How Dr. Lars Seitzinger and his team use the FMS screen for Sports Hernia’s at Pro Motion Clinic.
A big key in prevention of any injury is to use appropriate screening techniques. For screening athletes I am a proponent of Gray Cook’s Functional Movement Screen (FMS). The FMS is a seven part screen designed to predict risk of injury and should be done in it’s entirety on every athlete at least once. Of particular interest in the sports hernia area is the FMS-Hurdle Step (a test of the hip flexion pattern). An impaired hip flexion pattern usually demonstrates a lateral shift of the pelvis when attempting to flex the hip. This would indicate an impaired hip flexion pattern. In the impaired hip flexion pattern it is theorized that the deep flexors (psoas and iliacus) are weak or inhibited. This forces the athlete to use quadratus lumborum to hip hike to create the illusion of hip flexion. In essence, lateral flexion of the pelvis on the spine raises the hip. Cook advocates not focusing on individual muscles but rather on fixing the pattern. To fix the pattern we have adopted a “top down” approach to attempt to recruit the deep hip flexors.
In addition to improving the hip flexion pattern prevention of sports hernias must also center on developing proper hip range of motion and core stability. Hip motion and core stability are in effect linked. Impaired hip motion leads to excessive pelvic motion and excessive pelvic motion may be why a “groin pull” progresses into a sports hernia. From a flexibility standpoint the hip must be stretched into extension (Thomas position, psaos/ iliacus stretch) and internal rotation as well as into abduction. In many cases abduction stretching should be limited while the rest of the hip in effect “catches up”. After static stretching a program of multi-planar active mobility and strength must be established. Strength emphasis should be on unilateral strength. Unsupported single leg squats should form the core of the lower body program.
Plyometric training should address multi-directional hops and bounds. In addition, lateral conditioning on a slide board should be performed at least twice a week for prevention. It is important to note that the slideboard is unique in that it supplies eccentric stress to the adductors and concentric stress to the abductors.
Sports Hernia Prevention
Organization is key. For overall injury prevention we always follow a sequence of:
• Foam roll (See my Using Foam Rollers article)
• Static stretch (See my The Static Stretching Renaissance article)
• Dynamic warm-up
Remember, in a program designed for injury prevention there are really no options. You cannot elect to foam roll but, omit static stretching or elect to static stretch without rolling prior. Each piece of the puzzle has a specific purpose and the prevention program suffers when parts are omitted. Athletes must be given time to roll and, told the key areas in need of attention ( hips, adductors, t-spine). In addition athletes must be given specific stretches to perform and more importantly be both told how and shown how to perform the stretch. Most athletes perform what I like to call “fake stretching”. In “fake stretching” athletes get improperly positioned and make an attempt to look like everyone else. This is generally done to attempt to compensate for a large deficit. Remember, those that like to stretch are generally flexible and probably don’t need to stretch. Those that dislike it are those most in need. Try to find stretches that allow athletes to use their bodyweight to help or that use props like boxes, tables or rollers.
The next step in prevention is to perform specific strength exercises for the hip flexors in addition to psoas training above 90 degrees.
I like a three-step progression:
• Phase 1: Supine Hip Flexion
• Phase 2: Standing Hip Flexion
• Phase 3: Standing Hip Flexion/Adduction and Prone Hip Flexion
• Look for the excessive abduction/ limited extension pattern ( seated V versus Thomas Test) Generally an athlete with a Seated V type stretch of greater than 110 and a neutral Thomas position has an imbalance.
• Train hip flexion above 90 to improve psoas function. This can be done as warm-up/ or activation. Think 10 sec holds, not reps.
• Train hip flexion patterns progressing to a flexion/ adduction pattern. Be sure athletes use a flexion adduction pattern. Those with issues will want to internally rotate the hip and in essence recreate a hip flexion pattern.
Things to Avoid
Avoid the surgeon. Surgeons do surgery. It is their business. Doctors work on what I call the 1-2-3 model or the three I’s:
• Ingest: anti-inflammatories
• Inject: more anti-inflammatories
• Incise: we all know what that means.
We want to avoid the 1-2-3 Model. If you keep going back and saying you are not improving, you will get surgery. Surgery should be the last resort. That means if you have not really committed to proper rehab avoid surgery. As we mentioned in part one some therapists theorize that the forced lay-off and attention to rehab post-surgery rather than pre-surgery is what actually helps. If athletes were willing to take time off and listen to the trainers and therapists, innumerable surgeries could be avoided. I have seen at least three professional athletes who were scheduled for surgery avoid it by committing to a proper rehab program of exercises and soft tissue work.
Never let a Doctor go in and “take a look around”. That means they are unsure but, want to do surgery anyway. Usually this means they will go in, repair any small tear they see and often “release” the adductors. This in my mind only makes more scar tissue.
