Kinemove Rehabiliation Centers

La riabilitazione nello sport

Athlete’s Pubalgia: A Systematic Review

Bisciotti GN.

Physiologist Lead ASPETAR
- Qatar Orthopedic and Sports Medicine Hospital
- FIFA Excellence Center

Kinemove Rehabilitation Centers, Pontremoli, Parma, La Spezia (I).

Abstract

The athlete’s pubalgia is a problem that in the last years began to affect all classes of athletes, from amateur to professional. Some sports activity, as for example football, would seem for both intrinsic to and extrinsic factors at particularly risk. Despite the great importance that the athletes’pubalgia are taking in sport activity, its diagnosis is often not clear and the conservative treatments proposed are not sufficiently scientifically validated. The aim of this review is outline the athletes’pubalgia state of art from an etiological, diagnostically and rehabilitative point of wiew.

Introduction

The pubalgia represents a widespread problem in sport in both amateur and professional area. However the term pubalgia should, in fact, describes the symptoms, or better a series of symptoms of a disease whose epidemiology is little clear, especially given the complexity of anatomical type of the pubic region and the frequently overlap in the clinical situations of different diseases types (Bouvard et al. 2004). Even the term pubalgia, or more simply “groin pain”, is, according to some authors, ambiguous or at least simplistic and not suitable for the complexity of the disease in question (Vidalin et al., 2004). In spite of this "conceptual inhomogeneities”, both in terms of diagnosis and in regards of the possible therapeutic interventions, the pubalgia has become, from a typical pathology for high-profile athletes, a growing problem at every level of sport. Really the pubalgia currently affects mostly intermediate-level athletes, because of the conditions of practice are often not suitable for its prevention (Puig et al., 2004). The first pubalgia diagnosis is due to Spinelli more than seventy years ago (Spinelli, 1932) and since then this disease has never ceased to stir controversy and different conceptual interpretation (Irschad et al., 2001). From literature we can found that in Europe the sports activities at most risk are represented primarily by the football and after, in a lesser degree, by hockey, rugby and distance running (Arezky et al., 1991; Berger, 2000; Durey and Rodineau, 1976; Durey, 1987; Ekstrand and Hilding, 1999: Gibbon, 1999; Gilmore, 1998; Le Gall, 1993; Gal, 2000). However we must underline that none of the cited work relates the incidence of the disease in relationship with the number of licensed into the various activities in question and, above all, most of these studies would be rejected if you follow the minimum criteria of a meta- analysis (Orchard et al., 2000).

In any case, in the football, there no doubt that many technical movements may favor the onset of the disease: jumps, dribbling, cutting movements in general, takles performed sliding with abducted leg and adductor muscle contracted, certainly are factors that cause pubis symphysis high stress level, triggering a synergic mechanism between adductors and abdominals muscles (Benazzo et al., 1999). Moreover, the shoot movement and the run performed on surfaces that may be bumpy represent an other intense and abnormal functional stress factors for the pubis symphysis (Benazzo et al., 1999; Scott e Renström, 1999). Also in this regard, it is important to remember the theory formulated and proposed by Maigne (1981), based on the functional imbalance in which mechanically operates the football players’ column . Specifically, the Maigne’s theory argues that the game demands forced the football player in a constant hyperlordotic attitude. This particular situation creates, at dorso-lombar level, a conflict between the vertebral joints and the little and the big genital-abdominal nerve that is responsible of the groin region sensitive innervations. All these causes can easily justify that some authors that nearly one third of football players will develop groin pain during the course of their careers (Smodlaka, 1980; Koulouris, 2008).

The clinical classification

The clinical case related to the pubalgia, are distinguished according to the type of pathologic lesion and by the symptoms reported by the patient. However, very often, an inaccurate diagnosis, which achieve to an inadequate therapeutic interventions, transform this disease into a very debilitating pathology, that sometimes forcing the athlete to a sports activity long suspension and can at times get to prejudice an entire competition season. In our view, this discrepancy of clinical judgments is mainly generated by the excessive overlapping of possible clinical situations that are in any case between them, in terms of symptoms, very overlapping and inevitably making difficult to formulate a correct diagnosis. For example, we recall that some Authors (Jarvinen et al., 1997, Gal, 2000) identify from 15 to 72 cases of pubalgia which include for the most part muscle and tendon pathology (tendinopathy insertional, ectopic calcification, avulsions, hernia) but also bone and joint diseases, such stress fractures, osteochondrosis or osteonecrosis, to which are added infectious diseases and cancer, bursitis, nerve entrapment, pain of visceral source etc. It seems clear that all this underlines the fundamental importance of a correct diagnosis, without which is virtually impossible to set a rational and effective treatment plan.

The first step in this direction seems to adopt a correct and rational nosological framework. Currently, one of the most systematic and practical nosological references framework seems to be arising from Brunet (1983) and from the Durey and Rondineau’studies. (1976). According to the experience of these Authors, the sportsman’s pubalgia would refer to three different anatomo-clinical entity, that are often associated:

- The parieto-abdominal pathology, that affects the lower part of abdomen large muscles (external and internal oblique muscles and transverse muscle) and the anatomical elements that shape the inguinal channel.

