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Athletic Pubalgia

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Athletic Pubalgia Physical Therapy in Sport 14 (2013) 3e16 Contents lists available at SciVerse ScienceDirect Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp Masterclass A suggested model for physical examination and conservative treatment of athletic pubalgia Eric J. Hegedus a, Ben Stern b, Michael P. Reiman c, Dan Tarara d, Alexis A. Wright a,* a High Point University, School of Health Sciences, Department of Physical Therapy, 833 Montlieu Ave., High Point, NC 27262, USA b 360 Physical Therapy, 13215 N Verde River Drive Suite 5, Fountain Hills, AZ 85268, USA c Duke University Medical Center, Department of Community and Family Medicine, Division of Physical Therapy, DUMC 104002, Durham, NC 27705, USA d High Point University, School of Health Sciences, Department of Exercise and Sports Science, 833 Montlieu Ave., High Point, NC 27262, USA article info abstract Article history: Background: Athletic pubalgia (AP) is a chronic debilitating syndrome that affects many athletes. As Received 13 December 2011 a syndrome, AP is difficult to diagnose both with clinical examination and imaging. AP is also a challenge Received in revised form for conservative intervention with randomized controlled trials showing mixed success rates. In other 12 March 2012 syndromes where clinical diagnosis and conservative treatment have been less than clear, a paradigm Accepted 6 April 2012 has been suggested as a framework for clinical decision making. Objectives: To propose a new clinical diagnostic and treatment paradigm for the conservative Keywords: management of AP. Athletic pubalgia Sports hernia Design: Relevant studies were viewed with regard to diagnosis and intervention and where a gap in fi Diagnosis evidence existed, clinical expertise was used to ll that gap and duly noted. Treatment Results: A new paradigm is proposed to assist with clinical diagnosis and non-surgical intervention in Review patients suffering with AP. The level of evidence supporting this paradigm, according to the SORT taxonomy, is primarily level 2B. Conclusions: Further testing is warranted but following the suggested paradigm should lead to a clearer diagnosis of AP and allow more meaningful research into homogeneous patient populations within the AP diagnostic cluster. Strength-of-Recommendation Taxonomy (SORT): 2B Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction “hernia” appear to be losing favor since often, a hernia is not distinguishable (Davies, Clarke, Gilmore, Wotherspoon, & Connell, Athletic pubalgia (AP), broadly defined as pain in the groin and 2010; Zoga et al., 2008). Further, imaging including bone scintig- pubic region, is a relatively common entity in competitive athletes raphy, radiographs, and magnetic resonance (MR) are prone to false and considered one of the most common injuries in hockey (Agel, positive reports (Davies et al., 2010; Silvis et al., 2011). One recent Dompier, Dick, & Marshall, 2007), soccer (Arnason, Sigurdsson, author referred to this region of the body as, “the Bermuda triangle Gudmundsson, Holme, Engebretsen, & Bahr, 2004), and Austra- of sports medicine”(Bizzini, 2011). The implication of this state- lian rules football (Orchard & Seward, 2002). For such a common ment is that navigating through diagnosis and intervention is entity, relatively little is known about this syndrome. Similar to challenging, with a great probability of misdiagnosis driving inef- other syndromes, AP is a collection of signs and symptoms arising ficient treatment. One reason for this difficulty may be the reliance from multiple pathologies that are difficult to distinguish from one on a pathology-based diagnosis to drive intervention. another (Nam & Brody, 2008). Evidence of this fact are the multiple Two randomized controlled trials (RCTs), using the same active labels associated with AP (Table 1) and that as many as 90% of intervention protocol on heterogeneous patient populations, report athletes with chronic groin pain have multiple pathologies (Caudill, conflicting levels of success with conservative intervention in Nyland, Smith, Yerasimides, & Lach, 2008). Names using the term patients with AP (Holmich et al.,1999; Paajanen, Brinck, Hermunen, & Airo, 2011). Similar diagnostic and treatment issues have been reported relative to low back pain syndrome (LBPS). New classifi- * Corresponding author. Tel.: þ1 336 841 9270; fax: þ1 336 888 6394. cation schemes have been proposed to help improve the diagnostic E-mail addresses: [email protected] (E.J. Hegedus), [email protected] (B. Stern), [email protected] (M.P. Reiman), [email protected] process and create smaller, homogeneous patient groups where the (D. Tarara), [email protected] (A.A. Wright). effectiveness of treatment