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Athletic Pubalgia: Recognition, Treatment, and
Prevention
A Review of the Literature
Sarah B. Rabe, MS, ATC, LAT; and Gretchen D. Oliver, PhD, ATC, LAT
ABSTRACT
Athletic pubalgia is a term grossly misunderstood throughout
the sports medicine community. This syndrome is multifaceted
and lacks true definition. Athletic pubalgia involves a wide variety of structures surrounding the pelvis and often results in
cessation of physical activity. There are many factors contributing to athletic pubalgia, including sport, position, and gender,
and it should be addressed through an initial physical examination. Athletic pubalgia is difficult to assess through diagnostic
imaging and is often overlooked or misdiagnosed. To provide
optimal health care for patients, athletic trainers and health
care professionals must understand athletic pubalgia and distinguish it from other injuries. The purpose of this literature review is to aid in recognizing, treating, and preventing athletic
pubalgia and to highlight surgical options.
A
thletic pubalgia is a multifaceted syndrome
that lacks a true definition and confuses
many health care professionals. Athletic
pubalgia is referred to as a syndrome because it results from several different injuries.1 Athletic pubalgia is most commonly referred to as sport hernia,
sportsman’s hernia, Gilmore’s groin, and groin disruption,2 but it currently lacks a universally accept-
Ms Rabe is Assistant Athletic Trainer, Athletic Department, and Dr Oliver is from
the Graduate Athletic Training Education Program and the Department of Health,
Kinesiology, Recreation, and Dance, University of Arkansas, Fayetteville, Ark.
Originally submitted January 8, 2009.
Accepted for publication June 30, 2009.
Posted online September 4, 2009.
The authors have no financial or proprietary interest in the materials presented
herein.
Address correspondence to Gretchen D. Oliver, PhD, ATC, LAT, 309 HPER
University of Arkansas, Fayetteville, AR 72701; e-mail: [email protected].
doi:10.3928/19425864-20090827-01
ed definition.1 Athletic pubalgia is difficult to ascertain; however, clinicians’ ability to recognize the
syndrome has increased.3 Increased diagnosis could
be attributed to the recent increase in literature and
research about athletic pubalgia.
Essentially, athletic pubalgia is caused by muscular imbalances and weaknesses that result in an
uneven distribution of forces.4 Five percent of all
sports injuries occur in the groin area and are caused
by activities involving significant twisting and cutting in different directions.5 With a specific mechanism of injury, athletic pubalgia is viewed as sport
and position specific. Athletic pubalgia has been
found in 58% of football players,2 most commonly
in highly skilled positional players, and soccer and
ice hockey players.1
Athletic pubalgia primarily affects the pelvic region. The pelvis consists of four pelvic bones: the
coccyx, sacrum, and the two hip bones, which join
anteriorly at the pubic symphysis. The area of concern is the pubic symphysis and the forces acting
on it from muscular attachments. As Meyers et al4
described, it is common to think of the forces acting on the pubic symphysis as being housed in three
compartments: anterior, posterior, and medial. The
muscle imbalance or weakness involves the anterior, posterior, and medial muscles that have attachment on the pubic symphysis. Muscles of interest
include the abdominals, the hamstrings, the three
adductors, the gracilis, and the obturator externus.
Weak transverse and rectus abdominis often cause
the pelvis to tilt, altering the function of the pelvis.
If the function of the pelvis is altered, then other
muscles (eg, the adductors) will also have altered
function. Athletic pubalgia is often referred to as an
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exertional imbalance and temporary loss of postural
control. It is evident that athletic pubalgia is a pelvis
injury requiring a multidirectional approach of several medical disciplines.
The key diagnostic method that distinguishes athletic pubalgia from other injuries is symptom relief during rest6 and reaggravation when activity resumes.7 It is
speculated that athletic pubalgia is a symptom of an overuse injury. In a study of 21 athletes evaluated for chronic
groin pain and athletic pubalgia, 19 had two or more injuries that contributed to the groin pain, further emphasizing athletic pubalgia as a syndrome.5 The onset of groin
and lower abdominal pain usually leads to the discovery
of a weak abdominal wall, with athletes’ chief complaint
being a pulling sensation in the groin area.8
Often, athletic pubalgia is misdiagnosed as osteitis
pubis, groin strain, or abdominal wall strain.8 The pubis
symphysis is a pivot point for the transference of forces
from the lumbopelvic joint to the femoroacetabular joint.
