Click to jump to any section:
- Hip & Groin Injuries: Why They Happen
- Specific Sports Hernia Symptoms
- What Causes It In The First Place?
- Possible Repair Approaches
- Is Surgery Actually Needed?
- Sports Hernia Treatment: Rehabilitation Program
- Timeline Overview
- Week 1: Starting Out
- Week 2: Laying The Foundation
- Week 3: Fixing The Problem
- Week 4: Structured Review
- Week 5: Remodeling Tissue With Progressive Resistance
- Week 6: The Turning Point
- Week 7: Introducing Unilateral Training
- Week 8: The Test
- Week 9: Final Touches
- Week 10: Return To Sport
- Mobility Routine
- Soft Tissue Mobilization
- Critical Nutrition Needed For Healing
- Supplements To Increase Chance Of Success By 5-10%
- Supportive Equipment
Hip & Groin Injuries: Why They Happen
The ‘Sports Hernia’ is currently one of the most misunderstood training injuries. It plagues a handful of athletes and recreational enthusiasts, and is often career-ending. The pain, along with the high mental stress associated with the situation, often confines many individuals to a sedentary lifestyle of little to no physical activity.
News reports of athletes affected by this issue being benched for the season or even losing contract deals are unfortunately common.
From a medical standpoint, the debilitation is relatively new, with the first literature published in the 1980s. Now, however, there is much more knowledge that helps to explain where the groin pain originates from in the first place.
The cause of the condition is multifaceted:
- structural deficiencies in bone and surrounding tissue
- nerve entrapment contributing to poor movement patterns
- underlying musculoskeletal asymmetries that lead to uneven muscular development–in other words your body is uneven to the point that it causes poor posture, form, and limits your range of motion
The scientific community currently agrees that an individual’s unique makeup plays a large role, with some athletes being heavily “genetically susceptible” to the injury.
This makes sense given that bone structure is almost entirely genetic; vulnerable hip structures combined with years of heavy training or sports-specific movements (that lacks proper mobility and stretching protocols) is a recipe for this specific disaster. This doesn’t mean that certain people are necessarily doomed though.
It does mean that some people need to work harder at staying healthy and mobile due to any number of factors ranging from your career to what sports you play to how much you perform weighted lifts or other repetitive movements.
If you are an overly-active person, there is a very good chance you will need to apply additional effort to stay healthy.
At this point, it is worth mentioning that the injury in question is not a traditional Inguinal Hernia; in that case the abdominal lining (peritoneum) becomes weak and allows a “sac” to form by the membranous qualities of the abdominal wall along with the intestines. The “sac” then pushes through the weakest section in the wall.
What is being discussed in this guide, however, is what the Journal of Orthopaedic & Sports Physical Therapy calls an “indirect hernia.”
In this case, the weakness travels down through the inguinal ring and into the inguinal canal—ending at the scrotum for males, and labia for females. This “pathway” actually occurs before birth; it remains a highly susceptible place for injury after birth and throughout the individual’s life.
As described, it plagues both genders; males, however, are much more likely to develop the structural problem given how the inguinal ring relates to male reproductive organs. Lastly, it is critical to note that there is rarely ever any sort of protrusion associated with Gilmore’s Groin; this is largely the reason for difficulties surrounding proper diagnosis.
As explained previously, the inherent structure of one’s hip compartment plays an important role in the development of the condition. With this said, certain “structural abnormalities” are the foundation of how the injury can begin to form in the first place.
Currently, medical experts hypothesize that excessive abduction, adduction, flexion, and extension of the hip causes large enough shearing forces across the pubic region to produce tears and ‘micro’-tears in the fascia that surrounds the underlying musculature.
It then makes sense why soccer players often suffer from this injury: the action of kicking a soccer ball involves both hip adduction (bringing your leg in towards your body) and hip extension (bringing your leg forward and “up” to propel the ball forward).
Hockey provides the same scenario: pushing off doesn’t require adduction and flexion, but “retrieving” your ice skate by pulling your leg in and forward back to the skating starting position does.
Note: Fascia is the thin lining that surrounds muscle within your body; the fibrous nature of the tissue helps to protect you.
Furthermore, the problem is exacerbated by strong adductors, but a weak rectus abdominis (lower abdomen).
The Pectineus and Adductor Brevis become overworked. This leads to somewhat of a chicken and the egg argument: does the rectus abdominis become injured because it fails to meet the demands of the powerful inner thigh muscles, or because it is required to compensate when those muscles become strained?
Either way—there is an inherent lack of even strength throughout the hip compartment. As you will learn later in the guide, becoming stronger is much more important than stretching–but now you have some background information on why that is.
This is extremely common considering most athletes perform little to no core exercises, specifically lower abdominal exercises. Instead, training programs focus on heavy weights and hard field and track days. Coaches add to the equation further, pushing athletes to perform while rarely emphasizing stretching and mobility work until after an athlete is already suffering from pain.
When we say “core exercises” this does not only include workouts centered around working the abs, but also around strengthening and engaging the glutes, adductors, abductors, and lower abs, while foam rolling and stretching the hip flexors and psoas (for how to do this, view strengthing phase 1 below).
