CONSERVATIVE MANAGEMENT OF SPORTS HERNIA IN A PROFESSIONAL GOLFER: A CASE REPORT

Abstract

Study Design:

Case Report

Background

Activity‐limiting groin pain is relatively common in athletes who participate in sports which involve rapid or repetitive twisting, cutting, and/or kicking. Despite the reported prevalence of this condition in athletes, there is still much controversy as to the anatomical structures involved and most effective treatment approach. There is limited evidence favoring conservative management of sports hernia as opposed to surgical intervention in professional athletes, and there are no reports of sports hernia management in the professional golf population. The purpose of this case report is to describe the conservative management and decision making used with a professional golfer with symptoms consistent with a sports hernia which allowed for successful return to prior level of sport participation.

Case Presentation

The subject of this case report is a professional golfer who developed lower abdominal and groin pain after changes in conditioning routine. Clinical presentation was consistent with a diagnosis of sports hernia. Rehabilitation of this athlete included a structured core muscle retraining program which utilized a step wise progression through the neurodevelopmental sequence in order to allow for development of neuromuscular control and stability required for return to golf.

Outcome

This athlete was able to return to full golf participation after 13 physical therapy visits over 4 weeks.

Discussion

The available evidence supports surgical intervention over conservative management in the treatment of sports hernia in the athletic population. A structured and comprehensive rehabilitation program addressing core muscle weakness and contributing impairments adjacent to injury may be a beneficial treatment option prior to surgical repair potentially allowing return to sport in some athletes.

Levels of Evidence:

4

INTRODUCTION

Activity‐limiting groin pain is relatively common in athletes who participate in sports which involve rapid or repetitive twisting, cutting, and/or kicking.¹ Groin pain is reported to be responsible for 5‐18% of physician visits by athletes. A sports hernia may be one cause of acute groin pain and potentially lead to chronic groin pain in athletes.² The majority of these injuries are reported in sports such as soccer, football, track & field, tennis, and hockey.^1,3 Despite the reported prevalence of this condition in athletes, controversy exists regarding the anatomical structures involved and most effective treatment approach(es). ¹The available literature favors early surgical management and does not support the effectiveness of a conservative treatment approach in the athletic population.^4,5 However, a trial of relative rest and conservative care including physical therapy is recommended prior to surgical intervention.^1,6,7 To date, there is only one case study published on successful return to sport with conservative management of a professional level athlete after a diagnosis of sports hernia.⁸ There are no reports of management of symptomatic athletic pubalgia or sports hernia in elite level golfers. The purpose of this case report is to describe the conservative management and decision making used with a professional golfer with symptoms consistent with a sports hernia which allowed for successful return to prior level of sport participation.

CASE DESCRIPTION

At the time of injury, the subject was a 25 year‐old professional golfer who had played on the PGA Tour for six years. No history of groin or abdominal injury was noted, however, occasional complaints of right anterior hip “pinching” had been documented. The injury occurred during an independent exercise session in which the subject reported doing a lot of abdominal and upper body pull‐up exercises. He reported soreness during this session but did not identify it as pain until the next morning when he tried sitting up in bed. The subject reported pain with bed mobility and supine to sit transfer. He also reported pain when attempting planks, pull‐ups, or push‐ups. He reported symptoms when swinging a driver, however, had no pain with irons or wedges. He denied pain with sneezing, coughing, and toileting, and denied pain during sitting, walking, and at rest.

