A Strength Coach’s Guide To Preventing Sport Hernias 

By: Dr. Scott Gray

Sport hernias affect many athletes, especially those in team sports that require changing of direction, kicking, or twisting. According to some studies, 6% of all athletic injuries occur to the groin area.¹

When this injury does occur, it can turn into chronic groin and abdominal pain. Athletes can be sidelined for months and even a years time if conservative treatment doesn’t work.

As performance coaches we have the most important role and that is to prevent this injury from occurring in the first place.

In this post, we’ll discuss just that but….

Before we do we’ll need to cover some groundwork in learning exactly what a sports hernia actually is and that pathology behind it.

What Exactly Is a Sport’s Hernia?

As coaches we have all heard of the term sports hernia, but what exactly does that mean? Some believe it is a pulled groin. While others think it is a strained abdomen. In reality, it is potentially both of these but possibly even more complex than this….

Usually it involves a disruption in the posterior wall of the inguinal canal and enlargement of the superficial ring.³ In other words, a disruption of connective tissue that holds some nerves and vessels together.

Meanwhile, some consider it to be an injury to the fascial attachments of the external oblique, adductor longus and gracilis muscles as discussed above.²

What makes it more complex is that usually athletes have several other underlying conditions that are also present such as adductor tendopathy (wearing away of their tendon), instability of the pubic symphysis (pelvis moves too much), or femoral acetabular impingement (FAI) (hip doesn’t have adequate mobility due to morphological changes to the bones).

Even though the exact diagnosis is complex, the end result is groin and abdominal pain.

But Why Do Sports Hernias Occur?

The diagnosis itself is meaningless unless we can under WHY it occurs. After all, if we can understand the mechanism of injury we can come up with strategies to prevent it from happening in the first place.

Our job is to keep our athletes healthy, right?

 The reasoning as to why this injury occurs varies from person-to-person but usually involves three things according to most studies and mechanisms of injuries:

• Tight & Weak Adductor and Hip Flexors
• Poor Hip Mobility In Abduction, External Rotation, Extension
• Weakness Of Anterior Core

Do you see how we can help mitigate this injury? More on this later…. For now, let’s look at why these injuries occur at a deeper level.

Common sense shows us that most groin injuries occur in athletes that require kicking, twisting, and changing direction.

This makes sense because it is going to place a lot of load on the anterior hip and groin to eccentrically provide stability and control the pelvis to help decelerate then reaccelerate our bodies in motion.

When the hip is limited in mobility whether this be due to morphological changes to the joint, stiffness of the joint capsule, or muscle tightness the muscles can’t function optimally….

This places abnormal stress to the groin, hip flexors, or abdomen. These shear forces are more prominent in athletes with an imbalance between the strong adductor muscles of the thigh and relatively weak lower abdominal muscles. ^5,7

Consequently, this can result in excess shear forces to the inguinal wall, local soft tissues, tearing of the travsversalis fascia and conjoint tendon, irrational to the rectus abdominis, internal & external oblique muscles.^5,6,8

Also, when lacking mobility at the hip we will usually get this motion elsewhere. Often times it is at the trunk as most athletes are already predisposed because their anterior core is usually weak relative to their groin.

As a result, athletes will usually hyperextend their spine when their hip is in an abducted, extended, or externally rotated position. In this position everything is stretched to the max eccentrically across the anterior and medial hip and core.

Can you see how this can predisposed our athletes to injury?

That’s All Great But What Can I Do About It As a Coach?

Since the majority of sport hernias occur because of muscle weakness, tightness, or joint stiffness, we can have direct impact in preventing these types of injuries.

Here are 4 things coaches can do:

• Increase the mobility of the hip
• Strengthen the hip flexor and groin muscles eccentrically
• Warm-up properly
• Strengthen the core functionally

Now that we have discerned what coaches can do to help their athletes, lets take a closer look at each one of these.