A perfect example is the American Football off season; massive effort is dedicated to lower body and upper body strength while almost none is given to increasing abdominal integrity.
Asymmetries in tightness are the final vice to solidify a complete sports hernia. This happens when one plane of movement is unrestricted (in this case the sagittal plane), yet other ‘antagonist’ planes are tight and highly restricted (in this case the frontal and transverse planes).
In the end, this causes the hip to adopt odd compensatory biomechanics, which then lead to high stress on the abdominal wall—tears result.
Specific Sports Hernia Symptoms
There are several symptoms associated with a Sportsman’s Hernia:
- Tenderness around the pubic region, specifically the pubic ramus (see Figure 1 above)
- Discomfort when rising from bed, and a tendency to brace your legs with your hands when moving positions
- Sharp pain in your pubic region, aggravated by movement front to back and side to side (the frontal and sagittal planes of movement)
- Underlying dull pain when going about every-day activities (a constant, never-ending 2-3 on a 10-point pain scale–this is often the pain that causes such psychological torment, as it serves a constant reminder that you’re injured)
- Increased pain whenever you flex your abs or upon abdominal exertion
- Long-standing pain that lingers all day despite rest and the traditional prescription of ice and stretching
- Multiple doctor visits that fail to properly diagnosis the injury or provide an effective treatment plan; most of the times this is made worse by people visiting general doctors instead of searching for a specialist that really knows what they are doing
- Negative radiographs–imaging doesn’t seem to be a consistently effective way to diagnose given the complexity of that area of the body
- Negative MRIs (while MRIs are good at spotting structural issues, they are unable to properly analyze the fibrous tissues of the pubic area)
- Acute, Sharp, Point tenderness along the inguinal ligament and directly-surrounding tissue
Once all other areas are ruled out, and pain persists along the lines of the described symptoms, you most likely have the injury–an indirect hernia is likely present.
With all of that said, there is one “symptom” that appears to be a dead giveaway. If one experiences an insidious pain that slowly creeps up, getting worse with increased running intensity (sprints vs. jogging) or cutting movements, a “positive” diagnosis becomes highly probably.
The pain often originates on one side of the body, but can spread to the other, caused by compensatory measures the body enacts in an effort to protect itself.
But does this mean you have it on both sides? Probably not. Cases of double sports hernias are very rare. If you are feeling some pain on both sides, it’s probably for the reason described above: your “strong side” is being forced to pick up the slack of your “weak” injured side.
When it does develop on both sides, it is also likely because a proper diagnosis was failed to be reached over a long period of time. This allows the tissue damage to spread and can even cause other hip and lower back injuries.
The pain should be acute, sharp, and localized to one’s pubic ramus. It can, however, radiate to surrounding regions in cases where more extreme posterior wall defects are present. Roughly 30% of males who seek treatment for their pain also complain of testicular discomfort. The pain is always made worse by coughing, sneezing, or rapid tightening of the abdominal region.
In some cases the pain is intense enough to cause constant and unending agony, with some patients reporting concurrent debilitating pain that effects day-to-day life.
What Causes It In The First Place?
Certain sports are predisposed to lead players to develop Sportman’s Groin:
- Martial Arts that include high-velocity kicking
- Any sport that includes cutting, quick pivoting, sharp turns, and explosive kicks
The common denominator seems to be a combination of rapid adduction and hip flexion—this creates the shear forces described earlier that then become devastating to athletes who have neglected to strengthen and train their abs.
Sports Hernia Diagnosis
In the best scenarios, mostly including professional athletes, diagnosis can occur as quickly as 1-6 weeks.
The average duration before proper diagnosis, however, is 20 months. That is an extremely long time to be in such restrictive and mentally-destructive pain.
The worst cases documented record a pre-diagnosis timeline of 5 years—remember that as you navigate your way to solving this curse, many before you have had it much worse.
Diagnosis currently relies almost entirely on clinical visits to professionals who are trained in treating soft tissue debilitations. While MRIs and other scanning procedures can be useful for finding clear musculoskeletal imbalances, the hip compartment is a complex region of fibrous tissue—an ultrasound is the method of choice to ensure the highest level of accuracy during discovery. In a longitudinal study conducted, out of 59 consecutive patients there was only 1 false negative (failure to approve a diagnosis when the injury was indeed present).
Patients are asked to perform the Valsalva maneuver lying down while the inguinal canal is checked for any unusual “defects.” This helps to identify how large the structural deficiency may be prior to examination under the knife.
Note: The Valsalva maneuver is done by closing one’s mouth and creating internal abdominal pressure—this is the same thing as “bracing” your core with a big breath of air while lifting weights or performing an athletic movement.
It is important to get a “100% positive” on the diagnosis before moving forward with any intervention techniques. General physicians are not trained to properly recognize this debilitation; ensure you visit a suitable professional, or thoroughly understand the self-diagnosis procedure.
Self-Diagnosis Using The Pubic Probe Technique
Self-diagnosis is possible, as no special tools or resources are needed. Take your pinky finger and apply pressure directly on the “front crown” of your pubic bone (pubic ramus–see Figure 1 above). If the tender area reaches 8+/10 pain upon being touched, it is likely that an inguinal insufficiency is indeed present.
