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Bi-Lateral Inguinal Hernia
- a Case Study by Penny Taylor, MHFST
Client History
Dan [not the client’s real name] is a 24
year old professional footballer. He has
been training and playing full-time since the
age of 15. Prior to injury his routine
consisted of gym work and two to three
hours of training on a daily basis, plus one
or two full football matches per week.
Injury History
Dan first started to notice an ache in his
groin a year ago but thought little of it at
the time. Assuming that it was a muscle
strain he started a stretching regime.
Initially, the pain wasn’t too noticeable but
over time it started to get worse 24 hours
after any strenuous exercise. Over the
course of one year, the problems Dan had
been experiencing on just one side of the
groin was now affecting both sides.
Matters finally came to a head when Dan
could no longer find ways to relieve the
discomfort himself. By this stage, he was
experiencing problems simply getting out
of his car due to the pain in his groin area.
Dan’s post-op wounds following keyhole surgery
Needless to say, Dan’s performance as a
footballer began to suffer, and he was
unable to a full 90 minute match.
Suspecting a hernia, the Club Doctor and
Physiotherapist referred him to a
Specialist, who confirmed that he had a
bi-lateral inguinal hernia. Laparoscopic
(keyhole) surgery was arranged to correct
the condition.
Definition of a hernia
A hernia is the protrusion of an organ
through an abnormal opening. There are
different kinds of hernia, each of which are
typically named after the part of the body
closest to the affected area, e.g. inguinal,
femoral, umbilical, or hiatus.
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What causes an inguinal hernia
Inguinal hernias typically occur in males.
Elevated abdominal pressure can force
open the inguinal canals (which usually
‘close’ once the testes have descended)
and push a portion of the intestine into the
pocket created.
Hernias can also be classified as:
• Reducible - This is where the intestines
bulge into the membrane of the
abdomen (the peritoneum). These
hernias can often be manipulated back
into place, but will not normally stay in
place without surgery.
• Incarcerated/ Irreducible - This is where
the intestines bulge through and
become trapped
• Strangulated - This is when the blood
supply to the affected part of the (e.g.)
intestine is cut off.
Both incarcerated and strangulated hernias
are medical emergencies and require
immediate surgery. For his reason,
Doctors will often recommend that most
hernias are repaired, even if the patient
experiences no pain or discomfort.
The main symptoms
A lump or bulge will be noticeable
somewhere in the pelvis, abdomen, or
scrotum areas and will be clearly visible
beneath the skin. It may disappear when
lying down and reappear when
coughing, sneezing, or straining. A
hernia can develop gradually over the
years, without being noticed, or come
on quite suddenly. If there is any pain
and tenderness it is usually unilateral and
local to the conjoined tendon and
inguinal canal, but many radiate to the
adductor region and testicles. Sudden
movements or resisted sit ups will
increase pain, which will become
unresponsive to conservative treatment
over a period of time.
Detecting an inguinal hernia in males is
achieved by invaginating the inguinal canal
through the scrotum with the little finger. It
will be tender over the conjoined tendon,
pubic tubercle and mid inguinal region and
become worse when sitting up against
resistance.
Sports hernia or groin strain
Injuries to the groin are very common in
athletes who take part in sports that
require twisting and turning at speed,
such as football. Because of the weakness
in this area it is very common to have
more than one problem, so it can take
time to assess the other possible differential diagnoses. If there is no sign of a
hernia there may be disruptions to the
inguinal canal - this is known as a ‘sports
hernia’. The main symptom is insidious
unilateral groin pain during exercise which
will progress to normal everyday activities
if the athlete continues to train through
the pain. Sometimes, especially in football
players, a sudden tearing sensation may
be felt.
As well as an inguinal hernia, the other
injuries to consider with groin pain are
adductor tendonopathy and osteitis pubis.
However, it is possible to have two or
even all three of these conditions at the
same time.
Patient presentation and assessment
I first saw Dan 6 days after his operation.
The dressings were still on but he had
been making good progress by carrying
out isometric exercises and building up
strength. There was still some obvious
discomfort, and therefore the course of
action was to relax the abdominal muscles
around the incision areas and encourage
the healing process though massage and
electro therapy. All of this was under the
direction of my Course Tutor (also the
Club’s Sports Therapist) and the Club
Doctor.
Aims of treatment
The main aim of treatment was for Dan to
return to pre-op health and fitness as
quickly as possible, and reduce the risk of a
recurring injury.
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Due to the high level of fitness my client
already had, we were aiming towards him
being back to full-time training 2-3 weeks
after the operation and back in full play
after 4-5 weeks. This would primarily
involve isometric (static) contractions of
the abdominal and adductor muscles on
the first day after the operation, increasing
the sets and repetitions during the first
week, followed by dynamic concentric and
eccentric exercises to start strengthening.
