HERNIA

fessional sports, intensive daily training, club matches, international matches and the need to play back-to-back seasons in both codes has placed greater physical stress on players in these two sports. Goal kickers in both rugby league and union also suffer repetitive shearing forces to the pelvic and groin area and are most suscep- tible to the degenerative changes in the abdominal wall.

Surgical management Surgically the players are often found to have a torn oblique aponeurosis and con- joined tendon with a dilated superficial inguinal ring. The two most common types of surgery involve open or laparoscopic techniques (surgical instrument and view- ing tool inserted in the abdomen). If the muscular opening is too wide to draw together and suture, a patch of Prolene mesh (Fig.7) which allows tissue fluid and fibrous tissue to pass and grow through the holes may be used to repair the defect. Rehabilitation following surgery takes

Pre-operative factors to consider may include: Spinal assessment ● Standing ● Active and passive movement ● Manual spinal tests ● Neural tests Pelvic and lower limb assessment ● Passive movement ● Active movement ● Global mobility (active related to passive) ● Global stability ● Neural tests ● Functional tests

Biomechanical assessment ● Pelvic and lower limb mechanics ● Standing, walking, running (multi- directional) ● Video/digital analysis of functional movement patterns ● Examination of daily footwear (training shoes, moulded, studded boots)

Isokinetic assessment ● Isometric and concentric/eccentric patterns related to the hip joint ● Emphasis on adductors, medial and lateral rotators ● Assessment in side lying (classical test position) and standing (function- al) positions

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Figure 7: Ethicon Mersilene Mesh used in repair of PAWD injuries

between 4-8 weeks and needs to be func- tional in relation to the particular sport of the player.

Rehabilitation schedule In the ideal world a pre-operative physical assessment is very useful for the physio- therapist. This may assist in determining the root cause of the problem and provides baseline information on the player’s pre- operative physical and mental state.

Functional rehabilitation Ideally the early part of the functional

Although the following programme is designed specifically for PAWD reha- bilitation it also provides a very solid basis for the rehabilitation of groin and abdominal muscle strains.

rehabilitation programme should be taught prior to surgery so that the player has a full understanding of what is expected of them in the week following surgery. In many cases most players will only under- stand abdominal work in terms of the num- ber of sit ups or leg raises they can per- form, exercises which place an enormous emphasis on rectus abdominis and hip flexor strength and unwanted spinal load- ing.

Emphasis must be placed on the stabilising role the often neglected internal obliques and transversus abdominis play, in terms of functional movement and posture. Recent research has demonstrated the stabilising effect isometric contraction of the abdom- inal muscles has in producing strong, yet mechanically effective abdominals (6,7).

In this late pre-op/early post-op phase emphasis must be placed on maintaining stability in the neutral spine position. This requires time and a thorough explanation of what is required during what appear to be very simple exercises for the ‘un-edu-

Figure 8: Use of a pressure biofeedback unit to assist in posterior abdominal wall exercises

cated’ player. Physiotherapists often use terms such as bracing, hollowing, posteri- or and anterior pelvic tilt without realising that this language is alien to many of their patients. Instruct the player to pull their navel towards their lower back while con- tracting the deep and lateral musculature of the abdomen. The aim is a very subtle isometric contraction. The player may find it helpful in terms of feedback to place one hand over the site of the scar(s) to encour- age contraction and give manual re- enforcement in the early stages; the other hand can be placed over the rectus abdo- minis to discourage contraction in this overused site. Feedback can also be given with the use of a pressure biofeedback unit (Fig.8).

As the player progresses into week three, various other aspects can be introduced to strengthen and mobilise the affected area.

Figure 9a: Passive mobilisation of the hip joint

Figure 9b: Passive mobilisation of the hip joint

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