Pubalgia

Pubalgia
Definition/Description
Pubalgia also known as a sports hernia or athletics pubalgia is a chronic groin lesion.
Athletes with pubalgia have an imbalance of the adductor and abdominal muscles at
the pubis, that leads to an increase of the weakness of the posterior wall of the groi n.
This imbalance leads to a deep groin pain. [1]
Clinically Relevant Anatomy
When we talk about pubalgia, we must take some bones and muscles in
consideration. When we talk about the bones, we talk about the two femurs, the
sacrum and the coccyx. All the muscles that attach to pubic symphysis are important
for the anatomic perspective of pubalgia. We talk about the anterolateral abdominal
muscles ( external and internal oblique muscles, tranversus abdominis and rectus
abdominis) and the thigh adductor muscles (pectineus, gracilis, adductor
longus/brevis and magnus). Of all the muscles that attach to the symphysis the rectus
abdominis and the adductor longus are the most important for maintaining the stability
[2][3]
in the sagital plane of the anterior pelvis.
Epidemiology /Etiology
Pubalgia is most common in soccer, ice hockey, lacrosse, long-distance running,

kicking sports, Australian football, and cricket. All these sports involves repetitive
energetic kicking, twisting, turning or cutting movements, which are all risk factors for
causing pubalgia.[4] Athletes with pubalgia are predominantly male and generally
under the age of 40 years. Generally we can explain it because there are more males
that practice the sports that have a higher risk for pubalgia. A second reason we can
find in the fact that female patients generally have a larger and more robust caudal
rectus abdominis attachments on the pubic symphisis, a situation that is not seen in
male patients. A third reason is that the female pelvis is wider and has a larger
subpubic angle this can result in a better guiding of forces away from the pubic region.
The anatomic and biomechanical differences in the female pelvic structure may help
stabilize the pubic region and decrease the risk for pubalgia. [5]
There are different causes of pubalgia: [6][7]
1. Rectus adductor syndrome:

a) Adductor enthesopathy b) Pathology/asymmetry of the symphisis pubis
2. Sports hernia:
a) Myoaponeurotic parietal defect: - of the transverse bundle
- of the posterior wall of the inguinal canal
- of the anterior wall of the inguinal canal
b) Occult hernia of the abdominal wall
3. Locoregional pathologies:
a) Nerve compression: - ilioinguinal nerver (Maignes syndrome)
- Obturator nerve
- Femoral cutaneous nerve

- Genitofemoral nerve
b) Muscular disorders: - iliopsoas

- hamstrings
- iliopsoas bursitis
c) Joint diseases: - hip diseases
- sacroiliac disease
d) Genitourinary disorders: - adnexal
- urethral
- testicular and scrotal
- prostate
4. Previous injury
5. Muscle imbalance between adductor muscles and abdominal muscles
Characteristics/Clinical Presentation
Most patients with pubalgia have symptoms for months or years before a clinical
diagnosis is obtained. They report a deep, sharp pain in the groin or lower abdominal
region that can radiate to the proximal thigh, low back, lower abdominal muscles,
perineum or scrotum. [8][9] Most of all they complain about a unilateral groin pain, that is
relieved with rest and returns during activities like running, accelerating movements,
cutting, twisting, kicking, [10] Additionally they have also pain when they cough and
sneeze. The unilateral pain can evolve into bilateral pain. [11][12]
Differential Diagnosis
The diagnosis of pubalgia is difficult, because of the complex anatomy and the overlap
of symptoms between the different groin injuries. The clinician must also consider that
athletes with groin pain may have more than one diagnosis and the presence of one of
these related diagnosis does not necessarily eliminate the possibility of pubalgia.
Because of the overlapping symptoms between sports hernia and other groin pains,
its helpful to obtain imaging studies to rule out other causes of pain. [13][14]
Diagnostic Procedures
Imaging studies are important for the difficult diagnosis of pubalgia. Imaging studies
such as ultrasound, magnetic resonance imaging (MRI), computed tomography (CT),
herniography and laparoscopy can help with the diagnosis. Ultrasound has an
accuracy of 92% in finding a hernia in the groin. Dynamic ultrasound examination is
able to detect inguinal canal posterior wall deficiency in young males without clinical
signs of a hernia in the groin. [15]
MRI can show abnormalities in the musculofascial layers of the abdominal wall that
correlate closely to surgical findings of pubalgia. MRI can find also a stress -related
oedema within the symphysis pubis caused by the imbalance of forces and alt ered
motion across the joint. [16][17]
The use of CT-scans could help to indentify posterior inguinal wall deficiencies and
hernias. [18]
People with pubalgia test positive by a herniography. The test is positive if there is a
abnormal contrast flow outside the normal contours of the peritoneum.
Another study to detect a sports hernia is laparoscopy. Its an invasive technique, that
is very effective to diagnose pubalgia. An advantage of endoscopy is that a sports
hernia could subsequently repaired in the same session. [19][20][21]
Examination
The examination of patients with pubalgia can include 4 pain provocation tests: the
single adductor, squeeze, bilateral adductor and resisted sit-ups test. During the
single adductor and the bilateral adductor tests the patient should be lying supine with
his hips abducted and flexed at 80. The test is positive if the patient feels a sharp
pain in the groin, while attempting to pull his legs against pressing in the opposite
direction. People with pubalgia have also pain during the squeeze test while they are
[22][23][24]
lying in supine with the hips in 90 flexion.
Medical Management
When the patients still have pain after physical treatment surgical exploration and
repair is indicated. There are a lot of types of surgical treatment. [25][26] Open repair of a
sports hernia is one type of surgical technique. The technique involves reattaching the
rectus abdominis , conjoined tendon, and/or transversalis fascia to the pubis and
inguinal ligaments. [27]
Another type of surgical treatment is laparoscopic surgery. The technique is
performed by endoscopy, total extraperitoneal mesh placement behind the pubic bone
and/or posterior wall of the inguinal canal. Paajanen et all shows us that laparoscopic
surgery for pubalgia in athletes is more effective than nonoperative treatment. After
surgery repair the pain decrease after 1 month and 90% of the athletes who
underwent operation full returned to sports activities after 3 months. [28]
Physical Therapy Management
After pubalgia is diagnosed six to eight week of physical therapy is the first step in the
rehabilitation. [29] The treatment consists of rest, activity modification by mobilization
techniques, anti-inflammatory medication and physical therapy. The therapy consists
of core strengthening exercises target the abdomen, lumbar spine and hips and
stretching focuses on the hip rotators, adductors and hamstrings. The goal of the
therapy is to correct the imbalance of the hip and pelvic muscle stabilizers.
Therapeutic ultrasound treatments, cold tubs and deep massage of the groin region
may be also helpful. [30][31]
An active training programme is superior to physiotherapy treatment without active
training. [32][33][34]
References
1. Jump up Sportsmen hernia: what do we know? S. Morales-Conde, M. Socas, A. Barranco Level 1A