- The adductor muscles pathology which mainly affects the surface layer namely the adductor longus and pectineus muscle.

- The pubis symphysis pathologies.

Also the Bouvard’s theory (Bouvard et al., 2004) is interesting and worthy of note. These Authors have recently proposed a revision of the Brunet and Durey and Rondineau classifications and suggest to define with the term “pubalgia” a single disease characterized by acute painful into the pubic area, resulting from sports activity, that groups in isolated or associated manner four clinical forms:

- The pubic osteoarthropathy that affects the symphysis joint and the adjacent bone branches. In this case, the clinical analysis allow to differentiate the symphysis suffering depending from microtraumatic etiology from the rare infectious pubic osteo-arthritis (Baril et al., 1998; Durey, 1987, Ross and Hu, 2003). In this clinical status the bone modifications can be sometimes very evident appearing in form of erosion, or as real "nail shots” sometimes with bone fragments presence. Occasionally the erosions may occur in so marked and conspicuous manner so as to include, in differential diagnosis, also neoplastic erosive osteopathy (Ferrario et al., 2000).

- The inguinal canal sufferings whose diagnosis was for the first time formulated by Nesovic (Brunet et al., 1984), arbitrarily named "sports hernia since, in this case, doesn’t exist a true hernia (Durey and Rondineau, 1976; Fon and Spencer, 2000; Gilmore 1998). Although many Authors report an high percentage, ranging from 36 to 84%, of non-palpable hernias in the rebels groin pain forms (Renstrom and Peterson,1980; Ekberg, 1981; Smedberg e coll., 1985; Fon and Spencer 2000, , Srinivasan and Schuricht, 2002; Zoga et al., 2008; Davies et al., 2009), to the definition of "sports hernia" has recently added the term of "groin disruption" (Morelli and Smith, 2001). In this category are included all the painful symptoms caused by posterior wall anatomical defects, area where the striated muscles is absent (Fon and Spencer, 2000). The sufferings of the inguinal canal posterior wall can be highlighted by two instrumental examinations: the ultrasonography (Orchard et al., 1998; Bradley et al., 2003,) and the herniography (Ekberg, 1981 ; Smedberg e coll., 1985; Ekstrand e Hilding, 1999). Nevertheless there are also anterior wall inguinal canal lesions (Irschad e coll., 2001), that may occasionally lead to the suffering of the ileo-inguinal and ilio-hypogastric nerve trunks (Ziprin e coll., 1999 ; Fon and Spencer, 2000; Orchard et al., 2000; Irschad et al., 2001; Morelli and Smith, 2001; Srinivasan e Schuricht, 2002). In these second group furthermore we find the external oblique muscle aponeurosis lesion, the conjoint tendon lesion and the inguinal ligament and the transversal fascia lesions (Jaeger, 1982; Combelles, 1993; Christel et al., 1997; Gilmore 1998; Lynch and Renström, 1999; Ziprin et al., 1999; Morelli and Smith, 2001).

- The rectus abdominis insertional tendinopathy (Durey and Rondineau, 1976, Martens et al., 1987; Volpi, 1992; Ghebondini et al., 1996; Gibbon, 1999).

- The adductor muscles insertional and pre-insertional tendinopaty liable to complication by obturator nerve canal syndrome (Bradshaw et al., 1997; Bruckner et al., 1999; Srinivasan and Schuricht, 2002).


Very close to this clinical classification, especially in terms of nosological rationality, is the classification proposed by Benazzo et al. (1999) that didactically subdivides the possible clinical situation into three groups:

Group 1: represented by the adductor muscles and /or abdominal muscles insertional tendinopathy, occasionally associated with a pubic osteoarthropathy likely of microtraumatic source. The basic anatomical damage would be represented by an adductors muscle-tendinous unit sprain, regarding in most cases the longus adductor muscle with a possible rectus abdominis involvement at level of its insertion into the pubic crest. In this context it may also associated a bone secondary alteration at pubis symphysis. This type of injury would be, according to the Authors, the most prevalent in soccer.

Group 2: in this group we find abdominal wall lesions which are of varying nature and importance and especially the inguinal canal lesion as the hernia, the structural weakness of the inguinal canal posterior wall and the conjoint tendon abnormalities.

Group 3: this group includes all the less common causes of groin pain that are not directly linked to abdominal wall pathologies. In these clinical situations, that the Authors define with the term of “pseudo-pubalgia”, we can find ileopsoas, quadratus femoris and obturator internus muscles sprains or tears, nervous compression syndromes (especially regarding the ilioinguinal nerve, femoral cutaneous nerve, femoral nerve, perineal nerve and genitofemoral nerve), abdominal muscles perforating branches compression, spinal nerves anterior roots pathologies. A condition ascribable in this group, and relatively frequent in football, is the obturator nerve entrapment syndrome, whose pathogenesis, although not yet clearly defined, seems due to a fascia inflammatory process which could in turn cause an obturator nerve anterior branch compression at the level of its passage over the adductor brevis muscle (Benazzo et al., 1999). Furthermore to this group belong the bone lesions such as the pubic osteitis, the iliac bones and femur head stress fractures, pubic symphysis stress lesions and diastasis, osteochondritis desiccant, osteomyelitis and cancer pathologies.

