On this episode of the #AskMikeReinold show, we talk about getting back to weight training and sports activities after both sports hernias and inguinal hernias. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 212: Returning to Weight Training After a Sports Hernia
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Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about returning to weight training after sport and inguinal hernias.
Mike Reinold: So, all right, let’s get into it. We got a nice question today from Russell from Virginia. Russell says, “Hey, Mike and team. Big fan of the show. I’ve been diagnosed with a bilateral hernia, no imaging done, just manual testing by a general surgeon and urologist. The surgeon says back squatting under heavy load or other heavy core or ab strain can cause further tearing if not fixed surgically, and could also reoccur after surgery. My preferred style of training is power lifting and I’d be somewhat bummed if it’s a risk to me to go back to lifting heavy afterward. What are your thoughts on power lifting or high intensity core exercises with a hernia, or after a mesh repair? Have you worked with patients or clients with the same issue?”
Mike Reinold: So I’ll start off a little bit with this answer by saying, Russell asked here via a hernia and we weren’t a hundred percent sure if he was referring to an inguinal or a sport hernia. So why don’t we tackle that first? Anybody want to define the difference quickly before we get into maybe what it means to get back to lifting?
Dan Pope: You want me to take the inguinal part?
Mike Reinold: I feel like you’re going to answer this whole thing, Dan, but why don’t you tell us a little bit about what the difference between an inguinal and a sport hernia is?
Dan Pope: Yeah. So inguinal hernia, you can also have an umbilical hernia. There’s a femoral hernia too. And I think the easiest way to describe that is when your insides are trying to get onto the outside, right, and there’s some sort of tear in some of the musculature and the abdominal wall, and then you have your intestines are poking out. Yeah. So that’s the short of that. Did you want to answer the sports hernia part?
Mike Reinold: Yeah. The sport hernia is probably a little bit more vague, right? And it goes by some other terms like athletic pubalgia and stuff like that, where essentially it’s a similar region, right? So your inguinal area, your lower ab area, but there isn’t a true bulge. And I think that’s the difference. Dan said it really well. With the inguinal hernia, there’s a bulge of your intestines bulging through your abdominal wall. So that’s the true definition of a hernia. So a sport hernia is a junk term. There isn’t probably a true bulge, so there isn’t an inguinal hernia, but what they tend to think … I’m way over simplifying for this though, but if this is your core, you tend to have the layers of the fascia give way a little bit, or maybe it gives away off its distal attachment into the pelvis, and then you have a weakening of the abdominal wall.
Mike Reinold: So you could argue that they’re probably very similar realm in terms of how it changes your function, because it impacts your abdominal wall. So I don’t know, let’s answer this first through the realm of maybe a sport hernia, which is probably more common in athletes. And we tend to see this in athletes that tends to be, I don’t have an epidemiology study to back this up, but the people that are more anteriorly pelvic tilted and tend to work a lot and live a lot in hyperextension, tend to get this spread a little bit of their abdominal as they do their functional activity. So they tend to be the ones that we see it. We see it in pro athletes [inaudible 00:04:35] the guys that tend to be in hyperextension when they run, really anteriorly tilted, and it really tends to put a lot of strain on their anterior core.
Mike Reinold: So based on that, Dan, why don’t we go to you again and get back to the question on hand, which is about weight training. And the main concern is probably the big bearing down, right, the big load to be able to stabilize. What do you think about a sport hernia, somebody getting back with or without surgery, and what’s the likelihood they do well?
Dan Pope: Yeah. So in terms of a sports hernia, like you said, it’s a bit of a garbage pail term. Sometimes there’s an abductor related pathology. Sometimes it is more of the abdominal muscles. And it is something that can be treated conservatively, and it can get better over the course of time. I think the inguinal hernias are a little bit different, and some of the umbilical hernias are a little bit different. And I’ve had a bunch of athletes who’ve had this just because I worked with a lot of weightlifters, and all the pressure that you’re exerting when you’re doing intense weightlifting can increase your likelihood of having one of these. What’s challenging is that they’re almost always treated surgically via mesh, right? And I just briefly looked through some of the research this morning. I’ve looked through this in the past. There’s decent return to sport rates. And then some of these studies are actually looking at weight training specifically. So you’re having athletes are getting back to weight training.
Dan Pope: And I think the important part here is that you have to think about, why did you get injured in the first place, right? And oftentimes it’s a pressure management issue. And this was brought up to me by [Sarah Duvall 00:06:04] Initially because she’s a pelvic floor specialist, pregnancy and postpartum. These folks also have a lot of problems with hernia as well, and also prolapse, and they can be treated conservatively. And one of the ways you can treat that is by trying to teach people how to regulate the pressure and where they’re putting the pressure, right? So if you’re bracing and bearing down and most of your pressure is going towards that inguinal hernia, that can increase that problem. If you learn to brace in a way that maybe pulls that area in some and puts it elsewhere, you can get into a place where you can potentially lift without getting the surgery.
Dan Pope: That being said, I don’t see this very often, and I don’t think the mesh is a bad procedure. I do think you probably can get back to weight training afterwards. We probably need to make sure you have a good therapist to help out in that situation. Unfortunately, I don’t think it’s a skill that a lot of physical therapists have. But the thing is, I’ve seen a bunch of people who’ve had mesh and they get back to weight training pretty successfully. That’s just my personal experience.
