156. What Is a Sport's Hernia? Understanding Athletic Pubalgia

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In this episode of PT Snacks podcast, we delve into the topic of sports hernia, also known as athletic pubalgia. Listeners will learn about what a sports hernia is, how it occurs, and the anatomy involved, including key muscles and structures. The episode covers how to assess and treat this condition based on current research and offers insights into clinical challenges and differential diagnoses. We also discusse conservative treatments, exercise progression, and when surgical intervention might be necessary, providing a comprehensive overview for physical therapists and students.

00:00 Introduction to PT Snacks Podcast
00:43 Understanding Sports Hernia
03:55 Anatomy and Causes of Sports Hernia
05:03 Clinical Presentation and Diagnosis
06:42 Treatment Approaches
10:29 Surgical Options and Post-Op Rehab
12:02 Key Takeaways and Conclusion
12:58 Additional Resources and Offers

Ross JR, Stone RM, Larson CM. Core muscle injury/sports hernia/athletic pubalgia, and femoroacetabular impingement. Sports Med Arthrosc Rev. 2015;23(4):213‑220.
Europe PMC

Drager J, Rasio J, Newhouse A. Athletic pubalgia (sports hernia): presentation and treatment. Arthroscopy. 2020;36(12):2952‑2963.

Forlizzi JM, Ward MB, Whalen J, Wuerz TH, Gill TJ 4th. Core muscle injury: evaluation and treatment in the athlete. Am J Sports Med. 2023;51(4):1087‑1095. doi:10.1177/03635465211063890.
PubMed

Kraeutler MJ, Mei‑Dan O, Belk JW, Larson CM, Talishinskiy T, Scillia AJ. A systematic review shows high variation in terminology, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of athletic pubalgia/sports hernia/core muscle injury/inguinal disruption.

