ANDREAFERRETTI, ANGELODECARLI, EDOARDOMONACO
Introduction
Groin pain refers to pain in the area where the abdomen ends and the legs begin. For males, the terms groin and testicle are sometimes used inter- changeably. However, what causes pain in one will not necessarily do so in the other. Groin pain is also referred to as lower abdominal pain, genital pain, and perineal pain. In football players, groin pain is considered a pain in the pubic or lower abdominal or adductor region, which can be monolateral or bilater- al. In this chapter, we deal with groin pain in football athletes considering anatomy, etiopathogenesis, clinical presentation, diagnosis, and treatment.
Anatomy and Biomechanics
Anatomically, the adductor (longus, magnus, brevis), the pectineus, and the gracilis muscles comprise the muscular component of the medial aspect of the thigh. These muscles have their origin at the symphysis pubis and the inferior pubic rami before traveling along the medial aspect of the thigh and inserting on the linea aspera of the femur. The lone exception is the gracilis, which inserts on the medial aspect of the proximal tibia. The tendinous and aponeurotic attachments of the rectus abdominis and the internal oblique muscles are also found at or near the adductor’s origin. The close proximity of these various muscles often makes it difficult to distinguish the true source of the athlete’s pain. Anatomically, the pelvis is between two major muscular systems, the back and the lower limbs, and is the junction point of tensile forces coming up from the rectus abdominis and the internal oblique muscles and down from adductors. Moreover, loads of up to 8 times body weight have been demonstrated in the hip joint during jogging, with potentially greater loads present during vigorous athletic competition. The structures about the hip are uniquely adapted to transfer such forces. The body’s centre of gravity is located within the pelvis anterior to the second sacral vertebra; thus, the loads that are generated or transferred through this area are important in vir- tually every athletic endeavour.
Etiopathogenesis
The pathogenesis of groin pain can be extrinsic, such as overload or repeti- tive microtrauma, or intrinsic, such as anatomical disorder of the pelvis, hip, or groin. Many different theories about the cause of groin pain have been pro- posed based on the findings of the physical examination or the operation.
One of the most frequent causes of groin pain is disruption of the musculo- tendinous elements of the groin. This injury affects the external oblique aponeurosis, the conjoined tendon, and the inguinal ligament, resulting in weakness of the lower abdominal wall and occult hernias. Disruption of the external oblique aponeurosis also pre-disposes to entrapment or irritation of branches of the ilioinguinal or iliohypogastric nerves. Enthesopathy at the site of insertion of the abdominal and adductor muscles to the pubic bone has been described as another cause of groin pain. Among various causes of groin pain that have been proposed, a symptomatic, non-palpable hernia has been described, with an incidence of 36% to 90%. In the literature, the terms sport- man’s hernia and sports hernia are used for “the syndrome of a weakness of the posterior inguinal wall without a clinically recognisable hernia”, “bulge in the posterior inguinal wall consistent with a incipient direct (medial) inguinal hernia”, or “an imminent, but not demonstrable, inguinal hernia”. The term athletic pubalgia refers to chronic inguinal or pubic-area pain in athletes that is exertional only and not explainable preoperatively by a palpable hernia or other medical diagnosis and so may be a more appropriate term for these injuries. Possible causes of groin pain are summarised in Table 1.
Table 1.Common disorders of the hip and groin area (modified from [2])
History Cause
Acute onset Muscle
Contusions (hip pointer) Avulsion and apophyseal injuries Hip sprains and subluxations
Acetabular labral tears and loose bodies Proximal femur fractures
Insidious onset Sports hernias and athletic pubalgia Tendinopathies
Osteitis pubis Bursitis
Snapping hip syndrome Osteoarthritis
Other disorders Lumbar spine abnormalities Entrapment neuropathies
Incidence
Chronic groin pain is a well-recognised and problematic entity in athletes.
Besides football, sports such as ice hockey, cross-country skiing, and others that require repetitive kicking, evasive or side-to-side motion, and physical contact are a common cause of groin pain, but the incidence of athletic pub- algia is lower. Groin pain among (professional) football players has an esti- mated incidence of 0.5–6.2% [1, 2] and is responsible for a large proportion of time lost from sport and work. Interestingly, this syndrome is rarely seen in female athletes.
Classification
Classification of groin pain can be based on either the site of pain or on symptoms. Classification according the site of pain is:
- Adductor localisation;
- Abdominal localisation;
- Mixed localisation.
