Pubalgia

Definition/Description

Groin pain is a common entity in athletes, particularly those engaged in sports that require specific use (or overuse) of lower abdominal muscles and the proximal musculature of the thigh (eg, soccer, ice hockey, Australian Rules football). An increasingly recognized cause of chronic groin pain in athletes is athletic pubalgia (AP). Gilmore initially described “Gilmore’s groin” in the early 1990s. Over the years, many different names have been associated with this injury, such as athletic pubalgia, sports hernia, pubic inguinal pain syndrome, sportsmen’s groin, footballers groin injury complex, hockey player’s syndrome, athletic hernia, and inguinal disruption.[1]

Pubalgia is a chronic groin lesion. Athletes with pubalgia have an imbalance of the adductor and abdominal muscles at the pubis, that leads to an increase of the weakness of the posterior wall of the groin. This imbalance leads to a deep groin pain. Complete tearing or displacement can occur unilaterally or across the midline to the other side[2]. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while later, the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy.[3] As athletic pubalgia is a specific anatomical injury rather than a broad category of findings, an additional pathologic diagnosis, such as an inguinal hernia, does not exclude the diagnosis of athletic pubalgia. Unfortunately, the terms sports hernia and sportsman hernia, commonly used in the media and in professional communities, have largely confused the broader understanding of nuances and of the differences between the specific injuries and MRI findings[4].


Clinically Relevant Anatomy

When we talk about pubalgia, we must take bones and muscles in consideration. When we talk about the bones, we talk about the two femurs, the sacrum and the coccyx. All the muscles that attach to pubic symphysis are important for the anatomic perspective of pubalgia. We talk about the anterolateral abdominal muscles ( external and internal oblique muscles, tranversus abdominis and rectus abdominis) and the thigh adductor muscles (pectineus, gracilis, adductor longus/brevis and magnus). Of all the muscles that attach to the symphysis the rectus abdominis and the adductor longus are the most important for maintaining the stability in the sagittal plane of the anterior pelvis. [5][6]

Epidemiology /Etiology

Pubalgia is most common in soccer, ice hockey, lacrosse, long-distance running, kicking sports, Australian football, and cricket. All these sports involve repetitive energetic kicking, twisting, turning or cutting movements, which are all risk factors for causing pubalgia.[7] Athletes with pubalgia are predominantly male and generally under the age of 40 years. Generally, we can explain it because there are more males that practice the sports that have a higher risk of pubalgia. A second reason we can find in the fact that female patients generally have a larger and more robust caudal rectus abdominis attachments on the pubic symphysis, a situation that is not seen in male patients. A third reason is that the female pelvis is wider and has a larger subpubic angle this can result in a better guiding of forces away from the pubic region. The anatomic and biomechanical differences in the female pelvic structure may help stabilize the pubic region and decrease the risk for pubalgia.[6]

There are different causes of pubalgia:[8][9]

1. Muscle imbalance between adductor muscles and abdominal muscles

The pubic symphysis acts as a fulcrum for the anterior pelvis, and the structures implicated in the development of sports hernia/athletic pubalgia all have an intimate relationship with this fulcrum. Fibres from the rectus abdominus, conjoint tendon (a fusion of the internal oblique and transversus abdominus), and external oblique merge to form the pubic aponeurosis. This pubic aponeurosis is confluent with the adductor and gracilis origin, and it is also referred to as the rectus abdominus/adductor aponeurosis.[10].

During athletics, a large amount of force occurs at the anterior pelvis in which the pubis symphysis is its centre. The opposing forces of the adductor longus directly against the rectus abdominus at the pubic symphysis fulcrum point are thought to be implicated as the origin mechanism of athletic pubalgia [11].

The rectus abdominis and adductor longus muscles are relative antagonists of one another during rotation and extension from the waist. Contraction of the rectus abdominis muscle, in the presence of normal abdominal wall tone, places a posterior and superior force on the pubis and elevates the pubic region. Cadaveric studies have shown that transection of the rectus abdominis muscle origin causes an excessive downward tilt of the anterior pelvis, with a resultant increase in pressure in the adductor compartment. In contrast, the adductor longus muscle has an anterior-inferior force vector. An injury to one of these tendons predisposes the opposing tendon to injury by both altering the biomechanics and disrupting the anatomic contiguity of the tenoperiosteal origins. In turn, such disruption leads to instability of the pubic symphysis. Therefore, when the rectus is weakened, the adductor longus pulls in an unopposed fashion. Typically this is from chronic or acute intense muscle contractions by the athlete while hyperextending and/or twisting the trunk. The inequality of forces acting on the anterior pelvis leads to tearing at the insertion point of the rectus abdominus[11].

