis was noted over the lower abdominal or right thigh region. Physical examination revealed trunk AROM limited by pain; right hip AROM limited approximately 25% by sharp abdominal/groin pain in all planes of motion; hip strength 3-/5 limited in flexion and adduction by pain; 4/5 right hip flexion strength when passively placed in 90 degrees of flexion; pain with attempted abdominal curl-up test; and pain with palpation of the right lateral rectus abdominis border as it inserted on the pelvis, as well as pain in the inguinal ligament region and right adductor longus tendon. The physician found no palpable defect or hernia. An MRI was performed with no significant abdominal or adductor findings, as well as an absence of pubic symphysis pathology. Following the patient history, physical examination and MRI results, sources of injury such as back/pelvis and hip joint dysfunction, neural entrapment, and internal disorders were ruled out. A diagnosis was then made of sports hernia.
The decision was made to treat the subject’s injury with a conservative approach due to the physical findings, insignificant MRI results, and the experience of the physician and medical staff. For the purpose of this case report, the rehabilitation program can be described in three basic phases: Phase 1 – pain management/initiation of flexibility and stabilization, Phase 2 – strength and stability progression, Phase 3 – functional progression and return to sport. No time frame was assigned to each phase of rehabilitation, rather, the player’s subjective responses and objective clinical findings were used to guide advancement between phases.
Phase 1: Pain Management and Initiation of Stabilization Physical Evaluation:
Upon evaluation two days post injury, this patient’s findings are summarized in Table 1:
Pain level was rated with a verbal analog scale from 0 to 10, where 0 represents an absence of pain, and 10 represents the worst pain imaginable. The patients’ resting pain level was rated 3/10, and 8/10 with activity such as hip flexion and trunk flexion. Pain was also noted with basic bed mobility and coughing. Palpation revealed tenderness over the right lateral aspect of the pubic symphysis/rectus abdominis insertion, anterior aspect of the superior pubic rami as well as the adductor longus origin and tendon.
Trunk AROM was found to be within normal limits for all motions except extension, during which discomfort was noted over the lower abdominal region. Active range of motion of the right hip was limited secondary to pain in all planes. Passive range of motion for the involved hip joint was unremarkable with the exception of abduction and extension. Abduction was limited approximately 10% secondary to adductor discomfort proximally, while extension was limited approximately 10% secondary to discomfort over the anterior aspect of the hip and lower abdominal region.
Muscle strength was reduced in abdominal and hip muscle groups, both primarily due to discomfort. The abdominals were assessed following Kendall’s testing procedure for rectus abdominis, external obliques and internal obliques.44 Abdominal testing was graded 3+/5 for rectus abdominis and external/internal obliques. The ability to activate the transversus abdominis (TrA) was evaluated by manual palpation just inferior and medial to the pelvic ASIS landmark where it is most superficial,45 using the abdominal drawing-in maneuver in the supine position.46 Additional evaluation was performed with use of a pressure biofeedback cuff47 for this same contraction, and control of lumbopelvic neutral position.48,49,50,51 When palpating TrA during attempted contraction, the purpose was to feel for tightening without protrusion of the obliques or rectus abdominis. Use of the pressure biofeedback involved placing the pressure cell under the lumbar spine just superior to the buttocks with the patient lying in a supine position with both knees bent. The pressure cell was then inflated to 20 mmHg as indicated by the pressure gauge, and the patient instructed to perform an abdominal drawing-in exercise with pelvic floor contraction52 moving the pelvis from an anterior tilt into a neutral pelvic position. As the abdominal drawing-in exercise was performed the pressure gauge reading should increase with a goal of 40 mmHg which was monitored by the patient visually. The ability to attain a neutral pelvic position and then maintain the needle position on 40 mmHg was necessary before adding peripheral exercises with upper and lower extremities. The athlete was unable to actively contract the transversus abdominis when assessed with palpation, and unable to control a neutral trunk position when assessed with pressure biofeedback while attempting the abdominal drawing-in maneuver supine.
Hip strength was tested following the manual muscle testing procedures outlined by Kendall44 with the exception of adduction. Adduction was tested following the guidelines established by Dos Winkle,53 in which testing is performed at 0, 45 and 90 degrees of hip flexion. In addition hip adduction was tested at 0 degrees of hip flexion with the patient holding both legs just off the table unsupported. The author has found this test to be most difficult and painful in individuals with symptoms of sports hernia. The subject’s right hip was graded 3-/5 for hip flexion, extension, internal and external rotation, adduction in neutral with elevation, and 3/5 for adduction in all other positions. Hip abduction was graded 4-/5.
