Athletic pubalgia and associated rehabilitation

Abstract

Background: Evaluation and treatment of groin pain in athletes is challenging. The anatomy is complex, and multiple pathologies often coexist. Different pathologies may cause similar symptoms, and many systems can refer pain to the groin. Many athletes with groin pain have tried prolonged rest and various treatment regimens, and received differing opinions as to the cause of their pain. The rehabilitation specialist is often given a non-specific referral of "groin pain" or "sports hernia." The cause of pain could be as simple as the effects of an adductor strain, or as complex as athletic pubalgia or inguinal disruption. The term "sports hernia" is starting to be replaced with more specific terms that better describe the injury. Inguinal disruption is used to describe the syndromes related to the injury of the inguinal canal soft tissue environs ultimately causing the pain syndrome. The term athletic pubalgia is used to describe the disruption and/or separation of the more medial common aponeurosis from the pubis, usually with some degree of adductor tendon pathology.

Treatment: Both non-operative and post-operative treatment options share the goal of returning the athlete back to pain free activity. There is little research available to reference for rehabilitation guidelines and creation of a plan of care. Although each surgeon has their own specific set of post-operative guidelines, some common concepts are consistent among most surgeons. Effective rehabilitation of the high level athlete to pain free return to play requires addressing the differences in the biomechanics of the dysfunction when comparing athletic pubalgia and inguinal disruption.

Conclusion: Proper evaluation and diagnostic skills for identifying and specifying the difference between athletic pubalgia and inguinal disruption allows for an excellent and efficient rehabilitative plan of care. Progression through the rehabilitative stages whether non-operative or post-operative allows for a focused rehabilitative program. As more information is obtained through MRI imaging and the diagnosis and treatment of inguinal disruption and athletic pubalgia becomes increasingly frequent, more research is warranted in this field to better improve the evidence based practice and rehabilitation of patients.

Levels of evidence: 5.

Keywords: Adductor strain; athletic pubalgia; groin pain; rehabilitation; sports hernia transversus abdominis.

Figure 1.

Core‐stabilized FABER test. Figure 1. Posterior pelvic tilt. (A) Lying on your back relaxed with your hands placed over the anterior superior iliac spine (ASIS) on each side and tips of fingers applying a slight pressure to the soft tissue just medial to the ASIS. (B) Start the motion by drawing the pubic symphysis towards the umbilicus with emphasis on anterior musculature contracting. The fingers should feel the transversus abdominis contract equally on each side, the rib cage should depress and the lumbar spine should flatten with little effort applied.

Figure 2.

Hip conditioning and core stabilization exercise. (A) Start sitting on a ball positioning the knees and hips at 90 degrees with hands on the hips or thighs. (B) Place knees and feet together in midline and lift one knee while trying to maintain pelvic and trunk stability. (C) Once pelvic and trunk stability is achieved with the hands on the thighs, progress to opposite upper extremity (UE) placing opposing pressure on raised knee while other UE is raised in the air for additional stabilization challenge.

Figure 3.

Bridging coupled with lower extremity lift. (A) Lie on floor and bridge from pressure applied to the lower extremities against the floor. (B) Place a physioball under the legs and apply downward pressure to the ball as the legs straighten allowing the pelvis to rise from the surface. (C) Once able to bridge on ball, lift one leg into the air, keeping knee extended and trunk stabilized.

Figure 4.

Pelvic stability on unstable surface progression. (A) Sitting on an air filled balance disc, place knees and feet together in midline and find pelvic stabilizers with feet on ground. (B) With arms outstretched, maintain midline as you lift one knee towards chest attempting to hold pelvis and trunk stable. (C) Progress to lifting both legs off and balancing for a prolonged hold. (D) Once prolonged holds are achieved progress to the addition of a ball toss.

Figure 5.

Double leg & single leg balance and proprioceptive training. (A) Standing on a 360 degree balance board (Fitter International, Calgary, Canada) with knees and hips flexed try to maintain balance. (B) Progress to single leg activity with hips and knee flexed once bilateral is mastered. (C) Add a ball toss once single leg balance and control is achieved.

Figure 6.

Wall squat with pelvic stabilization. Place ball behind low back and squat to 90 degrees hip flexion, holding trunk and pelvis in place. Then, raise up one knee to lift foot from ground.

Figure 7.

Side plank. Lying on side. align shoulder, elbow, hips and ankles and raise up into plank maintaining alignment.

Figure 8.

Front plank progression (A) align shoulders with elbows and lift into forearm plank keeping pelvis in alignment (B) Progress to placing hands aligned with shoulders and fingers pressing into surface keeping pelvis aligned with plank position (C) Place hands on BOSU® (BOSU, Ashland, OH) and balance with the body held in plank position keeping pelvic alignment.

Figure 9.

Quadruped Training (A) Align the knees under the hips and the hands under the shoulders and maintain pelvic alignment as one leg is outstretched. (B) Once aligned extend one leg and the opposite arm maintaining pelvic and shoulder girdle alignment.