My feeling and the feeling of many of many therapist colleagues is that “sports hernia” surgery will be like the lateral release in the patella femoral joint, a surgery that had limited success and thankfully eventually went out of style.
Sports Hernia Rehabilitation Concepts
The same thought process used in prevention can be applied to the rehabilitation of the sports hernia. One of the most successful methods in dealing with sports hernias actually focuses on decreasing motion. Many current rehab protocols focus on training the deep abdominal muscles ( transverse abdominus and obliques) to stabilize the pelvis. Although this may be an initial part of the solution an approach that simply emphasizes core stability may be doomed to long-term failure. Eventually the tissues must be re-exposed to high velocity loads and contractions. If this is not done re-injury is a predictable result. Every failed sports hernia rehab fails when velocity ( sprinting) is introduced. Developing core stability in the presence of poor tissue quality only puts off the inevitable re-injury.
Another area of concern lies in the open chain versus closed chain debate. Many therapist and coaches have been misdirected and believe that all lower body work must be closed chain. This is what Alwyn Cosgrove calls the short-term over-reaction. The recovery stride in both skating and sprinting is a pure open chain movement. The athlete must convert from an explosive abduction/ extension action done in a closed chain fashion to an explosive flexion/ adduction pattern done in open chain fashion. It is possible that we have become too closed chain oriented without actually looking at function? Many therapists are attempting to use closed chain concepts to solve an open chain problem. This is one reason I like the slideboard for all athletes and one reason that we may not see a significant number of sports hernias in our athletes. All of our athletes, regardless of sport, will use the slideboard. The beauty of the slideboard is that the adductor and hip flexor muscles are exposed to eccentric/ closed chain loads as the athletes slide across the board. However in the transition the same muscles are used to recover the leg in an open chain flexion/ adduction action. The slideboard provides two levels of essential stress to the tissues which are critical in rehab. The major problem with the slideboard is in mediating or controlling the stress. This can initially be done by controlling velocity and by providing adduction assistance to the adductors. Velocity is controlled by asking the athlete to move slowly across the board. Our description of the initial exposure to the board is “public skating”, a pace that you would use when holding hands with a member of the opposite sex on a pond or rink. Assistance is provided by placing a Lifeline Lateral Resistor on the athletes ankles. The lateral resistor functions as an additional adductor and acts to pull the free leg and decrease stress on the target tissues.
Sports Hernia Rehab Program
The real key to sports hernia rehab is a program of gradually increased velocity. Many athletes may feel fine initially because the tissue is not lengthening at a rapid rate but seem to deteriorate at the end when the velocity of tissue lengthening increases. In addition, rehab rarely includes appropriate soft tissue treatment and as a result is doomed to failure as we explained in part 1.
Another big component of rehab is the “Does It Hurt” question (see my “Does It Hurt” article). The question “does it hurt” can only be answered yes or no. We will never use exercises that cause pain.
Our first phase of rehab begins approximately two weeks post surgery and actually focuses on healing. We try to begin to get the athlete working out again without forcing stress onto the groin and abdominal area. This involves removing exercises that indirectly apply load to the abdominals. The most notable things we avoid are pullup variations and single leg knee dominant exercises like split squats and one leg squats. The first two to three weeks of rehab should focus on wound care and pain management. The strength and conditioning coach should have little involvement until the athletic trainer or physician has determined that the athlete can begin “rehab”. Somewhere around week two to three post surgery the athletic trainer, tema doctor and physical therapist will begin to allow a controlled exercise program.
I like three-week phases.
Phase 1: Core
Core work focuses on the hips and glutes with almost no direct ab or groin work. One word of wisdom: “in rehab, strengthen around but not over the acute area”. Initially, I like to strengthen the abs and adductors indirectly when possible while incorporating one simple exercise for each area. The other advice is to always ask “does it hurt”. Remember, this is a yes or no question.
All exercises except the adductor squeezes and rollouts are done for 3×10 sec isometric holds and increase by 1 rep or ten seconds per week. Rollouts and adductors begin at 2×10 and add 2 reps per week.
• Cook Hip Lift – single leg bridge holds
• Quadruped Hip Ext (McGill Bird Dogs)
• Side Bridge – short lever
• Supine Psoas Holds
• Supine or Side Lying Adduction – squeeze an Airex or Pilates Ring if pain free 75 cm. Ball Rollouts (only direct ab work and only if pain free, larger dia, balls are lower stress)
Phase 1: Lower body strength (focus again on low stress exercises.)
Begin at 3×10, add 2 reps per week or 2 reps per day.
• Bodyweight Squats – add weighted vests, work to bars.
• Reaching 1 leg Straight leg deadlift
In addition, mini-band work can be done for the abductors as part of a general warm-up.
