Physical Therapist's Guide to Core Muscle Injury (Sports Hernia)
Core muscle injury, often misleadingly called a “sports hernia,” is a condition that mainly affects athletes who play soccer, hockey, football, and rugby, and who run track. It is more common in males than females. A full 94% of these injuries occur gradually from unknown causes; the other 6% are caused by a specific traumatic incident, such as being "checked" from behind while playing hockey. Stress from repetitive twisting, kicking, and turning at high speeds is a likely cause of injury. Casual exercisers and nonathletes can also experience this kind of injury. Physical therapists can help individuals with core muscle injury improve their abdominal and hip strength and flexibility in order to safely return to their desired sport or activities. Physical therapists are also part of the prehabilitation and rehabilitation team for people who require surgery for core muscle repair.
Core muscle injuries have been called athletic pubalgia and sports hernia, but this injury does not fit the common definition of a “hernia,” where an organ or soft tissue protrudes outside its normal cavity. There is no defect in the abdominal wall or herniation of the abdominal contents with a sports hernia. Injury occurs in the form of tears and weakening in the deep layers of the abdominal wall.
Repetitive hip and pelvic motions typical in sports can cause injury to the lower abdominal area. Imbalances between the hip and abdominal muscles can, over time, cause overuse and injury. Weakness and lack of conditioning in the abdominals also might contribute to the injury. Ironically, aggressive and unsafe abdominal exercise programs can also cause or aggravate a core muscle injury. A core muscle injury usually occurs where the abdominal muscles attach in your pelvis. There is no protrusion of organs, but there are tears in tendons and muscles, such as those surrounding the hip. This makes the term “hernia” a misnomer, as the term hernia means when organs from your abdomen come out through spaces, such as the inguinal canal. Nerve irritation can also occur, contributing to the uncomfortable symptoms.
Chronic groin pain is a hallmark symptom of core muscle injury. It occurs in 5% to 18% of athletes, and varies with the sport being played. Sharp groin pain with exertion is also a typical symptom. Pain often occurs exclusively with intense sprinting, kicking, twisting, or "cutting," and subsides rapidly with rest. Significant training and competition time can be lost due to related chronic groin pain.
With core muscle injury you may experience:
- Sharp or stabbing pain in the groin region that occurs mainly with running, sprinting, cutting, pivoting, kicking, or twisting.
- Pain felt while performing abdominal sit-ups.
- Pain that is often isolated to 1 side of the groin.
- Pain that radiates into the inner thigh.
- Pain isolated to the groin when coughing or sneezing.
- Minimal to no pain in the groin when resting, sitting, or sleeping.
- Tenderness to touch or pressure on the lower abdominal area.
Note: If you have groin pain that isn’t relieved with rest from activity, you could have other potentially serious medical conditions involving the digestive, urinary, or reproductive systems. Consult your physician.
If you see your physical therapist first, your therapist will conduct a thorough evaluation that includes taking your health history. Your therapist may ask whether you:
- Have groin pain that occurs when you are sprinting, twisting, or kicking.
- Have had any injuries to your hip, low back, or groin.
- Have recently completed any intense abdominal or core strengthening exercises.
- Get relief from your groin pain if you rest or don’t participate in your regular sport or exercise routine.
- Feel pain in your groin when coughing, sneezing, or "bearing down."
- Recall a particular movement or incident when you first felt pain in the area.
- Experience groin pain that limits your desired level of sport performance.
Your physical therapist also will conduct standard strength tests of your hip muscles, and tests to measure the flexibility of your hip and thigh muscles. Your physical therapist will assess how well you can isolate or contract certain muscles. A thorough examination of your hip and low back movements may also be performed.
Your physical therapist may use additional tests to investigate for knee joint or lumbar spine injuries.
To provide a definitive diagnosis, your physical therapist may collaborate with a sports medicine physician or other health care provider. The physician may order further tests—such as magnetic resonance imaging (MRI) — to rule out other injuries to your hip, low back, or pelvis, and further confirm the diagnosis of a core muscle injury.
Conservative treatment of core muscle injuries includes rest and physical therapy. Your physical therapist will provide treatments to target the key problems found during the examination. Your therapist will design an individualized treatment program for you that targets your condition and goals, to help you safely return to your sport or normal activity levels.
Some cases of more severe injury may require surgery. Most patients with a core muscle injury are advised to first attempt a conservative course of treatment for 4 to 6 weeks. If groin pain continues to occur after that time, surgery may be recommended. If you decide to have surgery, your therapist can help you regain your strength and flexibility following the procedure.