Increase Mobility Of The Hip

There are a plenty ways to increase mobility of the hip, some better than others.  The problem with most hip mobility programs they are done in the OKC rather than how the hip functions in sport which is in CKC.  For instance, lying on your back and doing hip external rotation may have its time and place but may not translate over to athletics.

Rather, here is a simple way to increase hip mobility functionally:

Do you agree this makes more sense?

Strengthen The Hip Flexor & Groin Muscles Eccentrically

 In sports that require stopping and starting the anterior and medial hip muscles need to control the pelvis to accelerated and decelerate. For this reason, we need to strengthen the muscles to do just that.  Rather than lying on our sides and doing hip adduction, we probably should train those muscles to combat the forces and types of contractions that is endures in most in athletics, right? You bet.  This involves eccentric strengthening.

Here are a few exercises that you can do to impart functional eccentric forces to the anterior and medial hip:

Proper Warm-Up

 It doesn’t matter if our athletes have the proper mobility and strength to control the forces at the hip to change direction if the nervous, skeletal, and muscular systems aren’t properly warmed-up.

Therefore, prepping the body for competition or practice is crucial. Here are a few warm-up exercises and strategies that you can use to help stretch the anterior and medial hip and to place the hip into functional positions to wake up the neuromuscular and skeletal systems.

So….

When your athletes are predisposed to getting in these positions in practice or competition they have “already been there” and their system can help combat and control this motion. Make sense?

Strengthen the Core Functionally

Last but not least, we need to strengthen the anterior core. We all know that our cores muscles need to be strong to be a great athlete and prevent injury.  In fact, you’re already probably doing this with your athletes. However, are you doing this in the same positions that would predispose your athletes to this injury?  For instance, we can do planks, swiss ball roll outs, and crunches until we’re blue in the face but it doesn’t necessarily translate into a stronger core when changing direction or in sport.

Will it have benefit? Sure it does.

We just need to integrate it from time-to-time in the positions our athletes are going to be in.

Lets take a look at a few of these examples you apply with your athletes right away.

Concluding Remarks For Preventing Sport Hernias:

 There you have it, 4 simple strategies coaches can provide to help reduce sport hernias. By providing and implementing these 4 tactics your athletes can stay in the game and reduce their chances for a sports hernias.

About the Author:

Dr. Scott Gray is am international speaker and renowned physical therapist specializing in sport and spine injuries. He routinely writes on his website www.scottgraypt.com where he educates other sport & manual physical therapists in addition to interviewing other elite physical therapists on his Redefining Physical Therapy Podcast. He currently resides in Southwest Florida where he helps athletes recover from injuries and return to sport.

References:

1. Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic literature review. British Journal of Sports Medicine. 2007;42(12):954-964. doi:10.1136/bjsm.2008.047373.
2. Choi H-R, Elattar O, Dills VD, Busconi B. Return to Play After Sports Hernia Surgery. Clinics in Sports Medicine. 2016;35(4):621-636. doi:10.1016/j.csm.2016.05.007.
3. Cohn R. Sports Hernia and Extra-Articular Causes of Groin Pain in the Athlete. Bulletin of the Hospital for Joint Diseases. 2015:90-99.
4. Cohn R. Sports Hernia and Extra-Articular Causes of Groin Pain in the Athlete. Bulletin of the Hospital for Joint Diseases. 2015:90-99.
5. Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. Journal American Academy Of Orthopedic Surgeons . 2007:507-514.
6. Leblanc KE, Leblanc KA. Groin pain in athletes. Hernia. 2003;7(2):68-71. doi:10.1007/s10029-002-0105-x.
7. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of Severe Lower Abdominal or Inguinal Pain in High-Performance Athletes. The American Journal of Sports Medicine. 2000;28(1):2-8. doi:10.1177/03635465000280011501.

8. Zoga AC, Mullens FE, Meyers WC. The Spectrum of MR Imaging in Athletic Pubalgia. Radiologic Clinics of North America. 2010;48(6):1179-1197. doi:10.1016/j.rcl.2010.07.009.