[ CASE REPORT ]

AIMIE F. KACHINGWE, PT, EdD, OCS, FAAOMPT¹šIJ;L;D=H;9>" MA, ATC²

Proposed Algorithm for the Management

of Athletes With Athletic Pubalgia
(Sports Hernia): A Case Series

I
t is estimated that 5% to 18% of athletes present to their exertion.1,58 Although using the term ath-
physician with activity-restricting groin pain.37,61,76 Groin letic pubalgia may be more appropriate
than sports hernia given that an actual
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pain is particularly common in sports that require athletes to

palpable hernia is not present,1,22,46,61 the
perform repetitive kicking, twisting, or turning at high speeds, term pubalgia infers that the physical ex-
such as soccer, football, basketball, track and field, tennis, and amination is inconclusive and the cause
hockey.37,58,75 Despite its prevalence, the literature is filled with of groin pain unidentified.4,63,77
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

puzzling and often contradictory information regarding the etiology, Despite consensus that a sports hernia
presentation, diagnosis, and treatment of groin pain in athletes.75 results from injury to muscular and/or
fascial attachments to the anterior pubis,
One injury presenting as groin pain clinically palpable hernia, the hallmark there is disagreement as to the exact ana-
is a sports hernia. Defined as a weakness symptom of a sports hernia is severe low- tomical area(s) of disruption.1,51,75,77 Tears
of the posterior inguinal wall without a er abdominal, pubic, or groin pain with associated with an athletic pubalgia may
involve any or all of the following: the
TIJK:O:;I?=D0 A case series of 6 athletes and therapeutic exercise. transversalis fascia at the posterior ingui-
with a suspected sports hernia. nal wall, the insertion of the distal rectus
Journal of Orthopaedic & Sports Physical Therapy®

TEKJ9EC;I0 Three of the athletes received

T879A=HEKD:0 Groin pain in athletes is
common, and 1 source of groin pain is athletic
pubalgia, or a sports hernia. Description of this
condition and its management is scarce in the
physical therapy literature. The purpose of this
case series is to describe a conservative approach
to treating athletes with a likely sports hernia and
to provide physical therapists with an algorithm for
managing athletes with this dysfunction.
T97I;:;I9H?FJ?ED0 Six collegiate athletes
(age range, 19-22 years; 4 males, 2 females) with
a physician diagnosis of groin pain secondary to
possible/probable sports hernia were referred
to physical therapy. A method of evaluation
was constructed and a cluster of 5 key findings
indicative of a sports hernia is presented. The
athletes were managed according to a proposed
algorithm and received physical therapy consisting
of soft tissue and joint mobilization/manipulation,
neuromuscular re-education, manual stretching,
conservative intervention and were able to fully
return to sport after a mean of 7.7 sessions of
physical therapy. The other 3 athletes reached this
outcome after surgical repair and a mean of 6.7
sessions of physical therapy.
T:?I9KII?ED0 Conservative management
including manual therapy appears to be a viable
option in the management of athletes with a sports
hernia. Follow-up randomized clinical trials should
be performed to further investigate the effective-
ness of conservative rehabilitation compared to
a homogeneous group of patients undergoing
surgical repair for this condition.
TB;L;BE<;L?:;D9;0 Therapy, level 4.
J Orthop Sports Phys Ther 2008;38(12):768-781.
doi:10.2519/jospt.2008.2846
TA;OMEH:I0 groin pain, mobilizations/manip-
ulations, therapeutic exercise, trunk stabilization
abdominis, the conjoined tendon at its
distal attachment to the anterior-supe-
rior pubis, and/or the external oblique
aponeurosis.4,18,48,51 Although some be-
lieve that an athletic pubalgia involves
the rectus abdominis tearing near its dis-
tal insertion,4 operative reports find that
only 6% to 8% of patients undergoing re-
pair for a sports hernia have an isolated
tear to the rectus abdominis.1,58 Operative
exploration often reveals multiple defect
sites in the aforementioned structures,
resulting in subtle weakness to the pos-
terior inguinal wall,22,23,56,80 inferring that
the pain related to athletic pubalgia may
be secondary to injury of these structures
in isolation, or in addition to an injury to
the rectus abdominis muscle.1,22,58
Athletic pubalgia has been reported

1
Assistant Professor, Department of Physical Therapy, California State University, Northridge, Northridge, CA. 2 Director of Sports Medicine/Head Athletic Trainer, California State
University, Northridge, Northridge, CA. This case series received exempt status from the Institutional Review Board Human Subjects Committee at California State University,
Northridge. Address correspondence to Dr Aimie F. Kachingwe, Department of Physical Therapy, 18111 Nordhoff Street, Northridge, CA 91330-8411. E-mail: aimie.kachingwe@
csun.edu