Besides these three types of clinical classification, we find, however, many Authors that still consider that the pubalgia as the same way as a "unique" clinical entity which is summarized in both a disease of the inguinal canal (sport hernia) (Christel et al., 1993; Christel et al., 1997; Gilmore, 1998; Berger, 2000), an adductors muscles insertional tendinopathy (Orchard e coll., 2000; Nicholas e Tyler, 2002), or in a pubic osteoarthropathy (Chanussot and Gholzane, 2003). However, as pointed out by some studies (Christel et al., 1997; Djian, 1997), we seem very important to make a distinction between so-called " true pubic diseases", that are real pubic diseases which directly affect the pubis skeletal structure, and the "false pubic diseases" represented by the insertional tendinopathy, hernia, sport hernia, nerve entrapment etc…. In addition, it should be noted that some Authors (Fredberg and Kissmeyer- Nielsen, 1996) are not in agree with the inguinal canal diagnosis enshrined as an isolated etiology but, on the contrary, they consider it as associated with a more general groin pain framework. Beyond this is important to note that the inguinal forms relate almost only the male population and how it is constituted for 70% of football players, followed by hockey players, rugby players and long distances runners (Gilmore, 1998; Smedberg and Roos, 2002; Vidalin e coll., 2004). However, others Authors consider that the term pubalgia should be used only for the parietal lesions and that all other forms should have a different and very specific nomenclature (Vidalin e coll., 2004). According to these Authors, in all "no parietal forms" including, the principal would be:

- The rectus abdominis tendinopathy

- The adductor longus m., pectineus m. and gracilis m. tendon damages, and the adductor muscle belly lesions.

- Damages at ileopsoas muscle level

- Pubic osteoarthropathy:

- Pubic stress fracture

- Coxo-femoral pathologies

- Maigne’s intervertebral syndrome, though this latter has a rarer incidence (Bradshaw et al., 1997; Delavierre et al., 2010)

Also other Authors are aligned, in some way, to this clinic vision. According to Gilmore (1988), in the clinical situation which he described with the term of "groin pain disruption”, is possible to find both a conjoined tendon lesion and a disconnection of this latter from the pubic tubercle. or even an aponeurosis external oblique muscle injury, or a dehiscence between the conjoined tendon and the inguinal ligament. In addition, in 40% of cases, there is an adductor muscles weakness. According Albers (2001), in 90% of the surgically treated groin pain cases we can see a fascia focal protrusion otherwise defined with the term "bulge". In particular, it is often pointed out a conjoined tendon abnormally high insertion. For these reasons the Author underlines the fact that the groin pain is caused by a myofascial pubic-abdominal abnormality (Pubalgic Abdominal Myofascial Abnormality, PAMA). Embracing the theory that sees the pubalgia term used only in the case of parietal disease and since, in bibliography is possible to find a widespread consensus on the dominant factors in the pubalgia framework, (i.e. inguinal canal dehiscence, inguinal canal posterior wall weakness groin pain disruption and PAMA), some Authors proposed that the “pubalgia” term may be in effect replaced with the more suitable “deep myo-aponeurotic parietal failure” ” (Vitalin et al., 2004).

Symptoms, clinic and diagnosis

The sufferings caused by the pubalgia are bilateral in 12% of cases, interest for 40% of the cases the adductor region and only into the 6% of cases the perineal area (Gilmore, 1998). The 2/3 of patients with pubalgia report a progressive painful symptoms onset, while only 1/3 of the subjects complaint a brutal onset (Gilmore, 1998). The pubalgia clinical framework is characterized by subjective and objective symtomatology.

The subjective symptoms are mainly identified in pain and functional helplessness (Hureibi and McLatchie, 2010; Garvey et al., 2010). The intensity of pain has highly variabilit and can range from a mere annoyance, which occurrence is determined by of the affected anatomical areas stress, until to acute pain, which intensity can be such as to affect even the patient's normal relationship life, during daily life activities such as walking, dressing, up and down stairs, even reaching sometimes to prevent sleep. The painful event can occur as a result of competition and / or training, it can be already present before the performance and disappear during warm up and then reappears later during the activity. In extreme cases, the painful symptoms effectively can preclude the performance. The pain may radiate outward, extending along the adductors and / or abdominals muscles in the perineum and genitalia direction, generating thus possible diagnostic errors (Garvey et al., 2010), the functional impotence is obviously correlated with the painful symptoms intensity.

