Athletic Pubalgia

In this section we list others of the more commonly seen entities causing hip pain in athletes. More detail is provided on the entity called athletic pubalgia, a chronic inguinal or pubic area pain that occurs in highperformance athletes. Athletic pubalgia is the most common fixable problem in this group of athletes. Please refer to some of our other recent articles for other details about these syndromes. The present section, to a large degree, represents an update on these articles,89-92 in addition to adding considerably more concerning rehabilitation.

For years, lower abdominal/groin pain has ended the careers of many gifted athletes. These injuries in Major League Soccer, the National Hockey League, the National Football League, and other sports organizations during the past few years have heightened the awareness of this problem. However, the pathophysi-ologic processes involved in these presumptive injuries have been poorly understood. In 1992 we reported success with an operation for a particular pattern of inguinal pain in a limited number of ath-letes.32 We found that a distinct syndrome of lower abdominal/adductor pain in male athletes appeared correctable by a procedure designed to strengthen the anterior pelvic floor. The operation we developed was based on some concepts first suggested by the work of a Yugoslavian surgeon named Nesovic (personal communication). This success led to a much larger ex-perience.90 The experience now numbers about 1800 patients. The location and pattern of pain and the operative success suggest the cause to be a combination of abdominal hyperextension and thigh hyperabduc-tion, with the pivot joint being the pubic symphysis. We have also improved our knowledge in diagnosing this injury, differentiating it from other injuries, and managing the associated symptoms more effectively.

Definitions and Epidemiology

Many people are afflicted with groin pain, including athletes and nonathletes alike. The differential diag nosis in these patients is extremely important. In this chapter, we confine our comments primarily to abdominal/groin pain in athletes. The term athlete refers to a patient actively or recently participating in competitive athletic activity as a livelihood or integral way of life. The term athletic pubalgia refers to chronic inguinal or pubic area pain in athletes, which is noted solely on exertion and not explainable preoperatively by demonstrable hernia or other medical diagnoses.

The incidence of athletic pubalgia in various sports is listed in decreasing order: soccer, hockey, football, track and field, baseball, basketball, racquet sports, and swimming. It can be inferred that this type of injury occurs most commonly during the autumn sports. Also, more than 90% of the patients that we have diagnosed with athletic pubalgia have been male. Most female patients are found to have other causes for their pain, such as endometriosis.93 The precise explanation for the difference in gender incidence is not known. Two possible hypotheses for the higher incidence in male patients are (1) a relatively low participation (until recently) of women in highly competitive sports and (2) a difference in pelvic anatomy. Our thought is that the latter hypothesis is much more likely.

Data from eight athletic trainers in Major League Soccer and the National Hockey League estimate that 9% of players on a given team suffer or will suffer from a syndrome consistent with athletic pubalgia. Another 12% of players have some minor degree of chronic discomfort, which is not disabling. Up to 18% of players had some type of groin pull in the past but with subsequent recovery.32 In another uncontrolled survey of one professional team, 4% of players over a 5-year period retired because of groin pain. This problem was the leading cause of injury-related retirement for that team.94

The previously mentioned survey suggests that groin problems are extremely common in highperformance athletes. Roughly half the patients recover from acute injuries without significant sequelae. The remaining half of the patients can be divided into two groups, one in which the chronic pain is minor and the other group in which the pain is severe enough to require significant medical or surgical attention.30

For the most part, patients afflicted with this injury are high-performance athletes. However, performance athletes and nonathletes do have a similar potential for this syndrome. Over a 10-year period we have seen this syndrome in only a small number of nonathletes. This small number represents less than 10% of cases that were evaluated for the suspicion of athletic pubalgia.

In contrast with the 95% success rate of pelvic floor repairs in the athletes, successful repair occurred in less than half of the nonathletes who underwent similar operations. The operated nonathletes also had more dif fuse symptoms and were more likely to be involved with legal claims and workmen's compensation.

Other Terminology Used to Describe Athletic Pubalgia

Various other terms have been used in the literature to describe what seems to be the same syndrome we have called athletic pubalgia. Those terms include Gilmore's groin, hockey groin syndrome, sportsman's hernia, osteitis pubis, snapping hip syndrome, gracilis syndrome, hockey goalie/baseball pitcher syndrome, and a variety of muscle strains, tendonopathies, and bursitises.