Treatment Without Surgery
Physical therapy will focus on addressing the key problems that are found during your evaluation. The key issues that are often found with this injury include poor hip strength and flexibility, and a reduced ability to activate or turn the abdominal muscles to stabilize the pelvis.
Targeted physical therapy treatments will address your condition without worsening or reproducing your pain.
Your physical therapist will also caution you to avoid certain activities and exercises that cause groin pain. Ice may also be applied to decrease pain in the area of injury. Your therapist may advise you to:
- Avoid aggressive or painful stretching.
- Avoid stretching your trunk and upper body.
- Avoid doing sit-ups.
Your physical therapy treatment may include:
- Icing and compression. During the initial phases of injury or when high levels of pain are being experienced, application of ice to the area may decrease pain levels.
- Stretching. Your physical therapist may help you perform hip and low back exercises to gently stretch and strengthen your muscles. Your therapist will educate you on the proper duration and frequency of exercises to improve muscle flexibility and decrease pain.
- Muscle retraining. Your physical therapist will teach you to target or activate the abdominal and hip muscles. This is a key part of your treatment; certain muscles may not be "firing" or contracting due to pain and inhibition.
- Strengthening. Targeted hip strengthening and nonaggravating core strengthening will be started once you are no longer experiencing pain.
- Manual therapy. Hands-on stretching, soft-tissue mobilization, and joint mobilization may be performed by your physical therapist based on your evaluation. Manual (hands-on) therapy may be performed to improve your hip-joint mobility and range of motion, or ease muscle pain and improve flexibility.
- Return-to-sport drills. Once you are able to progress without pain during treatment, your physical therapist will add movements specific to your sport or activity into your treatment program. For instance, you may return to running and light sport drills to prepare your body for the stress of full participation in your sport.
Core muscle injury is challenging to prevent because of the inherent stress and strain placed on the pelvis and hips during certain sports. That being said, a prevention program should be directed at those at the highest risk—males participating in soccer, hockey, and football. That program includes:
- Abdominal and core stabilization exercises
- Exercises to strengthen the hip adductor muscle
- Exercises to help decrease stress across the pelvis and lower abdominal area, where the sports hernia injury often occurs
Mitch is a high-school soccer player who has been experiencing left-sided groin pain over the past month. He has been trying to play this season, but experiences sharp groin pain when kicking the ball, twisting to defend his opponents, and sprinting. He has sat out 2 practices and 1 game, but his pain starts up again as soon as he tries to play. He can run with no pain, but is frustrated because he can't kick the ball as far or as hard as he once did. His dad calls his physical therapist.
Mitch's physical therapist, upon hearing his account of his recent pain, and conducting a hands-on examination, determines that Mitch is experiencing the signs and symptoms consistent with a core muscle injury. She recommends that Mitch receive conservative nonsurgical treatment for 4 weeks. She designs a treatment program that includes manual therapy and exercises targeted at his hip muscles to improve their strength and flexibility. She also teaches Mitch how to isolate his deep abdominal muscles, and help stabilize his pelvis with gentle soccer-specific kicking motions. During his treatment sessions, she also tells Mitch what exercises and activities to avoid, including sit-ups.
During the last phase of his treatment program, Mitch starts to run and perform drills to replicate movements similar to soccer, and prepare his body for the stress of rejoining the team.
After 6 weeks of treatment, Mitch is cleared by his physical therapist and physician to resume soccer practice—and is able to kick and play without any pain or limitations.
All physical therapists are prepared through education and experience to treat core muscle injuries. However, you may want to consider:
- A physical therapist who is experienced in treating people with core muscle injury. Some physical therapists have a practice with a sports or orthopedic focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of sports hernia. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139–144. Article Summary on PubMed.
Woodward JS, Parker A, Macdonald RM. Non-surgical treatment of a professional hockey player with the signs and symptoms of sports hernia: a case report. Int J Sports Phys Ther. 2012;7(1):85–100. Free Article.
Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin injuries in sports medicine. Sports Health. 2010;2(3):231–236. Free Article.
Unverzaqt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J Orthop Sports Phys Ther. 2008;38(2):63–70. Free Article.
Kachinqwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J Orthop Sports Phys Ther. 2008;38(12):768–781. Free Article.
Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15(8):507–514. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Andrew Sweeny, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.
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