INITIAL EXAMINATION

Initial physical examination revealed localized tenderness to palpation in the right lower abdomen, proximal to inguinal ligament. No palpable deformity or hernia was noted. Resisted right active straight leg raise at 45 degrees, or Stinchfield Test, was positive for reproduction of symptoms. Pain was also reproduced with resisted right hip adduction in zero degrees of hip flexion, supine to sit trunk flexion, and abdominal internal and external oblique muscle testing bilaterally. Prone passive hip internal rotation was non‐painful bilaterally and measured 35 degrees on right and 40 degrees on left. Special testing of the right hip revealed negative FADIR and Scour Testing. Modified Thomas Test was negative bilaterally. FABER testing revealed decreased range of motion on right compared to the left, however, was non‐painful. A modified, or core‐stabilized, FABER was performed to determine if activation of the subject's core musculature would improve range of motion by posteriorly tilting the pelvis and increasing femoro‐acetabular space. To perform the core‐stabilized FABER test, the subject assumes the FABER position and raises the arms to 90 degrees of flexion. The tester applies an isometric force against the subject's hands (into shoulder flexion), promoting activation of core musculature. An increase in range of motion (or decrease in pain if symptomatic) may suggest that core stability retraining may have a positive effect on patient outcomes. There was a notable increase in the subject's range of motion with the core‐stabilized FABER test on the right as compared to the standard FABER test, however, continued to be limited compared to the contralateral limb. (Figure 1).

Figure 1.

Core‐stabilized FABER test.

CLINICAL IMPRESSION

Based on the initial examination, several differential diagnoses were considered. The findings of asymmetrical and reduced FABER and hip internal rotation were suggestive of possible intra‐articular hip pathology. Phillipon reported 97% of patients with intra‐articular hip pathology had a positive FABER test.⁹ A positive Stinchfield Test was suggestive of possible hip labral pathology, as the activated psoas applies pressure on the labrum.¹⁰ Pain provocation during this resisted active straight leg raise could also be indicative of hip flexor tendinitis. Based on the location of the pain and mechanism of injury during an abdominal workout, an abdominal oblique strain was considered. Finally, because the pain was localized, proximal to the hip, and there was a specific mechanism of injury, a provisional diagnosis of sports hernia was made and a physician appointment was made the following day to further rule in/out this diagnosis and/or need for additional testing.

The physician reproduced the therapist's clinical examination with the same findings noted as above. Magnetic resonance imaging (MRI) was not ordered at that time. MRI and other imaging may be used to rule out other pathologies, however, is often normal in those with the diagnosis of sports hernia.¹¹ The subject was instructed to undergo conservative physical therapy for two weeks and if no improvements were made surgical intervention would be considered.

SECONDARY EVALUATION, INITIAL TREATMENT AND ACTIVITY MODIFICATION

The patient was seen by the therapist following the physician appointment for a more thorough musculoskeletal examination and initiation of treatment. Pain level was rated 4/10 during aggravating activities on a verbal analogue scale where zero is no pain and 10 represents worst pain imaginable. A Selective Functional Movement Assessment (SFMA) was performed to determine specific impairments related to the subject's total body movement dysfunctions.¹² Results of SFMA testing are shown in Table 1.

Table 1.

Results of Selective Functional Movement Assessment (SFMA) and identified impairments at initial examination and discharge.

SFMA Pattern	SFMA Rating at Initial Evaluation	Specific impairment(s) found at evaluation	SFMA Rating at Discharge	Specific impairment(s) at discharge
Cervical Patterns	FN		FN
Upper Extremity Patterns	FN		FN
Multi‐segmental Flexion	FN		FN
Multi‐segmental Extension	DP	*symptoms reproduced	DN	‐weight‐bearing thoracic stability/motor control dysfunction
Multi‐segmental Rotation	DN bilaterally	‐hip internal rotation joint mobility dysfunction ‐thoracic rotation stability/motor control dysfunction	DN	‐weight‐bearing thoracic stability/ motor control dysfunction
Single Limb Stance	FN		FN
Overhead Deep Squat	DN	‐upper quarter stability/motor control dysfunction ‐left ankle dorsiflexion tissue extensibility dysfunction	DN	‐weight bearing stability/ motor control dysfunction

FN = Functional/Non‐painful; FP = Functional/Painful; DP = Dysfunctional/Painful; DN = Dysfunctional/Non‐painful

Manual muscle testing revealed 4+/5 hip abduction on the right and 4/5 on the left, 4/5 hip flexion on right with pain and 5/5 on left. Rectus abdominis and abdominal oblique muscle testing reproduced subject's symptoms,¹³ however, the subject was able to perform a transversus abdominis contraction without pain or compensatory activation. Transversus abdominis activation was evaluated in hooklying by palpating medial and inferior to the anterior superior iliac spine (ASIS) bilaterally. A single leg bridge revealed a drop of the pelvis to the unsupported side when testing the supportive left side, indicating weakness of left gluteals.¹⁴ The subject was able to maintain a level pelvis when performing the test on the right. The subject was able to perform a single leg lateral step down from an 8‐inch step on the right lower extremity with proper form as described by Crossley et al.¹⁵ Single leg lateral step down of the left lower extremity revealed Trendelenburg drop from 8‐inch step but the subject was able to perform the step down correctly from 6‐inch step.