768 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
 in high-performance recreational, high
school, and collegiate athletes, 1 and
the escalading incidence of reports in
prominent professional athletes may
be partially explained by heightened
media awareness.40,52,59,75 The higher
reported incidence of this condition in
males versus females4,37,46,52,61 may be ex-
plained by a greater level of participa-
tion in highly competitive sports and/or
gender differences in pelvic anatomy. 58
Further evaluation of female athletes
often reveals a gynecological source to
their symptoms, including endometrio-
sis and ovarian cysts.1,46,58,61
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9bkij[he\I_]diWdZIocfjeci
The hallmark symptom of athletic pub-
algia is a complaint of “deep” groin or
lower abdominal pain with exertion40,58,80
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
that is relieved with rest but returns
upon resumption of sport-related activi-
ties.22,39,58,80 The groin pain is described as
deeper, more proximal, and more intense
than an adductor or iliopsoas strain.53,58,62
Symptoms are usually unilateral, al-
though pain often starts unilateral and
progresses to become bilateral.1,22,58,61,80
Symptom presentation is typically insidi-
Journal of Orthopaedic & Sports Physical Therapy®
ous; however, most patients recall a sub-
sequent acute event occurring after groin
pain was already present.39,53,59,61,75,80 The
pain is usually exacerbated by kicking,
sprinting, sidestepping, cutting, and/or
performing sit-ups.22,39,40,80 Some patients
may complain of referred pain along the
adductor longus tendon(s) with forceful
or resisted hip adduction,22,58,66 and most
report point tenderness over the superi-
or-lateral pubis.48,51 Occasionally, patients
with athletic pubalgia report groin pain
with sneezing and coughing,22,40,48,51,80 and
males may report testicular pain.40,51,58,80
Prospective validation studies of athletes
undergoing surgical repair of a sports
hernia, along with examination findings
of 3 of the participants in this case series
who subsequently underwent repair, re-
veal a cluster of 5 signs and symptoms to
be the most indicative of a sports hernia:
(1) a subjective complaint of deep groin/
lower abdominal pain, (2) pain that is
journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 769
exacerbated with sport-specific activities
such as sprinting, kicking, cutting, and/or
sit-ups and is relieved with rest, (3) pal-
pable tenderness over the pubic ramus
at the insertion of the rectus abdominis
and/or conjoined tendon, (4) pain with
resisted hip adduction at 0°, 45°, and/or
90° of hip flexion, and (5) pain with re-
sisted abdominal curl-up.1,22,39,58,80
?cW]_d]IjkZ_[i
The role of diagnostic imaging, includ-
ing magnetic resonance imaging (MRI),
computed tomography (CT) scans, and
bone scans, in the diagnosis of a sports
hernia is debated. Many studies report
MRI has limited ability to diagnose a
sports hernia and is beneficial only to
rule out alternative diagnoses.46,49,63,80 A
few recent studies suggest that MRI can
detect some musculofascial deficiencies
associated with a sports hernia, including
attenuation of the abdominal wall.4,75
Medically invasive procedures, in-
cluding laparoscopy and herniography,
can aid the diagnosis of a sports hernia.
The advantage of the endoscope is that
a sports hernia can be successfully diag-
nosed and subsequently repaired in the
same session.23,46 Herniography, a radio-
graphic examination utilizing a contrast
medium, may have diagnostic value but
is controversial and not commonly per-
formed in the United States.43,46,53,75 Ul-
trasound has been recently advocated as
a tool to diagnose a sports hernia, but its
use is presently limited.32,46,63,75,80
Jh[Wjc[djEfj_edi
Six to eight weeks of physical therapy re-
habilitation is often advocated as the first
course of intervention in the treatment
of athletic pubalgia,22,53 although the
very limited evidence available does not
support the effectiveness of conservative
care.74,76 In the only published prospective
randomized study to date, Ekstand et al24
randomized 66 male soccer players with
a sports hernia into 4 groups: (1) surgical
repair, (2) physical therapy 3 times a week
for 4 weeks, consisting of lower abdominal
strength training and anti-inflammatory
medication, (3) daily strength training,
consisting of 3 specific lower abdominal
exercises (only 1 of which was described),
and (4) control. The authors reported
that, although the daily-strength-training
group showed some significant improve-
ment at a 3-month follow-up, only the
surgical group had a significant reduction
in their symptoms with jogging, kicking,
and sprinting at 6 months.
Surgical repair of a sports hernia is of-
ten advocated if conservative intervention
fails,50,53,66,74 the athlete has an acute rec-
ollection of pubic musculature “tearing or
ripping,” and/or the patient is a collegiate
or professional athlete for whom a lengthy
trial of rehabilitation is impossible.5,58
Open repair of a sports hernia involves
reattaching the rectus abdominis, con-
joined tendon, and/or transversalis fascia
to the pubis and inguinal ligaments, and
is often reinforced with a polypropylene
mesh.40,48,50,53,58,63 If there is preoperative
involvement of the adductor longus ten-
don, the surgeon may opt to concurrently
perform an adductor tenotomy—typically
fractional lengthening.1,2,5,50,53,58,80 The
increasingly common laparoscopic pro-
cedure involves preperitoneal insertion
of a polypropylene mesh,1,22,39,46,63,74,80 re-
sulting in less postoperative pain, smaller
incisions, faster recovery rate, and has the
additional advantage in that a diagnostic
scope can be immediately followed by the
repair.46,61,80 Early outcome studies utiliz-
ing laparoscopic repair indicate high suc-
cess in rates of return to preinjury level
of play within 3 to 6 months.1,22,39,46,48,80
Surgical outcomes for nonathletes have
not been as favorable. This may be due to
lack of exertional pain and symptoms as-
sociated with the adductor muscles prior
to surgery and the confounding issue of
workers’ compensation claims.58
With the exception of a recent case
report on a high school athlete undergo-
ing surgical repair for a sports hernia,79
the management of this condition has
not been discussed in the physical ther-
apy literature, leaving clinicians with
little evidence to guide the differential
diagnosis and treatment of athletes with
 [ CASE REPORT ]
J78B;' Patient Characteristics and History

FWj_[dj 7][ =[dZ[h Ifehj C[Y^Wd_ice\?d`kho%:khWj_ede\Iocfjeci :_W]deij_YJ[iji

1 21 Male Basketball 1 y prior, "pulled groin" playing basketball, resolved; groin/lower abdominal pain insidious None
onset over past 2 wk
2 19 Male Track (hammer, Insidious onset of lower abdominal soreness 6 wk prior, after squatting; acute exacerbation Ultrasound ruled out
shot, discus) 4 wk prior, during discus throw inguinal hernia
3 21 Female Soccer Insidious onset groin/hip flexor pain 1.5 y prior, resolved; acute onset 2 mo ago when felt Radiographs negative
lower abdominal "rip" while squatting
4 20 Female Track (800 m) Insidious onset groin pain 1 year prior, while running track; insidious exacerbation over MRI: bilateral iliopsoas
past 2 mo strain and edema
5 19 Male Basketball 1 y prior, injured groin playing basketball, resolved; acute reinjury 1 mo prior playing basketball MRI: subchondral bone
edema at femoral head
6 22 Male Basketball 4 mo prior, abduction injury to groin playing basketball, resolved; 1 mo prior, hyperextension Radiographs negative
injury to lower abdominals; 3 wk prior, repeat of initial injury
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.

Abbreviation: MRI, magnetic resonance imaging.

groin pain. The purpose of this case series series qualified for exempt status from were unremarkable in all athletes. Mea-
is to describe a conservative approach to the Institutional Review Board Human surement of hip and lumbar motion has
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

treating athletes with a sports hernia and Subjects Committee at California State
to provide physical therapists with an al- University, Northridge.
gorithm for managing athletes with this All patients were examined by 1 physi-
dysfunction. cal therapist with over 15 years of clinical
experience in the orthopaedic setting, an
97I;:;I9H?FJ?ED American Physical Therapy Association
(APTA) board-certified orthopaedic clin-
FWj_[dji ical specialist, and a Fellow of the Ameri-
can Academy of Orthopaedic Manual
been found to have good to poor intraex-
aminer reliability.35,38,45,72
Strength Testing Manual muscle test-
ing to assess hip muscle strength was
performed and graded using a 5-point
scale.34 Although all athletes exhibited
at least a 4/5 hip strength rating in all
muscle groups, there were subtle differ-
ences between the athletes’ right and left

I
ix patients (4 males, 2 females;
Journal of Orthopaedic & Sports Physical Therapy®