Special Tests: Segmental lumbar and pelvic passive accessory motion testing was evaluated and assessed.54Manual evaluation of segmental motion has been shown to be reliable with experienced clinicians.55 While the interrater reliability with manual evaluation has proven to be poor, Gonnella et al reported good intrarater reliability with testing of joint mobility.54 Lumbar segmental mobility was found to be normal, however pelvic alignment and mobility were dysfunctional upon evaluation. Position testing of pelvic landmarks56,57 demonstrated a posterior rotated position of the right ilium on the left sacrum. Mobility testing demonstrated hypo-mobility of the right sacroiliac joint (SIJ).53,56,57 Passive accessory mobility testing of the hip was normal and equal bilaterally.53,55,76
Functional level was assessed with emphasis on ambulation and activities of daily living. The subject reported minimal discomfort with normal cadence walking; however did have abdominal and proximal deep adductor discomfort with ascent of stairs. This required climbing with single step progression and the assistance of the hand rail. In addition, considerable discomfort and difficulty were noted with sitting to supine and supine to sitting maneuvers such as getting in and out of bed.
Phase 1 Interventions:
The subject received manual therapy intervention and exercise rehabilitation 5 days a week. The first phase of treatment focused on pain management as well as early initiation of stabilization and exercise. Cryotherapy and interferential electrical stimulation58,59,60,61 were implemented due to their anti-inflammatory and analgesic effects. Manual therapy focused on soft tissue mobilization62 to address muscular tightness and length of hip musculature including flexors (iliopsoas, rectus femoris, tensor fascia latae), adductors (pectineus, adductor longus, adductor brevis and adductor magnus), and gluteals (gluteus maximus, gluteus medius and gluteus minimus). Soft tissue techniques were performed in a pain-free range of motion to avoid tissue trauma. Pelvic mechanics and mobility were treated using a left side lying technique with manual contacts of the therapist producing and anterior rotation of the right innominate.53,56This technique was performed using Grade III and IV mobilizations as well as grade V manipulation. Mobilization was performed with 5 sets of 20 repetitions. Treatment was discontinued when position and mobility were re-tested and assessed to be within normal limits (WNL) as compared to the opposite side.
Due to lower abdominal discomfort, the subject was unable to perform land based strengthening and stabilization training. Because of these limitations hydrotherapy was introduced with a pool exercise program taking advantage of the benefits of buoyancy on the reduction of weight bearing and tissue stresses, as well as the potential abdominal support provided due to hydrostatic compression of the water.63Aquatic exercise included walking, hip strengthening with straight leg swings against water resistance as tolerated by pain, bilateral squats, and modified trunk stability while performing the abdominal drawing in maneuver. As the patient was able to control the pelvis and trunk with the drawing-in stability exercise in the pool, knee lifts (within pain-free abilities only) were added to the exercise program. Once the subject was able to tolerate and control basic exercises in the weight reduced environment of the water, a land-based stabilization program was initiated to address deficits in trunk, hip and pelvic stability. Phase 1 of rehabilitation lasted four days.
Criteria for advancement to Phase 2 of rehabilitation included resting verbal analog pain scale rating of “0”, pain-free ADL’s including ambulation and ascent of stairs, and the ability to tolerate land based supine trunk stabilization training.
Phase 2: Stability and Strength Progression Physical Evaluation:
Following Phase 1 of the athlete’s rehabilitation, the findings were as follows:
Pain level was rated at rest 0/10 or no pain, and 3/10 during moderate intensity activities including pool jogging, land based trunk stabilization, and biking. No pain was noted with palpation of the right adductors, and minimal pain with palpation over the right lower abdominal region. Discomfort was noted over the right lower abdominal region with the resisted abdominal crunch test (single repetition). The resisted abdominal crunch was performed to test not only rectus abdominis strength, but also the attachment along the pubis for pain with resistance.
Trunk AROM was WNL for all motions except extension in which mild discomfort/tightness was noted over the lower abdominal region at end range. Active range of motion of the involved hip was WNL in all planes with the exception of right hip extension that was limited by approximately 25%. Passive range of motion for the involved hip joint was WNL all planes.
