Source: www.guardian.co.tt
By Asha De Freitas-Moseley
A few years ago, I thought that sportsman hernias were a rare diagnosis. However, since returning to Trinidad and practicing locally since 2007, I have seen at least five confirmed diagnoses of sportsman hernias (compared to none during the eight years I lived and worked in the USA). It is possible that the reason for this high number is due to the increased availability of imaging technology locally, particularly that of diagnostic ultrasound, allowing a clear view of the tissue beneath the surface, facilitating more accurate diagnoses of similarly symptomatic injuries; or, it could be due to the increased demands on athletes who are not subject to properly balanced training regimens; or perhaps, poor body mechanics is the underlying reason, whereby a motion analysis would be an excellent diagnostic tool to more closely study the athlete’s movement pattern. The specific reason for this injury has not yet been identified, if one even exists.
The sportsman hernia, also known as athletic pubalgia, sports hernia, Gilmore’s groin, or groin disruption is characterised by symptoms of diffused pain in the lower abdomen and groin region.
In acute cases, it can be felt by males (the more frequent victim of the two genders to suffer this injury) in their testicles. Pain is usually felt during sporting activity, particularly with hip extension and rotational movements and especially when these movements involve power. While any athlete that incorporates these movements are vulnerable to this type of injury such as hurdlers, rugby and hockey players, most of my athletes claiming this injury, so far, have been football players. The sportsman hernia is a result of a physical weakness of the posterior abdominal wall resulting in an unobservable, unpalpable bulge of the underlying tissues ie a bulge that cannot be seen or felt with your hands/fingers.
Conservative therapy i.e. rehabilitation has been recommended by physicians for initial management of this injury, particularly in the early signs of development. However, failing that, laparoscopic surgery is done whereby a synthetic, mesh-like material is used to reinforce the repaired abdominal wall. Data is still being gathered to accurately identify the effectiveness of surgical intervention. When dealing with this injury the muscles addressed include the rectus abdominus, oblique and transversus abdominis all of which originate in the area of complaint; structurally, the inguinal canal and inguinal ligament are also contained in this area; neurally, the ilioingual nerve is present and can become trapped in some instances. Due to the location of this injury, the groin becomes involved, shortening as a guarding response to protect the area that is injured and compensating for strength deficiencies in the kinetic chain.
When producing rotational forces as with the kicking action in football, the abdominal, oblique and core muscles work in conjunction with the abductor and adductor muscles of the lower body, to create a movement similar to an accordion, using opposing forces to extend and contract ipsilaterally to generate the necessary force to kick a ball, while balancing on the other leg. Similarly, in field hockey the athlete rotates the upper body, rotating away from lower body to generate the force needed to strike the ball with the hockey stick. Again, one leg is favored while opposing abdominal and lower body muscles work to create an accordion-like movement through the mid-section of the body. The mid-section is where the forces meet and where the sportsman hernia occurs, therefore this mechanism is one that is kept in mind while rehabilitating an athlete.
In treating this type of athlete, the priority is first to alleviate the pain. Modalities including ice and/or electric stimulation are incorporated to accomplish this, along with gentle stretching to address any loss of motion in the abdomen and/or groin area might be applied during the initial stages of therapy. Ideally, resting from activity is required for a period of four to six weeks. Once the pain has been eliminated the athlete is encouraged to activate the core muscles, which usually involves some muscle re-education. Athletes are typically very responsive to therapy, and are able to progress through very basic exercises quickly. Keeping the prescription exercises simple is very important, progressing the athlete gradually through intermediate to more complexed movements, always ensuring that proper body mechanics are applied and become habit.
Assessing the abductor and adductor strength of the lower extremity and addressing any muscle deficiencies or imbalances are also considered in designing the exercise prescription. Eventually, combined movements involving both upper and lower extremities are brought together, building endurance in the muscles before graduating to power movements. Some basic advice to those working with athletes on the field, with some background of injury management: The symptoms for sportsman hernia will include groin pain. If after a period of management whereby the athlete has experienced some pain relief but then seems to plateau, have them see a sports medicine physician for further assessment. What might appear to simply be a weak groin might actually be something more serious which, if left untreated, can lead to increased pain and further damage to the athlete.
Asha De Freitas-Moseley is a certified athletic trainer. She works with the athletes of Trinidad and Tobago from recreational to elite level at Altus Health Services Ltd, Port-of-Spain, and Total Rehabilitation Centre Ltd, El Socorro.