2. Rectus adductor syndrome:


a) Adductor enthesopathy

b) Pathology/asymmetry of the symphysis pubis

3. Sports hernia:


a) Myoaponeurotic parietal defect:

- of the transverse bundle
- of the posterior wall of the inguinal canal
- of the anterior wall of the inguinal canal


b) Occult hernia of the abdominal wall

4. Locoregional pathologies:


a) Nerve compression:

- ilioinguinal nerve (Maigne’s syndrome)
- obturator nerve
- femoral cutaneous nerve
- genitofemoral nerve


b) Muscular disorders:

- iliopsoas
- hamstrings
- iliopsoas bursitis


c) Joint diseases:

- hip diseases
- sacroiliac disease


d) Genitourinary disorders:

- adnexal
- urethral
- testicular and scrotal
- prostate

5. Any previous injury.

Characteristics/Clinical Presentation

Activities that can lead to athletic pubalgia involve running, kicking, cutting and twisting movements, and explosive turns and changes in direction[11]. In the United States, soccer, ice hockey, and American football players are most commonly affected. Most patients with pubalgia have symptoms for months or years before a clinical diagnosis is obtained. Athletes usually present with the complaint of the exercise-related unilateral lower abdomen and anterior groin pain, which is a deep, sharp pain that can radiate to the proximal thigh, low back, lower abdominal muscles, perineum or scrotum.[8] Most of all they complain about a unilateral groin pain, that is relieved with rest and returns during activities. Additionally they have also pain when they cough and sneeze. The unilateral pain can evolve into bilateral pain.[12]

Pain can occur gradually, but 71% of athletes will relate the recurrence to a specific event. This event can include trunk hyperextension and/or hip hyperabduction leading to increased tension in the pubic region. Kachingwe and Grech explained 5 signs and symptoms that they felt encompassed athletic pubalgia: “(1) a subjective complaint of deep groin/lower abdominal pain, (2) pain that is exacerbated with sport-specific activities such as sprinting, kicking, cutting, and/or sit-ups and is relieved with rest, (3) palpable tenderness over the pubic ramus at the insertion of the rectus abdominus and/or conjoined tendon, (4) pain with resisted hip adduction at 0, 45 and/or 90 degrees of hip flexion, and (5) pain with resisted abdominal curl-up.”

Differential Diagnosis

The diagnosis of pubalgia is difficult, because of the complex anatomy and the overlap of symptoms between the different groin injuries. The clinician must also consider that athletes with groin pain may have more than one diagnosis and the presence of one of these related diagnosis does not necessarily eliminate the possibility of pubalgia. Because of the overlapping symptoms between sports hernia and other groin pains, it’s helpful to obtain imaging studies to rule out other causes of pain.[13][2]

These include acetabular labral tears, adductor injuries, snapping hip syndromes, iliopsoas tendonitis, osteitis pubis, and femoroacetabular impingement[14]. One must rule out a true groin hernia, genitourinary and gynaecological disorders, and intra-abdominal sources of pain that can mimic athletic pubalgia symptoms.

Diagnostic Procedures

Imaging studies are important for the difficult diagnosis of pubalgia. Imaging studies such as ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), herniography and laparoscopy can help with the diagnosis.

  • Ultrasound has an accuracy of 92% in finding a hernia in the groin. Dynamic ultrasound examination is able to detect inguinal canal posterior wall deficiency in young males without clinical signs of a hernia in the groin.[2]
  • MRI can show abnormalities in the musculofascial layers of the abdominal wall that correlate closely to surgical findings of pubalgia. MRI can find also stress-related oedema within the symphysis pubis caused by the imbalance of forces and altered motion across the joint.[6]
  • CT-scans help to identify posterior inguinal wall deficiencies and hernias.[2]
  • People with pubalgia test positive by a herniography. The test is positive if there is an abnormal contrast flow outside the normal contours of the peritoneum.
    Another study to detect a sports hernia is laparoscopy. It’s an invasive technique, that is very effective to diagnose pubalgia. An advantage of endoscopy is that a sports hernia could subsequently be repaired in the same session.[15][16]
                                                 

Examination

The physical examination for sports hernia/athletic pubalgia begins with palpation of the potential sites of injury. Lower abdominal, adductor, and symphyseal pain to palpation are common in athletes; therefore, it is critical to determine if the pain is consistent with their symptoms. Exam findings include tenderness at or just above the pubic tubercle near the rectus insertion or hip adductor origin on the affected side[14]. The abdominal obliques, transverses abdominis, and conjoined tendon/rectus abdominus should be palpated[10]. Valsalva maneuvers such as coughing and sneezing can occasionally reproduce symptoms

Sensory disturbances and dysesthesias in the lower abdominal, inguinal, anteromedial thigh, and genital regions can be present with occasional entrapment of branches of the iliohypogastric, ilioinguinal, and genitofemoral nerves.

