Inguinal hernia, sports hernia, sportsman’s hernia, or groin disruption. It goes by many names, but this condition is on the rise.
The United States has seen an increase in prevalence of hernias from two diagnoses per week in 1986 to 25 diagnoses per week in 2008. This dramatic increase follows a confluence of factors, including an increasing population and increasing percentage of that population involved in some type of sport activity. The increase also results from an increasing accuracy of proper diagnosis. Sports hernias have historically been mistaken for strains in the groin, hip flexor, adductors, or abdominal muscles.
This coach also proposes that a major factor could come from the contrasting decline of overall physical well being (due to diet and sedentary lifestyle) with increased participation in sporting activities. Essentially, most people lead childhoods and adult lifestyles that leave them misaligned and weak, while asking their bodies to perform at a high level either in competition or weekend-warrior hobbies. Regardless of the multi-factorial root cause (and name of choice), this condition is on the rise.
Given the increasing prevalence and my recent first-hand experience, I would like to shed some light on this condition.
What Is a Hernia?
A hernia is simply a tear in muscle and/or surrounding fascia in the abdominal wall that allows an organ or fatty tissue to push through the opening. Hernias can technically occur anywhere but usually arise in an area already weakened and prone to tearing.
The common types are:
- Inguinal – By far the most common, consisting of about 70% of all hernias, and the category that a “sports hernia” falls under. The inguinal rings are openings in the abdominal wall near the front corners of the pubic bone, where the oblique muscles attach. In men, this site allows a bundle of nerves, veins, ligaments, and sperm ducts to pass through the abdominal wall to the testicles. In women, a ligament passes through that holds the uterus in place.
- Umbilical – Occurs behind the belly button at the gap where the umbilical cord passes through.
- Femoral – Occurs at a gap where the femoral artery passes through to the thigh.
- Incisional – Occurs at a site of incision from a previous abdominal surgery.
- Hiatal – Occurs when the upper stomach pushes through the hiatus, a diaphragm that the esophagus passes through.
How Do Hernias Occur?
The commonality with each of these conditions is they they each occur where a gap (with a greater potential to tear) already exists. Imagine a piece of fabric with a few small holes or slits. When stretched taught, it could technically tear anywhere but it is far more likely to tear at one of the small openings.
Therefore hernias occur from the combination of pressure and weakness.
Cause = Pressure + Weakness
Weaknesses can arise both congenitally (at-birth) or developmentally (from the activities or lifestyle). Many people have inbound weakness at one or many of the common hernia sites, several types of hernia are even common in newborn babies. Sport hernias typically arise from small tearing over time at the inguinal site.
Pressure also comes in many different forms. It can be either acute (from heavy exertion or explosive movement) or chronic (from a constant state of increased inter-abdominal pressure, like always “bracing” or carrying extra body weight).
Sport hernias specifically are thought to arise from competing tension between the lateral obliques muscles (the side abs) and the adductors (inside thigh muscle). Each of these muscle groups pull the pelvic in opposing directions. Sports and athletic training present nearly infinite opportunities for both the obliques and adductors to fire simultaneous such as heavy squats or deadlifts, sharp cuts from side to side, or twisting movements. This creates a tug of war and additional tension at the inguinal site that often results in tearing over time. Combine this with the pressure created while “bearing down” and you have the perfect recipe for herniation.
What Does This Mean for Your Training?
How can you apply this information to safeguard yourself from a potential sports hernia? We have little control over the “weakness” aspect of the hernia equation when it comes to congenital weaknesses. Chronic weaknesses, such as the small tearing over time, as outlined above, can actually be considered part of the “pressure” side of the equation. Inter-abdominal pressure is both a root cause of the chronic tearing and the exploitative factor that herniates the weakened site. Fortunately, the “pressure” aspect of the equation remains completely under our control.
Pressure: A Double Edged Sword
Creating inter-abdominal pressure (think bracing or “bearing down” in your core) has tremendous benefit. In fact, teaching athletes to fully engage their core remains one of my highest priorities as coach because of the benefits for both performance and safety in training and competition settings. However, this same pressure can also develop chronic tearing and lead to eventual herniation.
So, what’s an athlete to do?
Rather than fear pressure and heavy engagement, introduce ample rest and recovery activities to balance out your scales. Use full engagement and pressure for the valuable tools they provide, then cycle in an equal amount of full release and relaxation. Much of the problem with inter-abdominal pressure is not the engagement itself, but the lingering and chronic effects of not allowing it fully dissipate. Focus on utilizing the full spectrum, from full engagement to complete relaxation.
In training and in life, we have mastered the art of “turning on.” We know how to finish off a hard set, grind out that last rep, or pull an all-nighter to meet a deadline. However, we remain very ill-acquainted with the opposite end of that spectrum.
The best way to safeguard against chronically high (and eventually detrimental) abdominal pressure is to balance out constant engagement. Between sets and reps actively try to release pressure with deep breathing methods or techniques such as the RKC “fast and loose.” Apply the same commitment and dedication to your active rest and recovery days as you do to days in the gym.
The most undetectable and insidious abdominal pressure is that which we create when we do not need it at all. So many people maintain a moderate level of core engagement at all times. This can take the form of sucking in to shrink your gut, flexing your abs to show them off, or simply a force of habit from all of the training that you do. I was as guilty of this habit as anyone. My normal, “resting” state looked closer to a gymnastic hollow body rather than casual relaxation. Unfortunately, I am far from alone in this pattern.
Let It All Hang Out
A belly should distend slightly, regardless of how lean an individual is. Under normal circumstance, your belly and other organs should feel more like they are hanging rather than actively held in place. Learning to relax and let it all hang out is the most critical way to relieve chronic inter-abdominal pressure.
Whether you are guilty of unnecessary engagement or not, actively cultivate a relaxation, release, or “turning off” practice. Your entire system, and all of the associated parts, needs to experience a full spectrum of tension and relaxation for optimal performance. Sports hernias are an all-too-common example of the acute problems that can follow excessive chronic tension.
References:
1. Sheen AJ, Stephenson BM, Lloyd DM, et al “‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference“, Br J Sports Med 2014;48:1079-1087.
2. Pikus, Stephanie M., “Certified Athletic Trainer’s Knowledge on Sports Hernias” (2012). Masters Theses. Paper 292.