age range, 19-22 years) were in-
cluded in this case series. All were
collegiate athletes competing at the Uni-
versity. Participant rights were protected
and a Health Insurance Portability and
Accountability Act (HIPAA) waiver was
signed. The athletes were examined by
the team physician, given a diagnosis of
groin pain secondary to a possible sports
hernia, and referred to the consulting
physical therapist by the head athletic
trainer over an 18-month period. Patient
characteristics and history are provided
in J78B;'.
Athletes included in this case series
presented with all of the aforemen-
tioned 5 signs and symptoms consistent
with a sports hernia. Exclusion criteria
included the presence of a palpable in-
guinal hernia, any medical red flag signs
and symptoms, 9,30 evidence of lumbar
radiculopathy, and/or prior surgery to
the pelvic or lumbar regions. This case
Physical Therapists (FAAOMPT). The
examination consisted of a detailed his-
torical account by the patient and a phys-
ical examination.
>_ijeho
The subjective history included partici-
pant background information, mecha-
nism of injury, duration of symptoms,
and diagnostic tests (J78B; '). All par-
ticipants were screened for the presence
of any symptoms suggesting systemic
pathology.9,30
F^oi_YWb;nWc_dWj_ed
Hip and Lumbar Active Motion Hip and
lumbar active range of motion (AROM)
were measured using a standard goniom-
eter and inclinometer, respectively.64 All
athletes exhibited a 5° to 10° limitation
of hip extension bilaterally and an asym-
metrical limitation of hip rotation (J78B;
2). Thoracolumbar AROM measurements
sides. Manual muscle testing reliability
of the hip musculature has been found
to be poor.27
Passive Motion Testing Joint passive
accessory motion testing of the hip, sac-
roiliac joint (SIJ), and lumbar spine was
evaluated and graded on a 0-to-6 acces-
sory motion scale.29,41 The intrarater re-
liability using this scale to assess spinal
passive intervertebral motion (PIVM)
was found to be good in 1 published
study,29 although interrater reliability and
accuracy have been found to be poor.8,29,55
Ratings of 3/6 were considered normal
and ratings of 1-2/6 were considered hy-
pomobile, as noted in J78B;(.
Palpation The superficial pelvic and hip
regions were palpated for areas of tender-
ness. Palpation of pelvic alignment was
also performed with boney landmark
symmetry noted for the anterior superior
iliac spines (ASIS), posterior superior ili-
ac spines (PSIS), and iliac crests (J78B;().

770 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
 J78B;( Examination Findings

>_f7Yj_l[HWd][ FWbfWj_ed\eh If[Y_WbJ[iji%CkiYb[B[d]j^J[iji FW_dFheleYWj_ed FWii_l[7YY[iieho

FWj_[dj e\Cej_edH"B FWbfWj_ed\ehJ[dZ[hd[ii 7b_]dc[dj Fei_j_l[ J[ijFei_j_l[ Cej_ed>ofeceX_b_jo
1 Not assessed RL iliopsoas; RL L iliac crest and PSIS 90-90 hamstring test RL, Resisted hip adduc- L ilium posterior rotation; R
distal rectus higher; L ASIS lower Thomas test LR, Gillet's on L, tion at 45° hip ilium anterior rotation; L
abdominis at pubic forward bending on L; supine- flexion; resisted hip anterior glide, R hip
insertion to-sit on L curl-up posterior glide
2 Flex: 115°, 115°; L lower rectus abdo- Normal Ober's test B, Thomas test B Resisted hip ad- B hip posterior glide; RL
Ext: 13°, 10°; minis duction at 90° hip anterior glide
ER: 26°, 27°; flex greater than
IR: 21°, 21° 45° and 0° flex;
resisted curl-up
3 Flex: 116°, 118°; LR at pubic tubercle; L iliac crest and PSIS Thomas test RL, Gillet's on L, Resisted hip adduc- L ilium anterior rotation, R
Ext: 10°, 12°; RL distal rectus lower; L ASIS and forward bending on L tion at 45° greater ilium posterior rotation;
ER: 20°, 25°; abdominis pubic tubercle than 0° flexion; R hip anterior glide; L hip
IR: 28°, 20° higher resisted curl-up posterior glide
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4 Flex: 113°, 115°; B over pubic tubercle; R iliac crest and PSIS Ober's test RL, Thomas test Resisted hip adductor R ilium posterior rotation, R
Ext: 12°, 14°; B at adductor longus higher; R ASIS and RL, 90-90 hamstring test at 0° and 45° hip pubis superior glide; RL
ER: 29°, 39°; insertion pubic tubercle lower LR; Gillet's on R, forward flexion; resisted hip anterior glide; LR
IR: 42°, 42° bending on R curl-up hip posterior glide
5 Flex: 115°, 115°; L pubic tubercle; L iliac crest and PSIS Gillet's on L, forward bending on L, Resisted hip adduction L ilium posterior rotation, R
Ext: 8°, 5°; L iliopsoas higher; L ASIS lower supine-to-sit on L at 0° hip flexion; ilium anterior rotation; L
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ER: 28°, 15°; resisted curl-up hip anterior glide; R hip

IR: 22°, 22° posterior glide
6 Flex: 110°, 112°; L distal rectus abdo- L iliac crest and PSIS 90-90 hamstring test RL, Thom- Resisted hip adduc- L ilium posterior rotation;
Ext: 15°, 10°; minis insertion; L higher; L ASIS lower as test LR; Ober's test LR; tion 0° hip flexion; LR hip anterior glide;
ER: 15°, 10°; adductor longus Gillet's on L, forward bending resisted curl-up RL hip posterior glide
IR: 19°, 29° tendon on L, supine-to-sit on L
Abbreviations: ASIS, anterior superior iliac spine; B, bilateral; ER, external rotation; Ext, extension; Flex, flexion; IR, internal rotation; L, left; PSIS, posterior
superior iliac spine; R, right.

Utilizing palpation of these boney land- periodically over the course of treatment Others were omitted based on a negative
Journal of Orthopaedic & Sports Physical Therapy®

marks to assess static pelvic position has
been found to have poor interrater and
intrarater reliability.65,69
Special Tests/Muscle Length Applicable
special tests of the SIJ, pelvis, hips, and
lumbar region were performed,54 with
any test provoking the athlete’s symptoms
noted as being positive (J78B;(). Muscle
length testing was also conducted,54 with
any lack in flexibility noted. The reli-
ability and/or validity of these tests are
variable.16,19
Neurological Assessment Muscle stretch
reflexes (MSRs) of the quadriceps and
Achilles tendons were assessed bilat-
erally. Evidence moderately supports
the use of these tests as sensitivity is
generally good for determining lumbar
radiculopathy.33,42,47 The neurological as-
sessment was considered normal for all
of the athletes.
All clinical examination tests and
measures were subsequently reassessed
to determine if improvements were made.
Any deficits were noted and used to guide
the plan of care.
:_÷[h[dj_Wb:_W]dei_i
In part, the diagnosis of a sports hernia
is typically one of exclusion: patients
present with a normal physical exami-
nation and have no palpable inguinal
hernia, and other pathologies have been
ruled out.1,40,61 The differential diagnosis
of groin pain is challenging, based on
the significant symptom overlap among
various groin pathologies and the fact
that multiple dysfunctions often coex-
ist.5,37,62,66,80 A recent published case re-
port outlines the differential diagnosis of
a sports hernia.79
Many diagnoses (snapping hip syn-
drome, hip subluxation/dislocation, ac-
etabular labral tears, and bursitis) were
immediately ruled out due to the absence
of various signs and symptoms.5,59,62,63
radiograph or MRI report (avulsion frac-
ture, proximal hip fracture, stress frac-
ture)5,51,53,61-63,73 or based on the absence of
neurological signs and symptoms (lumbar
radiculopathy, pudendal/genitofemoral
neuropathy, obturator nerve entrap-
ment, ilioinguinal neuralgia).5,51,62,63,73
Inguinal hernia was ruled out, as there
was no palpable hernia. Other diagnoses
(rectus femoris strain, symphyseal insta-
bility)5,52 might have been concomitantly
present in some of the athletes, but the
investigators believed they were chronic
secondary dysfunctions.
Four highly probable dysfunctions
that were subsequently ruled-out in-
cluded osteitis pubis, adductor strain,
iliopsoas tendinosis, and rectus abdomi-
nis strain.5,28,37,52,53,62 Although the inves-
tigators believed these conditions were
not the primary source of the athletes’
exertional pain, they might have coex-
isted and/or contributed to the etiology

journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 771
 [ CASE REPORT ]
Athlete presents with cluster of 5 signs and symptoms consistent
with a sports hernia

