Pubalgia

Original Editors - Nick Kafkot

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Definition/Description

Pubalgia also known as a sports hernia or athletics 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.

Clinically Relevant Anatomy

When we talk about pubalgia, we must take some 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 sagital plane of the anterior pelvis.

Epidemiology /Etiology

Pubalgia is most common in soccer, ice hockey, lacrosse, long-distance running, kicking sports, Australian football, and cricket. All these sports involves 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 for 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 symphisis, 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.

There are different causes of pubalgia:

1. Rectus adductor syndrome:
a) Adductor enthesopathy b) Pathology/asymmetry of the symphisis pubis
2. 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
3. Locoregional pathologies:
a) Nerve compression: - ilioinguinal nerver (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
4. Previous injury
5. Muscle imbalance between adductor muscles and abdominal muscles

Characteristics/Clinical Presentation

Most patients with pubalgia have symptoms for months or years before a clinical diagnosis is obtained. They report a deep, sharp pain in the groin or lower abdominal region 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 like running, accelerating movements, cutting, twisting, kicking, … Additionally they have also pain when they cough and sneeze. The unilateral pain can evolve into bilateral pain.

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.

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 a stress-related oedema within the symphysis pubis caused by the imbalance of forces and altered motion across the joint.

The use of CT-scans could help to indentify posterior inguinal wall deficiencies and hernias.

People with pubalgia test positive by a herniography. The test is positive if there is a 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 repaired in the same session.
                                             

Examination

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.

Medical Management

When the patients still have pain after physical treatment surgical exploration and repair is indicated. There are a lot of types of surgical treatment. Open repair of a sports hernia is one type of surgical technique. The technique involves reattaching the rectus abdominis , conjoined tendon, and/or transversalis fascia to the pubis and inguinal ligaments.
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.

Physical Therapy Management

After pubalgia is diagnosed six to eight week of physical therapy is the first step in the rehabilitation.[27] The treatment consists of rest, active soft tissue mobilisations in case of muscle tightness, as well as joint manipulations of pelvis, SIJ and hip joint may be beneficial for decreasing pain associated with dysfunction, anti-inflammatory medication and physical therapy. 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 reeducation focussing 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 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. Autogene stretching serves a double function of loosening the tight muscles and helps with the proprioception. Coordination and stabilisation are vital for reintegration of the patient in the sport and daily activities. Therapeutic ultrasound treatments, cold tubs and deep massage of the groin region may be also helpful.[30][31]

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 programme is superior to physiotherapy treatment without active training.[32][33][34]

Resources

Web of Knowledgde, ScienceDirect, PubMed, Pedro, Pubalgia.info

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References

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