2. Jump up Understanding Sports Hernia ( Athletic Pubalgia): The Anatomic and Pathophysiologic Basis for Abdominal
and Groin Pain in Athletes, William C. Meyers, Edward Yoo, Octavia N. Devon, Nikhil Jain, Marcia Horner, Cato
Lauencin, and Adam Zoga Level 1A
3. Jump up Athletic Pubalgia and Sports Hernia: Optimal MR Imaging Technique and Findings, Imran M. Omar, Adam
C. Zoga, Eoin C. Kavanagh, George Koulouris, Diane Berging, Angela G. Gopez, Willuam B. Morrison, William C.
Meyers Level 1A
4. Jump up Pubic inguinal pain syndrome: the so-called sports hernia, G. Campanelli Level 1A
Meyers Level 1A
6. Jump up Sportsman hernia: what can we do? J.F.W. Garvey, J.W. Read, A. Turner Level 1A
7. Jump up US in Pubalgia, Giuseppe Balconi Level 1A
8. Jump up Sportsman hernia: what can we do? J.F.W. Garvey, J.W. Read, A. Turner Level 1A
9. Jump up Sports Hernia, Joseph F. Diaco, MD, FACS, Daniel S. Diaco, MD, FACS, and Lisa Lockhart, CRNFA
Level 2B
10. Jump up Sports Hernia: Diagnosis and Treatment Highlighting a Minimal Repair Surgical Technique, John M.
Minnich, John B. Hanks, Ulrike Muschaweck, L. Michael Brunt and David R. Diduch Level 2A
11. Jump up Proposed Algorithm for the Management of Athletes With Athletic Pubalgia (Sports Hernia): A Case Series,
Aimie F. Kachingwe, Steven Grech Level 4
12. Jump up Differential Diagnosis of a Sports Hernia in a High-School Athlete, Casey A. Unverzagt, Teresa Schuemann,
Jeffrey Mathisen Level 2B
Meyers Level 1A
21. Jump up Differential Diagnosis of a Sports Hernia in a High-School Athlete, Casey A. Unverzagt, Teresa Schuemann,
Jeffrey Mathisen Level 2B
23. Jump up Sports Hernia, Joseph F. Diaco, MD, FACS, Daniel S. Diaco, MD, FACS, and Lisa Lockhart, CR NFA
Level 2B
28. Jump up Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A
randomized clinical trial with magnetic resonance imaging of 60 patients with sportsmans hernia (athletic pubalgia),
Hannu Paajanen, Tuomas Brinck, Heikki Hermunen, Ilari Airo Pedro 7/10
33. Jump up Manual or exercise therapy for long-standing adductor-related groin pain: A randomized controlled clinical
trial, A. Weir, J.A.C.G. Jansen, I.GL. van de Port, H.B.A. Van de Sande, J.L. Tol, F.J.G. Backx Level 1B
34. Jump up Effectiveness of active physical training as treatment for long -standing adductor-related groin pain in
athletes: randomized trial, Per Hlmich, Pernille Uhrskou, Lisbeth Ulnits, Inge -Lis Kanstrup, Michael Bachmann
Nielsen, Anders Munch Bjerg, Kim Krogsgaard Level 1B

Pubalgia

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Pubalgia

Clinically Relevant Anatomy

Pubalgia is most common in soccer, ice hockey, lacrosse, long-distance running,

There are different causes of pubalgia: [6][7]

1. Rectus adductor syndrome:

- Femoral cutaneous nerve

b) Muscular disorders: - iliopsoas

Physical Therapy Management

1. Jump up Sportsmen hernia: what do we know? S. Morales-Conde, M. Socas, A. Barranco Level 1A

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