Athlete recalls hearing or feeling Athlete does not recall hearing Patient is not a high-
acute lower abdominal “rip” or feeling acute lower abdominal performance athlete
“rip,” and pain centered more in
groin versus lower abdominals

Category 1 Category 2 Category 3 Category 4

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Athlete who is Athlete who is 6-wk trial Rehabilitation

not scheduled scheduled to rehabilitation
to return to return to sport
sport for at within 4 mo
least 4 mo
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Undergo 3- to 4-wk trial If <80% If >80% If 100%

surgical rehabilitation improvement improvement, improvement,
exploration continue with return to sport
and repair rehabilitation
additional 2-3
wk
Journal of Orthopaedic & Sports Physical Therapy®

If <80% If >80% If 100% If <100% If 100%

improvement improvement, improvement, improvement improvement,
continue with return to sport return to sport
rehabilitation
additional 2-3
wk

If <100% If 100% Undergo

improvement improvement, surgical
return to sport exploration
and repair

Undergo
surgical
exploration
and repair

<?=KH;$Decision-making algorithm for determining course of rehabilitation.

772 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
 of the sports hernia. The clustering of
signs and symptoms led the investiga-
tors to deduce that these athletes’ pri-
mary dysfunction was a sports hernia.
The diagnosis was confirmed in the 3
athletes who underwent surgery; howev-
er, 3 of the participants did not undergo
an endoscopic examination and thus the
diagnosis of a sports hernia could not be
definitively made.
Jh[Wjc[dj7b]eh_j^c
Each athlete presented with a distinct in-
jury history and unique clinical findings.
The decision to initiate rehabilitation or
to undergo surgery was determined on a
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.
case-by-case basis. One purpose of this
case series is to provide the reader with
an algorithm to guide the management
of athletes presenting with groin pain
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(<?=KH;).
Most physicians agree that physi-
cal therapy rehabilitation should be the
first option in treating an athlete with a
suspected sports hernia. What remains
controversial is the length of time consti-
tuting a “trial” of physical therapy. We be-
lieve this answer depends on the nature
of the injury, the level of performance
Journal of Orthopaedic & Sports Physical Therapy®
expected of the athlete, and the length
of time before the athlete is expected to
return to preinjury level of play. Accord-
ing to the proposed algorithm (<?=KH;),
if the athlete presents with the cluster of
signs and symptoms, and heard or felt a
lower abdominal “rip or tear” during the
activity, yet is not expected to return to
sport for at least 4 months, then the ath-
lete should consider undergoing a surgi-
cal examination and subsequent repair if
applicable. If this athlete is expected to
return to sport within 4 months, then a
3- to 4-week trial of rehabilitation is ad-
vocated. If the patient notes at least an
80% improvement after 4 weeks of re-
habilitation, then rehabilitation is con-
tinued; if he/she does not report at least
80% improvement, the athlete should
consider surgical exploration and pos-
sible repair. If the athlete did not hear/
feel tearing during the initial injury, a
6-week trial of rehabilitation is advocated
journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 773
and progressed accordingly. Because evi-
dence suggests poor surgical outcomes in
nonathletes,59 rehabilitation is currently
advocated as the only course of action
with these patients.
Patients 1 through 3 elected for surgi-
cal repair of their sports hernia at varying
points of their rehabilitation and thus the
diagnosis of a sports hernia was made en-
doscopically. It is important to note that
although patients 4 through 6 presented
with the cluster of signs and symptoms
consistent with a sports hernia, they did
not undergo endoscopic exploration of
their injury. Thus, the diagnosis could not
be made definitively and only short-term
outcomes are presented. The important
message is that athletes presenting with
the characteristic signs and symptoms of
a sports hernia will undergo similar reha-
bilitation to address objective findings,
whether the definitive diagnosis has been
given or not, and the length of rehabilita-
tion will be guided by the outcomes. The
<?=KH; is merely a template to guide reha-
bilitation, as outcomes may vary due to
factors such as patient motivation, level of
pain tolerance, level of function, demands
of the sport, demands of position played
within the sport, and timing of the in-
jury relative to the patient’s competitive
season.
?dj[hl[dj_ed
All patients received the following manu-
al therapy interventions administered by
the same physical therapist: soft tissue
mobilization techniques to the lumbar
and hip regions, joint mobilization/ma-
nipulation techniques to the pelvis, SIJ,
and/or hips, neuromuscular reeducation,
and manual stretching. In addition to re-
ceiving manual therapy sessions twice a
week, the athletes underwent exercise re-
habilitation under the direct supervision
of the athletic trainer 3 times a week. The
head athletic trainer at the university had
14 years of clinical experience working
with collegiate athletes. All interventions
addressed specific objective impairments
found during the physical examination,
including muscle length deficits, strength
imbalances, and joint hypomobility. It was
the belief of the treating physical thera-
pist that these impairment may have led
to, or been the result of, the sports hernia
injury. The rehabilitation sessions contin-
ued until the patient was able to return to
pain-free sporting activity.
Soft Tissue Mobilization Techniques Soft
tissue mobilization (STM) techniques, in-
cluding effleurage and petrissage,13 were
used sparingly as needed to address mus-
cular tightness in the superficial posterior,
superior, and lateral pelvic musculature
and fascia. STM was occasionally incor-
porated to address significant myofascial
restrictions of the lumbar spine and pel-
vis,12 but were not utilized in the anterior
abdominals, adductor insertion sites, and
inguinal musculature, to avoid potentially
compromising vulnerable tissue.
SIJ and Hip Mobilization/Manipulation
Techniques Manual therapy interven-
tion included joint mobilizations/ma-
nipulations directed to the pelvis and/or
hips. The techniques are illustrated and
described in detail in 7FF;D:?N 7. Grade
III, IV, or V mobilizations/manipulations
were performed if joint hypomobility was
found. Mobilizations/manipulations per-
formed at the end of range are proposed
to have hypoalgesic effects,41,44,57,67,68,81
as well as mechanical effects, including
connective tissue elongation through
plastic deformation of the capsule and
other soft tissues,67 and/or by the break-
up of intracapsular cross-linkages and
adhesions.44,67,68,78 Each mobilization/
manipulation was applied for 30 sec-
onds, at a rate of approximately 1 mobi-
lization every 1 to 2 seconds, followed by
a 30-second rest. All mobilizations/ma-
nipulations were performed for 3 sets of
30 repetitions and were terminated when
the patient was believed to have normal
accessory motion.
Pelvic mobilizations/manipulations
included a posterior ilium rotation mobi-
lization on patients with an anterior rota-
tion positional fault and hypomobility of
posterior rotation, and an anterior ilium
rotation mobilization on patients with
a posterior rotation positional fault and

