Pubalgia; Groin Pain.. What it is, How and how it is diagnosed.

Posted by I1580918 on Wed, Feb 24, 2010  
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...was originally known as Sport's Hernia, and Sportsman's Hernia, and described abdominal and inguinal pain experienced by athletes without any evidence of actual hernia upon physical examination. There is confusion resulting from the various terms of nomenclature used to describe the condition of Pubalgia; Pubalgia seems to be the best fit for the condition though

mainstream media has promoted the use different nomenclature relating to Pubalgia. Other nomenclature Pubalgia is known by includes: Osteitis Pubis, Gracilis Syndrome, Pectineus Syndrome, Athletic Hernia, Athletic Pubalgia, Gilmore's Groin, and Groin Disruption. Initially the term was used to refer to a weakness in the posterior wall of the inguinal canal, because physicians associated that Pubalgic pain with the initial indication of inguinal hernia.

About Pubalgia...What is Pubalgia?

       Pubalgia is a medical condition caused by repeat trauma and hyperextension of the abdomen causing severe musculotendinous or musculoskeletal injuries and characterized by a slow onset of chronic (ongoing) pain, or aching in the lower abdominal regions, specifically the pelvis, groin, hip, testicular region and the lower extremities. It is also characterized by dilation in the superficial ring of the inguinal canal (see What is the inguinal canal, below). Usually a tear in one of the lower abdominal muscles, inguinal canal or associated connective tissues is the source of the pain. Pubalgia is typically experienced by athletes after partaking in intense athletic activities which place a great deal of stress or shear forces on the groin, pelvic area and abdominal regions.

      Symptoms are usually exacerbated by running, twisting and turning, rapid side-to-side ambulatory movements , and bending forward. Sports in which Pubalgia is found most frequently

are soccer, football, ice hockey, rugby, field hockey, tennis and track. Pain may also be experienced when coughing or sneezing. Athletes who do not exhibit sufficient strength and coordination through the region of the lower kinetic chain (which a special emphasis placed on the ankle and hip regions) are much more likely to suffer from micro tears to soft tissues and the possibility of sustaining an injury related to Pubalgia. Usually the exact location or source of pain is quite difficult for the patient to pinpoint due to the amount of nerve and muscular tissue in the abdominal cavity.

      Pubalgia has no obvious objective signs such as a bump or bulge, if this condition is observed it is most likely inguinal hernia and a physicians examination is highly recommended. London Surgeon Jerry Gilmore recognized the syndrome as a pathology in 1980 and devised a surgical repair technique for repairing the pathology. There are a number of combined factors which could lead to the experiencing of Pubalgia. Factors such as weak musculature, weakness in the abdominal or inguinal wall, unbalanced muscles, faulty training regiment (especially during warm-up), fatigue, flexibility constraints, poor body mechanics, previous injury and psychological state are all attributed to setting the stage for the possibility for Pubalgia to develop. However, more attention is given to neuromuscular factors such as poor neuromuscular control and lack of strength, which make a significant contribution to the possibility of injury in the pelvic/groin region. There are a wide variety of anatomical anomalies which may be observed upon surgical exploration that account for the pain observed by the patient.



What are the most frequent causes of groin pain?

○ Inflammation of the pubic bone, or a tear in tendons which connect to it.
○ Torn external oblique aponeurosis
○ A tear in the Myofascia of the transversalis
○ Torn conjoined tendon usually in proximity to the Pubic Tubercle
○ The early stages of development of inguinal hernia.
○ An anomalous attachment or tear of the adductor muscles, most commonly in proximity with the pubic bone.
○ An abnormal insertion of the Rectus Abdominis muscle (birth defect)
○ Changes within the lumbosacral section of the spine.
○ Changes in and around the interpubic joint area.
○ Neuralgia of the nervus ilioinguinalis
○ Entrapment of the ilioinguinal nerve or genitofemoral nerve.
○ Damage to the acetabelum (socket-joint) of the hip
○ Necrosis of the superior head of the hip bone.
○ Avulsion type injuries.
○ Detachment between the inguinal ligament and the torn conjoined tendon, which usually is the chief cause of the symptoms associated with Pubalgia.

Early efforts to image the abdominal and pubic regions had variable results. This may have been due to an incomplete understanding of the biomechanics of the pubic symphysis and the surrounding anatomy. Imaging techniques were not tailored for the best possible observation of the abdominal and pubic and thus less information was obtained in the diagnostic process.

