ATHLETIC PUBALGIA: SYMPTOMS, CAUSES, PAIN AND TREATMENT

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). Despite the high prevalence of groin pain in athletes, the cause of groin pain can be difficult to elucidate because of the complex local anatomy and the broad differential diagnosis.

 Chronic lower abdomen and groin pain is more prevalent in athletes involved in activities in which there are running, kicking, cutting movements, explosive turns and changes in direction, and rapid acceleration/deceleration. Soccer, ice hockey, and American football players tend to be most commonly affected in the United States. Other commonly involved sports include rugby, Australian Rules football, cricket, martial arts, basketball, baseball, field hockey, tennis, swimming, and long-distance running.
 

The most widely accepted theory of the pathogenesis is a disrupted rectus tendon attachment to the pubis and a weakened posterior inguinal wall. This develops as a result of an imbalance between the comparatively strong hip adductor muscles and the comparatively weaker lower abdominal muscles. The strong pull of the adductors, particularly against a fixed lower extremity, in the presence of relatively underconditioned abdominal muscles creates a shearing force across the hemipelvis, resulting in relative muscular overload with subsequent attenuation or tearing of the transversalis fascia and/or overlying musculature.
 

  Information extracted from:

-          Ellsworth, A. A., Zoland, M. P., & Tyler, T. F. (2014). Athletic pubalgia and associated rehabilitation. International journal of sports physical therapy, 9(6), 774.

-          Elattar, O., Choi, H. R., Dills, V. D., & Busconi, B. (2016). Groin injuries (athletic pubalgia) and return to play. Sports Health, 8(4), 313-323.   

 

SYMPTOMS

The pain may radiate into the adductor region, perineum, rectus muscles, inguinal ligament, and testicular area. The lower abdomen and groin pain is often aggravated by sudden acceleration, twisting and turning, cutting or kicking movements, sit-ups, coughing, or sneezing.

 The pain is activity related and generally resolves with rest. Taking time off from offending activities can lead to resolution of symptoms, but the hallmark is recurrence of the pain with resumption of sports. An acute presentation is much less common but has been reported with a trunk hyperextension, hip hyperabduction mechanism that can lead to partial or complete ruptures of the distal rectus abdominus/adductor aponeurosis.

  

Athletic pubalgia anatomy

PHYSICAL EXAMINATION

 The physical examination for athletic pubalgia begins with palpation of the potential sites of injury. Lower abdominal, adductor, and symphyseal pain to palpation is common in athletes; therefore, it is critical to determine whether the pain correlates with their symptoms. The abdominal obliques, transverses abdominis, and conjoined tendon/rectus abdominus should be palpated for tenderness.

 Occasionally symptoms can be reproduced by Valsalva maneuvers such as coughing and sneezing. The proximal adductor musculature (adductor longus, gracilis, pectineus) should also be palpated; resisted adduction in flexion and extension can be performed to elicit discomfort. Adductor tenderness has been reported in 36% of athletes with athletic pubalgia.

 The Consensus meeting suggested criteria for diagnosis of athletic pubalgia if at least 3 of the 5 following clinical signs are detectable:

 

(1) pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon,

(2) palpable tenderness over the deep inguinal ring,

(3) pain and/or dilation of the external ring with no obvious hernia evident,

(4) pain at the origin of the adductor longus tendon, and

(5) dull, diffuse pain in the groin, often radiating to the perineum and inner thigh or across the midline.

 

DIFFERENTIAL DIAGNOSIS

 A thorough history and a physical examination is needed to differentiate groin strains from athletic pubalgia, osteitis pubis, hernia, hip-joint osteoarthrosis, rectal or testicular referred pain, piriformis syndrome or presence of a coexisting fracture of the pelvis or the lower extremities. Many of these diagnoses may exist in the active patient and present with similar symptoms and pain patterns.
 

ADDUCTOR STRAINS

 Adductor strains represent one of the most common groin injuries among athletes. Adductor strains accounted for 10% of all injuries in soccer players. Injuries usually occur at the musculotendinous junction but may also occur at the bone-tendon junction (enthesopathy), producing tenderness on deep palpation of the involved muscle and pain on resisted adduction.

 Although the diagnosis of these injuries is usually made clinically, ultrasound and magnetic resonance imaging may be used in the acute setting.