can better be examined in patients with 1466-853X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2012.04.002 4 E.J. Hegedus et al. / Physical Therapy in Sport 14 (2013) 3e16 Table 1 3. Theories of pain and dysfunction in AP Synonyms for athletic pubalgia. Athletic pubalgia Because of the complex innervation of this region, one theory is Sports hernia that nerve entrapment is a potential source of pain in AP (Falvey et al., 2009). Theoretically, the most frequent nerve entrapment Sportsmen hernia Sportsmen’s groin in this region is that the cutaneous branches of the ilioinguinal or Pubic inguinal syndrome the genitofemoral (genital branch) nerves become entrapped Osteitis (Os) pubis secondary to weakness in the posterior wall of the inguinal canal Chronic groin pain (Akita et al., 1999; Bradshaw & McCrory, 1997). Gilmore groin Adductor-related groin pain The second and most prevalent theory is more biomechanical Prehernia complex in nature and may also explain the weakness in the posterior wall Symphysis syndrome of the inguinal canal. This biomechanical theory stated simply is Gracilis syndrome that an imbalance between normal anatomic structures can Groin disruption change the ability of those structures to dissipate load (Biedert, Warnke, & Meyer, 2003; Holmich et al., 1999; Meyers, Foley, Garrett, Lohnes, & Mandlebaum, 2000). This inability to transmit LBPS (Delitto, Erhard, & Bowling, 1995; Hall, McIntosh, & Boyle, load is key since the pelvic bone and pubic symphysis are vital 2009). These classification schemes have shown promise in the links in transferring forces from the lumbosacral region to the hip form of improved patient outcomes (Brennan, Fritz, Hunter, joint (Dalstra & Huiskes, 1995). Altered load tolerance in this Thackeray, Delitto, & Erhard, 2006; Hall et al., 2009). The purpose region may cause pelvic instability (Garvey, Read, & Turner, 2010; of this review is to propose a new paradigm which will serve as Mens, Inklaar, Koes, & Stam, 2006; Williams, Thomas, & Downes, a skeletal framework for clinical diagnosis and conservative 2000) as well as damage to tendons and other soft tissues and management of AP. The review may assist in guiding future their bony interface (Cook & Purdam, 2009; Cunningham, Brennan, research and improving patient outcomes with conservative O’Connell, MacMahon, O’Neill, & Eustace, 2007; Schilders et al., treatment for patients with AP. 2009). The resultant pain my further compromise the motor control of this region (Cowan, Schache, Brukner, Bennell, Hodges, 2. Operational definition and brief anatomy review Coburn, 2004). Because of the complexity of AP, the operational definition in 4. Proposed paradigm for clinical examination and treatment any clinical review of the topic is important to establish. For this paper, we will define athletic pubalgia as pain in the groin region, In the presence of such uncertainty with regard to a complex, medial thigh, lower abdomen, or pubic region that presents in painful, and recalcitrant entity like AP, we would like to propose athletes and may encompass the following pathologies: damage to a paradigm that, we hope, will aide in arriving at a diagnosis that the tendons, fascia, or sheaths in our defined region exempting will drive efficient and effective conservative intervention. We inguinal hernia and inflammation of the pubic bone from systemic present this paradigm in Fig. 1 and describe the paradigm in disease or fracture. greater detail hereafter. This paradigm will serve as the framework Captured by our operational definition of athletic pubalgia are upon which to lay the evidence about diagnosis and treatment of tendinopathies (Kalebo, Karlsson, Sward, & Peterson, 1992; AP. The paradigm can be sub-divided, for simplicity, into 2 halves: Schilders, Talbot, Robinson, Dimitrakopoulou, Gibbon, & Bismil, 1. examination leading to diagnosis; 2. intervention leading to 2009), osteitis pubis (Smodlaka, 1980), posterior inguinal wall return to function. The examination component begins with insufficiency (Hackney, 1993; Orchard, Read, Neophyton, & Garlick, a focus primarily, but not exclusively, on ruling out more common 1998), and nerve entrapments in the inguinal region (Ekberg, diagnoses that refer pain to this region, eventually focusing on AP Persson, Abrahamsson, Westlin, & Lilja, 1988). A brief review of as the “only diagnosis left standing”. This process, called diagnosis the anatomy of this region will further elucidate our operational by exclusion, has been advocated in other difficult-to-diagnose definition of AP. For a more thorough review of the anatomy of this syndromes (Spiegel, Farid, Esrailian, Talley, & Chang, 2010), espe- region, the reader is referred to Falvey, Franklyn-Miller, and cially in the absence of definitive diagnostic
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