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

SHOULDER INSTABILITY: EXERCISES

Anatomy

The shoulder or glenohumeral joint is a complex joint and is made up of different bone structures, including the clavicle, sternum, ribs, scapula or shoulder blade, and the humerus.

All these bone structures make up different joints that will give rise, together, to the shoulder joint complex.

- Acromioclavicular joint

- Sternoclavicular joint

- Thoracic scapular joint

- Glenohumeral joint

Shoulder Anatomy

Regarding the musculature, we have different muscles that make up the shoulder joint complex, among which the rotator cuff group, which constitutes the deepest muscle group, should be highlighted.

- Supraspinatus muscle

- Infraspinatus muscle

- Teres minor muscle

- Subscapularis muscle

All these joints that we have mentioned, allow together with the muscles a wide range of movement to the shoulder.

However, this great motor skills also produces repeated friction and overloading, in many cases reproducing the symptoms known as painful shoulder.

The painful shoulder is a fairly common reason for consultation, being the third most frequent cause of musculoskeletal consultation in Primary Care, behind lumbar and cervical pathology.

Shoulder pain is a symptom that concerns a multitude of pathologies, of which the vast majority are due to disorders of the periarticular soft tissues. There are other possible reasons for shoulder pain, such as injury, joint instability, or arthritis.

SHOULDER INSTABILITY

Shoulder instability is excessive movement of the humeral head relative to the glenoid. It is a common abnormality that is often seen in medicine and physical therapy. An appropriate rehabilitation program plays a vital role in the successful outcome after an episode of shoulder instability. The glenohumeral joint allows a great amount of movement, which makes it inherently unstable, being the most frequently dislocated joint in the human body, being more frequent to find dislocations or subluxations of the shoulder.

Due to poor bone congruence and joint capsular laxity, it relies heavily on dynamic stabilizers and the neuromuscular system to provide functional stability. Therefore, the differentiation between normal movement and pathological instability is often difficult to determine. There is a wide range of shoulder instabilities, from subtle subluxations (as seen in head athletes) to major instabilities.

Dynamic joint stabilizers are the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, major round, and subscapularis), the deltoid, the long head of the biceps, and the scapular musculature. These muscles are capable of generating compressive or coaptating forces in the joint, mainly in ranges of movement where the capsule and ligaments are loose.

In subjects with shoulder instability, muscle strength and neuromuscular control is impaired. They have scapulae that rest in downward rotation and have poor upward rotation, which reduces the area of ​​contact between the humeral head and the glenoid. Symptoms range from mild reports of pain to apprehension, compression, rotator cuff pain, and neuropathic symptoms.

The most commonly recommended initial treatment for shoulder instability is a rehabilitation program. This article tries to create an exercise program to help the shoulder to obtain a correct operation in subjects with instability.

EXERCISES

All included exercises are specific to the shoulder muscles and are designed to improve strength, power and endurance. They should be done with the chest open and the shoulder away from the ears. We will do 3 sets of 12 repetitions, 3 times a week for a minimum of 4 weeks. The initial shoulder position should be relaxed, away from the ear and without being rolled forward.

1. Diagonal: Extension + Adduction

With an elastic band attached above the subject, pull the resistance down and through your body to the opposite side of the leg. During the return movement, you should end with your palm up and your thumb facing up.

Extension + Adduction

2. Diagonal: Flexion + Abduction

Elastic band held at the bottom, start with the arm extended in a 45º position and the palm down. After turning the palm forward, proceed to flex the elbow and raise the arm up and over the affected shoulder. Rotate the palm down and back to bring the arm to the starting position. The opposite movement of the exercise 1.

Flexion + Abduction

3. External rotation

Elastic band attached to one side. Stand with the affected elbow fixed to the side, the elbow at 90º, and the affected arm through the front of the body. Grab the resistance and perform an external arm rotation, keeping the elbow resting on the side. Return to the starting position slowly and controlled.

External Rotation

4. Internal rotation

Elastic band attached to one side. Stand with your elbow fixed at your side at 90º, grasp the resistance and do an internal shoulder rotation. Return to the starting position slowly and controlled.

Internal Rotation

5. External rotation with 90º abduction

Shoulder abducted at 90º. Keeping the shoulder abducted, turn the shoulder back keeping the elbow at 90º. Slowly return to the starting position.

External Rotation with 90 degrees Abduction

6. Abduction

With a dumbbell, your elbow straight and your thumb up, raise your arm to shoulder level at a 30º angle in front of your body. Do not exceed shoulder height. Hold 2 seconds and lower slowly.

Abduction

7. 90º abduction in prone position

Lie on the table, face down, with the involved arm hanging directly to the floor and palm down. Raise your arm to one side, parallel to the ground. Hold 2 seconds and lower slowly.

Abduction in Prone Position

8. Abduction to 100º in prone position

Same as exercise number 7 but with the arm slightly in front of the shoulder (hitchhiker).

100 degrees Abduction in Prone Position

9. Ball

After those exercises, it is interesting continuing the progression with the help of a ball. You can put it in a wall or in the floor and support your weight generating a job of instability and balance for your shoulder.