hypomobility of anterior ilial rotation.
In patients with innominate asymmetry,
ilial anterior/posterior rotations were
followed by the sacroiliac regional thrust
manipulation technique performed twice
on each side. The sacroiliac regional
thrust manipulation technique has been
shown to be effective at decreasing pain
associated with hip dysfunction, low back
pain, and SIJ dysfunction.10,14,15,25,26
Hip anterior glide mobilizations/ma-
nipulations were performed when ante-
rior glide hypomobility was perceived to
be present, and hip posterior glide mobi-
lizations/manipulations were performed
when posterior glide hypomobility was
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.
perceived to be present. Any perceived
lumbar segmental hypomobility was
treated with grades III to IV central
posterior-anterior mobilizations/ma-
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
nipulations. The effectiveness of hip and
lumbar mobilizations/manipulations to
address hip dysfunction and lumbar pain
has been well documented6,7,11,17,70; but
these techniques have not been utilized
to address groin pain associated with a
sports hernia.
Neuromuscular Reeducation and Stretch-
ing Techniques After performing pelvic
Journal of Orthopaedic & Sports Physical Therapy®
and/or hip mobilizations/manipulations,
neuromuscular reeducation and manual-
stretching techniques were utilized to
assist in maintaining capsular mobility.
An anterior rotation mobilization/ma-
nipulation of the pelvis was followed by
a sequence of submaximal isometric hip
adduction, hip abduction, ipsilateral hip
flexion/contralateral hip extension, and
ending with hip adduction. Between each
30-repetition set of anterior ilial rotation,
the patient performed isometric hip flex-
ion for 10 seconds. Conversely, a posterior
ilial rotation mobilization/manipulation
was followed with a similar sequence, ex-
cept it included ipsilateral hip extension
and contralateral hip flexion with the
patient performing isometric hip exten-
sion between sets. The sacroiliac regional
thrust manipulation technique was fol-
lowed by hip adduction, abduction, and
reciprocal hip flexion and extension.
Hip mobilizations/manipulations
774 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
[ CASE REPORT ]
were followed by passive stretching to
the hip, including contract-relax tech-
niques.44 An anterior glide of the hip was
followed by stretching into hip extension
and external rotation; a posterior glide
was followed by stretching into hip flex-
ion and internal rotation.
;n[hY_i[Fhe]hWc
All patients performed the following ex-
ercise program 3 to 5 times a week in the
athletic training center under the direct
supervision of the athletic trainer.
Dynamic Flexibility All exercise rehabili-
tation sessions commenced with dynamic
stretching of the iliopsoas, quadriceps,
hamstrings, hip internal and external
rotators, and adductors on a Truestretch
Stretch Station (MF Athletic Company,
Cranstson, RI). During flexibility train-
ing on the Truestretch, the patient was in
a weight-bearing upright position, with
emphasis on proper body alignment.
All 3 planes of motion (sagittal, frontal,
and transverse) were incorporated with
4-point contact of both hands and feet to
encourage flexibility training in a more
functional, sport-specific manner.
Trunk Stabilization The initial 6 weeks
of exercise rehabilitation focused on
trunk stabilization according to the Wat-
kins-Randall Trunk Stabilization Pro-
gram (7FF;D:?N8).82 This 5-level program
progresses the patient through different
exercises rated 1 through 5 in difficulty,
with repetitions and sets determined by
the program being performed. While per-
forming trunk stabilization exercises, the
patients were instructed to maintain lum-
bar spine neutral, drawing their umbili-
cus toward their spine and isometrically
contracting their transverse abdominus
muscles. Once patients established prop-
er technique without pain at one level of
the program, they were advanced to the
next level of increasing difficulty.
Dynamic Exercises After establishing
mastery of level 3 trunk stabilization,
the patient began a series of dynamic
rehabilitation exercises (7FF;D:?N 9).
These exercises were typically initiated
3 to 6 weeks following onset of symp-
toms or postsurgery and concluded at
approximately 8 to 12 weeks postinjury
or surgery. Multiplane joint motion
emphasizing eccentric muscle contrac-
tions in a weight-bearing position is the
foundation of these dynamic exercises.31
Exercises included side-lying clams with
miniband resistance, side-stepping with
miniband resistance, step-ups, and mul-
tidirectional step-downs. Additional ex-
ercises included (1) single-leg bridging
into hip extension, (2) rotational planks
and multidirectional lunges in 3 planes
of motion, (3) single-leg balance exercises
with lower extremity or upper extremity
multidirectional reaches in 3 planes of
motion, and (4) split squats and single-
leg squats. These exercises are described
in detail in 7FF;D:?N9.
EKJ9EC;I
H
alf of the athletes received
conservative intervention and
were able to fully return to sport
after a mean of 7.7 sessions of physical
therapy. The other 3 athletes reached
this outcome after surgical repair and
a mean of 6.7 sessions of physical ther-
apy. The overall mean number of physi-
cal therapy sessions for all participants
was 7.2 (range, 3-15) over an average of
6 weeks. It is important to note that the
successful outcomes noted in these ath-
letes may be attributed to the surgical
repair in 3 of the athletes and/or may be
secondary to the positive effects of time
in all of the athletes.
The athletes were managed according
to the treatment algorithm (<?=KH;). Ath-
lete 2 fell under category 1. He felt a lower
abdominal muscle “tear” during a discus
throw, while competing in his track sea-
son. He believed he would be unable to
compete for the remainder of the season
but was anxious to return to competi-
tion next season to insure his scholarship
and thus elected to undergo endoscopic
examination and subsequent repair of a
sports hernia. After his repair, he under-
went 5 sessions of physical therapy and
was discharged due to return to sport-
 specific activities without symptoms.
Athlete 3 fell under category 2. She was
a collegiate soccer player who reported an
acute episode of feeling her lower abdo-
men “tear” during summer practice. She
intended to compete in the fall and thus
elected to undergo rehabilitation with
the athletic trainer for the remainder of
the summer. During the fall season, she
played with varying pain intensity and
disability, competing at about 85% of her
preinjury level. She finally elected to un-
dergo surgical repair of a sports hernia in
January of the following year, requiring 6
months of postsurgical rehabilitation be-
fore reaching 100% of preinjury status.
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.
This athlete is an example of someone
who, according to the proposed algo-
rithm, may have considered undergoing
surgery after 6 weeks of rehabilitation, as
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
she did not reach the 100% level of play.
However, she wanted to continue play-
ing the fall season, postponing her sur-
gery for an additional 2 months. It can
be speculated that this patient’s length of
postsurgery rehabilitation may have been
adversely influenced by the fact that she
continued to play her sport despite pain
and disability.
Journal of Orthopaedic & Sports Physical Therapy®
Category 3 included athletes 1, 4, 5,
and 6. Athlete 1 was a collegiate bas-
ketball player with insidious groin pain
during nonconference competition ap-
proximately 1 month before the start of
the regular season. He was able to re-
turn to play without limitations after 6
sessions of physical therapy (4 weeks)
and thus met the criteria for returning
to sport at 100% within the 6-week trial
of rehabilitation. He continued to play
without limitations for 1 month before
his symptoms returned insidiously, forc-
ing him to stop playing. At that time,
he elected to undergo surgical repair of
a sports hernia and returned for only 2
sessions of rehabilitation after surgery,
before self-discharging due to return to
sport without symptoms.
Athletes 5 and 6 were similar in that
both were collegiate basketball players
who were in season play at the time of
the injury and whose symptoms came on
journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 775
after reports of “pulling” a groin muscle
(but not “tearing”). Both returned to play
after a short course of rehabilitation—
patient 5 after only 3 sessions of physi-
cal therapy over 3 weeks, and patient 6
after 5 sessions over 4 weeks. Thus, both
patients were at 100% of their preinjury
level of play within the time frame of a
6-week trial of rehabilitation. Because
neither athlete underwent an endo-
scopic examination of their injury, the
definitive diagnosis of a sports hernia
was not made.
Athlete 4 was a collegiate track run-
ner who reported insidious groin pain
centered in the pubic area, groin, and
adductor insertion during the spring
season and had not returned to practice
when evaluated in the fall. At the time
of the physical therapist evaluation, she
had undergone rehabilitation in the ath-
letic training room throughout the fall
semester with minimal to moderate im-
provement, and her goal was to be able
to compete in track in 2 months. After
6 weeks of therapy she was able to com-
plete her track workouts with symptoms
after, but not during, her practice but
had decided to “red shirt” competition
until the following year. Thus, continu-
ing with rehabilitation did prove to be the
best course of action for this athlete, as
she continued to make gradual but steady
progress and reached 100% level of com-
petition after 15 sessions of physical ther-
apy over 12 weeks. This athlete did not
undergo an endoscopic examination and
confirmation of her injury.
:?I9KII?ED
J
his case series documents the
complex clinical presentation and
management of athletes with ath-
letic pubalgia. Because a sports hernia is
not visible, cannot be palpated, and of-
ten cannot be confirmed by imaging, the
practitioner should perform a careful and
thorough examination, screen for other
possible injuries and conditions, then
proceed with rehabilitation with little
guidance based on research evidence.
When determining the etiology of
groin pain, an important question is
the intensity and location of the pa-
tient’s symptoms. Pain without exertion
should be further evaluated for potential
systemic pathology. Complaints of tes-
ticular or epididymal pain, or cyclic pain
accompanying menstruation,59 should
be examined carefully to rule out geni-
tourinary abnormalities.1,23 Neurological
symptoms in the groin or upper scrotum
may suggest entrapment of the genital
branches of the ilioinguinal, obturator,
or genitofemoral nerves.3,59,73
Confounding the diagnostic dilemma
is the fact that patients may have multiple
injuries presenting very similarly. Surgi-
cal exploration of patients with athletic
pubalgia indicates that a small percent-
age of patients have a small direct or indi-
rect hernia in combination with a sports
hernia.23,39,43,52,80 Adductor involvement is
common in patients with athletic pubal-
gia,4,20,21,37,71 and 3 of the 6 patients in this
case series presented with a physician di-
agnosis and/or imaging confirmation of
an adductor strain. The finding that ad-
ductor pain often improves after sports
hernia repair suggests that adductor
tendonitis may be a secondary phenom-
enon to the initial injury.58 Conceptually,
if the rectus abdominis tendon is torn or
weak in comparison to strong adductors,
the pelvis may tilt anteriorly, leading to
increased pressure directly over the ad-
ductor compartment.58
Osteitis pubis is another diagnosis
presenting very similar to an adductor
strain and sports hernia.4,20,21,37 These 3
pathologies can occur simultaneously, as
the symphysis pubis is supported by the
rectus abdominis and adductor longus
aponeurosis.20 Authors report patients
with confirmed osteitis pubis failing to
respond to conservative treatment often
have successful outcomes after a sports
hernia repair,22,59 suggesting that osteitis
pubis can coexist with a sports hernia and
surgery may be beneficial for complete
resolution of symptoms.
The etiology of a sports hernia in-
volves injury to the pubic symphysis