All these localisations can be uni- or bilateral.
Classification according to severity of symptoms is [3]:
- Stage 0: no pain;
- Stage 1: pain only after intense sports activity; no undue functional impairment;
- Stage 2: pain at the beginning and after sports activity; still able to per- form at a satisfactory level;
- Stage 3: pain during sports activity; increasing difficulty in performing at a satisfactory level;
- Stage 4: pain during sports activity; unable to participate in sport at a sat- isfactory level;
- Stage 5: pain during daily activity; unable to participate in sport at any level.
History
The history of the injury may vary from an insidious onset with progressive pain during intense pre-season or in-season training to a sudden, simple, painful event. Tendon damage at the adductor origin or at the lower abdomi- nal insertion may commonly occur as an overuse injury. Pain localisation is also important to determine which structure may be causing the pain.
However, sometimes the pain may be poorly localised and felt in a number of different areas simultaneously. It is important to establish the time course of
the pain, as pain worsening after exercises, especially the following day, and gradually decreasing during exercise is indicative of an inflammatory condi- tion, such as tendonitis. It is important to establish which movements aggra- vate the pain, especially movements such as kicking, which may suggest an iliopsoas or rectus femoris strain; twisting, which may suggest an adductor muscle strain; or sit-ups, which may suggest a rectus abdominis injury or her- nia.
Clinical Approach
In patients with groin pain it is important to localise the area of pathology. The pathology may be in the adductor muscles or in the lower abdominal muscu- lature and may be unilateral or bilateral. Abdominal-wall-muscle injuries have been increasingly recognised as a source of chronic inguinal or pubic area pain in athletes and should be included in the differential diagnosis. The majority of these patients have lower abdominal pain with exertion; however, a small minority of patients have pure adductor-related pain. History and the physical examination can be difficult to distinguish from those seen with a sports hernia. These athletes commonly recall a distinct injury involving a combination of abdominal hyper-extension and thigh hyper-abduction and may complain of pain when attempting to perform a sit-up.
On physical examination, each region of the groin that has the potential to produce groin pain must be examined. This includes adductor muscles, pelvic bones, hip joint and its surrounds, hip flexors (including tensor fascia lata and sartorius) and lower abdominal muscles. The lumbar spine and sacroili- ac joints are also examined. Pelvis alignment must be assessed, and any leg- length discrepancy noted. Pain can be reproduced with adduction of the hip against resistance (Fig. 1) if the adductor muscles are involved or with flex- ion of the spine against resistance in an abdominal localisation. Occasionally, there is a pubic or peri-pubic tenderness along the adductor tendons near the pubis (Fig. 2), making this quite difficult to distinguish from a pure adductor strain. The site of pain can usually be identified with palpation along the course of the musculotendinous unit against mild to moderate resistance in adduction and on passive abduction and external rotation.
The clinician must not overlook the less common but important causes of pain in this region, such as intra-abdominal pathology (e.g., appendicitis), urinary tract pathology, gynaecological pathology, and rheumatological dis- orders (e.g., ankylosing spondylitis). Infection such as osteomyelitis should also be considered. Patients with tumours, such as testicular tumours, occa- sionally present with groin pain. Moreover, abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the
Fig. 1.Resisted movement: hip adduction. This should be performed with varying degrees of rotation to stress different adductor muscles. The neutral position stresses adductor longus preferentially, internal rotation stresses the pectineus, and external rotation the adductor magnus
Fig. 2.Palpation: the groin region is palpated from the pubis symphysis laterally to the anterior superior iliac spine. The patient should be relaxed with the hip abducted and the knee flexed
internal oblique muscle, can be an overlooked source of groin pain in the ath- lete [4]. Differential diagnosis must be made from other rare causes of groin pain originating from urological and orthopaedic diseases of the spine, the pelvis, and the hip, such as tenoperiostitis, hip-joint arthritis, osteochondri- tis, and infective pubis osteitis.
Investigations
Investigations have a significant role to play in the management of groin pain.
As with all investigations, they should be used to confirm a diagnosis sus- pected as a result of clinical examination. X-ray of the pelvis may reveal char- acteristic changes of the osteitis pubis, hip joint pathology (e.g., osteoarthri- tis), or stress fracture of the neck of the femur or pubic ramus. Sclerosis or osteophyte formation around the sacroiliac joint (SIJ) indicates that this joint may be a cause of referred pain although frequently, x-ray does not reveal SIJ abnormalities.
