Athletic pubalgia or “sports hernia” is an umbrella term describing several anatomic injury patterns. Correctly diagnosing and treating this entity can be challenging. A number of different terms, including “sports hernia,” “Gilmore’s groin,” osteitis pubis, “slap-shot gut,” “sportsman’s hernia,” and adductor or rectus strain have been used to describe a wide variety of pathologies in the area of the groin. However, recognition is growing that groin injuries in athletes comprise a complex set of injuries to the musculature of the abdominal wall, the adductors , the hip joint, the pubic symphysis, and the sacroiliac joint that can be a source of significant disability.
The complexity of the anatomy of the hip joint, pelvis, pubic symphysis, and the associated abdominal wall necessitates careful evaluation to accurately diagnose the source of an athlete’s pain. The pubic symphysis is a nonsynovial amphiarthroidal joint. Static stability of the joint is provided by the disk and four ligaments. The arcuate or inferior ligament has attachments to the inferior articular disk, the inferior attachment of the rectus abdominis, and the adductor and gracilis aponeurosis. The superior ligament spans the space between the pubic tubercles. The anterior ligament blends with fibers of the external oblique and rectus abdominis superficially. The deep portion of the anterior ligament attaches to the intraarticular disk. The posterior ligament is poorly developed. The pubic symphysis acts as the fulcrum for forces generated at the anterior pelvis. It represents the common attachment of the confluence of the rectus abdominis fascial sheath with the fascial sheath of the adductor longus, which merge anterior to the pubis to form a common sheath. The abdominal wall has a layered structure. From superficial to deep, the structures of the abdominal wall are skin, fascia, external oblique fascia and muscle, internal oblique fascia and muscle, transversus abdominis muscle and fascia, and the transversalis fascia. The posterior fascia is deficient in the lower third of the rectus. Fibers from the rectus, conjoint tendon (the fusion of the internal oblique and transversus abdominis fascia), and external oblique merge to form the pubic aponeurosis, which is confluent with the adductor and gracilis origin. The conjoint tendon inserts anterior to the rectus abdominis on the pubis ( Fig. 83-1 ).
Given the clinical identification of an association between athletic pubalgia and femoroacetabular impingement (FAI) and the recognition that loss of internal rotation of the hip is related to the development of groin pain and osteitis pubis, Birmingham et al. performed a cadaveric study looking at the effect of FAI on rotation at the pubic symphysis. At higher torque values, motion through the symphysis was much greater in cadavers with simulated cam morphology than in the native hip state. This finding supports the previous hypothesis that the altered rotational profile seen in the setting of FAI contributes to altered mechanics at the pubic symphysis.
One other possible source of pain has been theorized to be the result of entrapment of the genital branches of the ilioinguinal or genitofemoral nerves. The symphysis itself is innervated by branches of the pudendal and genitofemoral nerves. Some other reports have suggested that the iliohypogastric or obturator nerves could be involved.
Groin injuries have been discussed within the medical literature as early as 1932, when Spinelli reported on pubic pain in fencers. Gilmore recognized a “severe musculotendinous injury of the groin” in 1980 in three professional soccer players. He identified a triad of pathology including injuries to the external oblique aponeurosis and conjoint tendon, avulsion of the conjoint tendon from the pubic tubercle, and dehiscence of the conjoint tendon from the inguinal ligament, and later reported a 97% rate of return to sport after surgical repair.
In 1993, Hackney first used the term “sports hernia” to describe a syndrome of groin pain in athletes for whom nonsurgical management had failed. At surgery, he identified weakening of the transversalis fascia with separation of that fascia from the conjoint tendon, dilation of the inguinal ring, and one case of a small direct hernia. He treated all patients with a surgical repair of the posterior inguinal wall and obtained an 87% return to sport rate in 15 athletes. Irshad et al. described “hockey groin syndrome” in 22 National Hockey League players in 2001. These investigators found tearing of the external oblique aponeurosis and entrapment of the ilioinguinal nerve. Meyers et al. have proposed that use of the term “athletic pubalgia” is more appropriate than the more commonly used “sports hernia” for the constellation of injuries to the abdominal wall, hip flexors, adductors, and pubic symphysis presenting with pubic area or inguinal pain. They proposed that the primary pathology in athletic pubalgia is an imbalance between the strong adductors and the relatively weak abdominal muscles. Meyers et al. describe 17 different variants of athletic pubalgia, the most common of which are multiple tears or detachment of the anterior and anterolateral fibers of the rectus abdominis from the pubis and combined injuries to the rectus and adductors.
