Pubalgia is a common injury in the groin area. A hernia happens when an organ or tissue sticks through the muscle or tissue that holds it in place. Pubalgia refers to any strain or tear of the soft tissue in the groin. Over time, pubalgia may turn into a hernia.
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Studies are limited, however, lacking consistent objective criteria for making the diagnosis and assessing outcomes. PubMed database through January and hand searches of the reference lists of pertinent articles. Nonsurgical outcomes have not been well reported. The variety of procedures and lack of outcomes measures in these studies make it difficult to compare one surgical approach to another. This has added increased complexity to the decision-making process regarding treatment.
An association between femoroacetabular impingement and athletic pubalgia has been recognized, with better outcomes reported when both are managed concurrently or in a staged manner. From superficial to deep, the abdominal wall structures are 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 a fusion of the internal oblique and transversus abdominus , and external oblique merge to form the pubic aponeurosis.
Injury to the abdominal wall at the fascial attachments of the rectus and adductors onto the pubis is implicated in athletic pubalgia. Orthopaedic Sports Medicine: Principles and Practice. Philadelphia: Elsevier; Although the presentation can be variable, athletes typically complain of gradually increasing activity-related lower abdominal and proximal adductor—related pain.
The pain is activity-related and generally resolves with rest. Taking time off from offending athletic activities can lead to resolution of symptoms, but these frequently recur with resumption of sports.
Ice hockey, soccer, Australian rules football, and rugby have a particularly high incidence of groin-related injuries. Deep anterior and lateral pain with prolonged sitting, flexion, abduction, and torsional activities can be secondary to intra-articular hip pathology. Intra-articular hip and pubalgia symptoms may coexist. Lower abdominal, adductor, and symphyseal pain to palpation is common in athletes; therefore, it is critical to determine if the pain is consistent with their symptoms.
A resisted sit-up or crunch with palpation of the inferolateral edge of the distal rectus abdominus may re-create symptoms. Thirty-six percent of athletes with athletic pubalgia have adductor tenderness. Sensory disturbances and dysethesias 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. With reports of associated intra- and extra-articular hip pathology in athletes, it is imperative to evaluate the hip joint.
Various tests such as the anterior impingement pain with hip flexion, adduction, internal rotation are also indicative of concomitant hip joint pathology. Anteroposterior pelvic radiograph in a collegiate hockey player with clinical examination consistent with intra-articular hip and athletic pubalgia symptoms reveals bilateral cam type deformities solid arrow , acetabular retroversion dashed curved line , and ostieitis pubis dashed arrow.
Magnetic resonance imaging can be helpful for a number of hip and pelvic disorders. Coronal oblique and axial sequences through the rectus insertion and pubic symphysis should be obtained in addition to standard sagittal, coronal, and axial sequences.
In addition, MRI can identify stress fractures, synovial disorders, osteonecrosis, tumors, and myotendinous injuries about the hip and pelvis Figure 4. Because of the frequent overlap in pain location for various hip and pelvis disorders, diagnostic anesthetic injections are useful to determine the primary pain generators. Adductor and psoas-related pain can be identified with pubic cleft and psoas bursal injections, respectively.
When contemplating options, a period of non-surgical treatment should be initially attempted. However, there are issues unique to the athlete regarding timing, sports seasons, and level of athlete that are worth mentioning. If an athlete is in season and able to function at a high level despite pain, nonsurgical treatment and occasional nonnarcotic analgesics eg, nonsteroidal anti-inflammatory medications, acetaminophen are appropriate with consideration for surgery after the season if still symptomatic.
If the athlete is limited in season and unable to participate despite nonsurgical measures, surgery can be considered. In-season surgery may or may not be season-ending depending on timing and the length of the season. For higher level athletes, corticosteroid injections might be considered in an attempt to allow these athletes to complete a season.
The evidence, however, is lacking regarding the short- and long-term efficacy of these injections. Physical therapy should be instituted focusing on core stabilization, postural retraining, and normalization of the dynamic relationship of the hip and pelvis muscles.
Although normalization of the hip and pelvis range of motion is reasonable, aggressive attempts at improving range of motion or pain resulting from specific range of motion activities should be avoided. After a period of rest, a gradual pain-free progression to sports may be possible. It may be helpful to avoid deep hip flexion, low repetition, heavy weight strength training during this recovery period. When nonsurgical treatment options fail and the athlete continues to experience pain and disability, surgical treatment is considered Table 1.
Gilmore 8 described plication of the transversalis fascia, reapproximation of the conjoint tendon to the inguinal ligament, and approximation of the external oblique aponeurosis Table 1. No long-term follow-up was reported. They also reported a significant variation in the structures involved and an increasing number of female patients presenting with athletic pubalgia. A recent study reported on 43 National Hockey League hockey players who had sports hernia surgery over 7 years Table 1.