Dr. Gilmore used the term Gilmore's groin in his initial study published in 1992, involving 65 professional soccer players in the United Kingdom between 1980 and 198 7.95 Gilmore's groin was described as a condition consisting of three pathologic findings: a torn external oblique aponeurosis, torn conjoined tendon, and dehiscence between the torn conjoined tendon and the inguinal ligament. Gilmore thought this entity stemmed from hip hyperextension and rotation, as occurs in the soccer kicking motion. The onset predominantly idiopathic, which leads one to believe that repeated microtrauma is the major destructive force. A common sign on physical examination is a dilation of the superficial inguinal ring. However, Gilmore stated that the latter finding was not evident in 25% of his patients.

When we describe the syndrome of athletic pub-algia, we are referring to a syndrome that we believe is virtually identical to the syndrome that Gilmore describes.

Pelvic Anatomy

A complete description of the anatomy of the pelvis is beyond the scope of this chapter; however, a thorough understanding of the anatomy is essential to diagnose and treat groin injuries and groin and hip pain. For the purpose of our discussion, we describe the pelvis as a girdle,96 with two pairs of innominate bones, plus the sacrum and the coccyx. The innominate bone is composed of the ileum, the ischium, and the pubis, which also forms a portion of the acetabulum. In the normal state, there is little motion across the joints of the pelvis. However, when considering the highly dynamic pelvis of a performance athlete, it is useful to conceptualize the pelvis as being composed of many tiny joints. The normally static joints of the pelvis can be stretched in the athlete and this, in turn, can result in excessive motion at various sites within the pelvis.

Several important structures insert onto the pelvis and its anterior attachment, the pubic symphysis. These structures include the rectus abdominis, external oblique, internal oblique, and transversus abdo-minis.97 Structures that insert along the inferior as pect of the symphysis include the adductor muscles, pectineus, gracilis, obturator internus, quadratus femoris, and gluteus muscles. A series of ligamentous arches also exist between the pelvic bones, further stabilizing the joint.

In addition to previously mentioned stabilizing pelvic muscles and ligaments, there are a number of bursae of the anterior pelvis. Although the psoas inserts principally onto the femur, its bursa is rather large and complexly shaped so that it may even touch the anterior pelvic joint. There are also potentially clinically significant bursae behind the symphysis and near the lesser and greater trochanter of the femur.

Athletes exert high-velocity forces across the joints, muscles, tendons, and ligaments of the pelvis. With these considerable forces, damage can occur to any part of the athlete's pelvis, manifesting itself as groin pain.

Etiology

Most patients describe a hyperextension injury in association with hyperabduction of the thigh. The pivot point seems to be the anterior pelvis and pubic sym-physis. The location of pain suggests that the injury involves both the rectus abdominis and adductor muscles. In athletic pubalgia, the rectus tendon insertion on the pubis seems to be the primary site of pathology. However, other tendinous insertion sites on the pubic bone may also be involved (Figure 5.9). Because of the injuries of the tendinous insertion sites on the pubis, we can assume that we are dealing with a subtly unstable pelvis.

The location and progression of pain in these athletes suggest a disruption of the pivot apparatus and a redistribution of forces to other musculotendinous attachments during extremes of exercise. The accompanying inflammation includes osteitis, tendonitis, or bursitis, which can all contribute to the groin pain. The pain resulting from the inflammation can be temporarily alleviated by injections or antiinflammatory drugs. Deep massage therapy is another temporarily effective therapy. However, the lack of permanent relief by the previously stated methods suggests that the inflammation is not the primary problem and that stabilization of the anterior pelvis is necessary.98

By definition, pubalgia is not due to an occult hernia. Furthermore, the pattern of symptoms in athletic pubalgia patients, operative findings, and results of our studies all suggest that the lower abdominal pain and inguinal pain in these patients are not caused by an occult hernia. Although some patients were found to have occult hernias at the time of surgery, the hernias were usually found on the opposite side of the principal symptoms.65

The principal complaint of hernia patients is usually a bulge with superior and lateral inguinal pain, consistent with the location of the internal ring. The

Head Muscles
FIGURE 5.9. Insertion sites for muscles that commonly sustain strain injuries resulting in groin pain. (With permission of DC Taylor, WC Meyers, JA Moylan, et al. Abdominal musculature abnormalities as a cause of groin pain in athletes. Am J Sports Med 19:239-242, 1991.32)

pain in most pubalgia patients is near the pubis, far from the internal ring. In more than 80% of pubalgia cases, the pain is also associated with adduction of the hip against resistance. Progression of the pain often involves the adductors, perineal region, and eventually the opposite side. The combination of a distinct injury, localized pain, and progression suggests an initial injury with subsequent involvement of other structures adjacent to the injury. Athletic pubalgia most likely is not a result of multiple different injuries, particularly because most of these patients often describe a single inciting injury.