Possible Repair Approaches
Currently, there are 2 schools of thought surrounding the repair approach needed:
- Insertion of mesh in an attempt to rebuild the pelvic floor
- Minimal suture approach that focuses on using surrounding tissue to strengthen the posterior wall deficiency
Mesh Repair Technique
While some experts and medical professionals tout mesh as a viable solution, it isn’t. Placing mesh directly in one’s pubic compartment shocks the body; foreign material is unable to form well in the pubic compartment where constant shearing forces are taking place due to common body movement (and specifically during athletic moves that take place in the frontal and transverse planes of motion).
Contrast this with an inguinal hernia, for example, where the mesh can be applied to a “static” region of the abdominal wall where none of the described shearing forces are taking place.
Based on the raw statistics it is clear that the alternative approach produces much more favorable results.
Minimal Repair Technique
The “Minimal Repair” technique invented by Dr. Ulrike Muschaweck in Germany, however, is a suitable surgical approach that boasts very high success rates. The procedure utilizes a suture to fix the defect in the posterior inguinal wall—Muschaweck herself describes it as “nearly tension-free and the patient can, therefore, return to full training and athletic activity within the shortest time.”
Pain relief is achieved by decompressing the genital branch of the Genito-femoral Nerve, which is situated along the inguinal canal. Additionally, mesh is never used because athletes must retain full elasticity in the fibrous tissues of the abdominal structure.
Some doctors and surgeons have introduced the idea of an “adductor release” as a possible remedy. However, while the words work to disguise the real procedure (cutting your adductors—a key structure that your body was born with!), they do nothing to hide the stupidity. Do not allow a physician to “release” your adductors. A physician with an opinion doesn’t supersede human anatomy. If your doctor is telling you an adductor release is needed (or even worse–mesh), run for the hills!
According to clinical statistics published by Springer in 2010, 96.1% of patients who undergo the “minimal suture” approach resume training within just four weeks. The best cases even report pain relief at just 14 days post-surgery. From a realistic standpoint, even four weeks is highly ambitious—individuals who pursue this intervention method should stick to the rehabilitation protocol herein, and aim for a full recovery timeline that is closer to 12 weeks post-surgery.
Sports Hernia Surgery: Is It Actually Needed?
When is surgery an appropriate option to begin considering? There are a few things that play into the answer to this question:
- How long have you had the injury? The chances of success using non-surgical intervention drops exponentially as time increases.
- What is your age and recovery ability? While rest, nutrition, and intelligent supplementation all play a role in beating footballer’s groin, younger bodies simply recover faster, better, and easier.
- What activity led to the injury? If it is the result of a training “incident” where the patient can pinpoint the specific moment it happened, surgery is likely the only solution that will lead to a fully-recovered groin.
- What is your level of inguinal tenderness? 4+/5 on the pain and tenderness scale almost always requires that an athlete undergo surgery.
Using the guidelines above, the worst case scenario is that the individual has had the injury for several months, is possibly older or unable to recover adequately for other reasons (lack of sleep, poor food, high stress, line of work, etc.), and sustained it in an abrupt tear that can be singled out to a specific date and time.
If 6 weeks of the outlined healing methodology results in zero perceived pain reduction, surgical intervention is most likely needed. Regardless, anyone who believes they have suffered Gilmore’s Groin will benefit from the musculoskeletal “hip reset” that this program is built around.
Author’s note: I personally underwent the minimal repair procedure, and can gratefully say that I am now pain free; be advised that surgery is only one element of a successful rehabilitation protocol though—it is important to follow the entire process thoroughly.
Sports Hernia Treatment: Rehabilitation Program
The rehabilitation procedure is multifaceted and comprised of several different elements. The main concept though is simple; by strengthening the surrounding areas and working to fix whatever underlying muscular imbalances are present, pressure is lifted from the lower abdominal region. With this new lack of stress, the area can begin to heal and remodel itself.
Total sports hernia recovery time is approximately 12 weeks if the rehabilitation sequence is followed with strict adherence. Keep in mind that this is only an estimate. Everyone’s individual situation and genetic makeup is unique. With that said, there is a quote famous to the physical therapy community that sums it up:
“You can only do rehab once—make sure you do everything in your power to ensure you do it correctly.”
Unlike many injuries that find success in a sedentary recovery progress (a.k.a. sleeping with little to no physical activity), sports hernias absolutely require one to follow through with the active healing methodology. “Sitting around” is a bad idea. Why? The injury developed because of an inherent weakness; resting does nothing to resolve that underlying issue.
The timeline is made up of 10 weeks. Initial weeks are dedicated to developing strength and mobility in the sagittal plane. Gradually, exercises in the frontal and transverse plane are added.
- Sagittal Plane: Movement that occurs in front of, or behind the body.
- Frontal Plane: Movement that occurs along either side (left or right) of the body.
- Transverse Plane: Movement that occurs at the “trunk” of the body (twisting at the hips).
The general concept is “baby-stepping” the injured posterior chain back to full health by addressing each weak link one step at a time—beginning with the most fundamental of movement patterns.