The subject was educated regarding the avoidance of aggravating activities including supine to sit transfer and was taught supine to sidelying modification for getting out of bed. He was instructed to not swing a driver, however, continued practice with irons was permitted as this was non‐painful. Additionally, all strength and conditioning activities were ceased in order to avoid painful movements and risk of re‐injury.

Treatment was initiated based on the subject's provocative movements and to address the specific impairments found during the examination. Therapeutic neuromuscular retraining was prescribed in a step‐wise progression following the neurodevelopmental sequence of postures/positions.^16,17,18Exercise prescription using this sequence begins with non‐weight‐bearing positions and progressively loads the body from quadruped to transitional kneeling postures, and finally to standing. Exercise intensity progressed from isolated activation of transversus abdominis and gluteal musculature and perturbation retraining to resisted motions against external loads to sport specific activities.^19,20

EARLY REHABILITATION (1 WEEK)

Treatment began with Grade III and IV inferior and lateral femoroacetabular joint mobilizations with movement (in supine) to address hip mobility asymmetry. Neuromuscular retraining was initiated in non‐weight‐bearing positions including prone unilateral gluteus maximus isometrics, supine bridging, and supine transversus abdominis activation with biofeedback pressure cuff. Fundamental rolling patterns were performed in order to assess the subject's ability to coordinate movement of the extremities and core by shifting weight, crossing midline, and rolling from supine to prone and prone to supine leading with either upper or lower extremity (Figure 2). Hoogenboom et al proposed that dysfunctional or asymmetrical rolling is due to inefficiency in sequencing or motor control of core musculature.¹⁷ The subject demonstrated inability to roll properly from supine to prone with either upper extremity, suggesting poor proximal to distal core sequencing. A half foam roller was used as assistance to prop the subject into a ¾ supine posture and allow easier completion of the task. This assisted rolling intervention was utilized to restore the full supine to prone upper body rolling task.

Figure 2.

Supine to Prone Rolling

Exercises were then progressed to a quadruped position, including anterior/posterior pelvic mobility and extremity movement maintaining neutral spine (Figure 3). The quadruped position allows for loaded closed chain stability of the hips and scapulae while keeping the spine unloaded against gravity. Next, the subject was progressed to a transitional half kneeling posture. The half kneeling posture disadvantages distal portions of the kinetic chain and challenges proximal stability laterally.¹⁸ Therapeutic activities in this posture included reflexive neuromuscular stabilization in response to therapist application of perturbations as well as active upper extremity motion in PNF diagonal patterns (Figure 4). Finally, a standing posture was assumed for single limb activities such as single limb squats and hip drops to address contralateral pelvic drop noted during functional assessment. An example of early rehabilitation progression can be found in Table 2.

Figure 3.

Quadruped Hip Extension

Figure 4.

Half Kneeling with Perturbations

Table 2.

Early Rehabilitation Program utilized with Case Subject

Early Rehabilitation
Hip mobilization with movement	Grade III & IV inferior & lateral femoro‐acetabular mobs
Prone unilateral gluteal isometrics	10 × 5 seconds each
Supine transversus abdominis retraining with pressure cuff: Diaphragmatic breathing, marching, bent knee fall out	2 minutes each task
Fundamental rolling patterns	5‐10 repetitions of each pattern
Quadruped hip extension with neutral spine	2 × 15 reps each
Quadruped alternating opposite arm and leg extension with neutral spine	2 × 15 reps each
Half kneeling reflex stabilization against therapist perturbations	2‐3 sets of 30‐60 seconds each limb
Half kneeling upper extremity diagonal active range of motion in chop and lift patterns	2‐3 sets of 10‐15 reps
Single limb squat from step	2‐3 sets of 10‐15 reps; 6‐8 inch step
Standing hip drops	2‐3 sets of 10‐15 reps
Stationary bike	5 mins including four 20 sec sprint/20 sec easy intervals