Diagnosis

The syndrome of athletic pubalgia is common in highperformance athletes. The syndrome's features include disabling lower abdominal and inguinal pain at extremes of exertion. The pain progresses over months to years and involves the adductor longus tendons and the contralateral inguinal or adductor regions. The diagnosis of this syndrome is generally empiric.

Most patients remember a distinct injury during exertion. Usually, the abdominal pain involves the inguinal canal near the insertion of the rectus muscle on the pubis.32,99,100 The pain causes most patients to stop competing in sports.

In general, the pain is minimal at rest and begins unilaterally, but becomes bilateral within months or years if the injury is untreated. Two-thirds of the pa tients describe the pain with resisted adduction of the hip, which can occasionally be more prominent than the abdominal findings. The pain may also be fleeting, appearing and disappearing on one or the other side, or involve both abdominal and adductor components. Less than 25% of patients have significant, vague symptoms attributable to the anatomic location of the posterior perineum. Interestingly, involvement of the posterior perineum is associated with a decreased likelihood of successful repair.

When examining a patient suspected of having athletic pubalgia, the physical examination must be directed to obtain key findings. Most patients exhibit pain with adduction of the hip against resistance30 and pain with resisted sit-ups. Twenty-five percent of patients have pubic or peripubic tenderness. One-third have some degree of subjective tenderness along the adductor tendons near the pubis. Superior inguinal or real abdominal tenderness is uncommon. By definition, no patients have hernias.

A common finding that mistakenly dissuades one from making the diagnosis of athletic pubalgia is an MRI or bone scan result of osteitis pubis. When we first started doing pelvic floor repairs in the late 1980s, we avoided operating on anyone with an MRI or bone scan diagnosis of osteitis pubis. However, after a Swedish group101 had success with pelvic floor repairs in patients diagnosed with osteitis pubis, we also performed pelvic floor repairs on our patients who were previously denied the operation. Our patients subsequently did well, and, therefore, a diagnosis of osteitis pubis is not a contraindication for a pelvic floor repair. From the previously stated results, we can also conclude that CT and bone scans generally have no added value over MRI even if they show osteitis.

On the other hand, a distinct population of patients exists who have severe primary osteitis. They have continuous severe pain and tenderness at rest or exercise. This group of patients will not likely be helped by a pelvic floor repair.

The absence of an MRI finding should not prevent one from making the diagnosis of pubalgia. In fact, most patients on whom we have operated do not exhibit MRI findings of rectus muscle disruption. Most patients do well with pelvic floor repair in the absence of definitive MRI findings. Only 12% of patients had MRI findings that clearly indicated a problem at the rectus insertion site. The relatively small incidence of a specific diagnosis by imaging studies suggests that the problem may be an attenuation of the muscle or tendon due to repeated microtrauma.30

Nonspecific MRI findings, on the other hand, occur frequently and localize to the side or sides of injury in more than 90% of patients. The nonspecific findings include focal osteitis and nonspecific abdominal wall, perineal, or adductor findings. They also include asymmetry, distinct inflammation, cortical ir regularity, distinct fluid accumulation, irregularity of the rectus abdominis, atrophic changes, small pelvic avulsion fractures, or disruption of the pectineus muscle. It is possible that these nonspecific MRI findings may assist the surgeon in decision making, because the MRI can often predict the side or sides of injury. In addition, the MRI has been noted in its demonstration of other severe problems as per the differential diagnosis.33

A history of an inguinal hernia repair, either in childhood or adulthood, without evidence of a recurrent hernia should also not dissuade one from making the diagnosis of pubalgia. A previously successful hernia repair does little to rule out athletic pubalgia. The cause of the syndrome is pelvic instability, not occult hernia; the term sports hernia is a misnomer.