- Week 1: walking—minimize all pressure around the abdominal region (focus on not bracing your core)
- Week 2: walking longer distances + light elliptical work; the purpose of the elliptical machine is to move the body through a more full range of motion, while still avoiding all medium-high impact activities.
- Week 3 (Strength Phase 1): all focus is placed on fixing the hip issues that “got you here in the first place.” Additionally, the in-depth mobility routine is introduced as well. The athlete should still be focusing on minimizing abdominal pressure as much as possible. By now the patient should be walking 2+ miles on the elliptical pain free.
- Week 4: continue to progress in the core strengthening exercises. Additionally, the patient is encouraged to increase elliptical intensity to a light “jog.”
- Week 5 (Strength Phase 2): lower body strength and activation; old movement patterns begin to dissolve as emphasis is now placed on achieving proper abduction and adduction. Additionally, the first lateral movements are added, reintroducing the body to the frontal plane of movement.
- Week 6: patient continues to progress in all previously-introduced modalities. No new exercises or techniques are introduced, but it is imperative that progression continues in the form of additional sets and repetitions added to movements from the previous weeks. It is also worthwhile to note that this is aforementioned point at which someone should consider surgery if no progress has been made in alleviating the chronic groin pain.
- Week 7: unilateral strengthening exercises are introduced; all other modalities continue.
- Week 8: by now the athlete has undergone almost 2 months of an extensive rehabilitation and it is time to retest the pain threshold. To do so, find a flat running surface (a track works best) and perform 400m intervals at an 8:00 mile pace. “Awkwardness” and discomfort is likely to be felt, but if no pain is present, the athlete is ready to begin the process of reintroducing heavier lower-body strength training if it is required for sport.
- Weeks 9 (Strength Phase 3): athlete continues to become more comfortable through all planes and ranges of motion. Light ladder drills and slide board are added.
- Week 10: By now, the athlete should “feel” 90% or better when compared to their pre-injury condition. More aggressive ladder drills are introduced as long as zero pain is created in the hip and groin region.
Throughout the timeline, it is also important to follow the correct nutrition guidelines so that your body has a plentiful amount of amino acids from protein, glucose from carbohydrates, and critical acids from fats (explained in further detail below). Intelligent supplementation isn’t as important as eating correctly, but it can still make a large palpable difference (also explained in more detail below).
Week 1: Starting Out
Initially following surgery (or the incident that caused the injury if you are attempting to rehab nonsurgially—be advised that this is only possible for individuals who diagnose and react immediately) the goal is to simply build enough strength and flexibility to walk and move around. The surgical area will be extremely tender and painful—be particularly careful not to cause undue stress on the region.
Increase distance to up to 2 miles. Different individuals have radically different rehabilitation potentials. Some may experience terrible pain during the week following surgery, while others may be able to walk 2 miles daily. Therefore, it is important to only do as much as you can within your personal pain threshold. Remaining mentally optimistic while healing is imperative for a full recovery—that is only going to happen if you allow your body to heal without forcing it along too fast.
2 rest days are advisable—space them out among the other days.
Week 2: Laying The Foundation
If you aren’t yet walking 2 miles, aim to reach that milestone. If you are, it’s time to introduce the elliptical machine. Again, the goal is simply to work the lower body through the frontal plane in a controlled motion with zero impact (a.k.a. jogging).
Begin with zero incline and gradually work up to an incline level of “1” in the same workout. As always, do not proceed if you experience any pain—discomfort is fine, pain is not.
The “milestone” for the elliptical machine mirrors walking; aim to reach a distance of two miles. At that point, alternate between walking and elliptical work daily.
As with week 1, 2 rest days are recommended. Again, aim to space them out so that they are placed among your active days.
Week 3: Fixing The Problem
Congratulations! If you’ve made it this far, you’re right on schedule. If not, that’s okay—work to master the first two weeks before beginning the “secret sauce” of the program: core strengthening aimed at fixing your broken hips!
You will begin with movements that take place only in the frontal plane. However, before beginning any exercises, it is important to first perform the “ABCs” of injury prevention.
Note: this is different than the full rehabilitation mobility routine (click here to jump there now) described later in the guide that must be performed in one “setting”—this is instead the absolutely critical activation routine that will allow you to strengthen all areas of the hip region without placing undue stress upon the injury site. This is your new normal; the reason your body developed the injury in the first place is because large portions of your posterior chain weren’t activating. This warm-up routine fixes that mistake–don’t skip it.
- Foam Roll all tight areas of the hip area and lower body. General problem areas include:
- Iliotibial Band
- Hip Flexors
- Static stretching in the frontal plane—this means only the quads and hamstrings receive static stretching. Through trial and error, we have found that stretching the adductors does more harm than good during the initial weeks of the rehabilitation process.
- Dynamic warm up in the frontal plane—using an elliptical or walking at a brisk pace; warming up the posterior chain and legs will promote increased muscular activation and flexibility while going through the rehab movements.
Now that your body is limber and “awake,” it’s time to get started.
All exercises must undergo systematic progression. Just like with lifting weights, or running on the track—it has to get “harder” over time to make substantial and consistent progress.