Right hip strength was improved in all planes of motion to 4+/5, with the exception of adduction, which tested 4/5 with mild discomfort. The rectus abdominis improved to 4-/5 while external obliques and internal obliques were 4/5 with manual muscle testing scores. Manual palpation testing demonstrated that the athlete was able to initiate an active contraction of TrA and control a neutral trunk position supine during pressure biofeedback evaluation following guidelines outlined earlier.
Special testing found pelvic position and SIJ mobility to be WNL.
Functional level was improved and the patient was able to accomplish pain free ambulation, ascent and descent of stairs as well as full bed mobility with minimal discomfort. Pool exercise of moderate intensity as described in phase one interventions was tolerated well.
Phase 2 Interventions:
The second phase of rehabilitation began when the subject was able to tolerate supine transversus abdominis training with pressure biofeedback without pain. The subject continued to receive manual therapy interventions and exercise rehabilitation progression 5 days a week by the same physical therapist. The player was evaluated daily for trunk and hip ROM and strength, as well as with palpation of hip and abdominal musculature for tightness and pain. Following evaluation, manual therapy intervention consisted of soft tissue mobilization to address muscular pain and tightness described in phase 1. All soft tissue mobilization was performed in a minimal to pain-free manner to avoid further trauma. Modalities including IFC and cryotherapy continued, with the goal of reducing the risk of inflammation post treatment.
Exercises in this phase were initially based on a modified “dying bug” progression,64 with abdominal drawing-in and pelvic floor co-contraction to facilitate TrA recruitment. Activation of the TrA was initiated with the subject in the supine position due to the comfort of this position, ease of monitoring TrA activity by the therapist, and the ability of the therapist to instruct the subject in volitional control of TrA function in this position. Stabilization continued with progression to quadruped, kneeling, and half-kneeling positions, and eventually to standing activities which promoted additional muscular recruitment from multifidus, psoas, gluteals, and obliques.56,65,66 Exercises incorporated reciprocal upper and lower extremity motion with resistance bands, and activity progression stressing all planes of motion while controlling stability of the trunk and pelvis. Initially focus was directed on intrinsic trunk stabilization with the ability to contract TrA properly and maintain lumbar neutral in supine (Figure 4). As TrA control improved, peripheral demands were added, progressing to the ability to control the neutral pelvic position in supine with unsupported bilateral upper and lower extremities (Figure 5). Once this was achieved weight bearing exercise emphasizing lumbar neutral control with upper and lower extremity resisted motion was introduced in all planes including forward and lateral lunge walking, and rotational patterns (Figures 6–10). Difficulty was increased as the patient mastered each specific task with regard to hip, pelvis, and trunk components.
Supine Pelvic Neutral Position.
Supine Position with Reciprocal Upper and Lower Extremity Motion.
Standing Pelvic Neutral Position – Anterior View.
Standing Lateral Lunge Walk.
Standing Pelvic Neutral Starting Position – Lateral View.
Standing Forward Lunge Walk.
Standing Trunk/Pelvic Rotation.
Hip strengthening with an emphasis on gluteus medius and maximus muscle groups was incorporated into phase 2 treatment. This included bilateral and unilateral bridging, side-lying abduction leg lifts, and standing resisted hip abduction and extension. Weight room strengthening exercises were also initiated in this phase and performed under the direction of the primary author beginning with bilateral machine activities such as leg press, hamstring curls, and quadriceps extensions. This was progressed to unilateral performance of each, and then to weight bearing activities such as wall squats and weighted lunges in all planes of motion. Lunges were performed with a gradual increase in step length to increase difficulty. Resistance training utilized a 10 repetition maximum (RM) per set routine to stress muscular fatigue and build lower extremity strength during this phase.67 These activities were monitored closely for discomfort and correct performance, with verbal and tactile cuing for emphasis of lower abdominal/pelvic floor control.
Aquatic therapy continued with advancement of intensity including forward jogging, backward running, and lateral shuffles, with progression to sprints emphasizing hip motion and cadence. The pool used was 25 meters long and 5 feet deep. Running shoes were worn for foot protection. As higher intensity running was tolerated, the subject was timed during the pool runs. Goals were set prior to each aquatic treatment for repetitions at maximal effort, racing against previous best times. Verbal cuing was used to stress TrA contraction while maintaining trunk/pelvic neutral control during increasing efforts of exercise. In addition, kick board swimming was initiated and advanced with timed laps to emphasize hip strength and speed.