Radioisotopic bone scan shows a characteristic pattern of increased uptake in osteitis pubis and may confirm a suspected stress fracture in those cases where x-ray fails to demonstrate the fracture. Ultrasonography is useful in diagnosis of insertional tendinopathies of adductors muscles or lower abdominal muscles or in groin pain secondary to acute muscles strains, but its accuracy is debatable and it is operator dependent. Magnetic resonance imaging (MRI) is useful to study soft tissues and tendons and for detecting abnormalities within the muscles or pubic symphysis. MRI findings, such as bone marrow oedema of the symphysis pubis, have been reported in 50–70%
of athletes with groin pain [5, 6]. Peritoneography may be an appropriate investigation to confirm the presence of a direct or indirect inguinal hernia or reveal a bulge of the posterior wall of the inguinal canal that may not be detectable clinically. However, in all cases of groin pain, it is important to investigate the cause of pain with a multidisciplinary approach (orthopaedic, surgical, urologic, and radiologic).
Treatment
The treatment of an athletic pubalgia is complex, especially because diagno- sis could be difficult and symptoms underestimated. In the initial phase of the pain, reduction and/or modification of sport activity and training sessions is indicated to treat the pain. Ice and nonsteroidal anti-inflammatory drugs (NSAIDs) orally are useful in the acute inflammatory stage, such as a local injection of NSAIDs (mesotherapy) or electrotherapeutic modalities, such as laser and ultrasound.
The balance of the muscles of the upper thigh, particularly the adductor muscles, with those of the lower abdomen is important to prevent pain and recurrence of sintomatology, so a stretching and strengthening program of those muscles should be done, usually with postural exercises (Figs. 3–10).
Strengthening exercises progressing from concentric to eccentric for the major muscles groups in the groin, the hips, and the back are recommended, especially for the abdominal muscles. The athlete can begin functional exer- cises in water. Moreover, the athlete must repeat stretching exercises of abduc- tors muscles before and after training sections. Isokinetic exercises can also be done in the initial period of treatment.
Injections of corticosteroids and other medicaments, are occasionally required when conservative measures have failed or have been only partially successful. Injection should be regarded as only a part of the total manage- ment program. Repeated injections into the tendon should be avoided due to the risk of complete tendon rupture.
Surgical treatment is occasionally required for those few patients resistant to conservative treatment for more than 3 months and for high-level athletes.
Correction of the anatomical imbalance – as adductor tenotomy in cases of adductor localisation or abdominoplasty (herniorrhaphy) in cases of weak- ness of abdominal wall – is the goal of each surgical technique for groin pain.
Pelvic floor repair refers to a broad surgical re-attachment of the inferolater- al edge of the rectus abdominis muscle with its fascial investment to the pubis
Fig. 3.The athlete relaxes with knees bent and soles of the feet together. This comfortable position stretches the groin. The stretch is held for 30 s
Fig. 4.From the lying groin stretch, the athlete gently rocks the legs as a unit back and forth about 10–12 times. These are easy movements of no more than 1 inch in either direction. Movements are initiated from the top of the hips. This stretch gently limbers up the groin and hips
Fig. 5a, b.The athlete puts the soles of the feet toge- ther and holds on to the feet. The athlete con- tracts the abdominals while gently pulling for- ward, bending at the hips, until a mild stretch is felt in the groin. The stretch is held for 20–40 s
a
b
Fig. 6.From the lying groin stretch, the athlete gently rocks the legs as a unit back and forth about 10–12 times. These are easy movements of no more than 1 inch in either direction. Movements are initiated from the top of the hips. This stretch gently limbers up the groin and hips
Fig. 7.The athlete pulls the knee across the body towards the opposite shoulder until an easy stretch is felt on the side of the hip. The stretch is held for 30 s and is done on both sides
Fig. 8.It is possible to stretch the groin from this legs-elevated position by slowly separa- ting the legs, with the heels resting on the wall, until an easy stretch is felt. The stretch is held for 30 s, then the athlete relaxes
Fig. 9.The athlete places one leg forwards until the knee of the forward leg is directly over the ankle. The other knee should be resting on the floor. Without changing the position of the knee on the floor or the forward foot, the athlete lowers the front of the hip down- wards to create an easy stretch. This stretch should be felt in front of the hip and possibly in the hamstrings and groin. The stretch is held for 30 s
and adjacent anterior ligaments. This operation is similar but not identical to a Bassini hernia repair. Pelvic floor repair focuses on attachment of the rec- tus abdominis muscle fascia to the pubis rather than protection of the inguinal floor near the internal ring. Therefore, the principal difference between this surgery and a Bassini repair is in the orientation of the sutures.