As the understanding of intraarticular hip pathology has improved, the coexistence of labral pathology and femoroacetabular impingement with athletic pubalgia has increasingly been recognized. Larson et al. reported surgical treatment in a subset of athletes with coexistent femoroacetabular impingement and athletic pubalgia. Failure to treat both pathologies resulted in a low return to sport rate (25% if athletic pubalgia was addressed in isolation and 50% if the intraarticular hip pathology was addressed in isolation). This study resulted in the development of a surgical protocol to address both etiologies at the same surgery when athletes present with both symptomatic athletic pubalgia and intraarticular hip disorders (FAI). Using this approach, they achieved an 85% to 93% return to sport rate.
When addressing the athlete with groin pain, it is important to carefully investigate other potential sources of the athlete’s pain. Careful screening must be conducted for intraarticular hip pathology and associated hip pathomorphology if symptoms are present and are limiting. Additionally, it is important to be aware of the broader differential diagnosis of groin pain. Disorders of the gastrointestinal, genitourinary, or gynecological systems must also be considered, with several authors identifying tumors, Crohn disease, and other pathologies in the evaluation of the athlete with groin pain.
Groin injuries are particularly common among persons who participate in sports requiring repetitive twisting, pivoting, and cutting motions, as well as activity requiring frequent acceleration and deceleration. Hockey, soccer, ice hockey, and rugby players have a particularly high incidence, with a lower incidence reported in American football, basketball, and baseball players. Meyers et al. noted that in the 1980s, fewer than 1% of their patients with athletic pubalgia were female. During the past two decades, however, that situation has changed dramatically, and female patients now represent 15% of patients presenting with athletic pubalgia.
Athletes may report insidious onset of groin pain or less commonly have a more acute presentation. Although some variability exists in the location and characteristic of symptoms, Meyers et al. found that all of their athletes reported lower abdominal pain with exertion, whereas 92% had minimal to no pain at rest. Forty-three percent had bilateral symptoms and 67% had adductor pain after the onset of lower abdominal pain. Pain may also radiate to the rectus, perineum, or testicular region. Exacerbation typically occurs during activities involving kicking, acceleration, and pivoting. Abdominal crunches or sit-ups, coughing, or sneezing may also reproduce symptoms. Osteitis pubis presents in a similar fashion with pubic pain that may radiate to the adductors and is typically exacerbated by weight bearing. Intraarticular hip pathology typically presents with deep groin pain that may radiate to the anterior thigh and lateral hip. Considerable overlap exists between intraarticular hip and athletic pubalgia/sports hernia symptom presentation, which increases the complexity in making an accurate diagnosis on the basis of symptoms alone.
Assessment for athletic pubalgia/sports hernia should begin with palpation of the pubic symphysis, the insertion of the rectus abdominis, the adductor origin, the external and internal obliques, the transverses abdominis, the pectineus, the gracilis, and the inguinal ring for areas of tenderness. Pain can be precipitated via simulated coughing, resisted sit-ups (46%; Fig. 83-2 ), and hip adduction or the Valsalva maneuver. A hernia is not detectable upon palpation; however, tenderness is usually present around the conjoint tendon, pubic tubercle (22%), adductor longus (36%), superficial inguinal ring, or posterior inguinal canal.
Examination findings for osteitis pubis frequently overlap with athletic pubalgia and include tenderness of the pubic symphysis (67%), adductor origin tenderness (59%), pain with the adductor squeeze test (96%), and apprehension throughout hip range of motion. More severe cases may present with a typical “waddling” gait pattern.