Balance and proprioceptive exercises were initiated and emphasized during this phase of rehabilitation beginning with single and multi-plane wobble boards, progressing to unilateral lower extremity balance activities similar to the star excursion test.68 Balance reach exercises involved unilateral lower extremity weight bearing while dynamically reaching in various planes of motion for distance with the upper and lower extremities. This exercise was used not only for training, but evaluation as well. Initial measures while balancing on the right lower extremity demonstrated a significant asymmetry with upper and lower extremity reach as compared to balancing on the left lower extremity. This deficit was approximately 25%. Recent research has suggested a correlation between core stability and star excursion test results.69
Criteria for advancement to phase 3 included a verbal analog pain rating of minimal (1 on a scale of 0 to 10 as described previously) with moderate effort exercise, 5/5 MMT values for abdominals and hips, pain-free progression of standing stability exercises (Figures 3–7) with resisted bands in forward and lateral directions, pain-free pool sprinting 25 meter length x 40 seconds, star excursion lower extremity reach distance 80% involved versus noninvolved, and unilateral leg press 1 repetition maximum (RM) 90% involved versus noninvolved leg.70 The second phase of rehabilitation lasted 14 days.
Phase 3: Functional Progression and Return to Sport Physical Evaluation:
Following Phase 2 of this athlete’s rehabilitation, the findings were as follows:
Pain level was rated at rest 0/10 or no pain, and 1/10 during moderate/high intensity activities including pool running, trunk stabilization, and biking. No pain was noted over the adductors or right lower abdominal region with abdominal crunches.
AROM of the trunk was within normal limits for all motions including extension, and WNL for the right hip in all planes.
Manually tested hip strength was 5/5 for all hip muscle groups including the adductors. The rectus abdominis, external obliques and internal obliques all tested 5/5 as well. Pressure biofeedback evaluation found the subject was able to contract and control the trunk using the TrA in supine, holding the pelvis in neutral while performing upper extremity flexion with reciprocal lower extremity extension with a resistance band (Figures 4 and and5).5). Palpation evaluation of lower abdominal tone continued in weight bearing positions to provide feedback to the subject for the desired abdominal contraction. The therapist utilized tactile assessment to aid in evaluation of abdominal performance during activities in weight bearing (Figures 6–10). Although this manual palpation is a subjective judgment, the author has found it to be useful for assessing abdominal activity during upright moving activities.
Functional level was improved with pain free ascent and descent of stairs as well as full bed mobility without discomfort. Balance reach measurements improved to WNL by the end of phase 2. Pool exercise including, jogging/running/sprints and hip strengthening were all well tolerated.
Phase 3 Interventions:
This phase began when tolerance to all advanced stability exercises was achieved without pain in erect postures. Exercise progression was focused on trunk/pelvis and hip stability with increasing intensity. This initially was stressed with pool exercise emphasizing speed and stride length in straight planes, progressing to diagonal movements and pivoting.
Resisted bungee cord ambulation was also initiated and progressed in forward, backward, and lateral directions. As intensity was increased with no subjective reports of pain, the difficulty of tasks was progressed to include grapevine and pivoting motions, and later stick-handling (with a tennis ball instead of a puck) with and without obstacles, and speed bursts.
Additionally, lateral slide board training was used beginning with a short stride length (approximately 50% of normal stride) at 30 second timed intervals. The stride length was gradually widened requiring increased strength of pushing leg and stability of glide leg/trunk/pelvis. Interval times were initially increased to 60 seconds to facilitate endurance training, followed by more rapid push-off cadence requirements simulating higher intensity skating demands. Verbal cuing of TrA contraction continued as previously described. Stick handling and passing drills using a tennis ball were incorporated into the slide board activities to simulate core stability demands of skating while performing peripheral activities such as sport specific ice hockey skills. Once these activities were tolerated, on ice functional progression was initiated.
