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Athletic Pubalgia (Core Muscle Injury)

Groin pain is common with approximately 15% (range 5-23%) of all sports injuries result in groin pain (Litwin et al, 2011; Zoga et al, 2011).

WHAT IS ATHLETIC PUBALGIA?

  • Athletic pubalgia has been known by various terms over the years, including sports hernia, core muscle injury, adductor strain, osteitis pubis, "sportsman's hernia," or inguinal disruption (Heijboer et al, 2022).

  • Athletic pubalgia is an overuse injury due to chronic wear from repetitive trauma or stress resulting in injury of the pelvic joints or tendons (Jose et al, 2014).

  • In the majority of cases, the hip adductor muscle group and/or rectus abdominis are injured (Meyers et al, 2012).
  • Despite the historical term ‘sports hernia’ being used, athletic pubalgia does not cause a visible bulge in the groin, as there is no true hernia as seen with the more common inguinal hernia.

WHAT ARE THE SYMPTOMS?

  • Patients typically experience pain in the groin and/or lower abdominal wall. Some patients may experience pain that radiates toward the perineum or inner thigh.

  • Pain can be exacerbated by athletic activity such as kicking, cutting, or sprinting, and pain typically improves with rest.

HOW IS ATHLETIC PUBALGIA DIAGNOSED?

  • Various physical examination tests can be performed to help localize symptom to the core muscles. Diagnostic injections may also be utilized to determine the primary source of the groin pain.

  • Magnetic resonance imaging (MRI) and ultrasound are valuable in diagnosing pathology in athletes with groin pain, with the added utility of treatment using US-guided intervention (Lee et al, 2017).

    • Ultrasound can help visualize the adductor and abdominal muscles.

    • Magnetic resonance imaging (MRI) be used to image rectus abdominis/adductor longus aponeurosis and pubic bone pathology, but it can also evaluate other pathology within the hip and pelvis. MRI is especially helpful when groin pain is poorly localized.

TRADITIONAL TREATMENTS

Conservative Management

  • Management of athletic pubalgia depends on pain and severity, but initial treatment often consistts of rest, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy (Jensen et al, 2014).

Steroid Injections

Surgical Intervention

  • In recalcitrant cases that do not respond to conservative treatment, surgical management maybe necessary (Gill et al, 2020; Meyers et al, 2000). One study reported a mean return to sport as 112 days (range, 53–223 days), and the mean return was significantly shorter in isolated abdominal wall injuries 91.1 days (range, 69–125 days) when compared to athletes with adductor or dual tendon involvement 132.5 days (range, 88–223 days) (Kajetanek et al, 2018).

ARE THERE ALTERNATIVES TO SURGERY?

In cases that fail conservative management, case reports and case series have examined platelet rich plasma and prolotherapy for core muscle injuries.

Platelet Rich Plasma (PRP) Injections

PRP concentrates a patients own platelets from their blood to concentrate healing factors that play a central role in healing (learn more about PRP here)

  • In case reports, PRP has been used in the treatment of core muscle injuries (Kraeutler et al, 2021; Scholeten et al, 2015; Park et al, 2020; Singh et al, 2010; St-Onge et al, 2015).

  • In one report of a 20-year-old Division I collegiate lacross player, PRP was used to treatment athletic pubalgia symptoms (distal rectus abdominis tendinopathy) with an ultrasound-guided needle tenotomy and platelet-rich plasma (PRP) injection. In this cas , the patient returned to pain-free play at his previous level of intensity after the injection (Scholeten et al, 2015).
  • In another case report of a 28-year-old soccer player, a complete adductor longus tendon tear was successfully treated with 2 PRP injections and returned to soccer without symptoms (Singh et al, 2010).
  • In a case report of a 31-year old professional hockey player, 2 PRP injections successfully treated a tear in the rectus abdominis, rectus sheath and a portion of the conjoint tendon (St-Onge et al, 2015).
  • In a case report we published, a case of isolated osteitis pubis without overlapping rectus abdominis or adductor tendon involvement was successfully treated with an ultrasound-guided PRP injection of the pubic symphysis fibrocartilage (Park et al, 2020).

Prolotherapy Injections

  • In a series of 24 elite soccer and ruby players with chronic groin pain from osteitis pubis and/or adductor tendinopathy, monthly prolotherapy injections were administered and 22 of the 24 players returned to sport without pain (Topol et al, 2005).