Phase 2 Additions (Weeks 5-7)
In phase 2 we continue to progress all of the above exercises and add a short stance split squat if it can be done pain free. A short stance split squat is done in more of a 90/90 position to apply les stress to the anterior hip and anterior core. We want to begin to move to lunge type stances but, not aggressively. The stance can be lengthened if the exercise is pain free on both sides. Again here we follow a progression of bodyweight, to a weight vest, and eventually to a bar. It is important to note that up to this point we were working in the sagittal plane.
Physical therapsist John Pallof had an excellent progression concept. Pallof proposed a progression from sagittal plane (squats), to frontal plane (add lateral squats) and eventually to transverse plane. We further modified this to work mobility first and strength secondarily.
In phase 2, week 2 we will also add a bodyweight lateral squat. This is a low velocity frontal plane exercise. Some might view this as stretching or mobility work which it is all but, like many of our warm-up exercises, it will be loaded later. It is critical that the lateral squat precedes the lateral lunge. This maintains the integrity of our model of gradually increasing velocity and tissue stress.
In phase 2 week 3 we will add a rotational squat. This is the last step in preparation for a bodyweight lunge circuit or lunge matrix which we will add in phase 3.
Hip dominant work would progress by adding load to the 1 Leg Straight Leg Deadlifts and by adding Slideboard or Stability Ball Leg Curls. The slideboard leg curl is an excellent progression from the core work as it combines the actions of bridging into a concentric/ eccentric hamstring exercise.
In phase 2 of our velocity based model we will also introduce some low intensity agility ladder work and begin to add low intensity linear box jumps. ( 12-18 inches) again always with the warning that the exercises should not produce pain. Core work and strength work continue to progress with a goal of returning to normal strength levels.
Phase 2 Lower body strength (add single leg knee dominant exercises.)
Core work continues to progress in number of reps.6 x10 sec this phase.
Begin at 3×10 , add 2 reps per week or 2 reps per day.
• Short Stance Split Squat 3×10 ea leg
• Front Squats – 3×10 (these are done after split squats. This is a departure from normal but, this is rehab)
• 1 leg Straight Leg Deadlift- one dumbbell or kettlebell
• Slideboard Leg Curl
Add lateral squats 2×10 ea. side
Aadd rotational squats 2×10 ea side
Mini-band continues as part of a general warm-up.
In phase 3 we will again add increased velocity by switching from eccentric to concentric contractions in a more dynamic manner. In phase 1 and 2 we would classify the knee dominant exercises as static-supported exercises. This means that the pelvis is supported by the opposite limb in contact with the ground or a bench and that the body is not moving forward or back but, is “static”. This is in comparison to a lunge, which we would consider a dynamic exercise. In dynamic exercises gravity and bodyweight begin to add additional decelerative stress. In addition in phase 3 we will introduce what we cal static unsupported exercises. These are true one leg squats where the pelvis does not have the benefit of an additional support foot.
Plyometrics will be progressed adding all normal phase 1 stability based plyos. This a mix of box jumps ( single and double leg), lateral and medial hops ( R to R or L to L) , and lateral bounds ( R to L).
Ladder work will also progress in intensity. At this stage we will also begin to slideboard ( with lateral resistors) and add sled pushes and crossovers.
In addition we will move to phase 1 of our normal straight ahead speed progression and add a drill called Lean-Fall-Run. Lean-Fall-Run is exactly like it sounds. The athlete stands tall and literally falls into a 5-10 yd sprint. With a rehab client the instruction is three quick steps and coast. One set of five sprints is done with a walk back recovery.
Phase 3 Lower body strength (add lunges and one leg squats)
Core work stays at 6 x10 sec this phase.
Split squat, lateral squat and rotational squat are now done for one set of 10 ea side as part of warm-up.
• One leg squats 3×10 ea. side begin with 5 lb dumbbells
• Front Squats- 3×10 ( these are still done after 1 leg squats. Again a departure from normal but, this is rehab)
• 1 leg Straight Leg Deadlift- one dumbbell or kettlebell, continue to progress loads 5-10 lbs. per week. Athletes should be approaching 50-70 lbs in one hand.
• Slideboard Leg Curl- add weight
Forward Lunge replaces 1 leg squat.
In place squat circuit (split, lateral, rotational) is replaced by a lunge matrix type circuit. This is still a bodyweight multi-planar warm-up. Athletes should now be able to train normally with teammates but, should be carefully monitored.
Plyos and speed should continue to progress. Because athletes begin to add phase 1 sprint and plyos in phase 3, they are two phases behind for plyometric phases.
The truth is that there is still along way to go in the area of sports hernia rehab. Hope fully this article gives you some food for thought in regard to prevention and rehabilitation.