From the objective point of view, the patient complains pain on palpation and to the stretching against resistance. Moreover, in this context, is important to observe how the patient moves, walks and undressing (Kehlet, 2010). Another important aid factor for the clinical examination is to search a possible Malgaigne’s sign, namely the presence of a oblong curvature located between the crural arch and the oblique muscles bottom (Fournier e Richon, 1992). Concerning images diagnostic is always advisable to make pelvis radiography highlighting the pubis symphysis situation so to check possible bone erosions, pubic branch dysmetry, osteoarthritis (also frequent in young subjects) or hip joint pathologies (Ilaslan et al., 2010; Zoga et al., 2010; Thorborg et al., 2011). In this regard it is important to emphasize how, through a dynamic XR made in alternating monopodalic support (so-called “wader position”) we can make the diagnosis of symphysis instability when it is found a vertical offset greater than 3 mm between the pubis horizontal branch (Death et al.,1982; Christel et al., 1993 ; Ghebontini et al., 1996). The ultra sound (U.S.) finds its indication in inguinal or crural hernia suspicion and may , if necessary, be completed by a peritoneography (Davies et al., 2010) The bone scan is a lack specificity examination, in fact every type of symphysis bone lesion of traumatic, neoplastic, or infectious etyiology would lead to an increased uptake activity at symphysis level (Jansen et al., 2008; Davies et al., 2010). However, a previous uptake that normalize after a conservative treatment is an important factor which may argue for a possible return to sports activity (Lejeune et al., 1984 ; Zeitoun et al., 1995; Jansen et al., 2008). However, the election examination is the Magnetic Resonance Imaging (MRI), who can gives detailed informations concerning both bone situation and the insertional structures (Ghebontini e coll., 1996; Berger, 2000; Zoga e coll., 2008; Zoga et al., 2010). However also U.S., especially if carried out in dynamic conditions, can to highlight edema areas, hematomas (in case of or muscle-tendon tears), myxoid degeneration areas, chondral metaplasia or metaplastic calcification and fibrosis (Lorenzini et al., 2008; Davies et al., 2010). The clinical examination is based on several tests of muscle based both on the active contractions and passive and active muscle stretching (Unverzagt et al., 2007; Brown et al., 2008; Campanelli, 2010).

Predisposing factors

There are intrinsic and extrinsic factors that may predispose the athlete to the groin pain onset. Among the intrinsic factors, those receiving the greatest consensus among various Authors (Durey, 1984; Joliat 1986; Durey, 1987; Rochcongar and Durey, 1987; Orchard et al., 1998; Morelli et al., 2001; Bouvard et al., 2004 Robertson et al., 2009 Mardones et al.; 2010) are:

- Hip and/or sacrum-iliac joint disease;

- A clear lower limbs asymmetry;

- An excessive lumbar lordosis;

- A functional imbalance between abdominal and adductor muscles: in this case the abdominal muscles proved to be weak when compared to the adductor muscles that, on the contrary, would be strong and excessively stiff. In other cases weak abdominal muscles would linked to an equally weak, but very contracted, adductor muscles;

- An excessive stiffness at hamstrings muscles level;

- The coxopaties that obviously, both of malformation or degenerative etiology, constitute an additional pejorative factor.

Is important to remember that some Authors (Maffey and Emery, 2007) proposed, as intrinsic cause, in our view very correctly, a core muscles weakness or a delayed onset of trasversus abdominal muscle recruitment. Furthermore we must underline that debate exist in literature regarding the age and/or sport experience as risk factor for groin injury (Emery and Meeuwisse, 1999; Maffey and Emery, 2007; Aleman and Meyers, 2010).

Among the extrinsic factors (Brunet, 1983; Brunet et al., 1984; Volpi, 1992; Braun and Jensen , 2007; Hölmich et al 2010; Paajanen et al., 2010) we find:

- Inadequacy of the used materials: a typical example in football is the use of cleats too long on dry surfaces, or too short in case of soft ground (Puig e coll., 2004);

- Unsuitability pitch;

- Errors in the training planning.

However we must underline that concerning both the pubalgia intrisinc and extrinsinc factors in literature there is no strong evidence to support a causal association for any of this risk factors and pubalgia onset. In effect the majority of the studies finding in literature are based on conjecture, expert opinion or case series…

Then in the athletes the pubalgia would be induced by the combination of excessive muscular contractions by the abdominal and adductor muscles, by bone stress caused by torsions and impacts that would occur during the run, by violent movements performed with poor muscle control (such as sprint, shoots, tackles, direction changes etc..) and by mechanical constraints especially of torsional type at pubis symphysis level (Orchard et al., 1998; Wodecki et al., 1998; Gibbon, 1999; Braun and Jensen, 2007; Paajanen et al., 2010). The majority of Authors is in agree with the fact that in normal functional conditions the abdominals and adductor muscles have an antagonistic but biomechanically balanced function. During a pubalgic situation there is an imbalance between adductor muscles, that are too powerful, and the abdomen large muscles who are lack of muscle tone, or adductor muscles extremely stiff with poor elongations exercising an abnormal tension at the pelvis level. In fact, this functional imbalance would have a negative impact at the pubic level (Brunet, 1983; Brunet et al., 1984; Anderson et al., 1989; Christel et al., 1993 Christel et al., 1997; Kremer Demuth, 1998; Robertson et al., 2009). For some Authors (Kremer Demuth, 1998) the quadriceps muscle hypertonia would aggravate this functional imbalance.

In this regard it is important to remember that the rectus abdominis and adductor longus muscles are relative antagonists of one another during rotation and extension from the waist and furthermore of the the rectus abdominis and adductor longus origins blended together to form a common aponeurosis that attaches to the periosteum of the anterior aspect of the pubic body (Robinson et al., 2007).

