Instructional Course Lecture No. 105: Groin Pain in Soccer Players Ramon Cugat ISAKOS Congress May 11-16, 1997 Buenos Aires, ARGENTINA Manel Llusa, Pau Golano, Pau Forcada, Domingo Ruano Departmento de Ciencias Morfologicas. Facultad de Medicina Universidad de Barcelona Jordi Ballester, Francisco Biosca, Alberto Garcia-Fojeda Hospital del Mar Universidad Autonoma de Barcelona Instituto Nacional de Educacion Fisica, Lleida Ramon Cugat, Xavier Cusco, Montse Garcia, Xavier Juan, Juan Carlos Monllau, Angel Ruiz-Cotorro, Jaime Vilaro, Jaime Zuloaga Federacion Catalana de Futbol, Barcelona, SPAIN Mutualidad de Futbolistas Espanoles, Barcelona, SPAIN The dynamic osteopathy of pubis (D.O.P.) is, at the outset, an enthosopathy of insertion tendonitis of the adductor longus tendon and/or of the abdominals which at an advanced stage causes a degenerative arthropathy of the pubic symphysis. The syndrome was described in 1932 by SPINELLI as "the fencers' groin pain" and in 1949 BANDINI related it to soccer players. Therefore, the D.O.P. is pathology caused by micro traumatisms, which in at its initial stage affects the muscle-tendon-insertion complex. The adductor longus and the gracilis are generally affected and in few cases there are the rectus abdominis, the pyramidalis and the lateral aponeurosis of the obliquus externus abdonini. Symptoms usually arise with a dull pain located in the tendon-muscular union of in the muscular belly resulting from the practice of certain sports; soccer being one of them. Symptoms mentioned appear right after physical effort of hours later. If the factor or factors unfolding the symptology are not treated, symptoms may trigger off an entesopathy of the adductor longus and the gracilis at its insertion in the anterior side of the pubic between the spina and the pubic symphysis. At this stage, the athlete refers to an intensive pain in the groin region appearing during sporting activity of minutes after. This pain unables him/her to realize the abduction-flexion combined movement of the hip or the adductors' test (1). Pain disappears with rest or with non-steroid antiinflammatories 12/24 hours later. But if pain persists an arthropathy appears owing to the progressive deterioration of the pubic symphysis. Pubic symphysis arthropathy is distinguished by sporting activity total incapacity. It is a clinical symptom of constant pain of the insertions of one or both adductors and gracilis, or the pubic symphysis. It usually radiates the internal surface of both muscles and the ischium through the abdomino-genital or/and the obturator nerves. In some cases pain is felt in the inguinal rings when performing the Valsalva's maneuver. It is located in the suprapubic region of one or both sides and it radiates towards the inferior part of the abdomen. Examination shows that the inguinal channel, which in most of these lesions is dilated uni or bilaterally, is very sensitive but doesn't reach the hernia stage. In lesions affecting the upper level of the crural arch, Dr. B. NESOVIC states that most athletes suffering from such lesions present the Malgaigne's sign (2). 1. The adductors' test: is performed with the patient in supine decubitus position, hip flexed at 80 degrees and abducted. The examiner requests that an active adduction be performed while resisting. At that moment the patient feels a sharp and intense pain in the crural-inguinal region. 2. Malgaigne's sign: is performed through examination in orthostatic position. A spindle-shaped protuberance in the lateral and inferior zone of the abdominal wall is observed. Applied Anatomy The applied anatomy of the soccer player's dynamic osteopathy of pubis makes necessary the revision of the pubic regions both crurobturatic and inguinoabdominal as they aref all, one way or the other, involved in the etiopathology of this syndrome with participation of the bone, tendinous and muscular structures. The Pubic Region The pubic symphysis is an amphiarthrosis in which the articular surfaces are linked by a fibrocartilagenous disk reinforced by a series of ligaments named - owing to their location - superior pubic ligament and inferior pubic ligament. These ligaments cling to the fibrocartilagenous disk to the point that fibers intermix with it. Besides, there are two other anterior and posterior ligaments at the peripheral level not always differentiated in anatomical texts. The anterior ligament is thicker and made of tendinous fibers of the pyramidal, rectus abdominis, obliquus externus, gracilis and thigh adductors muscles. The interpubic disk frequently presents a inner tiny articular notch in age degeneration (or after pregnancy and delivery). From the vascular view, it is worth mentioning that irrigation of this area depends on small vessels originating in the adjoining arteries: the internal pubenda, obturator, inferior epigastric, medial femaoral circumflex and the external pubenda. The Crurobturator Region The thigh adductor muscles lie from their origins in the pubis and the ischiopubic ramus to the femoral linea aspera. They appear stratified in such way that the most superficial