Specific outcomes measures and longer term follow-up is not available for the majority of these studies, making it difficult to identify a clearly superior surgical technique or the long-term benefit of such procedures. The mean modified Harris hip score improved from 75 points preoperatively to 96 points at a mean follow-up of 29 months. With combined FAI and athletic pubalgia surgery, they all returned to professional competition. Therefore, it may be reasonable to consider FAI corrective surgery with later pubalgia surgery if symptoms do not subsequently resolve.
In higher level athletes, however, management of both disorders surgically, in a staged or concurrent manner, may allow for a more predictable return to sports with less time lost from athletics secondary to persistent symptoms and increased rehabilitation time.
This improved sphericity and offset improves hip range of motion, which might help to protect the athletic pubalgia repair or result in resolution of athletic pubalgia symptoms when a concomitant or prior repair has not been performed.
A careful history, physical examination, and imaging are needed for an accurate diagnosis. Although nonsurgical treatment should initially be attempted, there are limited data evaluating the efficacy of such treatment. Management of both may be necessary in some instances to improve outcomes. The author declared the following potential conflicts of interest: Christopher M. National Center for Biotechnology Information , U.
Journal List Sports Health v. Sports Health. Christopher M. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Evidence Acquisition: PubMed database through January and hand searches of the reference lists of pertinent articles. Study Design: Review article. Level of Evidence: Level 5. Results: Nonsurgical outcomes have not been well reported.
Conclusion: An association between femoroacetabular impingement and athletic pubalgia has been recognized, with better outcomes reported when both are managed concurrently or in a staged manner. Keywords: sports hernia, athletic pubalgia, impingement. Open in a separate window. Figure 1. Clinical Presentation History Although the presentation can be variable, athletes typically complain of gradually increasing activity-related lower abdominal and proximal adductor—related pain.
Figure 2. Figure 3. Figure 4. Diagnostic Injections Because of the frequent overlap in pain location for various hip and pelvis disorders, diagnostic anesthetic injections are useful to determine the primary pain generators.
Treatment Athlete and Treatment Strategies When contemplating options, a period of non-surgical treatment should be initially attempted. Nonsurgical Treatment and Outcomes Physical therapy should be instituted focusing on core stabilization, postural retraining, and normalization of the dynamic relationship of the hip and pelvis muscles.
Surgical Treatment and Outcomes When nonsurgical treatment options fail and the athlete continues to experience pain and disability, surgical treatment is considered Table 1. Table 1. Figure 5. Footnotes The author declared the following potential conflicts of interest: Christopher M. References 1. The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study. Am J Sports Med. J Orthop Sports Phys Ther. An year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results.
Clin J Sport Med. Treatment of a hip capsular injury in a professional soccer player with platelet-rich plasma and bone marrow aspirate concentrate therapy. Knee Surg Sports Traumatol Arthrosc. Sports hernia: diagnostic and therapeutic approach. J Am Acad Orthop Surg. Laparoscopic repair of groin pain in athletes. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. Gilmore OJ. Sports Med Soft Tissue Trauma. Hackney RG. The sports hernia: a cause of chronic groin pain.
Br J Sports Med.
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Learn about our expanded patient care options for your health care needs. Despite its name, a sports hernia is not actually a hernia. Although the symptoms are similar, the pain and pressure from sports hernias are caused by torn tendons that attach to the pelvis instead of an abdominal muscle separation and protrusion of intestine or other soft tissue. Sports hernias are typically caused by repetitive or explosive motions, especially those that require twisting of the pelvis such as football, hockey, soccer, rugby, skiing, running and hurdling. The soft tissues that perform these movements found in the lower abdomen and pubic area are most frequently torn or injured.
Understanding Sports Hernia (Athletic Pubalgia)
Chronic groin pain is a common problem and has been well-described in high-performance athletes. Its presentation in the recreational athlete has been less frequently described. We present the experience of a tertiary group of physicians specializing in groin pain and athletic pubalgia. Dynamic magnetic resonance imaging MRI protocol was employed. Surgery was performed in patients failing non-surgical management.
Athletes such as long-distance runners, soccer players, football players, lacrosse players, and wrestlers may hear the term "sports hernia" used to describe any type of groin pain, regardless of its cause. Some medical professionals disagree on what exactly a sports hernia is, and sometimes apply the term to several different types of common groin injuries. It is important to clearly understand the true nature of this condition, however, because it is a frequent cause of groin pain in some types of athletes. Not only that, it is sometimes a difficult condition for physicians to diagnose, so athletes who understand sports hernia and whether their own patient history might indicate risk factors can sometimes help doctors arrive at an accurate diagnosis. See Groin Strain and Injury. This article provides an in-depth review of a sports hernia injury, including its definition, common causes and risk factors, symptoms, and treatments.
Athletic pubalgia , also called sports hernia ,  core injury ,  hockey hernia ,  hockey groin ,  Gilmore's groin ,  or groin disruption  is a medical condition of the pubic joint affecting athletes. It is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. Football and ice hockey players are affected most frequently. Both recreational and professional athletes may be affected. Symptoms include pain during sports movements, particularly hip extension, and twisting and turning. This pain usually radiates to the adductor muscle region and even the testicles, although it is often difficult for the patient to pin-point the exact location.