On ice rehabilitation began with unidirectional lap skating of approximately 25% effort for a time period of 20 minutes. Each subsequent day addressed advancing of ice time, increasing subject effort, and adding skills. The subject was progressed to 30 minutes on ice the next day, and skills were advanced to include forward cross-overs in both directions and stick-handling with a puck. By the third day, the effort level was increased to 50% of maximum. By the end of the first week, ice time was increased to 60 minutes and included skills additions of backward skating, pivoting forward to back and reverse and low effort wrist shots. Skating intensity was elevated gradually to approximately 70 percent maximum effort. In the second week of on ice rehabilitation, the primary goal was to increase effort toward 90 percent of maximum. On ice skills began to incorporate passing drills and increased shooting intensity including backhand, snapshots, and slap shots. In addition, the subject began to perform drills with his teammates that were predominantly offensive in nature involving passing and shooting. Once the subject reached 90 percent effort without recurrence of symptoms limiting his performance, the final four days of his on ice work was focused on return to full practice demands including contact and battling drills. The final evaluation of return to play was based on the subject’s ability to participate in full on ice activities simulating game situations and intensity, including full acceleration, stops and start drills, one on one battling and full contact checking drills. His on ice practice time was approximately 120 minutes per day. It should be noted that the subject experienced several significant episodes of abdominal/groin discomfort during this phase of his rehabilitation, and daily evaluation was needed prior to on ice workouts for proper progression of sport specific tasks. This on ice progression lasted 17 days. The subject continued a maintenance stability warm-up program prior to on ice participation for the rest of the 2001-2002 NHL season. The entire duration of the third phase was 31 days. Please note that the summary of all findings and interventions by stage can be found in the Appendix.
OUTCOMES
The subject was treated for 49 days from injury until return to full competition. At the completion of phase 3, the subjective pain level was reported to be 0 to 1/10 with full on- ice participation. No pain was noted with coughing, and palpation of the rectus abdominis insertion or inguinal/adductor structures was pain-free as well. Both active and passive trunk and hip ROM were WNL and comparable bilaterally, as well as manual muscle test grades for all hip and abdominal muscle groups being 5/5. In addition, the subject displayed full functional ability with return to non-restricted on ice participation and game competition. The individual in this case study has continued to play professional ice hockey for the same NHL team for the past eight seasons without recurrence of these symptoms.
The subject of this case report was informed, and agreed to the intention of the authors to submit the data of this injury and rehabilitation for possible publication.
DISCUSSION
In a study of NHL players completed from 1991 to 1997, 617 “groin/abdominal” injuries were reported. Over this six-year period however, a significant increase in this diagnosis was noted from 12.99 injuries/100 players/year in 1991/92 to 19.87 injuries/players/year in 1996/97.71 While the incidence of this condition appears to have increased, a potential explanation of this rise may be attributed to more accurate identification by physicians and trainers.
Various explanations for the cause of a sports hernia have included anatomical deficiencies as well as repetitive and excessive stresses creating a lengthening and/or tearing of these structures,14,17,18 While many authors note frequent occurrence of the sports hernia with repetitive stress, this case report represents an example of a specific incident of excessive force resulting in injury. The individual in this case report had no previous history of groin or abdominal pain prior to the acute episode.
Studies addressing surgical repair of the “sports hernia” have noted involvement of the rectus abdominis,19,23 internal oblique,26 external oblique,9,27,29 transversus abdominis,72 as well as transversalis fascia and conjoint tendon14,18,40,73 as structures of dysfunction indicating the broad range of abdominal involvement. Another consideration is the close proximity of attachment of rectus abdominis and adductor longus tendons to each other and the pubic symphysis, creating a potential shearing effect across the anterior aspect of the pelvis as the hips move in all planes with the lower extremity in a closed chain position. This then creates potential for stretching and tearing of tissues such as the transversalis or conjoined tendon, weakening the region structurally and resulting in groin and lower abdominal symptoms.14,17
Treatment options for the patient diagnosed with a sports hernia have traditionally involved conservative care, followed by surgical repair for those individuals who do not achieve satisfactory recovery or are unable to return to their desired activity.17,18,21,22,24,40,42 While numerous reports have been written regarding repair and recovery of those who have sustained sports hernias, few have addressed the non-surgical care of these patients. Several authors have cited poor results with conservative treatment,15,21,26,39but have failed to define the specific detail or extent of non-operative treatment other than vague reference to rest, modalities, and therapy. While understandable considering the purposes of their studies, this information is important in order to develop a better understanding of non-operative methods of treatment that have the greatest potential for success.
The treatment methods utilized in this case report emphasized lumbopelvic stabilization with progression of peripheral extremity and postural demands, with incorporation of this core control into functional progression and return to sport. This progression of stabilization has been incorporated by the authors into the rehabilitation of multiple athletes with the diagnosis of sports hernia. While specific exercises and tasks in the rehabilitation program may vary depending on the anatomic details of the injury and the athlete’s response to treatment, the rehabilitation principles of the development of neuromuscular control and sequencing of the core musculature are consistent. Many options and various adaptations for exercise selection exist, however the authors have found the specific exercise selection to be far less significant than the application of the underlying principles. The primary emphasis of this rehabilitation program was on neuromuscular control and sequencing, as well as static and dynamic postural stability.