Mike Reinold: Yeah. And probably same thing with sports too. You can probably get back to sports and stuff. When you talk more specifically about a sport hernia, again being a junk term, it could be a few different things, like Dan brought up the abductors, or you could actually even argue it’s just some pressure on the nerves in the area and it’s not really anything bio-mechanically or structurally wrong we tend to have. But I think in addition to what Dan said with inguinal hernia, the one thing that we can add from our knowledge of sport hernias, I do think like we can brace differently, but we can also try to get ourselves in a better position to exceed where we have a little bit more of a neutral lumbopelvic position, a little bit more of a neutral brace. Some people love to brace just anteriorly, right? That’s a big Stuart McGill thing too, where people just crunch their abs and they don’t brace their abdominal wall, or especially the whole cylinder including pelvic floor, diaphragm at the top, those types of things. So I think we could probably also help people by trying to help them with their positioning and the way they lift. Right?
Mike Reinold: For me, with my heavy lifters, it’s been the people that … We’ve all seen them, right? They get into a deep squat and they’re ridiculously hyper extended at their back. Right? So maybe they’re super flexible or whatever it is, their sport required them to be in this position. But when they’re in this huge flex position with their ribs flaring tends to be the people that struggle with these types of things. What Dan said about an inguinal hernia is probably a little bit more with loading than just positioning as well, like Dan mentioned, but I do think trying to focus a little bit on that may be very helpful in trying to educate better positions to do their lifts. Right? What do you think Dave?
Dave Tilley: Yeah, the only two cents I have, because it rings a bell quite a bit, is that with more of the sports hernia also, very extreme, rapid flection extension cycles of the core of the pelvis can create quite a bit of problems for people. So there’s the running related sports hernia that you’re talking about, but I think a lot of gymnasts and a lot of swimmers sometimes get it where they have really aggressive kicking of their lower body, like arch hollow, and that causes a lot of problems with people, whether it’s on the abductor side or the abdominal side. But …
Mike Reinold: Yeah, no, I can see that. That makes sense. You get a lot of different ways to think of this, and that’s probably why we keep saying sport hernia is a junk term and why we see it both above and below the pelvis, right, with the abductor and groin, is maybe you have somebody that has rigidity in their hyper extending the back, or maybe you have somebody that is good at stabilizing their core, but they’re over hyper extending their hip past their neutral position or whatever it may be.
Mike Reinold: So I’ve always held out hope for these people that as long as we’re not past the point of it’s way too far, like we’ve fallen off the cliff, then we can make these modifications and some reeducation and try to help them when they’re starting to have pain. Unfortunately though, and I think Dan alluded to this by saying that he tends to see people post-surgical, most people try to work through it and then just make it worse and worse over time until they just don’t function as well, and then they end up needing surgery. So Dan commented quite a bit on this and said, he thinks you can get back after an inguinal hernia. There’s a ton of research that shows sports hernias, you can get back to surgery. NFL players get this all the time, NHL players getting this all the time. So if they can certainly get back, I think a lot of our recreational athletes can too. So I’m optimistic, but I would love to see you before it’s a real problem to see if there’s some things we can fix before it just goes past the point where we can’t really help anymore. Right? [crosstalk 00:10:39].
Lenny Macrina: If I could just add something too, it sounds like this person was searching for, he’s not satisfied with what the doc said, and maybe get a second opinion would be my … I’m always about second opinions when there’s a surgery being discussed. Because always, somebody will just want to jump in and do a surgery. So I would try to seek somebody who knows these types of injuries, whether it’s sports or inguinal hernia, and really try to see if somebody can give you a little bit more guidance. Or even some imaging too, imaging could be vague because it’s not always clear on imaging. But definitely a different physical examination from it from a different opinion.
Mike Reinold: Yeah. I was going to say that too. I was going to say, he hasn’t had imaging too. He did see a general surgeon and a urologist. So that’s a good sign. If it’s truly an inguinal hernia and they can palpate something …
Lenny Macrina: Right. Right.
Mike Reinold: It’s a hernia. What do you got Dan?
Dan Pope: What I will say too is that I think a lot of those surgeons probably aren’t big time weightlifters either. If you can find a surgeon that actually does weight training, you probably get a different answer. That being said, good luck finding that. I think that might be challenging. But definitely look around and see if you can find someone, not that you want a confirmation bias and just a surgeon tell you you’ll be fine, but I think you want someone who actually has the experience because if you start looking through the literature, like I said, there’s a few studies with return to sport being pretty good for weight training. Longterm outcomes, I don’t think we have that. So if they’re telling you that it’s just going to come back again, I don’t know what they’re basing that on. [inaudible 00:12:08] just when I’m going on. So …
Mike Reinold: That makes sense. The way we tend to do it in the pro sports model on something like this is, there’s a sports medicine physician, usually a surgeon, that’s involved in this diagnosis and this treatment plan. But they’re not the ones that do the surgery, right? So if you’re a pro athlete, you’re even probably getting seen by our sports medicine docs, but then they’re going to send you to their general surgeon to do the actual surgery. So maybe you also need a consult with a sports medicine doc in addition, maybe. It’s hard to find a general surgeon that power trains on the weekends, but I guess it happens. You can find one. But maybe also get a sports medicine consult, put your heads together about the potentials there. Right? So, awesome, great question. Hopefully we nailed that from both ends and made sure that we address it there.
Mike Reinold: I wanted to make sure we gave a good answer on that one that hit both of those, just to make sure that we were covering our basis. And I think it was good to highlight the difference a little bit. So awesome question. Good luck, Russell. If you have a question like that, again, head to mikereinold.com, click on that podcast link and fill out the form to ask questions. In the meantime, please head to iTunes, Spotify, whatever you do to listen to your podcast, and rate and review this. And we will be sure to keep doing this at Champion, or at home, or wherever it is. Thank you so much.
Mike Reinold: We don’t have Mike here, so … Isn’t that what Mike would have done?
Dan Pope: Yeah.
Mike Reinold: Thank you.