and surrounding soft tissue secondary
to mechanical stress and force attenua-
tion on the anterior pelvis.21,58,63,66 Some
participants described a lumbar hyperex-
tension injury, where the anterior pelvis
and pubic symphysis become the biome-
chanical pivot point.50,59 Other athletes
reported an insidious, chronic etiology
to their groin pain. This often includes a
subsequent acute traumatic event, which
suggests underlying microtrauma from
sport-specific activities requiring repeti-
tive active hip abduction/adduction and
flexion/extension, producing shear forces
across the pubic symphysis.71 Absence
of MRI findings documenting muscu-
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.
lar disruption further suggests that the
sports hernia injury involves attenuation
of the muscle or tendon due to repeated
microtrauma.4,59
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Abnormal mechanical load and force
attenuation on the anterior pelvis may
also result from foot or lower extremity
malalignment, limb length discrepancy,
and/or muscular imbalances that may,
over time, damage the pubic symphy-
sis, tendons, and/or fascia. 36,50,71 Some
theorize athletic pubalgia develops sec-
ondary to shortened and/or strong hip
Journal of Orthopaedic & Sports Physical Therapy®
flexor or adductor musculature, com-
pared with weak abdominals causing
shearing forces across the pubis.21,51,63,75
In addition, sport-specific activities in-
volving repetitive unilateral-extremity-
dominant jumping and side-to-side
motion may eventually result in muscle
strength imbalances and pelvic mala-
lignment.1,20,23,49,80 The patients in this
case series did present with muscular
imbalances, including unilateral and/
or bilateral hip flexor shortening, lim-
ited mobility of the hip anterior capsule,
and limited hip external rotation range
of motion. If athletes lack sufficient hip
extension, they may compensate with
excessive lumbar spine extension, which
may, over time, lead to microscopic tear-
ing of the lower abdominal musculature.
In addition, it was believed that many of
the athletes in this case series exhibited
pelvic asymmetry. A common occurrence
was an apparent ipsilateral anterior ilial
776 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
[ CASE REPORT ]
rotation on the dominant kicking/jump-
ing extremity and/or posterior ilial rota-
tion on the contralateral side.
The clinical significance of decreased
hip AROM was not noted initially, ex-
plaining why hip AROM was not mea-
sured in the first patient. Conceptually, it
can be suggested that a patient with tight
hip flexor musculature, often concomi-
tant with an ipsilateral anterior ilial ro-
tation, may present with a decreased hip
anterior glide accessory motion, leading
to decreased hip extension and external
rotation AROM. Conversely, a patient
with tight hamstrings, often associated
with ipsilateral posterior ilial rotation,
may present with decreased hip poste-
rior glide accessory motion, leading to
decreased hip flexion and internal rota-
tion AROM. These deficit patterns were
identified in these athletes, and when the
range-of-motion limitations were treat-
ed accordingly with joint mobilization/
manipulation techniques and passive
stretching, notable improvements in hip
range of motion and subjective improve-
ments in groin symptoms were noted.
Regardless of whether the athlete un-
dergoes surgical repair for a sports hernia
or is treated conservatively, it is impera-
tive that the clinician conduct a thorough
physical examination to treat the objec-
tive signs and symptoms accordingly. It
is our opinion that factors that can po-
tentially influence pelvic alignment, thus
force attenuation of the pelvic muscula-
ture, should be addressed with physical
therapy intervention, including deficien-
cies in muscle length, passive mobility
of the joints, and strength of the lumbar
spine, pelvic, and hip musculature.
If surgery is elected, the typical post-
surgical goal is for the athlete to return
to play within 6 weeks. If the athlete had
a chronic etiology and/or concomitant
injuries, he/she may need as much as 3
to 6 months of rehabilitation before re-
turning to play.1 Immediately following
surgery, the patient should rest for 2 to 3
weeks, particularly avoiding heavy lifting
and sudden movement to allow incisional
healing before starting rehabilitation.1
Physical therapy is initiated anywhere
from 1 to 4 weeks postsurgery.1 In the au-
thors’ experience, rehabilitation should
start with treadmill or elliptical-machine
endurance training, and should empha-
size strengthening, flexibility, and trunk
stabilization to address objective findings
and pelvic muscle imbalances.1 Physicians
and trainers typically allow the athletes
to return to play once they have no pain
with sport-specific activities, including
sprinting and cutting, can complete an
abdominal curl-up and bilateral straight-
leg raise/hip flexion with resisted hip ad-
duction without symptoms, and can fully
participate within their sport at an 80%
to 100% preinjury level. Because a cause-
and-effect relationship cannot be inferred
from a case series, follow-up randomized
clinical trials should be performed to
further investigate the effectiveness of
conservative rehabilitation comparing a
homogeneous group of patients, includ-
ing athletes and nonathletes undergoing
surgical repair for a sports hernia.
9ED9BKI?ED
J
he diagnosis of a sports hernia
should be considered in athletes
presenting with groin pain that ex-
hibits a cluster of 5 objective signs and
symptoms: complaints of deep groin/
lower abdominal pain, pain that is exac-
erbated with sport-specific activities and
relieved with rest, palpable tenderness
over the pubic ramus, pain with resisted
hip adduction, and pain with a resisted
sit-up. In this case series, 6 patients di-
agnosed with a probable sports hernia
were examined and treated with a mul-
timodal approach, including joint and
soft tissue mobilization/manipulation
techniques, stretching, and strengthen-
ing exercises. Three of the athletes were
treated successfully with conservative
care; the other 3 went on to undergo
surgical repair of their sports hernia.
All of the athletes were able to return to
sport at 100% of preinjury level of play
after undergoing postinjury and/or post-
surgical rehabilitation. T

