1. Return to Play from Sports HerniaBy
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 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 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 Week 11 Week 12, athlete was given a recovery week
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