PRP versus Prolotherapy Injections

  • In a retrospective cohort study out of Turkey, 15 elite soccer players with groin pain that failed conservative management were treated with either 3 weekly dextrose prolotherapy injections or a PRP injection. Patient had the same rehabilitation protocol and were allowed to return to sport 28-days after the injections, and both groups demonstrated less pain at both the 1- and 6-month follow-up. At 6-months the PRP group had less pain, but this was not statistically significant (Ozkan et al, 2020).

RESOURCES

  1. Gill TJ, Wall AJ, Gwathmey FW, Whalen J, Makani A, Zarins B, Berger D. Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete. Orthop J Sports Med. 2020 Jan 27;8(1):2325967119896104.
  2. Heijboer WMP, Weir A, Delahunt E, Hölmich P, Schache AG, Tol JL, de Vos RJ, Vuckovic Z, Serner A. A Delphi survey and international e-survey evaluating the Doha agreement meeting classification system in groin pain: Where are we 5 years later? J Sci Med Sport. 2022 Jan;25(1):3-8.
  3. Jensen J, Ho¨lmich P, Bandholm T, Zebis MK, Andersen LL, Thorborg K. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: A randomised controlled trial. Br J Sports Med 2014;48:332-338.
  4. Jose, J., Buller, L. T., Fokin, A., Wodicka, R., Subhawong, T., & Lesniak, B. (2015). Ultrasound-guided corticosteroid injection for the treatment of athletic Pubalgia: A series of 12 cases. Journal of Medical Ultrasound, 23(2), 71–75.
  5. Kajetanek C, Benoît O, Granger B, Menegaux F, Chereau N, Pascal-Mousselard H, Khiami F. Athletic pubalgia: Return to play after targeted surgery. Orthop Traumatol Surg Res. 2018 Jun;104(4):469-472.
  6. Kraeutler MJ, Mei-Dan O, Dávila Castrodad IM, Talishinskiy T, Milman E, Scillia AJ. A proposed algorithm for the treatment of core muscle injuries. J Hip Preserv Surg. 2021 Dec 10;8(4):337-342. doi: 10.1093/jhps/hnab084. PMID: 35505804; PMCID: PMC9052413.
  7. Lee SC, Endo Y, Potter HG. Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features. Sports Health. 2017 Sep/Oct;9(5):428-435.
  8. Litwin D, Sneider E, McEnaney P, Busconi B. Athletic Pubalgia (Sports Hernia). Clin Sports Med. 2011;30(2):417-34.
  9. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med. 2000 Jan-Feb;28(1):2-8.
  10. Meyers WC, Yoo E, Devon ON, et al. Understanding “sports hernia”(athletic pubalgia): The anatomic and pathophysiologic basisfor abdominal and groin pain in athletes. Oper Tech Sports Med 2012;20:33-45.
  11. Ozkan, O., Torgutalp, S. S., Karacoban, L., Donmez, G., & Korkusuz, F. (2020). Do Pain and Function Improve after Dextrose Prolotherapy or Autologous Platelet-Rich Plasma Injection in Longstanding Groin Pain?. Montenegrin Journal of Sports Science and Medicine, 9(2), 5-12.
  12. Park DJ, Sussman WI. Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report. Clin J Sport Med. 2022 Mar 1;32(2):e172-e174.
  13. Schilders E, Bismil Q, Robinson P, O’Connor PJ, Gibbon WW, Talbot JC. Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
  14. Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J. Successful treatment of athletic pubalgia in a lacrosse player with ultrasound-guided needle tenotomy and platelet-rich plasma injection: a case report. PM R. 2015 Jan;7(1):79-83.
  15. Singh JR, Roza R, Bartolozzi AR. Platelet rich plasma therapy in an athlete with adductor longus tendon tear. Univ Penn Orthop J 2010;20:42-43.
  16. St-Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. J Can Chiropr Assoc. 2015 Dec;59(4):390-7.
  17. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702.
  18. Zoga A & Meyers W. Magnetic Resonance Imaging for Pain After Surgical Treatment for Athletic Pubalgia and the "Sports Hernia". Semin Musculoskelet Radiol. 2011;15(4):372-82.

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