A patient who experiences pain symptoms without exertion most likely does not have athletic pub-algia. A certain amount of mild discomfort is certainly acceptable, but severe pain in the absence of exertion is a tip-off that the patient probably does not have the diagnosis of athletic pubalgia. Most patients with this syndrome clearly have pain only with extremes of exertion. With chronicity, the pain begins to interfere with some activities of daily living. Some pain may persist after activity, but almost never is the pain particularly severe at rest. The nonathlete who complains of constant pain almost certainly does not have the diagnosis, even if the symptoms and signs are in the right locations.

Lateral pain in the inguinal region also points toward a diagnosis other than pubalgia. If the pain is clearly lateral to the adductors, one should suspect intrinsic hip disease or a variety of other pelvic disorders.

True testicular pain or epididymal pain should also be ruled out before making a diagnosis of pubalgia. Upper scrotal pain can be in the distribution of the il-ioinguinal nerve, which can easily be involved in the inflammatory process. Pain and tenderness along the lateral edge of the pubic symphysis is consistent with the problem of pubalgia, but true testicular or epi-didymal pain generally is not. Pain with sexual activity is consistent with the syndrome of pubalgia so long as simple exertion is causing the pain; pain with ejaculation only is not consistent with the syndrome.

Management Considerations

Key questions concerning the surgical management of these patients include the following. Does the patient have symptoms that qualify him or her for the syndrome? How disabling is the syndrome? Can the patient be treated nonoperatively? Can the patient be treated medically on a temporary basis to allow the athlete to finish the season? Should one perform an adductor release? What operations are likely to work? And what is the role of nonoperative therapy?

To answer these questions, definitions and presumptions need to be addressed. Nonoperative therapy refers to trials of prolonged rest, rehabilitation, oral or injected steroids, or deep massage. The disabling pain has led to a curtailment or cessation of competitive athletic participation and diminution in his or her athletic ability. Acute injury refers to pain that has resolved or is clearly better within 2 weeks. Recurrent acute refers to evaluation within 2 weeks of a repeat groin injury after complete recovery from an initial episode. Chronic refers to the persistence of pain after 6 weeks without evidence of improvement at the time of evaluation.

Again, our data strongly suggest that the principal mechanism of athletic pubalgia is a disruption or attenuation of the rectus muscle insertion on the pubis. This disruption results in instability of the anterior pubis that is manifested by a rearrangement of focus to other musculotendinous attachments of the pubis. Therefore, the best repair would be a broad surgical reattachment at the inferolateral edge of the rectus muscle with its fascial investments to the pubis and adjacent anterior ligaments. This is the operation we most commonly use for athletic pubalgia, and in most cases, this repair significantly ameliorates or eliminates the adductor symptoms.

On a rare occasion, adductor symptoms may persist after pelvic floor repair and become particularly bothersome. This observation suggests that the adductor symptoms are most likely caused by a secondary chronic inflammatory process involving the superior edge of the inferior pubic ramus. This jagged edge rubs on the adjacent soft tissues within the adductor compartment, causing inflammation and pain. The weakening of the anterior abdomen causes a kind of compartment syndrome.

To alleviate the pain associated with this compartment syndrome, an adductor release is performed. An anterior and lateral release of the epimysium of the adductor fascia is performed to expand this compartment. The epimysium is the layer of connective tissue that encloses the entire muscle. During an epimysial release, the edema in the groin is noted to be released. This kind of fascial release is often successful.

Treatment Algorithms

We propose the attached algorithms for the treatment of patients diagnosed with athletic pubalgia. Algorithm 1 (Figure 5.10) describes groin injury treatment during the season, whereas algorithm 2 (Figure 5.11) concentrates on treatment between seasons. Generally, only treat the chronic or persistent acute recurrent problems surgically. Direct steroid injection into symptomatic bursa or other soft tissue sites may give enough temporary relief for patients to continue their season.100 When the process continues over several

Algorithm For Testicular Pain
FIGURE 5.10. Algorithm for groin injury treatment during the season.

months and the athlete cannot return to previously expected activity because of pain, an operation should be considered. Deep massage therapy has a role in patients with equivocal symptoms or others in whom surgery for one reason or another is not favored. The effectiveness of deep massage cannot be explained.

Results of Repairs and Releases

A success rate of 95% can be expected from surgical treatment in well-selected patients. This success was initially observed in 200 patients over a 3-year follow-up. The series has now been extended to over 2500 patients. We suggest operating only on the symptomatic side or sides. On the other hand, several patients with particularly severe MRI findings on the opposite side but without symptoms have also undergone bilateral repair with similar success rates.