This transfer of force is often shear in nature (ie, a shearing stress) and results in chronic stress.1 Athletic pubalgia’s mechanism of injury includes trunk hyperextension
with simultaneous hip hyperadduction accompanied
with changes in direction, twisting, turning, running, or
kicking.2,4,7,9,10 Shear forces across the pubis symphysis
can lead to separation of the internal oblique and transverse abdominis.5
Athletic pubalgia is a syndrome that encompasses
a wide list of injuries involving attachment disruption and instability.4 Most cases include a relationship between the inguinal ring and the anterior lower abdomen wall; the attachment sites of the rectus
abdominis and adductors on the pubis11; and an incompetent posterior wall of the inguinal canal12 with
no palpable hernia.5 The athletic pubalgia syndrome
commonly includes a lower abdominal and groin
injury secondary to a rectus abdominis injury associated with adductor pathology.13 The syndrome
often results from micro tears to the attachment of
the rectus abdominis. These tears alter the force distribution on the femur, leading to dysfunction of the
adductors.1 Nine out of 10 patients observed had
laxity or tears of the transversalis fascia at its attachment near the internal ring.14 Other structures that
can produce groin pain when injured are the adductor longus, iliopsoas, and rectus femoris.4 Meyers et
al4 describes grade classifications for the severity of
athletic pubalgia:
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Grade I is defined as single or multiple tears of the
rectus abdominis or adductor muscles.
l Grade II is defined as a partial avulsion from the
pubic symphysis.
l Grade III is defined as a complete avulsion with
associated micro tears.
l
FINDINGS
Athletic pubalgia is most commonly found in male athletes.7 Almost 2% of female athletes who have been diagnosed with a hernia have been found to have athletic
pubalgia.7 Originally, the discrepancy in athletic pubalgia reported in men versus women was based on the few
numbers of women participating in high-performance
sports.7 With increased research, the number of discrepancies between male and female athletes diagnosed with
athletic pubalgia relates to anatomical differences rather
than participation.2 Women have a wider pelvis, making
it more stable, which results in more efficient distribution of forces to the lower body.4 Strength differences
between the genders also contribute to the increased
incidence in the male population. Men usually have a
stronger muscular base than females, which leads to the
muscular imbalances causing athletic pubalgia.10
There is usually chronic, nagging, unilateral, or
bilateral groin pain associated with athletic pubalgia6,11; however, it is mostly reported as unilateral.3
The onset of groin pain is intensified with activity
but subsides when the athlete is at rest and returns
when activity resumes.1,2,6,9,12-15 The pain starts unilaterally and increases with exertional activity. If untreated, symptoms may affect daily living.6,16 Most
pain is centered on the pubis symphysis and tubercle
where the rectus abdominis attaches. The pain often
radiates toward the midline of the body and into the
adductors.3-5,7,9,10,12-14,16 Actions that reproduce this
dull, chronic pain include resisted hip adduction,
hip flexion and internal rotation, and resisted situp.3,6,7,10,12,14 Hip range of motion is also decreased
due to painful movements.7
Patients will notice pain when sprinting, cutting,
bending, and kicking.6,9,14,16 Patients are often weak
on a resisted sit-up and resisted hip adduction. Reduction of hip internal rotation may be a result of
increased shear force across the pubic symphysis,
and thus cause for suspicion of athletic pubalgia. It
is paramount that all other pathologies are excluded
after physical examination. Common groin injuries
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Athletic Pubalgia
are due to adductor strains and other musculotendinous injuries, resulting in pain without compromised
strength or motion. Pain can be found along the upper inner thigh, with tenderness around the origin of
adductor muscles, and can be increased with activity
and resisted hip adduction and extension,9,17 mimicking the mechanism of injury.10 Physical examination will not find an actual hernia, even though most
of these signs and symptoms lead health care professionals to believe that one is present.1,2,5,6,9,16 The
Valsalva maneuver, along with muscle testing of the
hip adductors, rectus abdominis, rectus femoris, and
iliopsoas, will produce some discomfort.9
Clinical findings can include a variety of conclusions, including inflammation of the pubic symphysis causing weakness and instability,11 dilated inguinal
ring or conjoined tendon along the inguinal canal,5,9,10
and weakness of the posterior abdominal wall.15,16
The weak posterior abdominal wall often occurs
from shear forces along the pubic symphysis, which
can separate the transversalis fascia and the internal
oblique aponeurosis, resulting in pain.1
Tab l e
Sports Rehabilitation Program
Lower Abdomen and Core Exercises
Posterior pelvic tilt with complete exhalation
Posterior pelvic tilt with complete exhalation while bridging
Posterior pelvic tilt with complete exhalation with a crunch
Front and side planks while maintaining pelvis neutral
Proprioception Exercises
Balance on unstable surface maintaining pelvic neutral (progressing
from double-leg stance to a single-leg stance)
Balance on unstable surface while throwing and catching a ball
(progressing from double-leg stance to single-leg stance)
Balance on unstable surface with BodyBlade (Hymanson Inc, Marina
Del Rey, CA) (progressing from double-leg stance to single-leg
stance)
These pathologies mimic athletic pubalgia because
they often have radicular pain in the groin area. Thus,
diagnostic imaging is primarily used to rule out the
susceptibility of other injuries and not necessarily as a
tool to determine athletic pubalgia.