What does this look like? For each movement, begin with 3 sets of 10 repetitions:
- Set 1 = 10 repetitions
- Set 2 = 10 repetitions
- Set 3 = 10 repetitions
With each rehab workout, add either additional repetitions, or additional sets. In the end, your goal is to work up to 4 sets of 15 repetitions for each movement.
As described already, the rehab program aims to build strength in the “easier” planes of movement before athletes advance to transverse movement and high-impact athletic activities. Because of this, there are 3 different phases of strengthening. Once you have mastered the first phase, move to the second. Once you have mastered both the first and second, move on to the third. Take note of the provided timeline and make sure you are following all other aspects of the guide.
Strengthening – Phase 1
- Light vacuums: It’s best to start in the supine position and gradually progress to a kneeling, and then seated position. Perform 15 “holds” for a duration of 5 seconds or longer.
- Bosu ball crunches: The bosu ball is a great tool to use for this injury specifically, because it allows for a much smaller, less intrusive range of motion.
- Hip bridges with maximum dorsiflexion: A large portion of long-term success in dealing with a groin injury comes down to glute activation—many people are tight and inhibited in this area in particular due to office jobs that include hours of sitting hunched over at a desk. By performing the proper mobility and working to engage your glutes, proper movement patterns for movements such as squat and deadlift then become much easier to execute. Dorsiflexion is the motion of flexing your toes towards your shin bones, put in simplest terms; in practice, this is done by attempting to have your ankles as far back as possible during the exercise.
- Dog legs: This is another great exercise that targets the glutes—except this time unilaterally (one side at a time). Make sure to get your leg at least parallel with the ground.
- Dirty Dog Legs: This is a very effective variation of the normal dog leg demonstrated above. It is recommended to alternate between the two; for both you should be focusing on squeezing and activating your glutes and your abductor muscles.
- Supine short-lever: Performing this exercises with different tibia/foot positioning will help to encourage not only abductor strength, but flexibility and the glute-hip “tie-in” effect. In short, your abductors aid with lateral movement of the femur in the frontal plane, as well as external rotation through the sagittal plane; by awakening this muscle (which is often asleep and inhibited in individuals suffering from sportsman’s groin) the hip can then move with greater mobility and less stress to the lower abdominal area (because the glutes and accessory muscles of the hips are actually working like they should).
- Supine Psoas hold: Probably the “worst” of all exercises in the first strength phase, this movement strengthens the thick, tendinous muscle that is responsible for holding together much of the posterior chain—specifically bracing the lower spine, lateral regions of the hip, and upper portions of the femur.
- Light supine adduction against a medium exercise ball: With this strengthening move it is absolutely critical to start very light, and progress slowly. The adductors are the “sweet spot” of the inner thigh and largely dictate pain flare-ups. Choosing the correct workout instrument will make a huge difference, so be sure to select a lighter ball before moving on to a thicker, larger one.
- Bodyweight squats: This one is self-explanatory; as always ensure that no pain is present when doing them. Full, deep squats are best—ditch the high squats and do it right.
- Bodyweight reaching one-legged deadlifts: Not only do these promote balance, they help build strength through hip extension and flexion—the hamstrings and glutes are the “main movers” of the lower body. Working on this exercise will build the key, fundamental strength needed for healthy, supple hips.
While performing the above throughout the week, continue to progress in distance and incline on the elliptical throughout all phases of the strengthening process.
As you can tell at this point, the rehabilitation methodology is extensive and multifaceted. By working to “revive” the hip from all angles, however, you can completely reset the poor muscular behavior and conditioning that led the injury to occur in the first place. With a “new” set of hips, your groin will finally be able to heal without the stress and tension of having to keep your posterior chain from falling apart.
Week 4: Structured Review
Continue to get better at all of the exercises outlined in the third week. Additionally, it is highly recommended that you review the initial portions of this guide, specifically the timeline, to review your progress and make sure your healing process is coming along properly.
The thing that separates great performers from the average, are those that can very critically think about the steps they’ve taken, and analyze both the positive and negatives so that constructive changes can be made. Humans are the only creature on the planet with metacognition–the ability to think about how we think. How does this apply here? Pause and reflect on the steps you have taken thus far. Perhaps some movements aggravated the injury site, and you decide to tone it down in those specific exercises. Maybe
It’s time to “up” the level on the elliptical—start with one mile on Monday and work up to 2 miles of consistent “jogging” on the machine by Friday.
If you aren’t on track to meet the 10 week plan, it’s time to step back and analyze if you are missing anything.
Author’s note: if you would like to receive advice tailored to your specific case, head over to our YouTube channel and leave a comment on one of the relevant sports hernia videos—make sure to include as many details as possible so that the situation can be assessed accurately, and so that you can receive advice based on a scientific, methodical approach.
Week 5: Remodeling Healing Tissue With Progressive Resistance
Now that you are at week 5, almost all of the sharp pain and tenderness should be gone. What remains will be a general feeling of “awkwardness” when performing movements such as squats and deadlifts—this is perfectly fine.
Now that weights are introduced into the program, it becomes doubly important to keep up with daily self-massage therapy (explained in detail below). As new muscle tissue is formed, and tendons regain strength and flexibility, they must be “trained” to grow correctly. Naturally your body will seek to return to its old, dysfunctional ways. However, by following this “remodeling” process your hips and groin can once again become like new!