 

Adductor strain

OSTEITIS PUBIS

 Osteitis pubis is an isolated or repetitive insult to the pubic symphysis and surrounding structures, usually involving the adductor muscles or gracilis. It is usually seen in athletes with high-stress forces transferred through the pelvis and the pubic symphysis during kicking, rapid acceleration, deceleration, or sudden directional changes. These forces can cause stress reactions and a lytic response in the bone.

 The classic clinical presentation is pain in the pubic symphysis. There may be also pain in the proximal adductor, the lower abdominal muscles, perineal pain, and testicular or scrotal pain. Concomitant pathology must be ruled out such as adductor pathology, athletic pubalgia, and labral tears.

 The diagnosis of osteitis pubis is almost always made clinically, and radiographs are rarely helpful.
 

Osteitis pubis

CONSERVATIVE TREATMENT

 Groin pain from abdominal wall injury is common and often is self-limited and heals. In some cases, the injury becomes chronic and this subgroup of patients often requires surgery. Factors affecting treatment strategies include: timing, sports season length, prior conservative treatment, activity level, and degree of limitation in upcoming athletic events.

 

Conservative treatment for athletic pubalgia

 Ellsworth et al. proposed a protocol of conservative treatment for athletic pubalgia divided in different phases: 

Phase I (1-2 weeks)

·         Pain and edema control

·         Education regarding sitting, standing and supine posture and neutral spine

·         Transversus abdominis recruitment

·         Hip and lumbar spine mobilization to increase ROM (Grade I & II)

·         Gentle active stretching of hamstrings, adductors, quadriceps, iliopsoas, and lumbar spine.

·         Strengthening with the addition of little to no weight of the Transversus abdominis and side lying hip abduction and extension

Phase II (2-4 weeks)

·         Cardiovascular warm up bike or elliptical

·         Gait training on pelvic motion and timing for heel strike, mid-stance and push off

·         Continue TA (Transversus Abdominis) recruitment and strengthening

·         Achieve full to functional ROM for lumbar spine and increase hip ROM

·         Initiate static core strengthening with the ability to maintain neutral spine

·         Increase recruitment of hip and pelvic stabilization, emphasizing gluteals, TA and multifidus

·         Initiate functional strengthening starting with double leg exercise and progressing to single leg as pain and strength improves

·         Spine and hip mobilization addition of rotation (Grade II & III)

o    Do not progress to phase III without the following being met

-       Decreased pain with ADL’s less than 2/10

-       Full functional ROM of lumbar spine and hips

-       Ability to recruit and maintain TA contraction with standing and single

-       leg activity

-       No pain with ambulation

-       No trunk lateral motion (Trendelenberg) with ambulation and single leg activity

Phase III (4-6 weeks)

·         Cardiovascular warm up on bike or elliptical with higher speed and resistance, use of a treadmill with fast pace walking

·         Patient should demonstrate good pelvic stabilization and easy recruitment of the TA with ambulation

·         Gait training and pelvic proprioceptive neuromuscular function (PNF) patterns should continue and have a good motor pattern developing

·         Full to functional ROM should be achieved in the lumbopelvic area and hips, reduce any remaining restrictions

·         Dynamic core training with use of neutral spine during activity and use of unstable surfaces

·         Standing stabilization with resistance or balance disturbances added, progress from double to single leg functional activity

·         Continue with active stretching

·         Myofascial release and soft tissue work to any remaining restrictions

o  Do not progress to phase III without the following being met

-       No pain with ADL’s, ambulation, and fast paced walking

-       Full functional ROM of hips, pelvis, and lumbar spine

-       The ability to maintain spinal neutral with standing, sitting, walking, and single leg activity with added challenges of unstable surfaces or perturbations

-       Able to recognize and correct postural dysfunction when neutral spine is not maintained

Phase IV (Week 6-8)

·         Cardiovascular warm up should be sport/ recreational activity specific

·         ROM should be progressed to full if only functional was achieved

·         Active stretching interspersed with static stretching should be implemented

·         Strengthening should consist of concentric and eccentric strengthening in a functional, isotonic, isometric and isokinetic fashion.

·         Manual myofascial release and soft tissue mobilization to rectify any remaining restrictions

·         PNF pattern training of LE and UE/LE patterns