<h4><b>Do you know what one looks like?</b></h4>
<h4><b>Do you know what to do when your client has a hernia?</b></h4>
<h4><b>Do you have a clear idea of what to do if you or someone you know has one?</b></h4>
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<span style="font-weight: 400;">There are many different causes of abdominal pain, but despite being quite common, there is little written about abdominal pain from a musculoskeletal perspective. Read on as we discuss some of the more common musculoskeletal disorders.</span>

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<h3><b>Incipient (Sportsman’s) Hernia</b></h3>
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<span style="font-weight: 400;">The various muscles of the abdominal wall are penetrated by the inguinal canal, which contains nerves and, in men, the spermatic cord, in women the inguinal canal, contains a small fibrous ligament. Where the inguinal canal penetrates the abdominal wall, weak spots arise, and this is the site of an incipient inguinal hernia. It is effectively a tear of the muscles and connective tissue in the area.</span>

<span style="font-weight: 400;"><img class="wp-image-3789 aligncenter" src="https://biomechanicseducation.com/wp-content/uploads/2017/10/hernia-1.jpg" alt="hernia" width="516" height="298" /></span>

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<span style="font-weight: 400;">There is some debate in the literature as to how this is diagnosed, but the symptoms include the following:</span>
<ol>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Lower abdominal pain</span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Stiffness or soreness after training.</span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Groin pain that is increased by running, sprinting, twisting and turning.</span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Groin pain that is increased when coughing, sneezing, etc.</span></li>
</ol>
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<span style="font-weight: 400;">It is claimed that in 30 percent of athletes, there is a history of sudden injury, but the majority indicate an incipient hernia is a gradual overuse injury. </span>

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<span style="font-weight: 400;">It depends upon the skills of the doctor or therapist as to whether a sportsman’s hernia can be diagnosed, but this problem accounts for many of the unsuccessfully treated abdominal and groin injuries seen in sports today. If any of your clients complain of the above types of symptoms, one of the main areas to check first is the sacro-iliac (SI) joint function.</span>

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<span style="font-weight: 400;">If there is an abnormal positioning of the SI joint, this can increase the load on the external and internal obliques and consequently the inguinal canal, causing damage. So before trying to manage a hernia, you need to try to correct any biomechanical causes that may be loading the area. </span>

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<span style="font-weight: 400;">The two best tests to check for correct biomechanical function of the pelvis are Downing’s Sign and the 4-Sign (Patrick Fabre’s sign). This was established by Barrow and Haines when they biomechanically tested over 4,000 people to look at which manual tests had the highest correlation with the biomechanical tests in the Lab for establishing pelvic function. </span>

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<span style="font-weight: 400;">Downing’s sign is a non-weight bearing test and also establishes whether there is a functional or apparent leg length discrepancy.  While this test is difficult to describe in text try this (or go to our YouTube Channel); lay your client supine, ask them to do a bridge, then taking their legs you lift their knees to their chest and then straighten their legs out to the floor or couch.  At this point measure any difference in height between their medial malleoli. Now move their hips by rotating them passively into adduction, then flexion, then abduction and then back down into extension.  Then take a look at the heights of their medial malleolus.  If their pelvis is working correctly that leg should have lengthened and the malleolus on that side should be lower.  Then reverse the movement and when you now measure the medial malleolus height that leg should have shortened again, making the leg lengths the same as they were after they bridged.  </span>

<span style="font-weight: 400;">Try on both sides. If the legs both lengthen and shorten, then the pelvis is working correctly.  If they don’t, then the pelvis is dysfunctional and can be loading the hernia area.  The 4-Sign can be found when you Google Patrick Fabre’s Sign and has much more written about it, but it’s usually applied clinically rather than biomechanically.  </span>

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<span style="font-weight: 400;">With this test, you lay your client supine (or you can do it seated) and cross one ankle over the other with the lateral malleolus placed outside the lower quad of the opposite leg.  Look at how low the knee drops to the floor or mat. Then repeat on the other side. They should be symmetrical, if they aren’t symmetrical then the pelvis is dysfunctional. </span>

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<span style="font-weight: 400;">In addition, if the pelvis is abnormally rotated, as well as causing a functional leg length discrepancy, it can increase the load on the symphysis pubis, which can also refer pain into the lower abdominals. The best way to mobilise the pelvis and correct any SI dysfunction through exercise is to perform anti-spasm exercises (a form of hold-relax exercise) for the hip extensors and specifically glutes and piriformis. </span>