Now that the anatomy of the region is understood more in depth techniques for diagnosis are becoming more adequate in detecting the subtle anatomical changes which elicit such conditions. It is recommended to get a full MRI scan of the pelvic region from multiple angles in order to get the best diagnosis, since there are quite a few muscles, ligaments, tendons, and nerve connections in the pelvic region. Better diagnosis leads to better treatment of the given condition.

Who Does Pubalgia Effect?
Anyone is susceptible to Pubalgia. However, this condition predominantly effects males under the age of 40 years. It is proposed that more males are susceptible to Pubalgia due to the fact that in Female anatomy, the Myofascia in the region of the abdominal aponeurosis and pelvis is more capable of adaptation to stresses due to the abilities of the abdominal region to adapt to childbirth and the subsequent stress placed on the Female anatomy because of the intense stretching of the region and thus Fascial connections may be more resilient in order to allow the region the ability to stretch but not rupture during gestation. In addition, the Female pelvis is wider with a larger sub-pubic angle than the male pelvis, characteristics which may aid the absorption of forces and transference of the forces away from the pelvic region to the rest of the lower extremities. This is a

protective mechanism which may have evolutionary value for protecting a Woman's abdomen and the likelihood of successful birth. Therefore it has been postulated that this is the reason that Pubalgia predominantly effects men.


Symptoms of Pubalgia

       Usually the symptoms of Pubalgia pain become apparent following any event that activates muscles in the pelvic region, or any action which causes an increase in intra-abdominal pressure

such as with increased strenuous athletic activities like sidestepping, kicking, running, sprinting, hip abduction (extension), and twisting and/or turning. In addition the actions of coughing, sneezing, sitting or standing may become difficult due to discomfort caused by pain. Pain is usually reported as localized and chronic tenderness in the groin area during and after exercise and presents itself without evidence of herniation.

       Pubalgia is usually characterized by pain around the abdomen, groin, hip, or thigh areas. Frequently the pain originates from a muscle or tendon injury in the inguinal areas near one of the attachments of the rectus Abdominis, or adjacent the Internal Oblique muscles near the Abdominal wall. Individuals usually experience an intense onset of pubic and deep groin or abdominal pain which is amplified by physical activity; the pain may radiate to the inguinal ligament, Rectus Abdominis, and the Perineum. Pain may also radiate to the lower extremities as well as the adductor muscle regions and may occasionally radiate into the testicles as well,

although it is often difficult for the patient to pin point the exacted location o the source of pain. Individuals sometimes attribute testicular pain to Pubalgia, but in reality; the two conditions are unique and separate. Pain may progress to the surrounding areas of the abdomen, and lower back as well. Symptoms are usually lateralized to one side (unilateral);however it is not uncommon for bilateral symptoms to occur.

       Patients may experience cycles of pain which go from less to more intense, however left untreated the condition is usually progressive over time and the pain becomes more intense to the point where it is not easy to perform normal daily functions. Most patients deal with the symptoms for a long period of time before seeking treatment and diagnosis can be obtained. Hernia-like symptoms may actually be related to the resultant weakening of the posterior wall of the inguinal canal, though no actual hernia exists in this condition.

Diagnosis of Pubalgia
How is Pubalgia usually diagnosed?

        A diagnosis is usually determined by a combination of assessment of the patients previous health history, a physical examination and diagnostic tests. Diagnostic tests include orthopedic and surgical examination as well the use of imaging techniques such as ultrasound, x-ray, CT or MRI scans and electrophyography. Most commonly, the catalyst in a valid diagnosis is thorough examination using various angles with MRI imaging scans as well as bone scans to reveal any inflammation to the pubic bone. Physicians are able to run test panels to determine if there has been any damage to bones or tissues in the areas effected as well as if an infection exists which could potentially be triggering the pain. (which is quite serious, and a very good reason to get checked by your physician if pain persists for more than a week.).