Our data also clearly indicate that many standard hernia repairs are inadequate in treating athletic pub-algia. In particular, laparoscopic hernia repair does not appear to be the correct solution for this problem. The laparoscopic repair emphasizes a tension-free mesh insertion that does not stabilize the anterior pelvis. We have now seen over 300 patients who had unsuccessful laparoscopic or open "hernia repair" and subsequently had successful pubalgia surgery.

The generally poor outcomes of the laparoscopic repair and other hernia operations provide additional evidence that the mechanism of athletic pubalgia is

Algorithm For Groin Pain
FIGURE 5.11. Algorithm for groin injury treatment between seasons.

not due to an occult hernia. However, a few patients have done well after hernia repairs. The small success rates seem likely due to general fibrosis, which accompanies all operations and inadvertently stabilizes the anterior pelvis. The Cooper's ligament or McVay repair for inguinal hernia seems more likely to treat the problem but also stretches the anterior abdominal musculature down to the more posterior attachments of the anterior pelvis. Therefore, this operation may not provide optimal anterior stabilization. We have seen inconsistent results with the McVay approach; thus, we recommend performing a rectus reattachment and adductor release to treat athletic pubalgia.

Postsurgical Athletic Pubalgia Rehabilitation

Although there are a variety of pathologies and differential diagnoses for groin pain among athletes, the majority involves some kind of muscle imbalance and pelvic instability. In many cases conservative physical therapy is able to correct these abnormalities and the athlete may return to competition with minimal game exposures missed. However, a select group of athletes sustain injuries that frequently recur or do not altogether subside with conservative treatment and result in a significant reduction of athletic competition. These athletes find the only viable opportunity to prolong their career is surgery. After surgery there must then exist a protocol to guide the physical therapy process, which protects and reinforces the repair. The following is a protocol guideline designed for postsurgical athletic pubalgia rehabilitation. However, it is constructed on the basis of the physiological tissue injury cycle, and its focus aims to restore muscular balance and pelvic kinematic symmetry. Thus, it may be thought of as a means to normalize any lower abdominal and pelvic dysfunction in a progressive manner for the goal of returning the athlete to highperformance competition.

The main goals of the athletic pubalgia repair are to reapproximate any damaged tissue and to regain normal muscular balance within the lower abdominal and adductor region. Thus, the goals of postsurgical physical therapy should be to provide an environment conducive to efficient tissue healing, further establish muscular balance within the lower abdominal and adductor region, and incorporate sport-specific progressive therapeutic exercise into the rehabilitation process to enhance the return of the athlete to their sport.

The two areas of concern in establishing muscular balance are the adductor and abdominal regions. The released adductor longus should be dealt with in a manner that promotes functional healing which entails the collagen lying down in a parallel, elastic, and elongated fashion. The abdominal region must be handled with great care by the therapist. The repaired rectus abdominis should be allowed to form a mature scar before being stressed with progressive functional training. The end result should produce an adductor region that has more laxity and an abdominal region that is more taut compared with preoperative conditions. Together these readjusted reciprocal muscles about the pelvis should be able to regain normal kinematics in sport. This normalized pelvic posture must then be stabilized through training of the deep abdominals such as the transverse abdominis and lumbar multifidus. With this base of normal kinematics established, the only thing left to do is prepare the athlete for return to sport, which involves training the athlete in all aspects of their respective sport. This principle of sport specifics should be kept in mind by the therapist and implemented where possible throughout the rehabilitation process, as it will prepare the athlete intrinsically from the standpoints of the musculoskeletal system and neuromuscular system, as well as with the psychologic aspects.

Preoperative Therapy

Before the operation, as far in advance as possible, the athlete should be educated on the proper techniques of core stabilization exercises. These exercises consist of drawing in the umbilicus and holding it. Then, progression into extremity movements while holding this drawn-in-umbilicus posture is performed. These exercises activate the deep abdominal muscles, specifically the transverse abdominis and obliques, which concurrently activate the multifidus, which together function to stabilize the pelvis and lumbar spine. The time period for this presurgical rehabilitation may vary as the time period from diagnosis to surgery may vary from days to months.

Postoperative Therapy

While we routinely try to get athletes back to full performance within 6 to 7 weeks after surgery, we describe here an off-season, 3-month rehabilitation process.