H;<;H;D9;I
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44. Kisner C, Colby LA. Therapeutic Exercise: Foun-
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45. Klassbo M, Harms-Ringdahl K, Larsson G.
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46. Kluin J, den Hoed PT, van Linschoten R, JC IJ,
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52. Lovell G. The diagnosis of chronic groin pain in
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58. Meyers WC, Foley DP, Garrett WE, Lohnes JH,
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@
CEH;?D<EHC7J?ED
WWW.JOSPT.ORG
 [ CASE REPORT ]
7FF;D:?N7

CE8?B?P7J?EDJ;9>D?GK;I
J[Y^d_gk[ :[iYh_fj_ede\J[Y^d_gk[ ?bbkijhWj_ed
Posterior š FWj_[dji_Z[bo_d]"\WY_d]j^[hWf_ij"^_fWdZad[[Wj,&–#/&– [insert: Kachingwe_FigAA1.tif]
ilium rotation š 8ejjec^WdZcWa[iYedjWYjel[h_iY^_WbjkX[hei_jo1jef^WdZcWa[iYedjWYjel[h7I?I
mobilization š <ehY[0(fWhWbb[b\ehY[im_j^Xej^^WdZije_cfWhjWÇjehgk[Èehfeij[h_ehhejWj_edjej^[
innominate
š 9Wdij[f_dX[jm[[dfWj_[djÊibem[h[njh[c_j_[iWdZ^Wl[fWj_[djf[h\ehc_iec[jh_Y^_f
extension  10 s, while therapist rests between mobilizations
š 7\j[hceX_b_pWj_edi[ii_edZed["Ze(i[jie\^ebZ#h[bWn(#i^ebZ"ceZ[hWj[YedjhWYj_ed
into ipsilateral hip extension, contralateral hip flexion, then adduction “setting”)

Anterior š FWj_[djfhed[ [insert: Kachingwe_FigAA2.tif]

ilium rotation š J^[hWf_ijijWdZiedYedjhWbWj[hWbi_Z[e\_b_kcjeX[ceX_b_p[Z$9Wd^Wl[fWj_[djZhef
mobilization ipsilateral lower extremity off plinth
š 8ejjec^WdZ]hWifiWdj[h_ehZ_ijWbj^_]^ad[[Ô[n[Zeh[nj[dZ[Z"Xh_d]_d]^_f_dje
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.

extension
š 9edjWYjm_j^kbdWhWif[Yje\^[[be\^WdZel[hfeij[h_eh_b_kcf_i_\ehcXoFI?I
š <ehY[07dj[h_eh#ikf[h_eh\ehY[el[hfeij[h_eh_b_kc_cfWhj_d]WÇjehgk[Èje_dZkY[
anterior rotation of the innominate
š 9Wd^Wl[fWj_[djf[h\ehc_iec[jh_Y^_fÔ[n_ed 10 s, while therapist rests between
mobilization sets
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

š 7\j[hceX_b_pWj_edi[ii_edZed["Ze(i[jie\^ebZ#h[bWn(#i^ebZ"ceZ[hWj[YedjhWYj_ed
into ipsilateral hip flexion, contralateral hip extension, then adduction “setting”
Sacroiliac re- š Fei_j_edj^[fWj_[djikf_d[m_j^_b_kcjeX[ceX_b_p[Zedeffei_j[i_Z[e\jWXb[ [insert: Kachingwe_FigAA3.tif]
gional thrust š FWii_l[boi_Z[X[dZfWj_[djjemWhZi_Z[jeX[jh[Wj[Z
manipulation š J^[hWf_ij^eeaiY[f^WbWZ[bXem_["h_]^j[bXem_di_Z[fWj_[djÊih_]^j[bXemXoj^h[WZ#
technique ing arm through patient’s clasped hand and stabilizing dorsum of hand against the
patient’s ribcage
š J^[hWf_ijfbWY[i^[[be\YWkZWb^WdZWjj^[7I?I
š M^_b[cW_djW_d_d]i_Z[#X[djfei_j_ed"Ô[nj^[fWj_[djÊibkcXWhif_d["m^_b[i_ckbjWd[#
ously rotating the individual towards you until the ASIS raises up off the table about 2.5 cm
š 7iaj^[fWj_[djjejWa[WZ[[fXh[Wj^WdZ"kfed[n^WbWj_ed"jWa[j^[WlW_bWXb[cej_ed
and perform a quick thrust at the ASIS in a posterior/inferior direction
Journal of Orthopaedic & Sports Physical Therapy®

š 7\j[hceX_b_pWj_edYecfb[j[Z"^Wl[fWj_[djf[h\ehc_iec[jh_YWZZkYj_edm_j^oekhÓij
between patient’s knees to “set” pubic symphysis
Hip anterior glide š Fei_j_edfWj_[djfhed[ [insert: Kachingwe_FigAA4.tif]
mobilization š IjWX_b_p_d]^WdZ]hWifiWdj[h_eh"Z_ijWb\[ckh"fei_j_ed_d]^_f_dd[kjhWb"ad[[/&–
š CeX_b_p[^WdZYedjWYjifeij[h_eh"fhen_cWb\[ckh
š ;n[hjWdj[h_eh\ehY[