INTERMEDIATE REHABILITATION (∼10 DAYS)

After one week, the subject reported 2/10 pain with sitting up from bed. He had been hitting wedges and irons (up to his 7 iron) daily without pain. Once the subject was able to demonstrate appropriate form and control with early rehabilitation interventions, therapy was progressed to include resistance exercises in the aforementioned neurodevelopmental postures. Interventions during this time included half kneeling chop and lift patterns with cable resistance, single leg Romanian deadlifts, and resisted side‐steps (Figure 5). Additionally, the subject was able to perform activities in both the lunge position and modified (hands and knees) plank positions. Recall that these postures were previously painful secondary to right hip extension and increased core demand, respectively. Rotational exercises without resistance were included to initiate return to golf activity. A sample workout from this intermediate period can be found in Table 3.

Figure 5.

Lift Pattern in Golf Posture

Table 3.

Intermediate Rehabilitation Program utilized with Case Subject

Intermediate Rehabilitation
Cat/camel	10‐15 reps
Lumbar locked thoracic rotations	10‐15 reps each side
Single leg bridge with hip abd/add	2‐3 sets of 5‐10 reps each side
4‐position Clamshell progression	15‐20 reps in each position
Modified plank with 3‐point upper extremity reach	2 sets of 5‐10 reps each side
Half kneeling torso rotations holding golf club overhead	1‐2 sets of 10‐15 each side
Half kneeling cable chop pattern with bar	2 sets of 10‐15 reps each side; 30‐40#
Half kneeling lift pattern with cable bar or medicine ball	2 sets of 10‐15 reps each side; 30# or 8# medicine ball
Squats with upper extremity flexion with resistance bands	2 sets of 10‐15 reps
Forward/backward walking lunges with medicine ball lift	10‐15 lunges forward, 10‐15 backward using 8# medicine ball. Repeat 2‐3 sets
Single leg Romanian Deadlift	2‐3 sets of 10 each; 15‐35#
“Stork Turns” Single limb closed chain hip rotations without moving upper body	2 sets of 10‐15 reps each
Lateral slides on Slideboard	Progress from 6ft to 8ft slides; 3‐5 sets of 20‐30 seconds

LATE REHABILITATION/ RETURN TO SPORT

By week three of therapy, the subject was able to perform a supine crunch without pain, however, still had 2/10 pain with supine oblique crunch bilaterally. He was hitting unlimited balls with all irons, but had not yet swung a driver. He was continuing to avoid strength and conditioning exercises of pull‐ups, dips, push‐ups, and planks and had modified his bed transfer to avoid symptoms. The subject's goal was to compete in a tournament in three weeks. Because the subject was hitting balls without difficulty at that time using irons, therapy exercises were progressed to include speed and plyometric activities to prepare him for the demands of swinging a driver and returning to tournament golf. Return to sport activities during this time included rotational throws against a rebounder with a three kilogram medicine ball in both half kneeling and golf postures, lateral bounding, resisted chop and lift patterns in golf posture, and single leg box jumps.

OUTCOMES

The subject was seen for 13 physical therapy visits over the span of four weeks. At the conclusion of therapy he reported 0/10 pain with all golfing activities and sitting up from bed. He reported 2/10 pain with planks, pull‐ups, and push‐ups, therefore these activities were excluded from his strength and conditioning routine for an additional six weeks until he was able to demonstrate pain‐free performance. Results of the SFMA at discharge can be found in Table 1. Objective testing revealed 30 degrees of hip internal rotation bilaterally, 5/5 hip strength throughout, and both single leg bridge and single leg squat tests were negative for contralateral pelvic drop. Standard FABER testing remained unchanged from initial evaluation but was still non‐painful and the Stinchfield Test was negative for symptom reproduction. Seven weeks post initial injury the subject was able to return to tournament competition without pain or limitation.