As previously indicated, the symptoms of femoroacetabular impingement, athletic pubalgia, osteitis pubis, and adductor strain can present with overlapping symptomatology and physical examination findings. An intraarticular injection of local anesthetic into the hip followed by physical examination or by having the athlete perform activities that typically provoke their pain can be useful. Pain that resolves with this injection can be assumed to be related to intraarticular hip pathology and treated accordingly. Persistent pain in the lower abdominal and proximal adductor regions after intraarticular injections are consistent with coexistent athletic pubalgia. Similarly, injection of the pubic symphysis may be useful for confirming the diagnosis of osteitis pubis. Radiocontrast dye can be used for the symphyseal injection, and extravasation of this dye up the rectus abdominis tract or down the adductor tract may indicate athletic pubalgia. Adductor pathology can be ruled in or out with an injection of anesthetic to the adductor cleft. Additionally, if psoas disorders are suspected, a diagnostic psoas bursal injection with anesthetic can be carried out as well. If impingement is suspected from the anterior inferior iliac spine, a subspine injection can be performed.
Plain radiographs are vital in the initial evaluation of the athlete with hip or groin pain. A number of pathologies including osteitis pubis, avulsion fractures, stress fractures, apophysitis, osteoarthritis, and femoroacetabular impingement/dysplasia may be identified on radiographs. It is essential to obtain good quality, properly oriented images according to an established imaging protocol.
The anteroposterior (AP) view ( Fig. 83-3 ) may be used to evaluate the pubic symphysis for evidence of osteitis pubis, including sclerosis, fragmentation, and cyst formation within the pubic ramus, as well as symphyseal widening. When evaluating for FAI, femoral head neck deformities and acetabular depth and version are assessed. In the adolescent athlete, the AP view can be useful to identify apophyseal injuries. Additionally, stress fractures of the femoral neck and pubic rami and sacroiliitis may be identified.
Stability of the pubic symphysis can be determined on single leg stance AP views. Symphyseal widening greater than 7 mm or vertical translation greater than 2 mm on a single leg stance view suggests instability of the pubic symphysis.
Magnetic Resonance Imaging
Magnetic resonance (MR) arthrography has been used for the assessment of intraarticular hip pathology. More recently, noncontrast MR has been evaluated and found to be sensitive for intraarticular pathology, including articular cartilage injury and labral pathology. Ideally, coronal oblique and axial oblique sequences through the rectus insertion and pubic symphysis should be obtained in addition to standard sagittal, coronal, and axial sequences. Magnetic resonance imaging (MRI) is 68% sensitive and 100% specific for rectus abdominis pathology when compared with findings at surgery and 86% sensitive and 89% specific for adductor pathology. It is 100% sensitive for osteitis pubis. Nonarthrogram studies may be preferred for in-season athletes to avoid the potential for irritation as a result of intraarticular contrast administration.
The MRI should be evaluated in a systematic fashion. The pubic bones should be evaluated for edema, subchondral sclerosis, and cysts suggestive of osteitis pubis ( Fig. 83-4 ). Evaluation of the tendinous insertions around the pubic symphysis should then be performed ( Fig. 83-5 ). Frequent findings include fluid signal within the rectus abdominis or adductor origin, thickening of either structure, peritendinous fluid, or partial or complete disruption of either tendon. Most commonly, a confluent fluid signal is present that extends from the anterior-inferior insertion of the rectus abdominis into the adductor origin, with a corresponding fluid signal in the pubis.
