Pubalgia

Original Editors - Nick Kafkot

Top Contributors - Vidya Acharya, Nick Kafkot, Khloud Shreif, Kim Jackson, Alexander De Bock, Lucinda hampton, Admin, WikiSysop, Claire Knott and Wanda van Niekerk  

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. The persistent groin pain that presents typically in competitive athletes without a definitive hernia is considered a general term, but sports hernia refers to a posterior inguinal wall deficiency.

Pubalgia is a chronic groin lesion. Athletes with pubalgia have an imbalance of the adductor and abdominal muscles at the pubis, which leads to an increase in the weakness of the posterior wall of the groin. This imbalance leads to deep groin pain. Complete tearing or displacement can occur unilaterally or across the midline to the other side. 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 in 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. 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.

Clinically Relevant Anatomy

• Bones and muscles attaching the pubis are important in understanding pubalgia.
• Femur, and pelvis and all the muscles that attach to pubic symphysis are important for the anatomic perspective of pubalgia.

• 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).

The muscles of the rectus abdominis and adductor longus, attached to the symphysis, are key in maintaining the front pelvic area's stability in the sagittal plane. Acting in opposing ways, these muscle sets tug the pelvis in different directions, serving as counterforces during the pelvis's bending, stretching, and turning movements .

Epidemiology

Determining the exact prevalence of athletic pubalgia is hard because of varying definitions, but it's thought to affect roughly 50-80% of athletes with long-term, unexplained groin pain. It is most common in soccer, ice hockey, lacrosse, long-distance running, kicking sports, Australian football, and cricket however, not limited to these sports. All these sports involve repetitive energetic kicking, twisting, turning or cutting movements, which are all risk factors for causing pubalgia. 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.

Etiology

Age and insufficient training or stopping training in off-season are considered risk factors for pubalgia. Athletic pubalgia mechanisms are theorized to include; increased groin tension from intense physical activity, potentially leading to tears in the inguinal region's support structures. Reduced hip motion which may stress and destabilize the pubic symphysis. There are different causes of pubalgia

Muscle imbalance between adductor muscles and abdominal muscles

The pubic symphysis (pubic bone joint) acts as a focal point on the anterior pelvis where the structures involved in the development of sports hernia/athletic pubalgia are closely related. Following are the abdominal wall structures from superficial to deep: the external oblique fascia and muscle, internal oblique fascia and muscle, transversus abdominus muscle and fascia, and the transversalis fascia. Fibers from the rectus abdominus, conjoint tendon of the internal oblique and transversus abdominus, and external oblique; all merge to form the pubic aponeurosis. This pubic aponeurosis runs together with the origin of adductor longus and gracilis which is also called as the rectus abdominus/adductor aponeurosis.

During athletics and sports, a large amount of force is subjected towards anterior pelvis with the pubis symphysis as the focal point. The rectus abdominus and adductor longus muscles pull in the opposite direction. The opposing forces of the adductor longus directly against the rectus abdominis at the pubic symphysis fulcrum point are thought to be the origin mechanism pf athletic pubalgia . 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 causing the pelvis to upward tilting. 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 abdominis.

Rectus adductor syndrome

• Adductor enthesopathy that involves irritation or inflammation where the adductor muscles (located in the inner thigh) attach to the bone. It's often caused by overuse or strain, particularly in activities that involve a lot of leg movement or pressure on the groin area, such as sports and cause referred pain to the inside of the thigh near to the groin.
• Pathology/asymmetry of the symphysis pubis, is reinforced by the suprapubic ligament above and the arcuate ligament below. Dysfunction in the rectus or adductor muscles results in heightened stress on the pubic symphysis, causing continuous minor injuries to the joint. This leads to periosteal inflammation and possible bone loss or osteolysis at the symphyseal edge of the inferior pubic ramus. As the pubic symphysis deteriorates, joint stability decreases and movement increases. This increased joint motion further destabilizes the pelvis, adding stress to the surrounding soft tissues. This ongoing cycle of movement and instability can cause more soft tissue damage, ultimately leading to the pain characteristic of athletic pubalgia.

Sports hernia

One theory by Muschaweck suggests it's due to a weakness in the inguinal canal's posterior wall, causing nerve irritation and pain at tendon insertion to bone. She also proposed that the transversalis fascia expands at its weakest point, enlarging the inguinal triangle. This leads to the rectus abdominis muscle moving upward and inward, increasing tension on the pubis and possibly causing partial or complete tears. This bulging might also compress the genital branch of the genitofemoral nerve, contributing to chronic groin pain.

Locoregional pathologies

• Nerve compression or inflammation of the conjoined tendon is another suggested cause.  Evidence from a study using radiofrequency denervation on the ilioinguinal nerve and inguinal ligament supports this, showing marked improvement in pain and function for up to 6 months.
  In addition, related nerve entrapments, such as of the obturator nerve, femoral cutaneous nerve, and genitofemoral nerve, can exacerbate this condition, causing additional symptoms like numbness, burning, or tingling in the thigh, groin, or genital areas. Accurate diagnosis and treatment of these conditions are essential for effective pain management and recovery.

• Joint diseases:

1. Hip diseases as femoroacetabular impingement, structural hip changes in femoroacetabular impingement (FAI) lead to reduced hip range of motion (ROM), causing pelvic instability and athletic pubalgia. Athletes with FAI compensate for limited hip movement by overusing the pubic-bone joint, increasing stress and injury risk to pelvic tissues. This compensation results in pubic symphysis breakdown and further pelvic instability, causing pain and potential injuries consistent with athletic pubalgia. High-level athletes, needing greater hip ROM for sports, are more susceptible to these issues.
2. Sacroiliac disease

Any previous injury

Despite various theories, the prevalent cause seems to be an abnormal tension in the inguinal canal that cause pain. This may manifest as tears in the external oblique, conjoined tendon, or inguinal ligament, or as a weakness in the posterior abdominal wall, without an actual hernia.