DISCUSSION

Sports hernias most commonly occur in high intensity activities involving cutting, pivoting, and kicking. While not reported in golf, the repetitive rotational demands of the sport place these athletes at increased risk for sports hernias. Although the available literature comparing surgical intervention to conservative management of a sports hernia favors surgical repair,⁵ an initial trial of conservative treatment of 6‐8 weeks is recommended.^1,21 Surgical repair is then recommended for those athletes who are unable to return to sport at their desired level after attempting conservative treatment.^8,22 Studies which show poor outcomes with conservative management typically fail to provide data regarding specific rehabilitation interventions and the rationale used for exercise progression.⁸ This case report adds support to the limited reports in the literature that have demonstrated successful outcomes with conservative management in high level athletes after a suspected sports hernia.^1,8 While there is a paucity of literature discussing abdominal and/or groin injuries related to the golf swing, the systematic, full‐body assessment and treatment approach discussed in this case has potential to be carried over into other sports.

The decision to proceed with conservative care versus operative management was in agreement with the algorithm proposed by Kachingwe et al. The authors recommended a trial of 4 weeks of physical therapy for athletes expected to return to sport within 4 months; if the athlete does not report at least 80% improvement after this trial, then surgical intervention should be considered. If greater than or equal to 80% improvement is reported an additional 2‐3 weeks of physical therapy is recommended.¹ The subject of the presented case report showed objective improvements during rehabilitation, tolerating core stabilization exercises in more challenging postures and gradual, symptom‐free return to hitting golf balls with longer club lengths. These improvements led the clinical team to proceed with the course of conservative treatment and not to recommend surgical consultation, further imaging studies, and/or more invasive interventions.

It is widely accepted that a sports hernia is due to an injury of the musculature and/or the fascial attachments along the anterior aspect of the pubis, however, there remains much disagreement as to which specific structures are involved.¹ This disagreement, the lack of definitive clinical testing for diagnosis, and frequently coexisting conditions make managing suspected sports hernias challenging for medical professionals. To aid with clinical diagnosis, Kachingwe et al reported a cluster of 5 symptoms which are most indicative of a sports hernia. These include: a subjective complaint of deep groin or lower abdominal pain, pain that is worsened with sport specific activities and relieved with rest, palpable tenderness over the pubic ramus at the rectus abdominis or conjoined tendon insertion, pain with resisted hip adduction at 0, 45, and/or 90 degrees of hip flexion, and pain with resisted abdominal crunch or curl up.¹ The subject of the case report demonstrated all five symptoms at time of initial presentation, thus supporting the clinician's original working diagnosis.

While this cluster of symptoms can aid in diagnosis of a potential sports hernia, the use of whole body functional movement assessments are recommended to identify underlying regional impairments adjacent to the symptomatic site which may predispose or contribute to the athlete's current injury.^12,23,24 The SFMA was the clinical tool utilized during the examination of this athlete. The findings of the SFMA combined with those of a more traditional orthopedic examination allowed for the development of a comprehensive rehabilitation program. The inclusion of a movement‐based assessment allowed the clinician to identify not only lower abdominal pain and weakness, but a thoracic extension & rotation stability dysfunction, hip ROM and strength deficits, and ankle mobility deficits which may have contributed to elevated injury risk or decreased performance. While the mechanism of injury for this athlete was an abrupt increase in volume of abdominal strengthening, several of this athlete's swing characteristics may have predisposed him to abdominal wall insufficiency and subsequent injury. Both hip internal rotation and thoracic rotation mobility and control are necessary for the golf backswing. Deficits in these areas can lead to compensatory motions in the frontal or sagittal planes. This golfer demonstrated notable trunk hyperextension during his backswing to compensate for the lack of rotation, thereby placing abnormal stresses across the anterior abdominal wall. Additionally, the lack of hip IR resulted in increased lateral sway away from the target during the backswing. This increased frontal plane motion may have resulted in excessive loading to the adductor muscle group. While a decrease in hip internal rotation has been correlated with low back injuries in golfers, there are no reports relating decreased hip motion to lower abdominal injuries in this population. Verrall et al suggested that decreased hip range of motion in Australian rules football players may predispose athletes to developing chronic groin pain due to compensatory and excessive pelvic motion or trunk hyperextension.²⁵ Although the demands of these two sports differ, decreased motion may also be a risk factor for those participating in golf.