A good example, concerning this subject, is the sailing boat allegory. As showed in figure 1 the rectus abdominal muscle is comparable to the boat mast, the sail would represent the oblique muscles, while the hull and the keel would be respectively the pubis and the adductor muscles. If the oblique muscles are too weak happens what is in the case where the sail was not well fixed and swiveled under a strong wind: in this case excessive forces transmitted to the mast would cause its collapse. So, in the specific case of pubalgia, the strong tensions at abdominal muscles level would cause damages at pubic level near the rectus abdominals and adductor muscles insertions. In this case, the oblique muscles strengthening, that in our example is the equivalent to the establishment of the sail into the hull (as showed in figure 2), drastically reduce the tension force at pubic level. However, we must remember that others Authors identify, as an additional pubalgia risk factor a ratio less than 80% between the adductor and abductor muscles strength (Nicholas e Tyler, 2002) whereas others Authors an insufficient ratio between the extensor and the flexors trunk muscles, also in this case the reference value would be equal to 0.8 (Gal, 2000). Finally, others studies (Bouvard et al., 2004) include among the predisposing factors the poor monopodalic equilibrium. However, our therapeutic experience does not allow us share this hypothesis, in effect the equilibrium management, both static and dynamic, reflects an extremely multifactorial control mode which makes difficult any inference especially in this specific field.





Figure 1: the boat mast represents the rectus abdominis, the sail the oblique muscles, the keel the adductor muscles, finally, the boat hull represents the pubis



Figure 2: the oblique muscles strengthening, represented into the figure by the sail fixation to the hull, allows to remove the disruptive forces at pubis level.


Finally, at anatomic level is important to remember that six of the seven adductor muscles are innervated by the obturator nerve and that their origin is closeness to the pubis, allowing them biomechanically to act in open kinetic chain as hip adductors but also to have an important stabilization role in closed kinetic chain. Not surprisingly, athletes affected by pubalgia show a strong potential in concentric muscle strength in the lower limb muscles in toto but showing in the same time a lack of postural muscles strength (Bouvard e coll., 2004; Nicholas e Tyler, 2002).

The conservative treatment

Unluckily at present in bibliography there is an important lack of high level, high quality primary evidence to support exercise therapy for groin pain in athletes. Currently a systematic searching of the literature identified only one level II study (Holmich et al., 1999). Furthermore, in general, the methodological quality of the evidence base is only moderate. Then, at the present state of knowledge, the data finding in the literature do not allow to have a general consensus as regarding the athlete’s pubalgia conservative treatment. In any case, the conservative treatment is still recommended as first choice of treatment by the majority of the Authors and would can achieve full recovery in about 80% of the cases (Bouvard et al., 2004; Irschad et al., 2001;Morelli and Smith, 2001; Orchard et al., 2000; Baquie, 2000; Fon and Spencer,2000; Linch and Renström, 1999; Gilmore, 1998; Kremer and Demuth, 1998; Wodecki et al., 1998; Christel et al., 1997; Djian, 1997; Arezki et al., 1991; Durey, 1984; Brunet, 1983; Durey and Rondineau, 1976). Only in the case of conservative treatment failure, conducted in accordance with appropriate therapeutic techniques and persisted for a sufficiently long time, it is necessary to consider a surgical solution (Christel e coll., 1993). Then, currently the common conservative strategies used in the athlete’s pubalgia management are based over composite therapies comprising pharmacotherapy, active and/or passive therapy (Verrall et al., 2007; Jansen et al., 2008). Furthermore all the exercises that formed the different pubalgia rehabilitation plans work, are often derived from the therapist personal experience without a standardized or evidence-based rehabilitation protocol. Finally, we must consider that athlete’s pubalgia, as already said, can encompass a wide range of pathologies and consequently some of these may not positively respond to conservative management. Generally the conservative treatment is preceded by an initial variable length rest period ( Jansen e coll., 2008). The fundamental elements that constitute a conservative work plan can schematically be divided into three categories: the first category is represented by the type of exercises and the progression of work plane, the second category concerns the intensity, the frequency and the duration of exercises and the last category concerns the exercises delivery modality.

Type of exercise and the progression of work plane

Concerning the type of exercises proposed during the conservative work plan, the study that show the most qualitative level included the strengthening exercises as main component of their plans work (Holmich et al., 1999; Rodriguez et al., 2001; Wollin and Lovell, 2005). The target muscles involved in the strengthening exercises are adductor, abductor, hip flexor, and deep and superficial abdomen muscles. The progression of the proposed exercises began with isometric contractions, to continue with the concentric contraction, until to reach, during the last stage of the rehabilitation protocol, the functional standing positions the most similar as possible to those required by the athlete‘s specific sport activity. In all protocols work we find the use of isokinetic exercises. Nevertheless only Holmich et al. (1999) used a predetermined graduated exercise protocol, while in the other study the Authors, in general line, adopted the three following criteria as an indication for exercises ;progression:

1. the absence of pain during the exercise

2. the full acquisition of functional control by the athlete

3. the ability by the subject to completely perform a functional exercise or a set number of repetitions during an exercise

For this category the available evidence suggests that strengthening exercise represent an important component in an effective pubalgia conservative work plane, also if the variability between the different protocols, in terms of the muscle groups focused, makes difficult to conclude on a specific target muscle group. (Holmich et al., 1999; Rodriguez et al., 2001; Wollin and Lovell, 2005). In any case, an important fact to underline is that there is agreement between the different work protocols to propose a exercises progression that start from the isometric contractions just to finish with the sport specific functional standing positions.