Strengthening – Phase 2
- Weighted Squats: If you are an athlete aiming to return to your previous strength levels, now is the time to re-introduce barbell back squats. Begin with high bar squats only; if you are a competitive strength athlete, wait to introduce low-bar squats until week 7.
- Unilateral split-squats are an excellent alternative if you do not have a reason to do heavy barbell squats. However, by doing these you will still be able to reap the rehabilitative benefits that come from exercising hip flexion and extension using weighted resistance. It is important to note, however, that athletes must wait until week 7 to introduce unilateral squatting.
- Weighted Deadlifts: All of the rules above the apply to squats also apply here. Slow progression is key—redisturbing the original injury is going to do nothing but set you back. All of the best career athletes understand the idea of training sub-maximally to promote long-term, sustained progress without constant injuries and setbacks that ultimately place a cap on your end-potential.
Focus on progressing slowly in the heavy, compound movements like deadlifts, squats, overhead press, and bench. The above video is 19 months after my surgery. Your success will largely be determined by how much you commit to the outlined process. It is possible, but you have to take it seriously.
- Lateral Bodyweight Squats (static side lunges): be sure to do these slowly, and with great care not to aggravate progress thus far. The reason being, is that these place pressure on the adductors (inner thigh muscles)—as mentioned before you want to be very careful when re-introducing stress to this muscle group.
Week 6: The Turning Point
If you’ve made it to week 6, good job—you’re now officially at the half way point of a full recovery. The reverse, however, could also be true. As discussed already, if you still haven’t found relief from the sharp, acute pubic pain, it is time to move forward with finding a surgeon.
While surgery may sound scary, many have gone before you with successful outcomes. Ensure that you select a doctor specializing in the minimal repair technique described earlier in the guide.
Author’s note: I personally debated whether surgery was the correct option given the horror stories I had read in the depth of the interwebs. However, after attempting to rehab non-surgically with no success, I moved forward and scheduled a date with the hospital. I can say that it was probably the best decision I have made regarding my health thus far in my life—I can now very gratefully say that I am pain free. You can be too; if it looks like surgery is the path, take it and get yourself into a positive mental attitude. Good outcomes happen to people who think positively. This isn’t just motivational talk—there is an endless amount of behavioral science evidence that suggest the benefits of optimism, especially when dealing with injuries and debilitations.
Hopefully though, you are feeling great and ready to start another week of progress towards your new life without constant nagging groin pain. Continue to progress with all exercises, movements, and aspects (elliptical, walking, self-massage, mobility, etc.) of the first 5 weeks. By continuing to progress in the two strength phases, your body will be able to solidify all of the bilateral improvements you’ve made thus far. This is the final preparation for week 7, where unilateral movement patterns are introduced.
Week 7: Introducing Unilateral Training
Welcome to the week of one-sided training! Up until this point, all movements and exercises have taken place bilaterally, or on both sides of the body in a symmetrical fashion. An easy example of this would be the bodyweight squat: both sides of your body are moving synchronously to complete the full range of motion.
One-sided movements, on the other hand, focus on training your body’s ability to fire asynchronously, which is an absolutely critical component in healing the body holistically. Furthermore, if you are engaged in high-level sport, this should be much of your bread and butter. Why?
- Split Squats: these are the holy grail of unilateral weighted exercises. There are couple of different variations, depending on foot positioning, but the general concept is the same: find a bench or something else to put your back foot on, and then squat down while holding dumbbells (though, when you start make sure to perfect the form before adding weight).
- Lateral Step-Ups: this is a popular exercise around most gyms, but it’s about to become even more popular for you specifically. This movement helps to train hip flexion and extension in the coronal plane (frontal plane).
- Pistol Squats: this is an advanced exercise that will require a bit of “cheating” if you do not have above-average leg strength. Find something to hold on to, and squat down on one foot—that’s it. They aren’t complicated, but boy do they work.
Week 8: The Test
Now that you’ve made it to week 8 (hopefully successfully!) it’s time to test the waters and see how far you’ve progressed. There’s a smart way to go about it though—taking the incorrect steps could set you back in your rehab process, or even worse: redisturb the injury site in a serious way that requires “re-surgery.”
What is the “smart” way to go about it? A controlled test that places enough stress on the injury site to gauge progress, without causing substantial trauma that would require days, weeks, or months of recovery time (with the worse-case scenario being a return to the hospital).
To do so, find a flat running surface. In most cases, this will be a local track. It is important that the surface is flat, because any amount of incline or decline would cause too much hip flexion and extension (running up-hill is much worse, but running downhill is still a bad idea especially given the increased force of impact from slightly longer “hang-time” in the air between steps).
Now that you’ve found a suitable location, it’s time to test. The goal is to run four 400m intervals at an 8:00 mile pace, which comes out to 2 minutes for each lap on the track—this is purposefully slow, so don’t try to push it if you feel like you can (again, the point is to undergo a conservative assessment of how much you’ve healed so far).