Repetitive trauma to soft tissues around the pelvis, sudden forceful movement as a combination of hyperextension of the abdominal muscles and hyperabduction of the thigh adductors as described by Dr. Tandy Freeman.

Characteristics/Clinical Presentation

Activities that can lead to athletic pubalgia involve running, kicking, cutting, twisting movements, and explosive turns and changes in direction. 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. 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.

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.
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.

These include acetabular labral tears, adductor injuries, snapping hip syndromes, iliopsoas tendonitis, osteitis pubis, and femoroacetabular impingement. One must rule out a true groin hernia, referred pain from genitourinary and gynecological disorders, or 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.

• 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. It has a specificity of 100% for detecting rectus abdominis tendon injury but less sensitive (68%) sensitivity for detecting adductor tendon injury.

• CT-scans help to identify posterior inguinal wall deficiencies and hernias.

• 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.

Examination

The initial assessment for pubalgia typically involves a multidisciplinary approach, including orthopedic surgeons or sports medicine doctors, athletic trainers, and physical therapists. The physical examination for sports hernia/athletic pubalgia begins with:

• Palpation of pubic symphysis and inguinal floors in the supine position for tenderness, weakness, or asymmetry. 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.
• Examination to detect any tenderness at or just above the pubic tubercle near the rectus insertion or hip adductor origin on the affected side.
• Assess the external inguinal ring for laxity/tenderness.
• History of bulge in the groin region may be an indicator of inguinal hernia, assessment for inguinal hernias or testicular pathology from sitting and standing.

• 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.
• 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.
• 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:

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 abdominis and/or adductor longus origin. After this rest period, return to sport can be trialed.

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.Most techniques have satisfactory results reported in the literature. Principles of operative management include reinforcement of the posterior wall and fixation of the rectus abdominis or conjoint tendon. 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 decreased after 1 month, and 90% of the athletes who underwent operation fully returned to sports activities after 3 months. 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 the 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 the timing of sports 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, 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.  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 focusing on the adductors and abdominal muscles where we begin with the controlled contraction of the Transversus Abdominis. When the TA contraction is under control, we add the pelvic and gluteal muscles with the Multifidi as a postural stabilizer. 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. Autogenic stretching serves a double function of loosening the tight muscles and helps with the proprioception. Coordination and stabilisation are vital for the reintegration of the patient in the sport and daily activities.

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.An active training program is superior to physiotherapy treatment without active training.

Post-operative rehabilitation program
The recovery plan after surgery is quite similar to the one for non-surgical treatment. It's important not to put too much strain on the repaired area too soon. A rest period of about 4 weeks is usually suggested after the operation. Massaging the adductors and the area near the incision can help, and it's also good to walk on flat surfaces. It's crucial to avoid doing too much with your trunk and legs.

Week 1	week 2-3	Week 3-4	week 5-6	Week 6-8
Take care of the surgical wound. Only do simple, everyday tasks. Avoid any lifting or activities that cause more pressure in the abdomen. Begin with walking on level ground the day after your surgery. Apply ice for 15 minutes every 2 hours during the first 24-48 hours.	Assess the pain level using touch and a pain scale. Start with light exercises in the pool if the incision is healing well. Start with standing exercises that activate the lower body and hip muscles, lifting your heels while standing. Begin activating key muscles like the TA, multifidus, iliopsoas, and deep hip rotators. Hip movements like squeezing in, spreading out, bending, and straightening while standing. Use manual therapy for the upper and lower back to keep or improve movement and range of motion, deep tissue massage on the adductor muscles, and gentle, easy stretches for the sides of your trunk, hip, psoas muscle, hamstrings, and quadriceps. Walk backwards for exercise.	Start balance and coordination exercises on both sides, then on one side. Activate core muscles carefully, watching for pain and how much weight they can handle. Work on stabilizing exercises for hip rotators and glutei muscles (Maximus and Medius). Mobilisation abdominal scar area gently, also do deep massages. Include easy stretches, then add active stretches with a bit of resistance. Use hands-on therapy to enhance movement and range of motion in the hip, lower back, and spine.	Regularly check the Visual Analog Scale (VAS) to track progress and how well pain is tolerated. Start exercises for balance and body awareness, both on one leg and both legs. Begin exercises to strengthen the adductor muscles, keeping an eye on any pain, in addition, add isometric exercises. Perform bent knee fall outs. We can use thera-band for resistive side stepping. Work on abdominal exercises moving forward and side-to-side. Lower heels while lying on your back with knees bent at 90 degrees. Hold seated isometric positions. Start plank exercises on knees then progress it. Combine exercises that integrate pelvis, hip, and trunk movements. Abdominal crunches.	Cardiovascular fitness is started 20-30 minutes, including warming up and cooling down. Keep strengthening the hips and lower legs, and progress with weights. Jog forwards and backwards, jump rope, and sprint over short distances. Work on agility and coordination exercises. Practice cross-over cariocas and straddle movements. Perform single-leg lowering exercises with added resistance, like using a Thera-band. Focus on core stabilization to engage the whole body. Include plyometric exercises. Emphasize on dynamic stabilization of the pelvis, and strengthening the side hip and glute muscles.

 Most athletes typically return to competitive sports in 5-8 weeks, though more complex or adductor-involved injuries might require a longer recovery period. The actual duration of rehabilitation can vary based on factors like the complexity of the surgery and the individual's ability to handle the recovery. In certain cases, the process may extend beyond the initial 8-12 weeks .