As walking was possible straight after the
operation, another aim was for Dan to
start jogging in 10 days time.
Due to the risk of developing a number of
injuries to the groin (especially as Dan is a
professional footballer) the importance of
pelvic flexibility, strength and stability is
important as a lack of these can contribute
to the development of osteitis pubis,
adductor strain and hernias.
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I was unsure exactly how far my client’s
body could be pushed.
Dan’s pre-operative fitness was good and
therefore he was at an advantage when it
came to recovery time and I was surprised
as to how soon he was able to return to
full match fitness. This may have been
because, as a full-time athlete, he could
balance rehabilitation and rest without
having to work, which can prove to be a
hindrance to recovery for non-professional
clients.
By the end of the third week, whilst there
were no problems with respect to the
hernia operation, Dan was experiencing
muscle cramps in his hamstrings and
calves, both lateral hip rotators were tight,
and the left and right ilio tibial bands were
painful and tight. Realising that I had just
been focusing on strengthening the site of
During Dan’s first appointment I removed
the dressings that had been in place since
the operation. The surgery wounds were
healing well at this stage but the dried blood
needed to be washed away as this was
starting to cause an itching sensation. In
addition to the exercises, I lightly massaged
around the abdomen and then carried out
laser and ultrasound treatments to help
promote the healing process.
Dan’s Rehabilitation Programme
Dan was still experiencing an ache in the
groin region, but this is quite typical and
can drag on for months after such an
operation, and is known as ‘chronic groin
pain’. This can occur if nerves get trapped
in the internal stitches or mesh, or if
surrounding tissue, etc, is damaged during
the operation. However, over time, this
pain seemed to reduce and only occurred
during certain exercises and stretches.
Days 3 and 4
(In addition to the exercises outlined above)
Pelvic tilt: lie on back, place hand in the small
of the back and push lower back into the
hand. Knee raises: lie on back, bend and lift
the knees. Three sets of 10 per day. Adductor
squeeze: lie on back, place rolled-up towel
between knees and squeeze the legs together.
Conclusion
I found it completely different working with
a professional athlete due to a number of
reasons …
Despite being under the direction of my
Course Tutor and the Club Doctor, I was
initially apprehensive about what to do and
how soon after the operation the
exercises could be done. I had never
treated a client who had had a hernia
operation before, or anyone so soon after
surgery. I found that I was quite cautious as
Exercises carried out in addition to
massage therapy:
Days 1 and 2 (Post-op)
Static contraction of stomach muscles: lie on
back, place chin on chest to give a light
stretch. Three sets of 10 as many times
throughout the day without pain.
Days 5 and 6
Cat stretch: on hands and knees, drop the
stomach, suck in abdominals. Hold for 20
seconds. Hold for 20 seconds and clench
buttocks (alternate contractions and stretches).
Day 7
Crunches: 500-800 a day.
Week 2
Straight line jogging every other day for up to 45
minutes and adductor stretches. These
exercises were in addition to all of the above,
depending on how the client was feeling
(obviously some days were better than others).
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the hernia and not the body as a whole, I
then added some active and passive
stretching exercises and extra massage to
Dan’s existing programme. This was a
particularly valuable lesson learnt.
Working with Dan has made me feel far
more confident in treating clients who are
professional athletes. It also made me
realise that this kind of work was of great
interest to me. I have since started to gain
practical experience at a local football club
and I will be the Sports Therapist for
Westmoreland Under 18’s Football Club
as of this September.
Penny Taylor, MHFST, completed this
case study as part of a VTCT Level 3
Diploma in Sports and Fitness Therapy
Techniques at Lancaster and Morecambe
College, Lancashire.
Week 3
Beginning on a flat, level surface:
• quarter speed normal jogging speed (NJS) in
straight line
• half NJS on straights, quarter NJS on bends
• three-quarter NJS on straights, half NJS on
bends
• full NJS on straights, three-quarter NJS on
bends.
Progress by adding bouts of acceleration and
deceleration, zig-zags and figure-of-8s.
Week 4
• 2 mins jog with football across pitch, alternating touches on the left and right feet
• as above but incorporating stretches A and
B (see below)
• 2 mins jog sideways with the football alternating left and right lead
• 2 mins jog with football incorporating
stretches C and D
• 2 mins jog sideways rolling foot over ball
and alternate left and right foot
• 2 mins jog with ball incorporating stretches
A and D.
Stretches:
Stretch A - adductor muscle stretch in the
squat position; Stretch B - adductor muscle
stretch sat on the floor; Stretch C - prone
lying stretch; Stretch D - adductor side stretch.
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