one is the adductor longus followed by the adductor brevis and in depth, the adductor magnus. The adductor longus is inserted in the pubis angle and in the inferior side of the pubic spine, it is covered by the femoral aponeurosis forming the internal rim of the Scarpa Triangle. At proximal level, it is worth remembering the link of this muscle with the inferior external pubendum artery. It is innervated by the obturator nerve (anterior and posterior rami). Anatomy texts note that it has an adduction, external rotation and anteversion of the thigh role. However, at clinical level, various pathology texts involve these adductor muscles in deformities in internal rotation of the thigh that can be observed in some spastic patients in whom adductors tenotomy solves the problem. The adductor brevis muscle originates in the anterior side of the pubic body, in the ischiopubic ramus. As already said, it is subjacent to the adductor longus. It is mainly related to the obturator nerve which anterior and posterior rami are in front (between the former and the adductor longus) and behind respectively. It is innervated by the obturator nerve (anterior and posterior rami), adducts and externally rotates the thigh. It has a double innervation receiving at the front part nervous fibers of the obturator and, at the back, a collateral ramus of the sciatic nerve. The gracilis muscle originates in the pubis and the symphysis to distally end inserted in the tibial side, together with the sartorius and the semitendinous, creating the superficial goose-foot. It is a biarticular muscle which acts as the thigh adductor and knee flexor. It is innervated by the anterior ramus to the obturator nerve. Because of its proximity and likeness to the adductor brevis, the pectineus muscle can be considered as part of the muscular obturator complex but its innervation depends of the femoral nerve. It departs from the pecten, where it joins other tendinoaperoneurotic structures to form the Cooper's ligament to the trifurcation line of the linea aspera and up to the lesser tronchanter (pectineus line). It acts as the hip flexor and external rotator, with a slight adduction component. The external obturator muscle is the deepest adductor muscle. Its fibers converge from the external surface of the obturator membrane and the pubis and ischium bone limits to surround the hip inferior capsule and steer through the posterior side to its insertion in the tronchanteric fossa. The obturator nerve coming out from the obturator channel shows its anterior division ramus, between the obturator and the pecten and the posterior division in the thickness of the muscle. It is an external rotator of the hip and in theory, and adductor although in practice its action is very partial. The adductor muscular complex can present some variations and muscular anomalies. Muscular fusions between the adductor brevis and longus or the pecten are not uncommon. The so-called adductor minimus has also been described as the superior fibers of the adductor magnus starting independently in the pubis inferior ramus. The Inguinoabdominal Region The external oblique muscle is inserted at the pubis level, between the spine and the superior angle of the pubis through the aponeurotic fibers to form two columns called, external column, inserted in the spine and expanding on the tendon adductor brevis muscle and the internal column inserted in the pubis symphysis and crossing with homonymous fibers of the opposite side to reach the upper edge of the pubis calling this component Colles' ligament or posterior column. The orifice or superficial inguinal ring is defined between these columns and is reinforced on the top by interspine fibers jumping from the internal or external column. In normal conditions, this ring allows the strait duct of the spermatic cord in males and the round ligament in females, being thus the extension of the inguinal channel. The floor of the latter corresponds to the inguinal ligament (Poupart's ligament), the conjoint tendon of the internal obliquus and transversus abdominis muscles (falx inguinalis) form the roof, the tendon of insertion of the external obliquus create the anterior wall and the fascia transversalis with its reinforcements (Henle's ligament and Hesselbach's ligament) form the anterior wall. Clinically, it is worth mentioning that the Malgaigne's line is linked in depth with the inguinal ligament. And also that the relation of the deep inguinal ring of the inguinal duct with the inferior epigastric artery, at the origins of the femoral artery, is an important reference. Finally, it has to be bore in mind that, medially, the spermatic cord doesn't lay directly on the inguinal ligament but is related to the insertion of the conjoint tendon and Gimbernat ligament (aponeurotic fibers going from the inguinal ligament to the medial area of the pectineus crest). Despite offering this anatomical introduction it shouldn't be forgotten that what is dealt here is a dynamic syndrome with mechanic characteristic, produced by an overload that worsens with exercise and betters with rest.