The intensity, the frequency and the duration of exercises

Concerning this issue only one study provided enough details concerning intervention frequency and duration to give it reproducible (Holmich et al., 1999). This study suggest a plan work of 90 minutes of strengthening exercises for the hip and abdominal muscles to performer three times per week for an overall duration of 8–12 weeks. For the Authors this plan work is sufficient to attain good outcomes and allows the athlete to return to sport without groin pain. In general, the conservative treatment length is including between a minimum of 2-3 weeks (Gilmore, 1988), just to a maximum of 6 months (Holt e coll., 1995). In any case the majority of the Authors agree for a length conservative treatment of around 6 months (Brunet e coll., 1984; Fournier and Richon, 1992; Zeitoun et al., 1995; Verrall et al., 2007; Weir et al., 2008; Machotka et al., 2009; Jansen et al 2010). In summary is clear that the variation in duration of rehabilitation work plans used, reflects the variation in the severity of groin pain across the different athlete’s populations.

The exercises. delivery modality.

In essence, the majority of studies report the use of one or more co-intervention that ranged from manipulation techniques and massage, (; Verrall et al., 2007; Weir et al., 2008; Machotka et al., 2009; Jansen et al 2010), anti-inflammatory (Brunet et al., 1984; Fournier and Richon, 1992; Holt et al., 1995; Zeitoun et al.,1995; Rodríguez et al., 2001), or corticosteroid medications (Batt e coll., 1995; Anderson et al., 2001; Omar et al., 2008). Some studies included jogging, running and cycling as co-intervention (Holmich et al., 1999; Rodríguez et al., 2001; Wollin et al., 2005; Verrall et al., 2007). Furthermore some studies underline the importance of the exercise programs supervisor by a physiotherapists (Holmich et al., 1999; Wollin et al., 2005; Machotka et al., 2009). This is, in our opinion, an important information in terms of service delivery.

The surgycal treatment

As repeatedly pointed out the athlete’s pubalgia may be caused by several pathologies often treated with conservative therapy. However, if conservative therapy failed, many of these pathologic situation require a surgical solution. In this final section will briefly describe the most common diseases that often require this type of solution.

Inguinal hernia

In athletes, direct inguinal hernias and femoral hernias are the most frequent hernia type (Gullmo, 1980). In this case both US scanning and MR imaging are effective for identifying the hernia sac and the relationship between the hernia sac and the inferior epigastric vessels. Especially the real-time dynamic US scanning during a provocative maneuvers, as for example Valsalva’s maneuver, allows a direct visualization that may help visualize a subtle hernia otherwise difficult to detect. The risk of bowel incarceration and strangulation is relatively high, for this reason most inguinal hernias are surgically repaired, particularly if they are symptomatic (Bax et al., 1999). Nevertheless, the hernias surgical repair has variable success; in effect patients sometimes have recurrent symptoms after the chirurgical procedures and are unable to achieve their prior levels of athletic performance (Omar et al., 2008). It has been proposed that the variable success of surgical repairs is due to the increasing stabilization of the pubic region because of progressive fibrosis (Omar et al., 2008). Furthermore, patients who undergo herniorrhaphy often require additional surgery to repair the rectus abdominis or adductor longus myotendinous attachments. However, patients with inguinal hernia have little chance of success with conservative treatment (Ahumada et al., 2005; Omar et al., 2008). After herniorrhaphy, in average 87% of the athletes have a positive outcome and are able to return to full, unrestricted athletic activity in 4 weeks or less (Srinivasan and Schuricht, 2002; Ahumada et al., 2005; Kachingwe and Grech, 2008).