Limited hip internal rotation, flexion, and abduction may indicate underlying femoroacetabular impingement. Various tests such as the anterior impingement (pain with hip flexion, adduction, internal rotation) are also indicative of concomitant hip joint pathology[10].

The patient may present with adductor and hip flexor weakness with dynamic movement.

Upon completion of an observational gait analysis, dysfunction can often be noted with the movement of the pelvis and femoral alignment of the lower extremities.

The examination of patients with pubalgia can include 4 pain provocation tests: the single adductor, squeeze, bilateral adductor and resisted sit-ups test.

  • During the single adductor and the bilateral adductor tests, the patient should be lying supine with his hips abducted and flexed at 80°. The test is positive if the patient feels a sharp pain in the groin while attempting to pull his legs against pressing in the opposite direction.
  • People with pubalgia have also pain during the squeeze test while they are lying in supine with the hips in 90° flexion. [2][17]
  • A resisted sit-up or crunch with palpation of the inferolateral edge of the distal rectus abdominus may re-create symptoms.

According to Kachingwe et al there are five signs that are indicative of a “sports hernia” now termed athletic pubalgia[16][18]:

1-A subjective complaint of deep groin/lower abdominal pain
2-The pain is exacerbated with increased exertion such as sprinting, cutting, sit-up and is relieved with rest
3-Palpable tenderness over the pubic ramus at the insertion of the rectus abdominus and/or conjoined tendon
4-Pain with resisted hip adduction at 0,45, and/or 90 degrees of hip flexion
5-Pain with resisted abdominal curl up.

Medical Management

Generally, conservative treatment should be attempted for 3 months before considering surgery. In-season athletes can trial a 4-week period of rest. Pharmacological treatments include nonsteroidal anti-inflammatories and oral steroid taper. Injections include selective corticosteroid or platelet-rich plasma injections into the rectus abdominus and/or adductor longus origin. After this rest period, return to sport can be trialled.

When the patients still have pain after physical treatment surgical exploration and repair is indicated. There are a lot of types of surgical treatment which make it difficult to compare outcomes.[2][13] Most techniques have satisfactory results reported in the literature. Principles of operative management include reinforcement of the posterior wall and fixation of the rectus abdominus or conjoint tendon.[14] Another type of surgical treatment is laparoscopic surgery. The technique is performed by endoscopy, total extraperitoneal mesh placement behind the pubic bone and/or posterior wall of the inguinal canal. Paajanen et all shows us that laparoscopic surgery for pubalgia in athletes is more effective than nonoperative treatment. After surgery repair, the pain decrease after 1 month and 90% of the athletes who underwent operation full returned to sports activities after 3 months.[19] Most also recommend adductor tenotomy when adductor pain and dysfunction is present. Femoroacetabular surgery should also be considered accordingly if recognized as a contributing issue, as previously discussed. A full return to sport is expected at about 6–8 weeks if an isolated athletic pubalgia repair is performed and 4 months if FAI surgery is concomitantly done.

Physical Therapy Management

Rehabilitation with physical therapy is first-line treatment for most patients with athletic pubalgia. However, treatment should be individualized based on the level of the athlete, the length of time before the athlete is expected to return to play, and timing of sport season.