Transcript

0:30

Hey everyone. Welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapists, students who are looking to grow your fundamentals in bite eye segments of time. Now, today we are going to cover sports hernia, but before we do, if you've found this show to be helpful in any way whatsoever, and if you listen to at least three episodes, if you wouldn't mind just pausing, writing a brief review wherever you listen, that would mean the world to me. And if you've already done so, thank you so much. I really appreciate you taking the time out to help PT Snacks grow. But today what we're gonna do is cover sports hernia or athletic acute bia. What exactly this is some ways that we can assess for it, and examples of how to treat it. That's in the research. But before I continue, what you need to understand is that this is something that doesn't really have the most clear definition in the research. So what I'm gonna do is cover what the consensus of the research is, but I really do think that over the next five, 10 years, this is probably gonna be a little better defined. So just keep that in mind. But chances are you might have come across this on social media, or maybe your patient has been diagnosed with it and you're like, what in the world is this? So we're gonna cover more on what that is today. Now something to note is that a sports hernia is not necessarily a true hernia. And what I mean by that is there's not a Bulger protrusion of abdominal contents like something that you would see within venal hernia. What we're actually dealing with is a soft tissue injury, more specifically in the region of the lower abdomen and in the groin, most often involving the rectus dominus, the adductor longus, and the structures that are around the pubic synthesis and inguinal canal. So what can happen is that these tissues can either tear or stretch or weaken, especially at their attachment points to the pubic bone and that in turn can cause pain during high demand athletic movements like kicking, sprinting, twisting, or cutting. So often the patients who are gonna get this are going to be athletes probably doing these sorts of activities in their sport field and ice athletes, all sorts. As I mentioned, this is called Athletic pubal, GIA. Or maybe more accurately would be a core muscle injury, which is a newer umbrella term that kind of captures the overall idea of dysfunction or relative instability at the junction of the core. In lower extremities. Not meaning instability, as in, oh, no the core's just gonna fall apart, but on the same lines that we do with other regions of the body where. Maybe the goal will be to build capacity, not necessarily improve mobility, right? So clinically, what makes this very challenging is that it can mimic other things. So we really have to do a good job of ruling out other differentials before going right to saying. Is a sports hernia, which really we should be doing anyways. But it can often mimic things like a groin strain, adductor tendinopathy, and even FAI or a labral tear, depending on the symptoms that the patient is presenting with. Although often if these patients have been given this diagnoses and they're given the typical standard treatment for these diagnoses, it'll often fail because the underlying problem wasn't identified. So before we get to carried away, we need to go into how does this even happen in the first place? And then we'll go into how to identify and treat. So let's talk about anatomy. I mentioned already what muscles tend to be involved, but picture you are looking at an anatomy book at the pelvis. It's more specifically the anterior region. So you've got the erectus abdominals that attach to the pubis from above, and then you've got the adductors pulling from below. And often these muscle groups can work together to help add stability to the pelvis in addition to other muscle groups, of course, and help transmit force between the legs and the trunk. But. Sometimes if there is an imbalance in force, like weak core muscles or overactive adductors or poor lumbo pelvic control, then that tension can start to strain the, a neurotic junction near the pubic synthesis. And over time, or with a single forceful movement, that tension can cause those tissues to start having problems where pain can develop. It's more common in males, especially in sports like hockey, soccer, football, and track, where high speed directional changes in torque are pretty constant. So clinically, usually these patients will say, I've got this like deep nagging pain, and usually it's in their lower abdomen or groin that either came on suddenly or has been gradually building. It feels worse with situps, coughing, kicking, sprinting, and sometimes it can radiate into the adductors or inner thigh. Now, in your exam, you might find that they have tenderness at the pubic synthesis pain with resisted adduction or a sit-up and aggravation with Valsalva movers, but. There is no visible or palpable hernia, so that's how we differentiate from other hernias, right? Remember, it's a core muscle injury, so this is why the diagnosis is primarily clinical. Now imaging can help rule out other things, and an MRI is gonna be considered the gold standard, especially for assessing soft tissue involvement. But it allows you to see, is there any bone marrow edema at the pubic synthesis or signal changes in the rectus or adductor tendons. A dynamic ultrasound could also be used and it seems to be being used more frequently especially in someone who knows how to use it. But no imaging really definitively confirms athletic pia. You'll have to combine history symptoms, exam findings, and rule out things that mimic it like an FAI labral tear, or even lumbar referred pain. So let's say we have a patient who we are suspicious of a sports hernia. For treatment, typically conservative management is gonna be the first line, especially if the symptoms are more on the recent side or mild. So acute, maybe we are just trying to let that area recover with relative rest. Sometimes NSAIDs will be prescribed or a structured rehab program. And from what I was able to read and research, it's. More about core control, hip strength, and neuromuscular coordination. The goal is to correct the whatever caused the overload at the pubic region. So this is where assessing the patient in front of you comes into play. Research can be very helpful, especially if the research that WA was done on subjects that look like your patient. But here is where we need to surmise with our patient's history. What might have caused that overload? Was it a programming error? Was it a recovery error where basically we're looking at what caused. The stress that was induced on that area to rise above the threshold of what that area could tolerate. And then understanding based on what the demands are of what that patient's trying to get back to, we'll say a sport for instance. We need to work backwards from that on where our patient is and utilize our knowledge on tissue healing times to apply just enough force to help our patient build resilience until. They have enough resilience to do the sport that they want to, so that's why understanding a, really having a good understanding of anatomy and understanding how different tissues work, meaning muscles, how would they respond to stress versus joints, et cetera, it's gonna help you better. Understand if you are ruling things or ruling them out. And then once you've identified the correct tissue, then using your tissue healing timelines, that's gonna help you to build a rough estimation on when maybe a patient's ready to progress, as well as building in some checkpoints along the way that may look like. Ways for you to continually assess if your patient's actually ready for the stress, or are you just guessing? We don't really necessarily wanna guess, and this may not be the most clearly laid out in research, at least what I've seen. If you've come across any of that, please send it my way. So some examples in the early phase, maybe we're working on just getting the core activated. That could be things like just contracting the core depending on where they're starting at. Things that are keeping a neutral core position like plank bridges. Maybe isometrics, which a plank technically is an isometric, right? Adductor, squeezes gentle mobility, calm things down as appropriate and as needed. And then as pain improves, maybe we're progressing to more more progressive hip strength, more. Multi-directional forces to the spine, starting with neutral spine, like anti-rotation, and then working through range of motion maybe more single leg exercises, and then progressing towards running progressions, trics, cutting drills, things to help not only let the muscles contract, but contract through range of motion, and then contract through range of motion with speed and power. Manual therapy and soft tissue mobilizations can help support these efforts, especially for if they need any further adductors, hip flexors, abdominal fascia, et cetera. But it's a tool in the toolbox right now, let's say conservative care does not seem to be working. So let's say we have an athlete who, they've been going through physical therapy and we feel confident about the quality of treatment for eight to 12 weeks. Surgery might be an option for them. And there's several different surgical approaches which I'll mention briefly'cause I'm not a surgeon. But some will use a laparoscopic mesh repair. Others might combine an adductor 10 tenotomy or rectus repair. But. From what I've seen, outcomes seem to be generally good. Studies show that over 80% of athletes return to sport often more quickly than with extended conservative care. Being really able to identify who's gonna be an early responder to conservative versus surgery, I think is a common theme across the board on our patients. Now post-op rehab is still crucial and should definitely follow that same principle in terms of progressions, progressive exercise, just based on the sports demands. But again, there's a lot of options on exercises that would fit under this bucket, right? So it can be helpful as well to see, okay, what of this may be my patient? We'll probably follow through and actually do, like some people just hate planks. Guys may not feel good to them. Maybe they have a concurrent shoulder injury and you need to work around that. Maybe if, maybe they have limited equipment, they're gonna be traveling, or limited time constraints. We need to make sure that we're customizing that to what the needs of our patient is. Key takeaway here. Athletica pia, or Sports hernia. Is a clinical diagnosis with, I would call it a complex presentation, and there can be a lot of overlapping pathology, right? So hernia can be a little misleading to say. Again, the umbrella term is core muscle injury, so there's no bulge that is there, but you do wanna keep it on your radar. If you have a patient who has persistent groin or lower abdominal pain, that doesn't really match the usual strain pattern. The goal as our job as clinicians is to be able to recognize what's in front of us.'cause it may see you, you may not see it And help our patients to build resiliency as appropriate and collaborate with a multidisciplinary team if it is necessary. So that's it for today, guys. I hope you had some good takeaways from today's. Session. But if you feel any, if you have any questions, feel free to just shoot the link below that says, send a text. And then I'll be able to respond to that the best I can. There's also my email below in the show notes that you can reach out to. And then if you on another note. If you are trying to grow your CE use maybe take a deeper dive into some of these topics. Renew your license soon, or maybe you're studying for a specialty exam prep course. Like the OCS or SCS Med Bridge is actually offering listeners over a hundred dollars off just for being here. So you can find that promo code below in the show link. But they've got tons of courses and webinars and. Test prep questions and things to help you to be able to grow in a way that is more in depth than maybe listening to on this podcast. And if you're a student, you definitely have an even better discount, so use that special promo code that's meant just for you. But that's it for today, guys, and until next time.