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<span style="font-weight: 400;">Once the pelvis is in good biomechanical shape, then core work can help to stabilise the pelvis after it’s in a correct biomechanical position and also working on the scar tissue around the inguinal canal to help the healing. Then when your client is ready, you can progress onto the functional stability work. </span>

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<span style="font-weight: 400;">It is critical that you work the adductors of the hip as well. This is because the adductors and the trunk muscles work closely to control and stabilise the pelvis, and for men especially, their adductors are often “weak” or inhibited. This may be one of the reasons that they have an incipient hernia in the first place. While today the latest trend is “functional movements,” there are times in rehab and conditioning when you need to isolate muscles first, and this is one example. As Mark Verstegen says: “First isolate, then integrate.” Working the hip adductors symmetrically in the seated adductor machine helps engage the adductors (and core when positioned correctly) and mobilise the symphysis pubis. Then progressing to asymmetrical adductor work on the total hip machine (hip conditioner) will introduce a more weight-bearing challenge with additional torque through the pelvis, and then functional movements can be a very effective way of integrating the pelvic and trunk musculature.</span>

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<span style="font-weight: 400;">The problem with functional movements, in this example, is that if one of the muscles is not firing correctly or is inhibited (in this case the adductors), and you do functional training for the hip and trunk, the body is a master of compensation, and other muscles can take over to protect it. The muscle needs to be “taught” how to contract and fire again, so it is able to be integrated into a functional pattern of movement. So in this case (as with many others), isolate then integrate.</span>

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<span style="font-weight: 400;">More often than not, the incipient hernias can be managed through exercise rather than surgery. Just try to make sure you correct the mechanical faults with the pelvis as well as strengthening the obliques.</span>

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<h3><b>Referred Abdominal Pain</b></h3>
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<span style="font-weight: 400;">Referred pain is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance from the site of an injury origin. The International Association for the Study of Pain, as of 2001, has not officially defined the term, so several authors have defined the term differently. Despite an increasing amount of literature on the subject, there is no definitive answer regarding the mechanism behind this phenomenon. Physicians and scientists have known about referred pain since the late 1880s, yet the true origins and causes of referred pain are unknown. However, we do know that referred pain can come from a number of areas, like the thorax (pneumonia, pulmonary embolism, ischemic heart disease and pericarditis), the spine (radiculitis) and from the genitals (testicular torsion). </span>

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<span style="font-weight: 400;">So if you have any uncertainty at all, refer your client to a relevant medical specialist. If you think there may be some cardiac involvement, refer to a cardiologist, and if you are concerned that the pain may be referred from the spine, then any good manual therapist should be able to help. Don’t worry too much about whether it’s a physiotherapist, osteopath or chiropractor. Consider the person rather than the qualification. Try to find one who understands biomechanics so he/she can work out why your client has the pain and also someone who understands exercise and is prepared to discuss the science with you to come to a logical conclusion.</span>

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<span style="font-weight: 400;">As long as there is no underlying clinical pathology, exercise is an excellent way of managing musculoskeletal-related abdominal pain and its many causes. The key is to identify the biomechanical causes (rotated pelvis, weak or inhibited adductors, tight lumbar spine, tight thoracic spine etc) and manage them. Then progressively condition the relevant muscles, and the abdominal pain usually looks after itself. </span>

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<i><span style="font-weight: 400;">With thanks to Martin Haines, Specialist Biomechanics Coach, Chartered Physiotherapist.</span></i>

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<h3><b>References</b></h3>
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<ol>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Anderson, DM, Mosby's Medical Dictionary 6th ed, St Louis, Mo: Mosby; 2002. </span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Fredberg U, Kissmeyer-Nielsen P, The sportsman's hernia – fact or fiction? Scand J Med Sci Sports, 1996 Aug;6(4):201-4. </span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Giles LGF, Taylor JR, Low back pain associated with leg length inequality, Spine 6:5, 510, 1981. </span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Lacroix VJ, Kinnear DG, Mulder DS, Brown RA, Lower abdominal pain syndrome in national hockey league players: a report of 11 cases, Clin J Sport Med, 1998 Jan;8(1):5-9. </span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Marx J, Rosens Emergency Medicine: Concepts and Clinical Practice 6th ed, St Louis, Mo: Mosby; 2006. </span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Thompson, Ann and Skinner, Alison. eds. "Tidy's Physiotherapy." Butterworth-Heinemann Ltd. 12th ed. 31 Mar 1991</span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">http://www.sportnetdoc.com/injury/09-02.htm</span></li>
</ol>