What is athletic pubalgia?
Hip and groin pain in athletes has been a diagnostic dilemma for a long time due to the complex anatomy surrounding the hip. Athletic pubalgia has long been known as a sports hernia since its clinical presentation can be similar to that of true hernias. However, developed understanding of the mechanism of injury causing athletic pubalgia has revealed that it is very distinct to that of a true hernia. While actual hernias refer to protrusion of an organ through a weakened abdominal wall, athletic pubalgia (“sports hernia”) is due to weakened or torn musculoskeletal structures that attach to the pubis, specifically those of the pubic aponeurosis.
What is the mechanism of injury?
The abdominals and the groin muscles both connect at the pelvis. This attachment point acts as the fulcrum between the two opposing muscle groups (figure 1). Like with many causes of functional joint pain, weakness in one of the two opposing muscles will cause an imbalance at the central meeting point of the muscles. So, the force generated by the stronger muscle will be unopposed and cause it to pull on the weaker muscle and over time this can potentially cause a tear.
In the case of athletic pubalgia, the abdominals end up being relatively weaker and unable to pull back against the groin muscles at their fulcrum – the pelvis. So essentially, these opposing muscle groups are constantly playing a game of tug-of-war and the losing, weaker muscle becomes strained or tears.
The most common way in which athletic pubalgia occurs is from repeated intense muscle contraction while hyperextending and/or twisting of the trunk. Most athletes can attribute the initial injury to a specific event. An exaggerated movement that demonstrates the mechanism of this injury is when a soccer player hyperextends their hip in preparation for a powerful kick far across the field (figure 2). The hyperextended hip pulls on both the groin muscles as well as the abdominal muscles causing the weaker abdominal muscles to become injured.
What are the symptoms?
Symptoms of athletic pubalgia can present acutely or insidiously as pain in the groin and lower abdomen that radiates toward the perineum and proximal adductors. Once the initial injury occurs, pain in the groin can be exacerbated by common athletic movements such as kicking, cutting or sprinting. A period of rest can often resolve symptoms; however, it is typical to see the pain return as soon as the athlete returns to play if the underlying cause is, in fact, athletic pubalgia. Due to the complexity of the structures in the hip, a very thorough physical examination is necessary to properly diagnose athletic pubalgia as well as rule out any other potential etiologies that can cause groin pain.
What are the treatment options?
The treatment for athletic pubalgia can vary from a conservative physical therapy approach to a more invasive surgical approach. Choosing the right treatment depends on the severity of the injury as well as the timing of the athlete’s sport season. First-line treatment for athletic pubalgia is rehabilitation consisting of core strengthening and stabilization as well as pelvic tilt and postural training. A conservative treatment approach should be done for 3 months before attempting to return to play. In-season athletes can attempt a 4-week trial of rest along with NSAIDs or possibly oral corticosteroids. Additional adjunct therapies with physical therapy may include corticosteroid or platelet-rich plasma injections into the rectus abdominus or adductor longus.
If pain continues after adequate rest and therapy, the athlete may opt for surgical repair. There are multiple surgical procedures including laparoscopic and open procedures that have proven to be efficacious for the treatment of athletic pubalgia. The primary goal of surgery is to reinforce the posterior wall of the rectus abdominus to provide the adequate strength to balance the forces between the rectus abdominus and the adductor muscles. Though both the conservative and invasive treatment options are available, the invasive surgical approach has shown to result in higher number of athletes returning to full sport after 1 year.
References:
Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athletic Pubalgia: A Review. R I Med J (2013). 2016 Oct 4;99(10):31-35. PMID: 27706276.
Elattar O, Choi HR, Dills VD, Busconi B. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health. 2016 Jul;8(4):313-23. doi: 10.1177/1941738116653711. Epub 2016 Jun 14. PMID: 27302153; PMCID: PMC4922526.
Ellsworth AA, Zoland MP, Tyler TF. Athletic pubalgia and associated rehabilitation. Int J Sports Phys Ther. 2014;9(6):774-784.
Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic sur- gery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with mag- netic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011 Jul;150(1):99–107.
Image: Figure 2; https://www.leventefe.com.au/athletic-pubalgia-and-groin-injuries/
By Mauricio Aranda and Alee Vladyka