Weeks 1 through 4 make up phase I of the postoperative rehabilitation program. At this time, the patient is going to rest mainly, refrain from any strenuous activity, and work on maintaining normal upright posture, avoiding any ranges of pain.

Phase II, Weeks 5 to 7 (Core Stabilization and Pool Therapy)

Around week 5 the patient enters phase II. This phase is characterized by core stabilization and pool therapy exercises. At this time the most basic core stabilization exercises, which were learned preoperatively, should be implemented. By week 7 the athlete should progress

Supine Marching Exercises

FIGURE 5.12. Supine marching. Begun early in phase II, this entails performing reciprocal arm and leg marching movements while maintaining the drawn-in umbilicus posture to create a focused contraction of the transversus abdominis muscle, which stabilizes the pelvis and lower back during a dynamic activity.

FIGURE 5.12. Supine marching. Begun early in phase II, this entails performing reciprocal arm and leg marching movements while maintaining the drawn-in umbilicus posture to create a focused contraction of the transversus abdominis muscle, which stabilizes the pelvis and lower back during a dynamic activity.

from supine marching (Figure 5.12) with reciprocal arm movements into a running motion simulation (Figure 5.13) with both feet off the ground, flexing opposite hip/knee and shoulder simultaneously. This is a continuum of the core stabilization progression and is training the trunk to stabilize under a stressful functional activity, as it must when returning to sports.

During week 5 it is also beneficial to begin very light stretching of the adductors. The objective here is to make sure the fibroblasts lay down in a parallel elastic arrangement to maintain flexibility and minimize scar shortening, in addition to achieving healing of the muscle in the lengthened state. Then, by week 6 the patient should begin light quadriceps and hip flexor stretching, while focusing on keeping a neutral pelvis. Any abdominal pain should be avoided.

The second directive of phase II focuses on pool therapy where the athlete may work in functional patterns. Pool walking is the first step, initiated at week 5. Later in the second month the patient progresses by increasing the distance and speed of the pool walking, so that pool running is achieved by week 7. At this time multidirectional activities, such as cariocas and side-slides, may also be incorporated in the pool. This strengthens all muscles involved in gait and initiates stress to the healing tissue in a manner that it will experience once returning to sport. Thus, the tissue will begin to heal, with both the ability to accommodate movement and at the same time to limit excessive motion during activity. Also at this time mini-squats, heel raises, and standing hip abduction/adduction/flexion/extension should be performed in the pool. On land the patient may begin elliptical running and straight leg raises (SLRs) in flexion/extension/abduction.

Phase III, Weeks 8 to 10 (Progressional Strengthening, Endurance, Agility)

By week 8 the athlete should be advancing into phase III, which is characterized by progressive strengthening, endurance, and agility activities. This is a period in which the athlete's rehabilitation becomes more dynamic, intense, and functionally driven. This phase tests and strengthens all components of the muscu-loskeletal (including the new repair) and neuromuscu-lar systems. The athlete is now well into the remodeling stage, and these exercises force the remodeling tissues to progressively develop to withstand repeated stress such as occurs during athletic competition.

Week 8

Week 8 exercises have been set up to give the patient some variability in exercises and also some choice in which exercises to do on each desired day (Table 5.4, Figures 5.14, 5.15, 5.16). It is constructed so each day the athlete will get abdominal and core stability training both statically and dynamically, cardiovascular work on a machine and, independently, lower extremity strengthening and balance training. By category, the patient is developing stability (category A), endurance (category B), strength (category C), and proprioception (category D). Categories A, B, and C may be mixed to the patient's predilection; however, category D should be performed last so we can first fatigue the musculoskeletal system to create an environment in which we could then tax and get as much gain out of the neuromuscular system as possible.

Week 9

The setup in week 9 is a progression toward gaining more sport-specific/functional training (Table 5.5, Fig-

Pubalgia Exercises

FIGURE 5.13. Supine running. Begun later in phase II, this is an exercise progressed from supine marching, which is done with the same drawn-in umbilicus posture to create a focused contraction of the transversus abdominis muscle, which stabilizes the pelvis and lower back during an even greater dynamic activity.

FIGURE 5.13. Supine running. Begun later in phase II, this is an exercise progressed from supine marching, which is done with the same drawn-in umbilicus posture to create a focused contraction of the transversus abdominis muscle, which stabilizes the pelvis and lower back during an even greater dynamic activity.