Sports hernia

Sports hernia, also known as sportsman’s hernia, athletic hernia, incipient hernia or cryptic hernia, represents a difficult clinical problem. (Muschaweck and Berger, 2010). The diagnosis of sports hernia is formulated when no inguinal hernia is found, but there was a localised bulge in the posterior wall of the groin canal during the Valsalva manoeuvre. As the canal is widened, the rectus muscle is medially and cranially retracted, this retraction causes increased tension, causing the pubalgia. (Muschaweck and Berger, 2010). Sports hernias rarely improve without surgery (Polglase et al. 1991; Hackney, 1993; Ingoldby, 1997; Ekstrand and Ringborg, 2001; Farber and Wilckens, 2007; Moeller, 2007) and the surgical repair should be considered when conservative treatment, over a period of 6 to 8 weeks, has failed and when careful examination has excluded other potential pain sources (Caudill et al., 2008; Muschaweck and Berger, 2010). At present in the case of surgical repair the surgical technique most used is represented by the use of heavyweight or lightweight meshes with laparoscopic positioning (Susmallian et al., 2004; Peeters et al., 2010). This “tension free”” technique involves placing prosthetic synthetic suitably shaped non-absorbable and biocompatible, which act as mechanical reinforcement of the abdominal wall (Susmallian et al., 2004; Peeters et al., 2010). After laparoscopic repair, the recovery before full return to competition is generally between 2 and 8 weeks (Hackney, 1993; Azurin et al., 1997; Ahumada et al., 2005; Kumar et al., 2002; Kluin et al., 2004; Genitsaris et al., 2004; Edelman and Selesnick., 2006; Van Veen et al., 2007; Caudill et al., 2008). However, in a meta-analysis study (Caudill et al., 2008) the Authors found that the period for a sports activity restart is in average 17.7 weeks for patients who underwent open approaches and 6.1 weeks for laparoscopic repairs. Nevertheless several Authors underline mesh-related complications, such as infections with chronic groin sepsis and fistula formation, complications that sometimes requires the mesh removal (Avtan et al., 1997), or may caused mesh migration and penetration into the bladder or bowel (Bodenbach et al., 2002; Lange et al., 2003), or also foreign body reaction with decrease of arterial perfusion and testicular temperature (Peiper et al., 2006) with secondary azoospermia (Shin et al., 2005; Peiper et al., 2006). Is interesting to note that in 2003 Muschaweck et al. (Muschaweck, 2003; Muschaweck et al., 2010) developed a new surgical technique named “Minimal Repair’’ Technique”. The aim of this surgical intervention was stabilize the posterior wall by a nearly tension-free suture, without use prosthetic mesh. The Authors chose to avoid to use a prosthetic mesh to allow the athletes full elasticity and slide bearing in their abdominal muscles after surgery, contrary the meshes insert may result in localized stiffening of the abdominal muscles ((Muschaweck et al., 2010). In Authors opinion this technique presents, beyond to avoid prosthetic mesh insertion, other several vantages such: no general anaesthesia required, less traumatisation and lower risk of severe complications. Furthermore, the Authors underline a sport activity faster restart after this surgical technique compared to the laparoscopic or open approaches mesh positioning. In their study the Authors report that on average, their patients resumed moderate training after 7 days, felt a complete relief of pain after 14 days and the return to full activity was achieved after 18.5 days ( Muschaweck et al., 2010)

Adductor tendinopathy

Adductor tendinopathy is one of the most common causes of pubalgia in athletes’population. The adductor tendinopathy is frequently related to an adductor longus overuse or to its aponeurotic injury (Akermark and Johansson, 1992). The vast majority of patients respond positively to the conservative treatment, both in case of overuse tendinopathy or in muscle-tendon injury. Little is published in case of chronic adductor-related groin pain when conservative measures fail (Atkinson et al., 2010). Adductor tenotomy is proposed for recalcitrant cases to conservative treatment (Akermark and Johansson, 1992; Lohrer and Nauck, 2007; Atkinson et al., 2010; Robertson et al., 2010). The criteria for surgery is an history of long standing (ranging from 3 to 48 months according with the various Authors) and distinct pain at the origin of the adductor longus muscle, refractory to the conservative treatment. Into the considered studies (Akermark and Johansson, 1992; Van Der Donckt et al., 2003; Atkinson et al., 2010), the subjects returned to the competitive sport after 19.8 weeks (range 27-14 weeks). Always into the three cited studies the 70.6% of the subjects (range 90-62%) performed after surgery their sport activity at the same level, the 24% (range 32-9%) at reduced level and the 5% abandoned their sport activity. Is interesting to note that some Authors associate to the adductor tendon release a pelvic floor repair (Meyers et al., 2002; Nicholas and Tyler, 2002). Surgically treated adductors acute tears have rarely been described in bibliography. We cite only one study (Lohrer and Nauck, 2007) reporting three cases of acute proximal adductor longus insertional tear, repairing using suture anchors and followed by post-operative rehabilitation. The three subjects considered in this study re-established their full sport ability after five, six and seven months, respectively.

Osteitis pubis

Osteitis pubis is a common disease in soccer players, long-distance runners, and hockey players and his etiology is believed to result from the pubic symphysis instability (Omar et al., 2008). The loss of symphysis stability causes a chronic repetitive shear and an unbalanced tensile stress of the muscles inserted on the pubic symphysis. This biomechanical alteration cause an inflammatory responses with osteitis and periostitis. Osteitis pubis is normally a “self-limiting” disease, but requires long time, in average 12 months (Anderson et al., 2001). The management is initially conservative with physical rehabilitation, NSAID and/or steroid injections. The surgical treatment, consisting in symphyseal arthrodesis, is reserved for the subjects whose symptoms do not respond to conservative treatment (Anderson et al., 2001; Omar et al., 2008).

Hockey goalie–baseball pitcher syndrome

This is an unusual syndrome caused from an epimysial or myofascial herniation of the adductor longus muscle belly occurring several centimeters away from the site of its pubic attachment (Meyers et al., 2002). The etiology of myofascial herniations in hockey goalie–baseball pitcher syndrome has not been established, also if several Authors have suggested a relationship with chronic repetitive stress at level of neurovascular penetration (Gokhale, 2007). The treatment of recalcitrant pain is the surgical epimysiotomy and debridement (Mellado and Perez, 1999).