The internal ring is usually left intact. “Adductor release” refers to complete division of all the anterior epimysial fibres of the adductor longus muscle about 2–3 cm from the pubic insertion, leaving the muscle belly intact.
Multiple longitudinal incisions into the tendinous insertion site on the pubis and bone drilling in the pubis are also made, similar to surgery for tennis elbow or jumper’s knee. Some recent studies have shown a high incidence of occult hernia and especially sports hernia in athletes with undiagnosed groin pain, and the herniorrhaphy has had reported success with either a conven- tional or laparoscopic approach. Frequently, the abdominal wall is reinforced with mesh during these repairs. Moreover, the use of a diagnostic endoscopy could be justified in undiagnosed groin pain in athletes because with this Fig. 10.The athlete places the ball of the foot up on a secure sup- port of some kind. The down leg is pointed straight ahead. The athlete bends the knee of the up leg while moving the hips for- wards. This movement should stretch the groin, hamstrings, and front of the hip. This stretch is held for 30 s. Both legs are stretched
procedure, abnormalities can be diagnosed and treated. Postoperatively, ath- letes can return to sports within 6–12 weeks after specific rehabilitation tar- geted at abdominal strengthening, adductor muscle flexibility, and a graduat- ed return to activity. Laparoscopic pre-peritoneal hernia repair should be considered as a treatment modality in athletes presenting with chronic groin pain and allows good results at long-term follow-up [7–9].
The Authors’ orientation in surgical treatment of groin pain in based on the site of pain and clinical evaluation. In cases with abdominal and adduc- tors pain, we prefer an association of abdominoplasty of Bassini and an adductor tenotomy with scarification of tendons at insertion site and bone drilling. In cases with only adductors pain, adductor tenotomy should be enough. In this case, the return to sport activities is quicker – within 2–3 months. However, surgical treatment ensures a resolution or significative improvement in pain in no more than 70% of athletes and after a prolonged period of post-operative rehabilitation. Therefore, surgery should be per- formed cautiously in top-level athletes [3].
Conclusion
In conclusion, athletic pubalgia remains a vague diagnosis, with a long dura- tion of symptoms of various origins and pathogenesis and is a therapeutic challenge. Further studies are required for a better assessment of incidence, natural course, optimal clinical and imaging evaluation, and selection of the most effective forms of treatment [10, 11].
References
1. Volpi P, Pozzoni R, Galli M (2003) The major traumas in youth football. Knee Surg Sports Traumatol Arthrosc 11:399–402
2. Anderson K, Strickland SM, Warren R (2001) Hip and groin injuries in athletes. Am J Sports Med 29:521–533
3. Ferretti A (1996) Traumatologia dello sport. CESI, Roma
4. Taylor DC, Meyers WC, Moylan JA et al (1991) Abdominal musculature abnormali- ties as a cause of groin pain in athletes. Inguinal hernias and pubalgia. Am J Sports Med 19:239–242
5. Slavotinek JP, Verrall GM, Fon GT, Sage MR (2005) Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imag- ing findings and athlete outcome. Am J Sports Med 33:894–899
6. Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC (2001) MR findings in athletes with pubalgia. Skeletal Radiol 30:270–277
7. Genitsaris M, Goulimaris I, Sikas N (2004) Laparoscopic repair of groin pain in ath- letes. Am J Sports Med 32:1238–1242
8. Srinivasan A, Schuricht A (2002) Long-term follow-up of laparoscopic preperitoneal
hernia repair in professional athletes. J Laparoendosc Adv Surg Tech A 12:101–106 9. Kluin J, den Hoed PT, van Linschoten R et al (2004) Endoscopic evaluation and
treatment of groin pain in the athlete. Am J Sports Med 32:944–949
10. Puig PL, Trouve P, Savalli L (2004) Pubalgia: from diagnosis to return to the sports field. Ann Readapt Med Phys 47:356–364
11. Meyers WC, Foley DP, Garrett WE et al (2000) Management of severe lower abdom- inal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 28:2–8