TABLE 5.4. Rehabilitation Protocol: Phase III, Week 8.a

Category A

Group 1: Core-stabilization exercises (3 sets of 15 repetitions) + (daily sitting) Plank exercises (30 sec 2X, in all three directions) (see Figures 5.14, 5.15)

Group 2: Crunches (20 repetitions 1-2X holding at top 2-3 sec) [stabilize pelvis] Push-ups (15-30 repetitions 2-3 X)

Category B

Group 1: Jogging 1/2 mile forward; 100 yards backward (straight only) Elliptical (30 min)

Group 2: Pool exercises

—Increase repetitions and intensity from week 6

--In deep well (with noodle floaties)

—Reciprocal flexion/extension scissor kicking (1 min X3) —Bilateral abduction/adduction (leg portion of jumping-jacks) (1 min X3) Stationary bike (20-30 min)

Category C

Group 1: Heel raises (increase reps: 2X unilateral, 1X bilateral) Minisquats (20-30 repetitions X2)

Group 2: Straight leg raises (2-3 sets) flexion/extension/abduction

Category D

Group 1: Standing on wobble board (1 min X3)

Group 2: 1 leg standing on mini-tramp (mimic sport) (1 min X3) (see Figure 5.16)

aOne group from each of the four categories must be selected for each day, and the opposite group must be completed on the following day. Complete all stretching from week 6 (2X for 30 sec, 2-3 X per day).

ure 5.17). Running and agility work on land (category A) is now 66% of the rehabilitation, while the other 33% involves pool work and isolated strengthening (category B). Abdominal strengthening is a key component to protecting the repair; thus, it is involved 100% of the time. Now that the patient is involved in highly demanding athletic activity, it is important that a day of rest is given to ensure physiologic recovery. All stretching activities from the previous week should be continued.

Week 10

Week 10 is a further progression toward sport-specific training and returning to athletic competition (Table 5.6, Figure 5.18). Now running and sport-specific activity encompass 83% of the rehabilitation time,

How Maintain Figure Exercise
FIGURE 5.14. Plank exercise (prone). Begun in week 8, this exercise isometrically strengthens core stability through targeting all the abdominals. It is essential to maintain a straight and rigid core with a slightly posterior pelvic tilt.

while pool therapy and isolated strengthening make up 17%. Abdominal work and stretching are performed on all rehabilitation days, and again the rest day is essential for physiologic recovery of stressed tissues.

During week 10, specific activities that simulate particular aspects of the athlete's sport, such as cutting and changes of direction, should be initiated. This crucial aspect of the rehabilitation progression further tests and strengthens all components of both the mus-culoskeletal and neuromuscular system.

Phase IV, Weeks 11 and 12 (Sport Specifics)

Weeks 11 and 12 Around week 11 the athlete enters phase IV of the rehabilitation protocol (Table 5.7, Figure 5.19). At this

Prone Lying Exercise
FIGURE 5.15. Plank exercise (side lying). Begun in week 8, this exercise also isometrically strengthens core stability, although in comparison with the prone plank exercise, the side-lying exercise focuses more on the internal and external oblique musculature.

FIGURE 5.16. Mini-tramp (sport-specific activity). Begun in week 8 as part of category D, the athlete mimics a skilled activity specific to his or her respective sport while balancing one legged on a mini-tramp. This activity provides core and extremity strengthening while retraining the athlete's proprioception in a sport-specific

FIGURE 5.17. Plyometrics (two-feet lateral hops). Began in week 9 of phase III, this is the introductory exercise of plyometrics. The athlete performs small, quick, side-to-side hops over a line on the floor. The duration of this exercise may initially be 30 seconds and progress up to 1 minute or more. Plyometrics are useful in training the neuromuscular and musculoskeletal systems for sport.

FIGURE 5.16. Mini-tramp (sport-specific activity). Begun in week 8 as part of category D, the athlete mimics a skilled activity specific to his or her respective sport while balancing one legged on a mini-tramp. This activity provides core and extremity strengthening while retraining the athlete's proprioception in a sport-specific

FIGURE 5.17. Plyometrics (two-feet lateral hops). Began in week 9 of phase III, this is the introductory exercise of plyometrics. The athlete performs small, quick, side-to-side hops over a line on the floor. The duration of this exercise may initially be 30 seconds and progress up to 1 minute or more. Plyometrics are useful in training the neuromuscular and musculoskeletal systems for sport.

