Athletic Pubalgia, Part 1: Anatomy and Diagnosis

CLINICAL EVALUATION Lindsey E. Eberman, PhD, ATC, LAT, Report Editor Athletic Pubalgia, Part 1: Anatomy and Diagnosis

Kelly E. Copperthite, MS, ATC • Sports Therapy and Rehabilitation, Hamden CT

Although less common than some other Athletic pubalgia can be difficult to lower extremity diagnoses, groin injuries are diagnose, which is largely due to an unclear becoming more prevalent in athletics and etiology. The onset of pain might be acute, cause them to miss a significant amount of but most often symptoms are insidious5 and participation time.1 Injuries to the pelvic area are often related to trunk hyperextension are among the most difficult to accurately and leg hyper-abduction,6 and are associated assess and manage.2 One example is athletic with kicking, changing directions suddenly, pubalgia, also referred to or sprinting.5 These movements, along with as a sports hernia. The the antagonistic adduction and flexion forces, Key PointsPoints term hernia actually mis- generate a shearing force across the pubic Groin injuries are difficult to diagnose. represents this injury,3 symphysis, which ultimately imposes stress because there is no pro- on the inguinal wall. This can lead to tearing The soft tissue of the pelvis must with- trusion of the organs or a or avulsion of the pelvic floor structures.1 stand significant amounts of force. palpable bulge.4 Athletic Pain may be elicited by palpation in various pubalgia involves tear- areas across the pelvis,3 specifically at the Pelvic injuries are becoming more common ing or fraying of muscle, pubic symphysis, rectus abdominis tendon, among athletes. tendon, and fascia from and adductor longus tendon, which may the pubic bone.1 be unilateral or bilateral.6 Pain may radiate Athletes are increasingly being diagnosed to the inner thigh or across the midline of as having athletic pubalgia. Two factors likely the pelvis.5 Objective findings can vary, but play a role: (a) Off-season conditioning pro- often include pain with resistance to active grams that focus on lower extremity strength adduction, trunk flexion,1 hip flexion, and development without abdominal strengthen- internal rotation.5 Numerous studies have ing may create a pelvic floor muscle imbal- reported preoperative diagnostic imaging to ance, which predisposes athletes to the be inconclusive,1 but MRI, CT, and ultrasound development of the condition;1 (b) clinicians imaging have been used to identify the exis- are becoming more aware of the diagnosis. tence of pathology.3 Due to lack of definitive Athletic pubalgia is more prevalent in men, findings, rest and conservative care are often because they have a heavier and narrower prescribed, which provides only temporary pelvis that affects the distribution of forces relief.7 (See Table 1 for common findings of across the pelvis.3 athletic pubalgia.)

4  SEPTEMBER 2010 Athletic Therapy Today The muscles that cross the pelvis are mechanically Table 1. Common Findings Associ- inefficient, because of the large forces that they must ated with Athletic Pubalgia generate with relatively short lever arms.1 The pubic Male symphysis and the rectus abdominis muscle form the Pain palpable across the pelvis of unknown etiology anterior portion of the pelvic floor. Unilateral or bilateral pain Symptoms noted with kicking, sprinting, sudden direc- Pathology tional changes, trunk hyper-extension, or leg hyper- abduction Due to the complexity of pelvic anatomy, a number of abnormalities may play a role in the development of Pain with resisted hip adduction, flexion, internal rotation, and trunk flexion athletic pubalgia. Some studies have reported findings of abnormalities of the pubic symphysis (where the Pubic tenderness rectus abdominis attaches),1 and others have reported Largely inconclusive diagnostic studies spiny projections on the inferior pubic ramus at the No protrusion of organs origin of the adductor tendon. When the rectus abdominis weakens, the force of the adductor longus becomes unopposed, which Anatomy results in the imposition of unbalanced forces on the hip joint that can lead to injury.3 Pelvic ligaments can The coccyx, sacrum, ilium, ischium, and pubis bones become inflamed, and branches of the genital nerves form the bony pelvis, which is joined anteriorly by the may become entrapped, leading to associated pain pubic symphysis (often involved with athletic pubalgia) and further complicating the diagnosis.1 and posteriorly by the sacrum. The pubic symphysis contains a fibro-cartilaginous disc and is stabilized by Differential Diagnoses ligaments and muscles; it acts as a fulcrum for move- ment.3 The ligaments of the pelvis are the strongest in Adductor or Rectus Femoris Strain: Frequently the body and can withstand high levels of force. The occurring at the myotendinous junction or muscle ligaments act like bands to help stabilize the anterior belly, due to explosive movements or eccentric pelvis and to prevent hyper-extension and hyper- contractions. Strains present tenderness, edema, abduction of the hip. and weakness. The numerous muscular attachments to the pelvis Avulsion of the Adductor Ligament: Tearing of the allow for the transfer of force from the upper body to soft tissue off the bone, or an avulsion fracture, can the lower extremities and enable the pelvis to with- occur if the force of the pull is great enough, usu- stand the compressive forces created by body weight. ally the result of a violent eccentric contraction.1 Pelvic structures—the inguinal ligament, the conjoined tendon, and the pubic symphysis—serve as the distal Pubic Symphitis (or Osteitis Pubis): Painful inflam- attachment for the abdominal muscles.2 The rectus mation of the pubic symphysis and surrounding 2 abdominis and external oblique muscles play a major soft tissue due to repetitive stress. This condition 1 role in pelvic stabilization. The rectus abdominis con- may coexist with athletic pubalgia. tributes to abduction, adduction, internal rotation, and Adductor Hematoma: A hardened mass of blood external rotation of the hip, and it contracts with the in the adductor muscle secondary to trauma. adductors to produce anterior pelvic tilt. Adductor Tendonitis: Painful inflammation at the The muscles of the pelvis control forces of six to adductor tendon, which is usually due to repeti- eight times body weight that act across the hip joint tive forces imposed on the tendon. while walking and jogging.1 These forces increase as strength gains are made, which may explain the Adductor Calcification: The abnormal deposit of elevated incidence of hip pathologies in athletes.3 calcium at the site of injury, which can be caused

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