You will undoubtedly feel a novel “awkward discomfort,” but this is okay as long as you feel zero sharp pain. If at any point in time during the run you feel pain, STOP immediately—it isn’t the end of the world, but it could be the end of your rehabilitation process if you decide to push it (because you’ll be right back to home base, in terrible pain with nothing to show for it).
Hopefully, everything goes well and you can continue on to the final 2 weeks!
Week 9: Final Touches
The final process of the program is introducing stress to the area we have avoided thus far: the adductors. Up until now, the focus was on restrengthening and mobilizing surrounding areas. If you’ve followed the process thoroughly, you’ve done that successfully. Now, it’s time rebuild the area of concern.
Strengthening – Phase 3
- Slide-board: Undoubtedly, this is probably the number one exercise to treat groin injuries. Because it is such a high-stress exercise, however, it is only safe to begin on week 5. Athletes should give extra attention, focus, and care to this movement and ensure that progress is being made in the form of additional repetitions and/or sets each rehab session.
- Ladder work: Gentle ladder work is introduced—only footwork drills that take place in the sagittal plane are allowed.
- Standing Trunk Rotation: This will require the use of a cable gym or resistance band tied to a squat rack or any other solid structure.
Week 10: Return To Sport
Aggressive ladder work and sport-specific modalities are introduced during the final week of rehab.
What is meant by “sport-specific modalities?” If you play soccer, get out there and start practicing your footwork drills again. If you play tennis, it’s time to start working on your serve again. If you play golf, get out to the driving range and hit some golf balls. You get the point—it’s time to be an athlete again!
But on top of anything specific to your discipline of choice, it’s critical to add in more ladder drills that focus and train movement patterns in the frontal and transverse planes.
One Thing Has To Be Clear: our modern lives cause many of the injuries that we face, especially this one. We weren’t meant to sit all day, type away at computer screens, bend our necks down at our phone screens, hunch over while driving our cars.
We were meant to leap, run, and defend ourselves to survive and pass on our gift of life to the next generation. Luckily though, over the past 200-300 years humans have been able to design tools and devices to make our lives easier and much better overall. It has allowed man to escape the brutal race for human society to focus on the higher aspects of human intelligence.
Yet, those conveniences also come with a price tag. Our “lazy” lifestyles contribute many of the ailments we face, especially sports injuries. It makes perfect sense: you train hard for 1-3 hours multiple days a week, but when you aren’t training, you are using poor movement patterns and worse posture. This leads your body to become terribly inhibited, especially in the posterior chain. The effect? Tight musculature that leads to uneven structural development. Not good!
But it isn’t a lost cause; by relieving the tightness and inhibition, we can allow the body to return to its natural movement patterns, thereby promoting even muscular and structural development again that can build long-lasting rehab success.
To perform the exercises in this video, you will need 2 items:
- Foam Roller
- Lacrosse Ball
These are critical items that you should have anyways. Now is the time to pick them up if you don’t have them.
Pro Tip: If you don’t want to order online, I recommend you check discount clothing stores in your area like Ross, Marshalls, and TJ Maxx. Believe it or not, often times these places have quality foam rollers and other mobility “devices” very cheap!
Soft Tissue Mobilization
The tendinous tissue of the groin takes 21-30 days to remodel itself, solidify the initial healing process, and in general “stabilize” the region enough to hold abdominal pressure again.
During this time period, it is absolutely critical to focus on breaking up the tissue in that region. This can be done by professionals trained in soft tissue debilitations. However, it can just as easily (and arguably more effectively for the groin in particular) be done by you!
Immediately following surgery, the body begins to deposit scar tissue within the wound—a natural healing process that takes place.
Digital stimulation of the incision area helps to promote blood flow. Not only that, it helps to remodel the collagen by providing pressure to the scar site. Last but not least, it gives the area flexibility—something that is obviously hyper-important for the groin region.
You should try to apply as much pressure as possible without pain. It’s always best to begin light and slowly build up to a “deeper” massage.
Additionally, massaging in all 3 ways will ensure maximum benefit:
- Circles (A in Figure 3)
- Vertical (B in Figure 3)
- Horizontal (C in Figure 3)
Creams and moisturizers are encouraged to deliver additional moisture. Some of the best products include:
- Copper Scar Cream
Critical Nutrition Needed For Healing
Arguably the most important aspect of your healing process is making sure that you provide your body with plenty of healthy food! You need wholesome food sources for energy and the essential proteins that make up the fundamental structures of your body. Do not skip or underestimate this aspect of the process.
There’s already a complete nutrition section on the site, so this will be a really brief overview of the basics.
- Eat 1 gram of protein per pound of bodyweight. For example, if you weigh 170 pounds, eat 170 grams of protein per day.
- Eat .4 grams of quality fats per pound of bodyweight. This includes things like red meat, eggs, dairy products, fish, and so on. If it’s processed and packaged on the frozen food isle, it probably doesn’t count.
- Eat the rest of your daily calories in good carbohydrates like pasta, rice, oatmeal, vegetables, beans,and fruits.
Eating right really doesn’t have to be hard, despite what everyone chalks it up as. Just follow the simple, well-agreed-upon guidelines above and focus the rest of your concentration elsewhere.