TABLE 5.5. Rehabilitation Protocol: Phase III, Week 9.a

Category A

Jogging 1/2 to 1 mile as tolerated and with good symmetric form Agility drills

Backward running (30 yards 4X) Side-slides (30 yards 4X each direction) Cariocas (30 yards 4X each direction)

Sprinting 1/2 to 3/4 speed X4 (30-50 yards, with a 25 yard warm-up and slow-down) Figure 8's (15 yards X 5 yards, #8) (5 cycles 1-2X at V2 to 3/4 speed) Lunges (3 sets of 10)

Plyometrics: Two feet together, small lateral jumps over a line (30-45 sec X3) Abdominals

Plank sxercises (45 sec 2X, in all three directions) Abdominal crunches (30 repetitions 2X holding at top 2-3 sec)

Begin bilateral leg lowering exercise (10 repetitions 1-2X) (knees flexed to 90 degrees) Category B

Pool exercises as done in week 7

Heel raises on land (increase reps, 2X unilateral, 1X bilateral) Minisquats with 5-10 lb dumbbells (30 repetitions 2-3 X)

Straight leg raises (SLR) (2-3 sets) flexion/extension/abduction/adduction (once repetitions of 10-10-15 are achieved, ankle weights in 2-lb increments may be added) Adduction is now added into the SLRs since abdominal strength has been increased and additional adductor strength is necessary for lateral agility movements. Abdominals

Plank exercises (45 sec 2X, in all three directions) Abdominal crunches (30 repetitions 2X holding at top 2-3 sec)

Begin bilateral leg lowering exercise (10 repetitions 1-2X) (knees flexed to 90 degrees)

aTwo of 3 days category A will be performed, and on the third day category B will be performed. Two cycles of categories A and B equals 6 days; the 7th day is a rest day.

TABLE 5.6. Rehabilitation Protocol: Phase III, Week 10.

Category Aa

Jogging 1-11/4 miles (with ball of particular sport) as tolerated and with good symmetric form Agility drills

Backward running (50 yards 5X) Side-slides (50 yards 5X each direction) Cariocas (50 yards 5X each direction)

Sprinting 3/4 speed (75 yards, with a 25-yard warm-up and slow-down) Figure 8's with ball (15 yards X 5 yards, #8) (8 cycles 2X 3/4 speed) Lunges (3 sets of 10) Polyometrics

Two feet together, small lateral jumps over a line (45 sec X2) (see Figure 5.17) Two feet together, small forward/backward jumps over a line (45 sec X2) 4 square (45 sec X2) Push-ups

Regular (30 repetitions X2) Plyometric push-ups (15-20 X2) Abdominals

Plank exercises (45 sec-1 min, 2-3 X, in all three directions)

Abdominal crunches (30 repetitions 3X holding at top 2-3 sec) [may add weight to chest in 5-lb increments for increased resistance] Bilateral leg lowering exercise (15 repetitions 2X) (with knees extended) Proprioception

Wobble board with one leg in middle of board (1-2 min X3 each leg). Actively do a sports activity (kick soccer ball, catch/throw a baseball or football, etc.) Mini-tramp (2 min X3 each leg); actively do a sports activity (as wobble board)

Category Bb

Hip machine (3 sets weight to tolerance) flexion/extension/abduction/adduction Pool exercises as done in week 8 with progression in repetitions and/or sets Heel raises on land (increase reps: 2X unilateral, 1X bilateral) Minisquats with 10-15 lb dumbbells (30 repetitions 3X) Abdominals

Plank exercises (45 sec-1 min, 2-3 X, in all three directions)

Abdominal crunches (30 repetitions 3X holding at top 2-3 sec); may add weight to chest in 5-lb increments for increased resistance Bilateral leg lowering exercise (15 repetitions 2X) (with knees extended) (see Figure 5.18A, B)X

aCategory A is to be performed 5 days of a 7-day period; category B is to be performed 1 day of the 7 days, and the 7th day is a rest day. b2X per week.

time sport-specific exercise should be the major focus of the training sessions while increasing the running mileage in 1/4-mile increments. The goal at this point is to incorporate all aspects and every motion that oc curs in the athlete's particular sport into rehabilitation before returning to athletic competition.

In addition, a base of exercises should be incorporated to complete the recovery process. Plyometrics

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