      Usually during examination of inguinal incision as well as exploration of the external oblique aponeurosis, it is discovered that there is a small tear in the External Oblique aponeurosis near the emergence of the neurovascular bundle associated with the terminal branches of the

anterior primary Ramus of the Iliohypogastric nerve. Pain in the groin can be attributed to a number of different sources such as the lumbar spine, the sacro-iliac joint, the hip joint, the abdomen, as well as the genito-urinary system. Diagnosis of Pubalgia requires a thorough examination and skilled differentiation between the structures as well as an intricate knowledge of the anatomy of the pelvic region. The most notable clinical sign is the dilation or widening of the superficial inguinal ring of the effected side, it is possible for a physician to perform a physical examination to determine if this condition is present.
       Pubalgia may be misdiagnosed during an initial visit to a primary care physician as groin pain associated with normal exercise. The physician may recommend rest as well as the application of ice as well as heat to quell the symptoms of pain, anti-inflammatory drugs and physical therapy; Otherwise known as conservative treatment. Pubalgia may be quite difficult to diagnose for a primary care physician. Diagnostic confusion is often derived from the complex nature of the anatomy and biomechanics of the pelvic region and pubic symphysis. There are a large number of muscles, tendons, and nerves in the pelvic region and thus a large number of potential sources of groin pain. Each of these sources of pain may have similar symptoms, but have different sites of the actual injury. Much of the confusion in diagnosis also relates to the fact that previously the complicated anatomy of the anterior pelvic region was not a surgical specialty or concentration within medical science, and therefore less emphasis was placed on physicians familiarizing themselves with the complex anatomy of the region. The pelvic region was in effect "no mans land" for a wide range of specialties until recently. If conservative therapy does not relieve the symptoms of Pubalgia, your physician will most likely refer you to a specialist for further evaluation. Pubalgia has a spectrum of related pathological conditions which result from musculotendinous injuries and the subsequent instability caused in the region of the pubic symphysis. Pubalgia is usually the diagnosis when there is no indication of inguinal hernia upon physical examination.

       The actual mechanism of athletic Pubalgia are poorly understood, in the past, imaging studies have been deemed inadequate or unhelpful in the use of diagnosing Pubalgia. Magnetic Resonance Imaging is now more reliable for helping to diagnose athletic Pubalgia as opposed

to in the past where it was less reliable due to a deficit in the knowledge associated with the anatomical structures and pathophysiological changes of the region. A full MRI survey of the pelvis, in addition to a high-resolution MRI of the pubic symphysis is an adequate technique for assessing and diagnosing the various causes of Pubalgia; Providing vital information regarding the location of the injury and determining the severity of the pathological condition.

        Most commonly, MRI and surgery results have shown that the prevalence of the injury originating along the lateral border of the Rectus Abdominis just superior to its pubic attachment, or at the origin of the Adductor Longus. With either of these injuries there is a repetitive unbalanced contraction in antagonistic muscle causing it to be locked short and distorting our bodies natural way of dealing with the stresses and forces exerted on the pelvic region. This lack of opposing force can then lead to degeneration and tearing of tendons which were not initially involved in the injury. Our body can be paralleled to an intricate tensegrity structure; when a certain element of the structure is out of alignment or not operating correctly, the balance is disrupted and the integrity of the entire structure is compromised. Once this integral harmonious balance is disrupted it leaves the body open to further pathological conditions and injuries. It is for this reason that Pubalgia pain may actually result from the initial injury as well as the chronic repetitive stresses to the antagonistic tendons and ligaments or the destabilized pubic symphysis.

Treatment of Pubalgia

The best form of treatment is preventative maintenance. Preventative maintenance exercise concentrating on developing core stability with special focus to the pelvis and trunk area is the best way to ensure that one does not experience Pubalgia. Athletic trainers are beginning to understand the inherent value of developing core strength and stability. Training regiments are being developed that concentrate specifically on eccentric exercises designed to improve the stability of the anterior pelvis and surrounding core muscles.

 It is important to maintain an exercise regiment that incorporates training the abdominal and adductor muscles as well as thigh adductors. Strengthening the abdominal  oblique's may be the most important factor in prevention. This has shown to help reduce the occurrence of injuries to the region. It is very important that when training for athletic activities that one does not forget to include reciprocal training using both the agonist and antagonist muscles.

 It is important not to increase strength of certain muscles groups without improving others

which link to it in the kinetic chain. Balance and moderation is the key. If muscle strength is not balanced and stable, excessive external loads, shifting the axis of balance resulting in more stress  placed on certain soft tissues  resulting in micro tears of the said tissues. This evens out the strain on the body (remember- Our human anatomy is just one large tensegrity structure… Harmony and balance of each opposing anatomical piece is key to the integrity of the body as a whole.)