Exercise with ball

The benefits of this type of exercise in the stability and strengthening of the shoulder have been verified in the current scientific literature, becoming the treatment of first choice for all those shoulder pathologies that are unstable.

SCIATICA RELATED TO HERNIATED DISC: SURGERY OR CONSERVATIVE TREATMENT

Herniated disc and sciatic

The column vertebrae are formed with 7 cervical vertebrae, 12 thoracic, 5 lumbars, 5 sacral and 3 coccygeus. Between each vertebra there is a disc formed with the annulus fibrosus and nucleus pulposus giving movement to the back, support and cushion the body´s weight.

The lower back is more prevalent to have a herniated disc having to support more weight than the other vertebrae and because it has a high mobility in flexion. The area of least resistance offered by the fibrous annulus is the posterior part. The nucleus is slightly delayed with respect to the geometric centre of the disc. This situation together with the bending movement causes the nucleus to exert more pressure on the back of the annulus.

Over the years, annulus wear down and nucleus can to go out. Usually, the herniated disc is not symptomatology but if nucleus affects the sciatic nerve we can feel symptoms. The most important symptom of sciatica is lumbosacral radicular leg pain that follows a dermatomal pattern radiating below the knee and into the foot and toes (1, 2).

Lumbar vertebrae

(Information extracted from: Jacobs, Wilco CH, et al. "Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review." European Spine Journal 20.4 (2011): 513-522)

The prevalence of sciatic symptoms reported in the literature varies considerably ranging from 1.6% in the general population to 43% in a selected working population (3). Although the prognosis is good in most patients (4), a substantial proportion (up to 30%) continues to have pain for 1 year or longer (5, 6).

 The goal of this study was to assess the effects of surgery versus conservative therapy (including epidural injections) for patients with sciatica due to lumbar disc herniation.

 In total, five studies were identified. One study compared early surgery with prolonged conservative care followed by surgery if needed (7); three studies compared surgery with usual conservative care (8,9,10), and one study compared surgery with epidural injections (11).
  

Early surgery versus prolonged conservative care

 1.       Relief of leg pain was faster for patients assigned to early surgery. Intention to treat analysis
showed statistically significant more leg pain relief in favour of early surgery as compared with prolonged conservative care at 3 months. There was no significant overall difference between the two groups in disability scores during the first year. The median time to recovery was 4 weeks for early surgery and 12 weeks for prolonged conservative treatment (7).
  

Surgery versus usual conservative care

 2.       Both patient and observer ratings demonstrated that discectomy was significantly better than conservative treatment at 1 year. After 1 year, 24 of the 66 patients (36%) in the conservative care group versus 39 of the 60 patients (65%) in the surgery group reported a good outcome. No significant differences in outcomes were reported at 4 and 10 years follow-up (9).


 3.       Overall, no significant differences were found for leg pain or back pain, and subjective disability throughout the 2 years of follow up. Visual analog scale leg pain scores, however, improved more rapidly in the discectomy group first 6 weeks (8).


 4.       Confirmed disc herniation showed that both the surgery as well as the conservative treatment group improved substantially over 2 years of leg pain and/or back pain (10).
  

Surgery versus epidural steroid injections

 5.       Patients undergoing discectomy had the most rapid decrease in their symptoms. The decrease in leg pain in the discectomy group was significantly greater than in the epidural steroid injection group at 3 and 6 month follow-up intervals, but not beyond 1 year. There were no significant differences between groups for back pain throughout the follow-up (11).

 

Epidural steroid injection

Conclusions

 In general, there is evidence that early surgery in patients with sciatica provides for a better short-term relief of leg pain as compared to prolonged conservative care. But no significant differences were found between surgery and usual conservative care in any of the clinical outcomes after 1 and 2 years.

  

Bibliography

 1. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B (2010) Sciatica. Best Pract Res Clin Rheumatol 24:241–252

 2. van Tulder M, Peul W, Koes B (2010) Sciatica: what the rheumatologist needs to know. Nat Rev Rheumatol 6:139–145

 3. Konstantinou K, Dunn KM (2008) Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976) 33:2464–2472

 4. Legrand E, Bouvard B, Audran M, Fournier D, Valat JP (2007) Sciatica from disk herniation: medical treatment or surgery? Joint Bone Spine 74:530–535

 5. Vroomen PC, de Krom MC, Slofstra PD, Knottnerus JA (2000) Conservative treatment of sciatica: a systematic review. J Spinal Disord 13:463–469

 6. Weber H, Holme I, Amlie E (1993) The natural course of acute sciatica with nerve root symptoms in a double-blind placebocontrolled trial evaluating the effect of piroxicam. Spine (Phila Pa 1976) 18:1433–1438

 7. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW (2007) Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 356:2245–2256

 8. Osterman H, Seitsalo S, Karppinen J, Malmivaara A (2006) Effectiveness of microdiscectomy for lumbar disc herniation: amrandomized controlled trial with 2 years of follow-up. Spine (Phila Pa 1976) 31:2409–2414

 9. Weber H (1983) Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131–140

 10. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296:2441–2450

 11. Buttermann GR (2004) Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am 86-A:670–679