Hip poste- š IjWdZedeffei_j[i_Z[e\_dlebl[Z^_f [insert: Kachingwe_FigAA5.tif]

rior glide š FbWY[Y[f^WbWZ^WdZkdZ[hd[Wj^_iY^_kcehYWdki[m[Z][jeijWX_b_p[
mobilization š Fei_j_ed^_f_d/&–Ô[n_ed"'&–WZZkYj_ed
š 9WkZWb^WdZYedjWYjifWj[bbW"[n[hj_d]feij[h_eh\ehY[j^hek]^bed]Wn_ie\\[ckh
š 9Wdki[ij[hdkc\ehceh[YedjWYj%fh[iikh[

Lumbar cen- š 9edjWYjif_dekifheY[iim_j^f_i_\ehc%^ofej^[dWh[c_d[dY[e\Y[f^WbWZceX_b_p_d] [insert: Kachingwe_FigAA6.tif]

tral PA hand or can use thumb-dummy thumb technique directly over spinous process
mobilization š 7ffboZ_h[YjF7fh[iikh[m_j^\eh[WhciZ_h[Yjbo_db_d[m_j^\ehY[

Abbreviations: ASIS, anterior superior iliac spine; PSIS, posterior superior iliac spine; PA, posterior-to-anterior.

journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 779
 [ CASE REPORT ]
7FF;D:?N8

JHKDAIJ78?B?P7J?EDFHE=H7C
;n[hY_i[ 1 2 3 4 5
Dead bug Supported, arms over- Unsupported, arms over- Unsupported, arms al- Unsupported, arms al- Unsupported, arms al-
head, marching, 3 head, 1 leg extended, 3 ternate with legs, legs ternate with legs, legs ternate with legs, legs
sets  30 s sets  1 min extended with weight, extended with weight, 3 extended with weight,
3 sets  2 min sets  3 min 3 sets  4 min
Partial sit- Forward, hands on Forward, hands on chest, 3  10 forward, 3  10 3  20 forward, 3  3  30 forward, 3 
ups chest, 1 set  10 3 sets  10 left, 3  10 right 20 left, 3  20 right, 30 left, 3  30 right,
weight on chest unsupported, weights
overhead and behind
Bridging Slow reps, double-leg, Slow reps, double-leg, Single-leg, 1 leg extended, On ball, double-leg, feet on On ball, double-leg, feet
2  10 weights on hip, 2  20 3  20 ball, 4  20 on ball, 5  20
Prone Gluteal squeeze, alter- Alternating arm/leg lifts, On ball: flies, swims, su- On ball: superman with Ball: all exercises with
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.

nating arm/leg lifts, 2  10 perman, 2  10 weights, prayer, push- weights, 4  20

1  10 ups, walk-outs, 2  20
Quadriped Alternating arm and Alternating arm and leg, Alternating arm and leg, Alternating arm and leg, Alternating arm and leg,
leg, hold, 1  10 hold, 2  10 hold 5 s with weights, hold 10 s with weights, hold 15 s with weights,
3  10 3  10 3  20
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Wall slide Less than 90°, 1  10 90°, hold 20 s, 1  10 90°, hold 30 s, 1  10 90°, hold 15 s with 90°, hold arms extended
weights, 1  10 with weights, hold 1
min, 1  10
Aerobic Walk, land and water 10 min cycle or water run 20-30 min swim, elliptical 45 min stair climber, ellipti- 60 min jog/run
or run cal, swim or jog
Journal of Orthopaedic & Sports Physical Therapy®

780 | december 2008 | volume 38 | number 12 | journal of orthopaedic & sports physical therapy
 [ CASE REPORT ]
7FF;D:?N9

:OD7C?9;N;H9?I;I
;n[hY_i[ :[iYh_fj_ede\;n[hY_i[ ?bbkijhWj_ed
Single-leg bridging into š FWj_[djikf_d["m_j^'ad[[WdZ^_f\kbboÔ[n[Z$FWj_[dj^ebZiÔ[n[Z[njh[c_jo [insert: Kachingwe_FigAC1.tif]
hip extension close to chest. Opposite leg has foot fixed to the floor with knee flexed at 90°
š FWj_[dj[nj[dZi^_fe÷j^[ÔeehXoYedjhWYj_d]]bkj[kicWn_ckie\b[]j^Wj_i
contacting the floor
š Fhef[hj[Y^d_gk[_iZ[cedijhWj[ZXoa[[f_d]YedjhWbWj[hWb[njh[c_joÔ[n[Z
at the knee and hip with knee held close to the chest
šFWj_[djf[h\ehci)i[jie\'&je(&h[f[j_j_edied[WY^[njh[c_jo

Rotational planks š FWj_[dj^ebZibkcXWhif_d[_dd[kjhWbfei_j_edm^_b[_iec[jh_YWbboYedjhWYj# [insert: Kachingwe_FigAC2.tif]

ing the transverse abdominis
š FWj_[djX[]_di[n[hY_i[_dWfhed[fei_j_ed^ebZ_d]XeZoikif[dZ[Zed
Downloaded from www.jospt.org at on April 30, 2024. For personal use only. No other uses without permission.

flexed elbows and feet

š ;bXemickijX[a[fjjkYa[Z_dm_j^_dj^[Wb_]dc[dje\j^[jhkdajeb_c_j
contraction of the latissimus dorsi
š FWj_[dj^ebZifhed[fei_j_ed\eh(&eh)&i"j^[dhejWj[ijeb[\ji_Z[\eh
20-30 s, followed by rotation to right side for 20-30 s
š FWj_[djf[h\ehci)i[jie\'c_dWdZ)&i
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Single-leg balance with š FWj_[djXWbWdY[ied'b[]m^_b[h[WY^_d]_dWbbfbWd[ie\cej_edm_j^[_j^[h [insert: Kachingwe_FigAC4.tif]

Journal of Orthopaedic & Sports Physical Therapy®

lower/ upper extrem- contralateral leg or contralateral arm

ity multidirectional š FWj_[djckijikYY[ii\kbboZ[cedijhWj[Ô[n_edWjWbb)bem[h[njh[c_jo`e_dji
reaches (ankle, knee, and hip) and must center balance
š F[h\ehc(i[jie\+h[f[j_j_edi

Split squats š FWj_[djijWdZi_dWhkdd_d]#ijh_Z[%ifb_j#ijWdY[fei_j_edWdZY[dj[hiXeZo [insert: Kachingwe_FigAC5.tif]

weight and trunk between lower extremities
š FWj_[djbem[hiXeZo"m^_b[a[[f_d]jhkda_dWdkfh_]^jfei_j_edXoÔ[n_d]j^[
hip and knee on the front leg and extending the hip and flexing the knee on
the back leg
š FWj_[djbem[hij^[XWYaad[[jemWhZij^[Ôeeh"m^_b[\hedjad[[Ô[n[ije/&–
š ?\fWj_[dj^Wi_dikøY_[djijh[d]j^ehhWd]["fWj_[dj_i_dijhkYj[Zjef[h\ehc
the exercise through available range of motion
š FWj_[djf[h\ehci)n'&m_j^j^[h_]^jb[]WdZb[\jb[]_dj^[\ehmWhZfei_j_ed

journal of orthopaedic & sports physical therapy | volume 38 | number 12 | december 2008 | 781