DIFFERENTIAL DIAGNOSIS
PREVENTION and TREATMENT
Proper diagnosis requires a thorough evaluation. It
is difficult to diagnose an injury or syndrome with
unclear etiology and pathology. A large part of the
treatment is to exclude all other injuries and narrow the diagnosis, which relies heavily on diagnostic imaging. Imaging, including magnetic resonance
imaging (MRI), rarely indicates positive findings for
athletic pubalgia and is mainly used to rule out other
pathologies.6,7,9,11,13,16 Hip pathologies, which mimic
the symptoms of athletic pubalgia, are lengthy and
include:
l Articular lesions.
l Osteitis pubis.
l Stress fracture.
l Rectus abdominis tendinopathy.
l Adductor pathology.
l Hernias.
l Sacroiliac joint pathology.
l Intrinsic hip pathology.12
l Snapping hip syndrome.9
l Avulsions.
l Nerve pain.2
l Bone edema.17
l Lumbar disc referred pain.18
Prevention is paramount in decreasing the number
of patients who experience athletic pubalgia. Core
and hip stability and flexibility should be emphasized.4 Preparticipation physical examinations
should include clinical assessment of core stability
and hip flexibility. Identification of weak and overcompensating muscles to treat the imbalance before
athletic pubalgia presents itself should also occur.4
Strengthening and developing coordination of the
hip adductors, flexors, internal rotators, core stabilizers, gluteals, and spinal musculature is important.10
The Table describes a rehabilitation program that
focuses on these muscles. Typical rehabilitation
should include isometric holds that target the lumbopelvic hip complex musculature. Difficulty of
the rehabilitation exercises can be enhanced by increasing the number of repetitions and the length of
holds. The hip adductors, hip flexors, and lumbopelvic stabilizers need to work in sync to functionally control the lumbar spine, pelvis, and femur.1
Any imbalance, strength deficit, or lack of flexibility will affect the forces exerted across the pubic
symphysis, femoral acetabular joint, lumbar spine,
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posterior or anterior abdominal wall, and pelvic
floor.1 The goal of all prevention programs should
be obtaining core control.
In addition to making sure there are adequate
strength balances, it is also important that a thorough
history is obtained of lumbar, abdominal, pelvic, and
femoral health. A functional movement screening test
should also be included.16 By obtaining a solid history
of any predisposing factors, the clinician can develop a
rehabilitative program to address the areas of concern
and hopefully prevent athletic pubalgia. It is important
to note that there are several contributing factors to
athletic pubalgia. Athletic pubalgia should be viewed
as a multifaceted syndrome of several underlying conditions acting on the kinetic chain, resulting in a progression of events that eventually leads to inability to
perform.
Nonoperative treatment of athletic pubalgia includes rest, anti-inflammatory medications, strengthening of the core musculature, and regaining postural
control.2,7 Along with these treatments, incorporating
deep massage of the adductors and using hot and cold
therapy has demonstrated success.9 The core stability
program corrects the imbalance between the hip and
the pelvis.9 At least 6 to 8 weeks of a sports-specific rehabilitation program should be performed before surgery.6,7,9,14,16 The sports-specific rehabilitation program
should be as strenuous as possible to allow any imbalance to correct itself. Strengthening and stabilization
of the abdominal wall, along with massage and stretching of the adductors, should be performed routinely.6
After a well-prescribed, sports-specific rehabilitation
program has failed, surgery is then considered to correct the imbalance or the damage the imbalance has
caused.
SURGICAL OPTIONS
Surgical options should be considered when 6 to 8
weeks of nonsurgical treatment fail and a thorough
physical examination has dismissed other potential
injuries. Typically, surgical repairs of the hip, groin,
and lower abdominal injuries are divided into an
open or laparoscopic approach. If the approach taken
is an open technique, the surgeon evaluates the insertion of the rectus abdominis, external oblique aponeurosis, and the conjoint tendon for abnormalities.
