DIAGNOSIS

A comprehensive understanding of the relationships between the many systems of the kinetic chain is vital to the analysis of the complexities associated with any syndrome or injury. 

The sports hernia is clearly due to the thinning of either the abdominal rectus or obliques and its fasciae (1, 7).  The challenge is unraveling the CAUSE of the injury and appreciating interrelationships of all muscles involved, not just one or two.  If one piece of the puzzle is neglected, prevention and reduction will become unattainable, rehabilitation will be prolonged, and surgery will be warranted in increasing numbers. 

Inclusion of the role of rotation for several involved muscles has yet to be delineated during the initial examination leading to the diagnosis of sports hernia, as it is neglected with many other common sports injuries.

For example, if the internal rotators of the hip are long and inhibited, the obliques will also be long and inhibited.  This will cause instability of the hip and the resulting action will be for the short adductors, pectineus, adductor brevis and adductor longus, to become short and overactive, as mentioned above (6, 7). 

Rotators are the innermost stabilizers for the hip, its core.  If they are found to be weak, the nervous system will select a larger group of muscles to assume the role of stability, specifically, the hip flexors.  When they are put into the position to protect, the hip flexors become short and overactive, and pull the pelvis anteriorly (8).  The diagnosis is deemed anterior pelvic tilt or Lower Crossed Syndrome; however, these issues are the effect, NOT the cause. 

Strength analysis of muscles that rotate the hip must soon become the examination of choice to diagnose the original cause of sports hernia.  Strength in rotation of other major joints that circumduct, such as ankle, shoulder and wrist, will be the primary area of investigation for many sports injuries. 

STRUCTURAL IMBALANCES

The most widely accepted correct position of the pelvis is when observing from the side view.  Both the ASISs and the pubis should be in the same plane.  In other words, the pubis symphysis should be directly in line with the ASISs, not in front or behind them.

Also visualizing from the side, the ASIS and PSIS should be relatively even with each other in a line drawn through them and parallel to the floor (9). 

A sports hernia is most likely to occur in an athlete whose pelvis has tilted anterior (anterior pelvic tilt) on at least one side.  In this position, the ASIS will be notably lower than the PSIS on either or both sides.  In either case, the pubis symphysis will be posterior to both ASISs. 

CONTRIBUTING FACTORS

The most obvious cause of anterior pelvic tilt in athletes is imbalance between quads and hamstrings.  Due to work load and muscle type, quads tend to be short and overactive, while hamstrings and glutes tend to be long and neurologically inhibited.  To complicate matters, most sports and strength programs put a greater emphasis on strengthening quads and stretching glutes and hamstrings. 

Also, quads fall into the muscle category type of stabilizers, while hamstrings and glutes are powerful movers.  If trained with equal intensity, the quads will get stronger and shorter, while the hamstrings and glutes will become relatively weaker and inhibited.  Failure of the strength coach or athlete to realize this relationship will lead to serious structural imbalances. 

Weak abdominals, both rectus and obliques, are also major causative factors; however, weak abdominals are most likely the result of anterior pelvic tilt as described above, caused ultimately by excessively strong quads and hip flexors (10, 11).  As the pubis symphysis drops away from the abdominals, they become over long and stressed.  They cannot fully contract from this position, no matter the strength of the athlete. 

Other mechanical forces are involved, such as imbalances of other hip flexors and extensors.  A short psoas will tend to pull the pelvis anterior, lengthening the glutei through inhibition.  The same flexor/extensor relationship between tensor fasciae latae and gluteus medius/minimus exists.

The position of the pelvis described above predisposes the athlete to sports hernia.  The abdominal rectus and obliques are put into an elongated, weakened and thinned position (7).  When the pubis symphysis tilts downward and shifts posterior, the short adductors are severely disadvantaged mechanically, subjecting them to injury.  They are now positioned well behind the dynamic action of the thigh lifting upward and/or outward, as in kicking a ball, skating, sprinting or quickly changing direction (3, 6, 12, 13).

Most noteworthy, an anterior pelvic tilt renders the muscles providing internal rotation virtually useless.  Without participation of the rotators, the short adductors become shorter and more overactive, and the abdominal rectus and obliques become more elongated.  The athlete is now in the prime position for the action which will produce the sports hernia injury. 

RELATIVE STRENGTH ISSUES

New training discoveries, biomechanical research, nutritional developments and advancing education have enhanced the capacity for an athlete to build muscle. 