Acetabular labral tear

In general line, the hip disease may cause groin pain, over synovitis, osteoarthritis, intra-articular bodies, tears of the ligament teres, the most commonly problem at hip level is the acetabular labral tears (Overdeck and Palmer, 2004). The anterior-superior part of the labrum is poorly vascularized and for this reason is susceptible to injuries, particularly during hyperextension and external rotation (Overdeck and Palmer, 2004; Morelli and Weaver, 2005). Dance, golf, hockey and soccer are associated with a higher incidence of hip injuries (Mason, 2001). Labral tears are initially managed conservatively with rest and NSAID therapy. The subjects with persistent symptoms often require labrum surgical debridement. The surgeon during surgery, might decides to correct also other morphologic abnormalities of the acetabulum or the proximal femur predisposing the patient to femoro-acetabular impingement, to prevent in this manner the progressive cartilage loss and osteoarthritis (Huffman and Safran, 2002; Philippon, 2006). The hip arthroscopy is both a diagnostic (gold standard) and therapeutic tool, although it is technically more difficult than arthroscopy of other joints, as for example knee or shoulder. In effect, during this procedure, to access the hip joint, is necessary a distraction of the hip of about 10–15mm, and this traction may causes several complications, such as neuropraxias (Huffman and Safran, 2002). Also if in a number of case series, arthroscopy has been shown to give benefit in recent traumatic labral injury (Dorfmann and Boyer, 1999; Byrd and Jones, 2000; O’Leary et al., 2001) is important to note that is often disappointing in chronic hip pain, which is probably associated with degenerative change, and chondral lesions of the acetabulum (McCarthy and Busconi, 1995; Brukner et al., 2006).

Internal snapping hip

The internal snapping hip, or coxa saltans, may be an occasional cause of pain in the anterior part of the hip and in the inguinal region. This pathology is caused by the iliopsoas tendon contact with an osseous protuberance, most commonly the iliopectineal eminence or the anterior-inferior iliac spinal process. The contact happens when the iliopsoas tendon moves from an anterolateral to a posteromedial position, this causes in the subject a snapping sensation frequently accompanied by a snapping sound. The chronic repetitive motion may develop iliopsoas bursitis and tendinosis (Brittenden and Robinson, 2005). The conservative treatment consists in pain control with NSAID therapy and/or corticosteroid injections in cases of bursitis, iliopsoas muscle stretching is also recommended (Brittenden and Robinson, 2005; Blankenbaker and Tuite, 2006). Surgical lengthening of the iliopsoas tendon occasionally, although rarely, is necessary in subjects that do not respond to conservative treatment (Morelli and Weaver, 2005).

Osteoid osteoma

Osteoid osteoma is a benign bone tumor usually observed in subject between the ages of 5 and 30 years. Normally is most common in the long bones, especially in the femur and tibia, but it can also involve the pubic bones where it may mimics the pubalgia symptoms (Omar e coll., 2008). Total removal of the osteoid osteoma nidus generally results in a complete resolution of symptoms, while at the contrary, his partial removal may lead to recurrent symptoms (Cantwell et al., 2004; Ghanem, 2006).

Nerve entrapment

The groin and upper thighs. sensory and motor innervations is provided by several nerves including the obturator, femoral, iliohypogastric, genitofemoral, ilioinguinal, and lateral femoral cutaneous nerves. An entrapment of any of these structures may causes groin pain mimicking pubalgia (Bradshaw et al., 1997; Harvey and Bell, 1999 Omar et al., 2008). Concerning for example the obturator nerve, its entrapment may be caused from a fascial thickening of the adductor compartment, or from a “mass effect” caused by an obturator hernia, a pelvic fracture, or from an acetabular paralabral cyst(Bradshaw et al., 1997; Harvey and Bell, 1999 Omar et al., 2008). A femoral nerve entrapment may be caused by surgical procedures for hip arthroplasty, herniorrhaphy, and abdominal hysterectomy (Morelli and Weaver, 2005), while ilioinguinal and genitofemoral nerves entrapment was observed after abdominal surgery in blunt trauma or in muscle hypertrophy (Morelli and Weaver, 2005). The treatment of nerve entrapment syndromes often requires a surgical resolution normally consisting in débridement of perineural scar tissue or division of constricting fascia (Morelli and Weaver, 2005).

Conclusions

The athlete’s pubalgia is still in any case an interesting and controversial subject of discussion, especially as regards its therapeutic management, either conservative or surgical. Anyway, it seems very important to underline the enormous importance in this field for a proper and early diagnosis. In fact, only after having diagnosed the precise groin pain etiology is possible refer the patient to the most appropriate type of treatment. For this reason, clinical examination must, in most cases, be supported by appropriate imaging studies, which could help specialist in the diagnosis. Furthermore, also the conservative treatment, in the cases where it is recommended, must follow clearly defined intervention criteria, in relationship with the patient's functional progress and in full respect of the pain reported by the subject.

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