Supplements To Increase Success By 5-10%
Supplements play a small, but important role in your success. When considered holistically, supplements make up around 5-10% of the overall healing process. They aren’t fancy or sexy, they simply provide your body with essential micronutrients that aren’t found in today’s food. We can get our macronutrients from food (protein, carbohydrates, fats), but not even close to what our body needs in terms of vitamins, minerals, and essential substances.
There are only 4:
- Fish Oil
- Quality Multivitamin
- Vitamin D
- Creatine To Promote Augmented Cellular Function
Fish oil is a very common supplement. It is a general term that refers to the omega-3 fatty acids (EPA and DHA). These fats are found naturally in fish. From a price standpoint, fish oil is much cheaper when taken as a supplement though. The point in taking it is to stabilize your body’s internal ratio of omega-3 to omega-6. This ratio signals bodily eicosanoids–signaling molecules that have countless health benefits:
- Inhibiting Inflammation
- Improved Immune Response
- Reduction Of Perceived Pain
- Regulation Of Cell Growth
- Improved Flow Of Blood To Tissues (especially important when you’re trying to heal!)
When this ratio is met through supplementation, several health benefits follow:
- Healthier Blood Passages
- Reduced Lipid Count
- Much Lower Risk For Plaque Stoppage
- Reduced Risk Of Diabetes
- Reduces Risk Of Several Types Of Cancer
- Reduction Of Excess Triglycerides
Next up is a good multivitamin. This doesn’t mean the bottle of 100 for $5 at your local dollar store. You get what you pay for when it comes to supplements, and that goes doubly for vitamins and minerals. Cheap vitamins rely on cheap sources that your body is unable to utilize. By paying just a bit more ($18-30$/month range) you can get a product that actually works, and that you can actually feel (giving your body much-needed essential micronutrients will dramatically change how you feel–if you’re constantly sluggish, there’s a good chance this is why).
I personally recommend 2 options that include digestive and joint health minerals on top of the 24 essential organic-containing compounds and periodic elements that drive cellular function.
- Animal Pak
- Orange Triad
Third is Vitamin D. This will already be found in your multivitamin, but not at a high enough dose to reap the hyper-effective benefits (this makes sense–1 vitamin can only weigh so much). It is fat soluble and absolutely necessary for basic human survival. The main source is the sun, but it is also contained naturally in eggs, fish, and dairy products.
What are the benefits?
- Increased Cognition
- Better Immune Health
- Healthier, Stronger Bones & Structural Tissue
- Enhanced Mood
Last up is Creatine, probably the most-researched fitness/health compound out there. It is naturally-occurring within the body, where its job is the storehouse for powerful phosphate groups that provide phosphocreatine to fuel essential high-energy processes within the body, specifically during periods of high cellular stress. It does this by aiding in the production of ATP (adenosine triphosphate).
When your body needs to perform a critical cellular function, it relies on some form of metabolic process to make that happen: it needs energy. This is pretty “duh” but the science behind it is quite intriguing; creatine works by transforming ADP (adenosine diphosphate), a biproduct of metabolic processes, into usable ATP–the powerful energy “houses” your body loves. Those ATP molecules in turn transport chemical energy throughout your body’s cells, helping along metabolism. Awesome!
Note: when taking creatine it is important to drink plenty of water. 1 liquid ounce per pound of bodyweight is recommended anyways for general health, especially if you are an athlete. For example, if you weigh 160 pounds, you should drink 160 ounces of water a day, or 1.25 gallons.
Last but not least, there are certain items that you can buy, notably compression gear, that will support your groin, hip flexors, quadriceps, and hamstrings by providing continued pressure that promotes structural integrity, increased blood circulation, and faster healing. Additionally, it will aid athletes looking to return to their respective sports faster, as it becomes especially useful and beneficial during dynamic physical activity.
So what are your options? There are two general “classes” that you have to choose from. What you choose will come down to your price range. The cheaper options lack some of the benefits of the more expensive alternatives.
Class 1: General Braces. These are perfect for normal day-to-day activities, including work and school. They fit discretely under clothing and provide all of the benefits described above. There are two issues, however, with this option. First, the fit can sometimes be off–braces aren’t nearly as form-fitting as compression shorts. Secondly, and more importantly, they can’t be used during sports, running, lifting weights, or even stretching/mobility. This creates an issue for someone looking to reap the benefits of compression at all times.
Class 2: Special Compression Shorts. If you have a bit more money to spend, this is definitely the option to go with. You will reap all of the positive things described above, and also be able to go about any and all activities normally, especially those that revolve around your rehab process. Being able to have constant compression during the hip strengthening exercises outlined earlier increases activation and decreases harmful tension on the injury site. It is a no-brainer if you have the luxury of being able to pay a bit more.
By now you know what happened, if it happened, why it happened, how it happened, how to fix it, and how to live pain free once more. Using the steps outlined above, I retrained my body, fixed my pain, and have since went on to pursue my fitness and strength goals. I will be honest, it is a long road filled with many obstacles.
That doesn’t mean it’s impossible, or even insurmountably difficult. By believing in the process and trusting in the science behind it you will overcome this.
P.S. If you haven’t already, make sure to check out our sports hernia posts section that dives into specific nuanced points on the injury.