While most view this as an advantage, caution must be exercised in this area.  These perceived advances in training are largely responsible for a sharp rise in injuries, especially at the collegiate and professional levels, where the athletes are bigger, stronger, faster and leaner.  Until the real cause of the most common injuries is fully understood and embraced, i.e., high ankle sprains, labral tears, hip and shoulder instability, ACL/MCL injuries, gluteus medius/minimus tears, and sports hernias, they will continue to rise in exponential proportions.

The underlying problem lies in the relative strength of large to small muscle groups.  If we add strength and mass to the large muscle groups while failing to proportionally strengthen the small groups, a destructive scenario culminating in injury and decreased performance output will persist.

To be clear, if heavy weight and/or dynamic functional exercise programs are used producing high force for the prime movers, it cannot be expected that the equivalent load or force will be achieved for the small stabilizers/rotators using only body weight stability, balance, flexible bands or lightly weighted exercises. 

Even if the focus is on small stabilizer/rotator groups, the larger surrounding muscles are typically impacted more than the target group, making them relatively weaker still. 

Although not the specific intent of this article, this can be demonstrated when attempting to strengthen the external rotators of the shoulder, the infraspinatus and teres minor.  The athlete may use a non weight bearing, open kinetic chain, such as a dumbbell, to accomplish the external rotation.  The large muscles, acting as synergists to stabilize and rotate, will be the beneficiaries of the bulk of the load since they have a greater capacity for these actions.  In the process, the targeted small muscles may gain a small amount of strength, but become RELATIVELY weaker.

If a muscle is designed for a specific action, and we choose not to strengthen that action; we are inviting a host of problems.  The hips, shoulders and ankles all have muscles that rotate, and they rotate in a horizontal plane, ie., relative to a line drawn parallel to the floor.  Generally, current athletic programs do not effectively train these rotators to their fullest capacity and capability. 

We strengthen flexors of the body with flexion exercises, and extensors with extension exercises, using heavy weights or dynamic functional exercise programs.  The same regimen exists for large adductors and abductors.  The science and knowledge to make these large muscle groups as powerful as possible is well known; however, the training protocols for the most critical muscles of the body – the small stabilizers/rotators – are not emphasized.  This creates HUGE PROBLEMS for the athlete and indeed the athletic program.

The hip ROTATES in two directions, internally and externally, but these rotators are trained EXCLUSIVELY in ABDUCTION.  The ankle ROTATES in two directions, internally and externally, yet trained EXCLUSIVELY with STABILITY exercises.  The shoulders also ROTATE internally and externally, and though some train them in rotation; inadequate efforts will persist in shoulder development until RELATIVE STRENGTH ISSUES are fully understood. 

Specific to sports hernia, the internal rotators of the hip must be trained against a strong resistive force in ROTATION.  The body must be weight bearing with the pelvis in a neutral position so that the rotators will receive the greater share of the exercise – NOT the prime movers. 

Once the muscles of internal rotation are strengthened to their greatest capacity, they will have reached their full relative strength potential with respect to the prime movers which surround them.  The pelvis will have attained a more neutral position, so the short adductors will no longer be mechanically disadvantaged.  The abdominal rectus and obliques will also return to their strongest positions, which will tremendously reduce the possibility of injury to the abdominals, both rectus and obliques.

A specific exercise program which addresses prevention, reduction and rehabilitation of the sports hernia is outlined below.  The athletic programs which choose to adopt this program and follow it diligently will significantly reduce the CAUSE, dramatically diminish recovery time and the necessity for surgery of many sports related injuries, to include the sports hernia.

EXERCISE PROTOCOL FOR PREVENTION, REDUCTION AND REHABILITATION

Weeks 1 – 6 are intended specifically for REDUCTION AND REHABILITATION.  For PREVENTION, more aggressive exercises that are included in Weeks 7 – 12 may be added during Weeks 1 – 6.

Each star (*) represents a specifically rotational strengthening exercise of the hips, pelvis or shoulder.  Each can be accessed by logging on to the following site: RotationIsTheAnswer.com →FAQs →The Answer Exercise Videos →Click onto the applicable rotational exercise.  Progressions for exercise resistance may be found at RotationIsTheAnswer.com →FAQs →Protocols Progression

Reasoning of Shoulder External Rotation as it applies to sports hernia: Since the latissimus dorsi is a strong component in creating an anterior pelvic tilt though its broad attachment to the thoracolumbar fasciae, external rotation at the shoulder is strongly recommended if the athlete is assessed as having internal rotation of the shoulder. 

Abdominal Crunch Series is found at RotationIsTheAnswer.com →FAQs →Crunch Workout.

Phase I:  Weeks 0 - 2
Perform these exercises 6 days a week