Athletic Pubalgia (Sports Hernia)

Athletic pubalgia (also known as a sports hernia) is the result of increased muscular loads placed on the pubis from repetitive, high-volume twisting, cutting, running, and kicking activities.

Athletic Pubalgia is a collective term for all disorders that cause chronic pain in the region of the pubic tubercle and the structures attached to the pubic bone (inguinal region), including osteitis pubis, a chronic inflammatory and overuse condition of the pubic symphysis and adjacent ischial rami.

See Also: Hip Muscles Anatomy

Athletic Pubalgia Causes

Athletic Pubalgia typically results from a sports injury. It usually results from a single-leg movement, where the weight-bearing leg is rotated as the other leg performs a movement such as kicking, or during activities such as sprinting and pivoting. During this kind of motion, small shearing movements occur in the pubic symphysis.

The condition is rarely found in women, this may be because of variations in pelvic anatomy between men and women and strength differences or participation levels between genders.

A number of abnormalities in joints and muscles around the groin may increase the mechanical stress placed on the pubic region:

1. limited hip ROM;
2. increased adductor muscle tone;
3. increased rectus abdominis tone;
4. iliopsoas muscle shortening, often associated with hypomobility of the upper lumbar spine;
5. lumbar spine/SIJ dysfunction;
6. decreased lumbopelvic stability.

Symptoms

Some patients describe an acute episode with resulting disability, but this often follows a period of low grade symptoms. The actual source of pain may be one of the following:

1. the transversalis fascia,
2. conjoined tendons of the adductor group,
3. the insertion of the rectus abdominis,
4. the external oblique aponeurosis,
5. the avulsion of the internal oblique from the pubic tubercle.

Clinically, the patient will describe deep lower abdominal or groin pain that is present with activity and abates when activity stops. Classically, symptoms return soon after resuming activity after a period of rest. In most cases, the pain is unilateral at onset, with progression to bilateral pain in about 40% of cases.

Males may complain of testicular pain.

Examination findings include the following:

1. Pain may be elicited with passive hip flexion, when combined with hip adduction, or with passive abduction with a straight or bent knee. However, in some cases, ROM may appear normal.
2. Point tenderness at the pubic tubercles, rectus abdominis insertion, adductor origin, and inferior pubic rami.
3. Pain is intensified with sit-ups and resisted hip adduction.

Unlike an inguinal hernia where the defect is palpable, no palpable defect is present with a sports hernia.

Imaging

Plain film radiographs may be ordered to rule out other underlying bony trauma;

MRI is useful in identifying defects in the surrounding muscle or fascia.

Athletic Pubalgia Treatment

Athletic Pubalgia Treatment non-operative treatment includs:

1. A period of relative rest and anti-inflammatory medications.
2. Ultrasound, electrical stimulation, thermotherapy, and cryotherapy as appropriate.
3. stretching, and exercise may be indicated for those athletes who describe a gradual onset of symptoms and who can tolerate a prolonged rehabilitation process.
4. Effective warm-ups and preparation before the sporting activity can play an important preventative role.

Stretching as tolerated to the muscles surrounding the injured area:

1. The short and long adductors.
2. Hip flexors (iliopsoas and rectus femoris).
3. Hip internal rotators.
4. Abdominals.
5. Gluteal muscles.

Those for whom conservative treatment has failed or high-level competitive athletes with an acute diagnosis of athletic pubalgia may be candidates for corrective surgery, which is associated with a good outcome. Multiple surgical techniques have been recommended, including:

1. imbedding reinforcing mesh over the weakened area (herniorrhaphy),
2. repair of the rectus abdominis insertion,
3. releasing the adductor tendon.

References

1. Preskitt JT. Sports hernia: the experience of Baylor University Medical Center at Dallas. Proc (Bayl Univ Med Cent). 2011 Apr;24(2):89-91. doi: 10.1080/08998280.2011.11928689. PMID: 21566750; PMCID: PMC3069511.
2. Kachingwe, AF, and Grech, S: Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J Orthop Sports Phys Ther, 38:768, 2008.
3. Litwin, DE, et al: Athletic pubalgia (sports hernia). Clin Sports Med, 30: 417, 2011.
4. Meyers WC, Foley DP, Garrett WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med 28:2–8, 2000.
5. Understanding Athletic Pubalgia: A Review – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Algorthrim-for-Treatment-of-Athletic-Pubalgia_fig3_309286310