 Conservative treatments have statistically shown to be wholly ineffective at relieving the condition of Pubalgia. However, upon experiencing groin pain for which the cause is not readily known, it is recommended to rest, use ice and anti-inflammatory medications, and to avoid the application of heat, which may make inflammation worse. The healing power of ice is far more substantial for conditions in which inflammation is present than the application of heat.
When the physician diagnosis a minor cause of the condition such as muscle strain, or sprain, usually over-the-counter medication is recommended to help achieve relief from the symptoms. Aspirin, Acetaminophen or ibuprofen can be used to help quell the pain as needed, but should be taken in accordance to the instructions given by the physician. However, should these conservative treatments of Pubalgia pain prove ineffective, surgery is highly recommended. An athlete will experience pain that progressively gets worse if treatment is not sought.

Conservative treatments usually involve strengthening of the pelvic muscles, and should mainly be used for preventative measures as opposed to actual treatment of the condition once it

becomes chronic. It is recommended that an individual experiencing prolonged pain to seek the diagnosis of a physician or specialist who is experienced in sports injury management and treatment. Conservative therapies frequently include injections of steroids into the pubic symphysis or the adductor tendon origins. These injections may have provided temporary relief from symptoms, however patients often experienced a resurgence of the condition upon resumption of athletic activity. Therefore steroid injections are not considered to be an effective treatment of the underlying injury in the long term. Usually when athletes have not responded to conservative rehabilitation surgery is advised.

 The basis for the current techniques for surgical reconstruction are quite similar to those performed for inguinal hernias are often effective for use in sports hernias as well. Most procedures involve minor variations of the standard hernia repair. Once Pubalgia has been identified, the condition can be corrected surgically by reinforcing the muscles that were torn from the bone. The most effective technique being used today is laparoscopic surgery which involves a small number of 1/4-inch incisions into which instruments are inserted to visualize the muscle damage as well as perform repair.

Synthetic mesh material is usually used to reinforce the connection and ensure proper repair. Since this technique involves less extreme incisions, recovery time is significantly shorter. Less medication is needed because there is less pain present as a result of the surgery, and scarring is usually minimal. Usually patients are able to walk the first day of the surgery; though no exercise is permitted save for walking for at least two weeks after the operation procedure. Laparoscopic surgery is highly recommended as the recovery time is about 2-4 weeks as opposed to open-surgery which is more traumatic for the body and takes anywhere from 10 weeks to 6 months for full recovery to be possible. After two weeks has passed, patients are able to resume aerobic activities such as biking, jogging, and swimming, however no heavy lifting or sprinting is recommended until four weeks have past; at which time the patient can return to playing their sports as normal.

Pelvic floor repair is a common technique in which the Inferolateral margin of the rectus Abdominis is reattached to the fascia overlying the anterior pubis and the anterior pubic ligament. This technique does not affect the internal ring of the pelvic floor and is performed in conjunction with an adductor tendon release or "Tenotomy" where several longitudinal incisions are made in the anterior Epimysial fibers of adductor Longus at its pubic attachment. This treatment shows to have a 95% success rate when used, usually with the athletes reporting resolution of the injury or at very least a substantial improvement in symptoms allowing athletes to return to pre-injury levels of athletic activity.

Approximation surgery of the torn edges of the external oblique aponeurosis using nylon mesh usually leads to a full recovery in between 5 and 6 weeks following the operation. Pelvic floor surgery as a treatment for athletic Pubalgia has show to be effective in 96 % of the applications of its use. Newer techniques such as high-powered laser therapy and Myopulse have shown a 90% rate of injury resolution. Between 65 and 90% of athletes are able to return to sports activity after surgery for Pubalgia, rehabilitation has been shown to take anywhere from 6-8 weeks. Overall, 89% of procedures were considered successful. Laparoscopic repair seems to be the best bet, with a trans-abdominal preperitoneal technique used for hernias; patients were able to return to sporting activities 2-3 weeks after surgery. The fact that laparoscopic encourages a shorter recovery time suggests that this treatment is highly recommended for athletes seeking to get back into their activity of choice with less downtime.

Rehabilitation after surgery can take anywhere from 4 weeks to nearly 1 year depending on the treatment approach. The goals of rehabilitative treatments are to reduce the amount of pain and inflammation the individual is experiencing while improving flexibility and muscle conditioning in the associated areas (concentrating on core strength), thereby strengthening muscles which were once weakened. No sudden twisting or turning movements should be performed in effort to keep from aggravating the injury. Gradually fitness routines will become more intense until the individual is able to return to the prior level of fitness. Pain associated with the adductor inflammation may dissipate during exercise once the body is properly warmed up, however if it remains untreated it is likely to become worse.

 SOURCE: ; your source for information on groin pain and pubalgia online.


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