Updated: Mar 21
The best treatment for abdominal tendinopathy is a carefully graded rehab programme that is pitched at the right intensity to allow the tendons to calm down and regain the strength they've lost due to the injury. In this article I'll explain how to design such a plan and also what other factors you should keep in mind when doing your rehab. Remember, if you need more help with an injury, you're welcome to consult our team of sports physios online via video call.
In this article:
The anatomy and symptoms of abdominal tendinopathy
The pictures above of the abdominal wall and the pelvis show where the rectus abdominis muscles (your six-pack) are attached to the pubic bone. It also indicate where the adductor muscles (the inner thigh muscles) attach to the pubic bone.
This is important, because the tendons of these two sets of muscles are actually attached to each other via a thick layer of fascia that crosses over the pubic bone. They work together as you do sports, and if one of them gets injured it often affects the other as well. This is why you may end up getting adductor tendon injuries if you neglect abdominal tendinopathy or vice versa.
Another bit of anatomy to take note of is the pubic symphysis, indicated by that little gap in the middle of the pubic bone, because osteitis pubis, which affects this area, is often also associated with tendinopathies of the abdominal and/or the adductor muscles.
Pain caused by abdominal tendinopathy usually starts on one side of the body where the tendons attach to the pubic bone and pubic symphysis. In severe cases, it then crosses over and both sides become painful.
The pain can also refer up into the abdominal wall, or down into the adductor muscles, and into the genital area (front groin).
However, there can be many other causes of pain in these areas, so it is important to have it checked out by your doctor to see whether it might actually be something like a bladder infection or a hernia.
If you want to be sure about your diagnosis, the best thing to do is to get either an ultrasound scan or an MRI scan. An MRI scan, if you have access to that, would be my preference, because then you can also see the state of your pubic symphysis as well as your adductor tendons. As mentioned above, injuries in these three areas often go together.
Causes of abdominal tendinopathy
Abdominal tendinopathy is an overuse injury that can either develop suddenly (because you do a very hard training session) or slowly over time (because you don't allow enough recovery time between sessions).
One would think that the main cause of abdominal tendinopathy would be overdoing it in the gym with sit-ups and crunches, and yes, that is one way to get it. But, surprisingly, this injury is also quite common in running sports - especially ones that involve a lot of twisting and turning, such as football/soccer, and hockey. This is because your abdominal muscles are active and working whenever you're upright and moving.
Long-distance runners are also known to develop abdominal tendinopathy, but for them it is often a secondary injury as a result of an injury to the adductor tendons or osteitis pubis.
Another common cause of abdominal tendinopathy that is not linked to sport is giving birth, as this process obviously puts a lot of strain on that area.
Treatment for abdominal tendinopathy
The most important treatment for abdominal tendinopathy is a combination of relative rest and strength training. The relative rest allows the pain and sensitivity to settle down while the strength training is needed to restore the strength that was lost due to the injury.
Relative rest/load management
Once injured, the abdominal tendons lose some of their strength. This means that they are now not strong enough to cope with the forces and loads put through them by your sport. So, if you continue to do your sport as usual and you don't dial it down a bit, you will just keep on making it worse. You also won't see results from your rehab, because you're trying to strengthen the tendons on top of the load that your usual sport activities put through it.
This is why relative rest or load management is important. Initially, you have to reduce the amount and maybe even the type of sport you do to a level that doesn't aggravate your injury. By how much you should reduce it will depend on your type of sport and how severe your injury is. The aim with this is to establish a baseline of sport that you can do that does not cause an increase in your symptoms.
For instance, if you're a footballer, it will very likely mean that you need to cut out high intensity sessions like matches and movements where you twist and turn. So, it will likely mean a break from football for a while, but you may still be able to run to maintain some of your fitness. However, if even running hurts, you'll have to replace it with something else.
Runners may have to reduce their speed and distance. However, for some people, even that doesn't work. If it's really sensitive, you may have to stop all running for a while and just do some cycling or cross-training until it's recovered and strengthened enough to cope with running again.
Weight lifters will likely have to reduce the weights they lift and try to find a level that doesn't aggravate their pain.
Top tip: Keep in mind that a tendon might only tell you the next day if you’ve overdone it, so if your abdominal tendons complain first thing in the morning, think about what you did the previous day that might have upset them.
That part of your abdominal tendon that's injured is now weaker than what it should be to absorb the forces during your normal sport, so you have to strengthen it.
It's important to remember that this is an overuse injury. So, you have to be quite mindful of how you introduce exercise and strength training. If you go and do lots of heavy strength training immediately, you will just over-strain it and it will feel worse.
Also, you have to keep in mind what else you've got going on. So, for instance, if you've got osteitis pubis as well, then you want to avoid anything that puts a big rotational/torsion force through that pubic symphysis area in the initial stages of rehab – you want to keep exercises nice and symmetrical at first.
You can take a look at the detailed videos we’ve made about the treatment of osteitis pubis and of adductor tendinopathy. These two things need to be addressed if you've got them at the same time as your abdominal tendinopathy.
Low load isometric contractions (like an isometric crunch), where you tense your muscles without moving, tend to work really well for abdominal tendinopathies, especially in the early rehab stages. The specific movements and the dos and don’ts of the exercises that I prescribe for my patients are best demonstrated in the video below, from 09:50 onwards.
The first few exercises are nice and symmetric, so people who also have osteitis pubis can get started with those without flaring up their condition.
Top tip: It's important to increase the exercise intensity and complexity gradually over time. What exercises you should progress to and what level of intensity you should work up to will depend on your sport and your individual goals.
Recovery days are important
One of the most common mistakes people make when recovering from abdominal tendinopathy is that they overdo their rehab. They are so desperate to get better that they fall into the trap of thinking that if they do their exercises every day, they'll recover quicker.
But the opposite is actually true. Whenever you exercise, your body sustains microdamage. This is normal. Your body then repairs this microdamage and that's how you grow stronger over time. However, if you don't allow enough recovery/repair time between your training sessions, the microdamage accumulates and causes overuse injuries like abdominal tendinopathy.
Tendons take much longer than muscles to recover after exercise (about 42 to 72 hours). So you have to allow enough time between your rehab sessions for this to take place, otherwise you'll just end up overtraining it again.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
Cook, J. and S. Docking (2015). "“Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians." British Journal of Sports Medicine 49(23): 1484-1485.
McAleer, S. S., et al. (2015). "Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy." Physical Therapy in Sport 16(3): 285-299.