Richardson et al, found active contraction of the TrA by individuals performing an abdominal drawing-in exercise affected stability of the pelvis by increasing stiffness of the sacroiliac joints.30 Further study has shown the functional role of the TrA in postural control and stability during unilateral weight bearing, including increased symmetrical TrA activity in normal healthy individuals during unilateral activity.74Multiple studies by Hodges et al75,76,77 have demonstrated that TrA activation in healthy individuals occurs prior to other muscular firing related to upper and lower limb movement. In contrast, significant delays in firing of the TrA have been shown to be present in individuals with low back pain.75,76,77,78 Further research on subjects with low back pain confirmed a delayed TrA activation when tested with electromyography (EMG) prior to voluntary TrA exercise activation. Following a single treatment the same subjects displayed improvement in TrA response time approaching that of normal individuals.16
Anatomically, the TrA is the deepest layer of abdominal muscle, wrapping around the abdomen between the lower ribs and pelvis. The transversalis fascia, which lies deep to the transversus abdominis, is part of the endoabdominal fascia that encases the abdominal cavity and forms the posterior wall of the inguinal canal. It is reinforced by aponeurotic fibers from the transversus abdominis, although these have been described to occur in varying quantities.72 In an anatomical dissection, Condon72 describes the complex anatomy of the transversus abdominis and transversalis fascia and their relationship in the protection of this region. Together they comprise the transversalis fascial sling. Contraction of the TrA functionally pulls the transversalis fascia sling together, laterally, and superiorly forming a “shutter” mechanism. The movement of the transversalis fascia acts to draw the internal inguinal ring under the muscular wall of the internal oblique, functionally closing this space.72,79 In addition a “sphincteric” mechanism occurs causing constriction of the internal inguinal ring at the same time.79 This mechanism protects the area during activity and strenuous events from increasing intra-abdominal pressure which could lead to a hernia.
Although the transversus abdominis doesn’t completely cover the lower abdominal region and has limited aponeurotic fiber attachments to the transversalis fascia that forms the posterior inguinal restraint, the basis for this exercise protocol may be partially explained by a means similar to the “shutter” mechanism described by Condon.72 With the anatomical attachment of the transversus abdominis to the transversalis fascia, exercise targeting the deep abdominals produces a “corset” type action to support and stabilize the abdominal wall. This contraction causes the transversalis fascia to become taut and to generate a “bracing” effect throughout the lower abdomen to aid in stability of the lower trunk, pelvis and hips.
Limitations of this case report include the difficulty of arriving at the diagnosis of sports hernia, as this syndrome most likely represents many related but potentially distinct pathologies. Diagnosis is also difficult in that there is no definitive physical examination or radiological test that objectively defines this pathology. As a result, diagnostic testing relies heavily on the exclusion of other pathology.
In actuality, the only definitive diagnosis of a sports hernia is likely through surgical exploration and successful recovery following surgical treatment. In addition, while the subject of this case report had a successful recovery and returned to his pre-injury level of competition, the underlying reasons for this success are difficult to define. As a professional athlete his pre-injury level of fitness, his compliance with the treatment program, and motivation to return to his sport are large contributors to his success. The treatment program in this case report requires a high level of effort and attention to detail. Without this motivation, effort and dedication, the chances of recovery are diminished significantly. Another limitation is the fact this case report represents a single individual. A larger number of subjects would help to distinguish the effectiveness of such conservative measures in the treatment of sports hernia. In the authors’ experience, the conservative treatment outlined in this case report has proven successful in a number of the patients with sports hernia diagnoses that have been encountered. However, there are subjects who do not respond to this treatment protocol, and have subsequently undergone surgical repair. Future research to define the various pathologies that are responsible for this diagnosis, the diagnostic tests that yield objective evidence of the pathologies, and those findings that would direct patient assignment to either conservative or operative protocols would be helpful.
In review of the literature, no case studies were found specifically addressing conservative treatment of a sports hernia with return to full activity. While this patient responded exceptionally well to conservative methods, the authors do not believe this is an exclusive treatment option. An appropriate, successful rehabilitation program is modified depending on the anatomic contributions to the injury and the patient’s response to each phase of the program. In the instance where a conservative program fails, operative intervention may resolve the patient’s symptoms. In the authors experience conservative treatment has been very effective, however there are examples of individuals who may not respond to this treatment, or do not have the dedication necessary for success.