Treatment decisions are based on the degree of limitations and the ability to participate in the athlete’s respective sport, duration of symptoms, pathology identified on physical examination and imaging, response to prior treatment modalities, and where the athlete is with respect to his or her training, sport season, and upcoming athletic events. Conservative management should be attempted prior to surgical intervention. The common locations of pain are the groin (FAI, athletic pubalgia, or adductor), lower abdomen or pubic symphysis (athletic pubalgia or adductor longus), posterior hip (FAI, proximal hamstring, low back, sacroiliac joint, or sciatic nerve entrapment disorders), or lateral thigh/hip (iliotibial band or gluteus medius/minimus). If no treatment has been provided, then rest, use of nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, and injections in select situations should be initiated. If the athlete continues to be symptomatic after 6 to 12 weeks of nonsurgical treatment, surgery might be considered. The timing of the surgery depends on the degree of disability and the point in the season. If the athlete’s season is underway, an attempt can be made to delay surgery until the season is completed if the athlete is productive and functional. Surgery can then be performed at the end of the season if the athlete remains symptomatic. If the athlete is not able to compete at a reasonable level, then in-season or season-ending surgery can be considered. If the athlete has a combined pathology such as FAI and athletic pubalgia, these conditions can be surgically addressed at the same setting to minimize postoperative rehabilitation time and total time lost from participation. However, no evidence has indicated that carrying out these procedures separately or in a staged manner has any negative impact on outcome.
Muscle imbalance between the abductors and adductors appears to contribute to injury. Tyler et al. found that professional hockey players were 17 times more likely to sustain an adductor strain if their adductor strength was less than 80% of their abductor strength. In a follow-up study, they were able to demonstrate a clinically and statistically significant decrease in adductor strains in the same population with institution of a preventative adductor strengthening program.
Treatment starts with a brief period of rest, judicious use of ice and NSAIDs, and institution of a core and contralateral lower extremity strengthening program. Once the athlete is able to perform a pain-free concentric contraction of the adductor against resistance, the program can be progressed to core strengthening and adductor-specific exercises. It has been suggested that the athlete can progress to sport-specific training when the adductor strength is 75% of the ipsilateral abductor and passive range of motion is normal.
One randomized clinical trial is available that presents 8- to 12-year follow-up data after nonoperative management of adductor-related groin pain. The initial study randomly assigned 59 athletes to either a passive rehabilitation protocol consisting of modalities and stretching or an active rehabilitation protocol emphasizing strengthening of the core, abductors, and adductors. In the initial study period, 23 of 29 patients treated with 8 to 12 weeks of active therapy had returned to sport by 4 months after initiating treatment. In the passive therapy group, only 4 of 30 patients had returned to sport at the 4-month mark. At 8 to 12 years after treatment, 50% of the active rehabilitation group had no adductor pain with activity, no groin pain during or after activity, and were active in athletic activity at or one level below their previous level of athletic activity in the same sport. Only 22% of the passive therapy group met the same criteria.
The literature includes one case report of injection of a complete tear of the adductor longus with platelet rich plasma, with return to competitive soccer without surgery. However, evidence for platelet rich plasma injections in the area of the hip and pelvis is lacking.
Surgical treatment of proximal adductor pain is indicated when 3 to 6 months of conservative management has failed to improve symptoms. Akermark and Johansson published a case series of 16 competitive athletes with long-standing (mean, 18 months) and recurrent groin pain localized on physical examination to the adductor origin. Conservative management with rest, stretching, NSAIDs, and corticosteroid injections had failed for all of the athletes. Surgical treatment involved open tenotomy 1 cm from the adductor origin. All patients experienced improvement and were able to resume sporting activities at some level. Ten of 16 patients were pain free. The leg treated with surgery was weaker in adduction torque in all patients after full recovery.
Atkinson et al. reported on 48 athletes who underwent 68 percutaneous adductor tenotomies for adductor strain. All patients were significantly restricted in their chosen sport before surgery, and 54% were able to return to full participation in their sport at a mean of 18.5 weeks. Schlegel et al. reported on 19 professional football players who sustained spontaneous rupture of the adductor longus. Twelve of 19 had groin or abdominal pain that preceded acute rupture. Of the 19 athletes identified, 14 were treated conservatively and nine underwent surgical repair with suture anchors. The nonoperative group returned to play at an average of 6 weeks after injury with no noted strength deficits. The group that underwent surgery returned to play at an average of 12 weeks after injury, and 20% experienced wound complications. Given that minimal functional deficits occur after spontaneous rupture of the adductor at its origin, controlled release in the context of a surgical procedure might similarly have few long-term functional consequences.