There are several differences in the treatment approach used in this case compared to the treatment strategy reported by Woodward et al which led to the successful return to sport of a professional hockey player with conservative treatment.⁸ Core muscle strengthening and retraining was used in both cases, however one key difference in this case was the level of emphasis on the use of intermediate developmental postures such as quadruped and kneeling. In transitioning from non‐weight‐bearing to more functional upright postures the intermediate positions of quadruped and half kneeling allow the clinician to identify asymmetries and compensatory strategies which are often utilized by the athlete to complete tasks in standing. The quadruped position allows for closed kinetic chain stability training of the hips while minimizing the demands on or influences from the spine. Because of the narrowed base of support and disadvantaged lower limb in half kneeling, this posture increases demands on proximal spine and hip stability and magnifies dysfunction which may appear minimal in standing.¹⁸ Additionally, half kneeling allowed for dissociation of upper body movement from a stable lower body which is a requirement for the golf swing.

The initial management of this athlete focused on relative rest, activity modification, and isolated core muscle activation exercises. There was no utilization of cryotherapy, soft tissue mobilization, and/or other modalities in the management of this athlete. No trigger points were identified throughout the adjacent musculature that warranted soft tissue interventions. Modalities for pain modulation were not included due to the patient complaining of pain only with specific movements or during activity. After adequate activation was demonstrated, the emphasis of the core muscle training shifted to functional movement pattern retraining as opposed to isolated muscle activation. Pattern retraining was utilized to mimic the demands of daily activities and sport where core activation is an unconscious reflexive response to movement or perturbation rather than being conscious or deliberate.^18,19,20

Initially this athlete reported reproduction of symptoms with swinging long irons and his driver during practice. In an attempt to prevent deconditioning and loss of sport specific strength and flexibility the athlete was permitted to continue to practice his short game and hit wedges or short irons on the condition that no symptoms were produced. As rehabilitation progressed and symptoms diminished, the athlete was allowed to gradually resume hitting longer irons and woods based on the principles of the interval sport program similar to those discussed by Reinold et al.²⁶ The athlete was required to demonstrate a satisfactory clinical exam including necessary range of motion, minimal or no pain, and the ability to complete explosive rotational lumbo‐pelvic stabilization activities in the clinic setting without compensatory patterns or pain provocation prior to being progressed to more demanding club lengths.

There are several limitations of this case report. The lack of a definitive patho‐anatomic diagnosis makes generalizing these results to all athletes afflicted with a “sports hernia” difficult. Even with clustering specific clinical tests to assist clinicians with diagnosing athletes with lower abdominal or groin pain, “sports hernia” remains a diagnosis of exclusion with the definitive diagnosis only being made through surgical exploration.⁸ The interventions included in the rehabilitation program require knowledge and understanding of the neurodevelopmental sequence. The treatment approach and interventions selected require a great deal of attention from the clinician in order to accurately ensure successful performance and when to appropriately progress the athlete. Similar to the case report by Woodward et al, the athlete's pre‐injury fitness level and motivation may be higher than that of a less active individual or recreational athlete.⁸

Future research should focus on further development of clinical prediction rules to assist clinicians in identifying which presentation patterns of sports hernias would benefit most from conservative treatment. A better classification system could aid clinicians in determining what duration of intervention is necessary to determine whether there is benefit from conservative care, preventing a prolonged course of treatment and greater time away from sport. Further work is needed to identify the specific pathological structures involved in sports hernias and how the clinical presentation differs. This would allow for development of clinical trials in order to more accurately compare outcomes of various interventions.

CONCLUSION

This case report presents the clinical decision‐making used in the management of a sports hernia in a professional golfer. The use of a movement‐based evaluation in addition to special testing around the source of pain allowed for identification of regional impairments, which may have contributed to the injury. A structured and comprehensive rehabilitation program addressing core muscle weakness and contributing impairments adjacent to the site of injury may be a beneficial treatment option prior to surgical repair potentially allowing return to sport in some athletes.