The treatment consists of rest, active soft tissue mobilisations in case of muscle tightness, as well as joint manipulations of the pelvis, SIJ and hip joint may be beneficial for decreasing pain associated with dysfunction[20][16], anti-inflammatory medication and physical therapy. Therapeutic ultrasound treatments, cold tubs and deep massage of the groin region may be also helpful. First of all, the range of motion must be recovered and improved.[18]  After that, the therapy consists of core strengthening exercises target the abdomen, lumbar spine and hips and stretching focuses on the hip rotators, adductors and hamstrings. The goal of the therapy is to correct the imbalance of the hip and pelvic muscle stabilizers. Another crucial part is the neuromuscular re-education focussing on the adductors and abdominal muscles where we begin with the controlled contraction of the Transversus Abdominis.[18] When the TA contraction is under control, we add the pelvic and gluteal muscles with the Multifidi as a postural stabilizer.[18] It’s also important to train the adductors in closed and open chain improving the proprioception as well as the co-contractions with the postural muscles to restore this equilibrium.[20][18] Autogene stretching serves a double function of loosening the tight muscles and helps with the proprioception.[18] Coordination and stabilisation are vital for the reintegration of the patient in the sport and daily activities.[20]

It is important for any patient, especially for sportsmen that the cardiovascular endurance must remain or improved during the revalidation. So we can begin each session with some cardiovascular exercises.[16][18]

An active training programme is superior to physiotherapy treatment without active training[18].

References

  1. Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports health. 2016 Jul;8(4):313-23.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Morales-Conde S, Socas M, Barranco A. Sportsmen hernia: what do we know?. Hernia. 2010 Feb 1;14(1):5-15
  3. Dimitrakopoulou A, Schilders E.Sportsman’s hernia? An ambiguous term. Journal of hip preservation surgery.2016 Feb 24;3(1):16-22.
  4. Zoland MP, Maeder ME, Iraci JC, Klein DA. Referral Patterns for Chronic Groin Pain and Athletic Pubalgia/Sports Hernia: Magnetic Resonance Imaging Findings, Treatment, and Outcomes. American journal of orthopedics (Belle Mead, NJ). 2017;46(4):E251-6.
  5. Meyers, William C.; Yoo, Edward; Devon, Octavia; Jain, Nikhil; Horner, Marcia; Lauencin, Cato; and Zoga, Adam,'"Understanding “Sports Hernia” ( Athletic Pubalgia): The Anatomic and Pathophysiologic Basis for Abdominal and Groin Pain in Athletes" (2008). Department of Radiology Faculty Papers. Paper 5. http://jdc.jefferson.edu/radiologyfp/5.
  6. 6.0 6.1 6.2 Omar IM, Zoga AC, Kavanagh EC, Koulouris G, Bergin D, Gopez AG, Morrison WB, Meyers WC. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics. 2008 Sep;28(5):1415-38.
  7. Campanelli G. Pubic inguinal pain syndrome: the so-called sports hernia.Surg Technol Int. 2014 Mar;24:189-94.
  8. 8.0 8.1 Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do?. Hernia. 2010 Feb 1;14(1):17-25.
  9. Balconi G. US in pubalgia. Journal of ultrasound. 2011 Sep 1;14(3):157-66.
  10. 10.0 10.1 10.2 Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014 Mar;6(2):139-44.
  11. 11.0 11.1 11.2 Cohen B, Kleinhenz D, Schiller J, Tabaddor R Understanding athletic pubalgia: a review. Rhode Island Medical Journal. 2016 Oct 1;99(10):31.. (accessed on 3.11.18)
  12. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. journal of orthopaedic & sports physical therapy. 2008 Feb;38(2):63-70.
  13. 13.0 13.1 Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and treatment highlighting a minimal repair surgical technique. The American journal of sports medicine. 2011 Jun;39(6):1341-9.
  14. 14.0 14.1 14.2 Cohen B, Kleinhenz D, Schiller J, Tabaddor RUnderstanding athletic pubalgia: a review. Rhode Island Medical Journal. 2016 Oct 1;99(10):31.. (accessed on 3.11.18)
  15. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. journal of orthopaedic & sports physical therapy. 2008 Feb;38(2):63-70.
  16. 16.0 16.1 16.2 16.3 Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. journal of orthopaedic & sports physical therapy. 2008 Dec;38(12):768-81.
  17. Joseph F. Diaco, MD, FACS, Daniel S. Diaco, MD, FACS, and Lisa Lockhart CRNFA,Sports Hernia, (Available online 9 February 2005.)
  18. 18.0 18.1 18.2 18.3 18.4 18.5 18.6 18.7 Ellsworth AA, Zoland MP, Tyler TF. Athletic pubalgia and associated rehabilitation. International journal of sports physical therapy. 2014 Nov;9(6):774.
  19. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011 Jul 1;150(1):99-107.
  20. 20.0 20.1 20.2 Serner A, van Eijck CH, Beumer BR, Hölmich P, Weir A, de Vos RJ. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med. 2015 Jun 1;49(12):813-.