This cannot be performed if the approach were laparoscopic.15
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A common open technique advocated by Meyers et
al17 which involves stabilizing the pelvis by reattachment
of the rectus abdominis and its fascia,15 has had a 97%
return to previous activity level. An open approach can
require 3 months to heal before return to full activity.18
Repair of the external oblique aponeurosis can require 6
weeks to heal along with a modified shouldice repair.18
Gilmore19 has reported that a successful repair requires
the open approach. Other open repairs reported by Kumar et al20 indicated that of the 35 patients (34 men, 1
woman) who underwent an open repair of a tear in the
external oblique aponeurosis and darn or mesh repair of
the posterior inguinal canal, 93% returned to previous
activity levels.
In the laparoscopic repairs, it is assumed that all pain
is caused from an incipient hernia.15 Inserting mesh will
reinforce and strengthen the area. With the laparoscopic
approach, there is better visualization of the defect, and if
the individual has bilateral defects, both can be repaired
through one incision.13 However, with laparoscopic repair, other areas of the external oblique aponeurosis,
conjoint tendon, or insertion of the rectus cannot be examined. Meyers et al17 reported that laparoscopic repairs
cannot address the causative pathology as well as open
repairs.
Success rates for the conventional or laparoscopic
technique have shown results from 89% to 97% return to previous activity.9 It is evident that laparoscopic repair has the fastest return to activity and
best success rate (approximately 95%.)15 Ingoldby21
compared open techniques to laparoscopic techniques and found that all patients were able to return to their preinjury activity levels with no severe
pain. Return to play for laparoscopic repairs have
been reported as early as 4 weeks or less.9 Typically,
most patients return to play in 4 to 6 weeks for laparoscopic repairs and within 1 to 6 months for open
repairs.9
After surgery, rehabilitation should focus on gradually rebuilding the core musculature. Rehabilitation starts
soon after surgery, with gentle walking and light activities of daily living, and then progresses to more strenuous walking and stationary biking with light stretching.7
Strengthening of the core musculature, including lower
back and adductors, should be performed, along with
stretching and massage.7 The final stages of rehabilitation
consist of functional activities (eg, jogging, sprinting, and
cutting and pivoting), preceding return to activity.7
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Athletic Pubalgia
CONCLUSION
Athletic pubalgia is a complicated and multifactorial
syndrome that should be approached with caution
and attentiveness. The purpose of this literature review was to distinguish athletic pubalgia from other
injuries. Clinicians should recognize this syndrome
early to prevent further injury to their athletes. Early recognition through thorough evaluations of the
injury, including palpation of the areas of concern
and manual muscle testing in attempt to rule out all
possible conditions, is paramount to injury diagnosis. Many times, patients will describe chronic lower
abdominal, pelvic, and thigh pain that radiates into
the groin.3 If a patient does describe these symptoms,
clinicians should investigate the possibility of athletic pubalgia.
However, one must be cognizant that these findings will not always lead to a diagnosis of athletic
pubalgia. Athletic pubalgia may be caused by an
acute injury through trunk hyperextension and hyperadduction of the thigh presenting with tenderness
over the pubic tubercle and symphysis. More often,
a patient will report activity-induced groin pain unresponsive to conservative treatment.15 Typically, the
mechanism of injury is not the case. Clinicians must
be knowledgeable of the condition and have a high
index of suspicion when a patient reports unresolved
groin pain. Most imaging studies will present as normal, and the patient will typically not respond to the
nonoperative treatment. Surgical options should be
explored when there is no response to nonoperative
treatment after 6 weeks.
Most patients can return to preinjury competition
within 2 to 6 weeks after a laparoscopic repair and within
1 to 6 months after an open repair.5,7,8,20-24 Athletic pubalgia, being such a complicated syndrome, warrants further
research to truly understand its components and requires
a universal understanding by the medical profession to
distinguish it from hernias, sports hernias, and other pathologies.
REFERENCES
Further RESEARCH
Continual research, such as injury surveillance studies and reliability and sensibility studies of current
evaluation methods dedicated to athletic pubalgia,
are necessary for this syndrome to be universally accepted and to distinguish it from other injuries involving the hip and pelvis. Further research should
Athletic Training & Sports Health Care | Vol. 2
strive to find a standard definition, a common mechanism of injury, and a universal statement defining
athletic pubalgia and its symptoms. In addition,
more imaging studies should be performed to improve our understanding of the pathology. Currently, athletic pubalgia’s definition is inconsistent and,
therefore, the syndrome is misdiagnosed.4,6,13,15 Further research on appropriate evaluation, diagnosis,
and rehabilitation to correctly acknowledge athletic
pubalgia is crucial.
n
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2010
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