Athletic pubalgia

Athletic pubalgia or groin pain in athletes is a clinical syndrome of chronic lower pelvic and groin pain, usually encountered in athletes. It is either a musculotendinous or osseous injury that involves the insertion of abdominal muscles on the pubis and the upper aponeurotic insertion of the adductor muscles. Although it can occur following an acute injury, it is most often the result of repeated microtrauma.

Terminology

Athletic pubalgia was first described as Gilmore’s groin and has been commonly known as sportsman's hernia or sports hernia, although the latter two are a misnomer since an actual hernia does not occur. Groin disruption injury is another term that has fallen out of favor. Around 2020, core muscle injury or groin pain in athletes ⁷ have been preferred terms by some to refer to athletic pubalgia.

Epidemiology

Approximately 15% (range 5-23%) of all sports injuries result in groin pain ^2,3; groin pain is more common in males.

Risk factors

Groin pain is common in the following sports ^2,3:

• football (soccer)

• ice hockey

• rugby

Clinical presentation

Athletic pubalgia is a diagnosis of exclusion. Other more sinister causes of groin pain must first be ruled out. The symptoms are usually non-specific and include:

• tenderness on palpation of the medial inguinal floor

• tenderness on palpation over the pubic ramus

• exacerbated pain with resisted hip adduction

Pathology

The sheetlike inferior aponeurosis of the rectus abdominis muscle is continuous with the proximal aspect of the adductor aponeurosis (especially adductor longus). The resultant shared aponeurotic plate is fused to the anterior surface of the pubic tubercle and pubic body slightly off midline in the ipsilateral pubic region ¹¹.

The term athletic pubalgia refers to a spectrum of injuries that includes tendinopathy of the aponeurosis, separation of the aponeurotic plate from the pubic bone, frank tearing of the aponeurotic plate, myotendinous strain within the rectus abdominis or abductor longus muscles, pubic tubercle apophysitis, and stress reaction/fracture in the parasymphyseal region of the pubic bones ¹¹.

Radiographic features

The preferential imaging modality for the diagnostic workup of ‘groin pain’ in athletes is MRI, however, some helpful imaging features can be observed in other imaging modalities.

Plain radiograph/CT

• degenerative changes

• alignment abnormalities

• widening of the symphysis

• assist in excluding other causes of groin pain e.g. osteoarthritis, femoroacetabular impingement

Ultrasound

The following features can be detected on ultrasound examination ⁷:

• anechoic defects and/or partial or full-thickness discontinuities of the tendon insertions in case of tears

• loss of normal fibrillary architecture, thickening and hypoechogenicity of tendon insertions in case of tendinopathy

• spurring and irregularities of the pubic bone

• symphyseal effusion

• periarticular hyperemia on color Doppler

• reproduction of symptoms on pressure with the ultrasound transducer

Potential pitfalls:

• anisotropy on assessment for tendinosis

• protrusion of pre-peritoneal fat through the Hesselbach triangle during abdominal strain

MRI

MRI can show findings of:

• osteitis pubis ⁷

  • subchondral bone marrow edema, involving the entire anterior-posterior diameter of the pubic bone as a result of an osseous stress response

  • subchondral sclerosis and irregularities in chronic or longstanding cases

• adductor tendon injury ^7,8

  • thickening of tendon insertion sometimes with concomitant signal alterations as a sign of tendinosis

  • partial or full-thickness tears displayed as fluid-filled defects, with or without tendon retraction

  • linear fluid signal running along the inferior margin of the inferior pubic ramus known as ‘secondary cleft’

• injury or tear of the aponeurotic plate: fluid-signal intense subperiosteal cleft running from the symphysis along the inferior margin of the superior pubic ramus also known as ‘superior cleft’ ^7,9

• or a combination of all with a cleft extension of tears or clefts from the symphyseal joint capsule into the adductor tendons or rectus abdominis muscles ⁷

It can also show insertional tendinopathy, tears and iliopsoas bursitis in iliopsoas-related groin pain.

Furthermore, the objective of MRI in the evaluation of groin pain is not only to demonstrate pathologic findings of the pubic bone, the rectus abdominis-adductor longus aponeurotic plate and the adductor insertions but also to rule out or identify potential other causes of groin pain ⁷, e.g. inguinal hernias and hip-related groin pain.

Potential pitfalls:

• ‘primary cleft’: developmental cleft in the posterosuperior central portion of the symphysis

Treatment and prognosis

Depending on the site of injury and the final diagnosis there are different treatment options ^ref:

• adductor-related groin pain: supervised active physical training, multimodal treatment including adductor manipulation or operatively with a partial release

• pubic-related groin pain: pubic symphysis injection

• inguinal-related groin pain: hernia repair

Differential diagnosis

Causes of groin pain in athletes are divided into three categories ^ref:

• defined clinical entities for groin pain

  • adductor-related 

  • pubic-related

  • iliopsoas-related

  • inguinal-related

• hip-related causes of groin pain 

• other causes of groin pain in athletes

  • piriformis syndrome

  • pelvis stress or insufficiency fracture

See also

• groin pain (summary)

• osteitis pubis