Keywords sports - epidemiology - inguinal - hernia - pubalgia - athletic injuries
Introduction
Pubalgia refers to lower abdominal and inguinal pain involving the pubic bones, the
pubic symphysis, and adjacent structures. The condition may be associated with systemic
inflammatory diseases or genital and urinary infections.[1 ]
This type of pain is frequent in athletes, especially those of sports that demand
intense and multidirectional muscle contractions.[2 ] Pubalgia is reported in approximately 6% of all chronic injuries related to sports.[3 ]
[4 ] According to Brunt and Barile[5 ] (2013), its diagnosis and management are always challenging, as symptoms are insidious
and diffuse in a complex anatomical region, and multiple causes can coexist.
The pubis functions as a fulcrum for several movements, and adjacent muscles provide
dynamic stability. Falvey et al.[6 ] (2009) have described the groin triangle in layers, from the superficial to the
deepest, and the structures that can cause pain in the region. Regarding anatomical
aspects, Meyers et al.[7 ] (2005) have described the concept of macro-joints (lumbosacral, sacrococcygeal,
sacroiliac, and pubic symphysis) and micro-joints (muscle attachments, including the
psoas and adductor muscles).
There are four main groups of causes of chronic groin and pubic pain: pubalgia, adductor
muscle dysfunction, hip joint conditions, and osteitis pubis. In athletes, pubalgia
is the weakening of the posterior wall of the inguinal canal with dilation of the
transverse fascia and widening of the inguinal triangle.[8 ]
The main mechanism of injury is trunk hyperextension, thigh hyperabduction, and an
imbalance between the strong thigh adductors and weak lower abdominal muscles. This
creates a shear force in the pubic symphysis. The incidence of pubalgia is higher
among football, rugby, and hockey players.[8 ]
Today, three major theories describe the pathophysiological aspects of athletic pubalgia.
The first theory suggests that the main cause of the condition is ilioinguinal or
iliohypogastric nerve entrapment by the external oblique muscle, causing a slightly
more proximal pain.[9 ]
[10 ] The second theory states that pubalgia is due to a weakness in the posterior abdominal
wall, with compression of the genitofemoral nerve by the pseudoherniated bulb.[8 ] Finally, the third theory suggests a muscle imbalance due to a precursor lesion
in the adductor musculature increasing the pressure in the adductor compartment. This
results in macro or microscopic lesions in the pubic attachments close to the pubic
cartilage plate.[11 ]
Athletic pubalgia is diagnosed based on the clinical complaint, physical examination
findings, and imaging tests, such as radiography, magnetic resonance imaging, and
ultrasound.[12 ]
[13 ]
The initial treatment is conservative, with rest, analgesic and anti-inflammatory
drugs, and physical therapy. Surgical treatment is indicated for refractory cases.[8 ]
The present paper describes the epidemiological profile of athletic pubalgia at a
reference center for the care and treatment of athletes. In addition, it aims to establish
links with age group, gender, the type and level of sport, training frequency, characteristics,
time until diagnosis, location of symptoms, and the semiological tests and maneuvers
more frequently used.
Materials and methods
The present is a retrospective study based on case series that was conducted after
obtaining approval from the institutional Research Ethics Committee (under opinion
number 2.925.919). We reviewed medical records of patients with lower abdominal and
inguinal pain regardless of gender, age, the type of sport, the frequency of the training,
the time elapsed since the onset of symptoms, and previous follow-ups with a specialist
from October 2015 to February 2018.
Patients diagnosed with prostatitis, urinary tract infection, varicocele, ovarian
cyst, endometriosis, appendicitis, diverticulitis, adhesions, overactive bladder syndrome,
and those surgically treated for athletic pubalgia were excluded from the study.
All 245 participants underwent a clinical evaluation with the application of a direct,
specific questionnaire ([Fig. 1 ]), as well as a physical evaluation ([Fig. 2A-J ]).
Fig. 1 Model of the evaluation form/directed questionnaire.
Fig. 2 Routine physical examination and provocative tests. (A ) Orthostatic compression of the anterior compartment (EF1); (B ) simultaneous hip and abdomen flexion against resistance (EF2); (C ) adductor contraction against resistance with a flexed knee (EF3); (D ) adductor contraction against resistance with an extended knee (EF4); (E ) palpation of the inguinal ring (EF5); (F ) palpation of the adductor attachment in the pubis (EF6); (G ) palpation of the pubic body (EF7); (H ) oblique muscle test against resistance (Grava maneuver) (EF8); (I ) flexibility tests, especially for the hamstrings (EF9); (J ) hip range of motion (EF10).
The routine physical examination consisted of the provocative tests shown in [Fig. 2 ]. We categorized age into groups and expressed the characteristics as frequencies
and proportions (%). Data comparison used the Fisher exact test. The statistical analysis
was performed using the R (R Foundation for Statistical Computing, Vienna, Austria)
software, version 3.6.1. Values of p < 0.05 were considered statistically significant.
Results
Epidemiological profile of the patient with athletic pubalgia
This case series comprised 245 participants, 29 women and 216 men, with ages between
14 and 75 years. Most of the participating athletes were Brazilian citizens from 21
different states (Acre, Amazonas, Bahia, Ceará, Distrito Federal, Espírito Santo,
Goiás, Maranhão, Minas Gerais, Mato Grosso, Pará, Pernambuco, Paraná, Rio de Janeiro,
Rio Grande do Norte, Rondônia, Roraima, Rio Grande do Sul, Santa Catarina, Sergipe,
and São Paulo). And four athletes were foreigners (from Angola, Guinea, France, and
Portugal).
A total of 44 participants were professional athletes, 19 practiced sports at the
university/school level, and 182 played recreationally. Acute pain was reported by
36 participants. After the medical evaluations, 23 participants had indications for
surgical procedures to mitigate their symptoms.
Distribution of sports practiced by athletes with pubalgia
The participants practiced 25 different types of sports ([Fig. 3 ]), and 3 stood out as the most common among participants, either as the main or as
secondary activities. The most prevalent primary sport was soccer (N = 148), followed
by running (N = 81) and gym workout (N = 70).
Fig. 3 Prevalence of sports among athletes with pubalgia.Esporte principal = Main sportFutebol = SoccerCorrida = RunningMusculação = Gym
workoutLutas = Combat sportsTênis = TennisNatação = SwimmingCiclismo = CyclingFutsal = Indoor
soccerSurfe = SurfVôlei = VolleyballTriathlon = TriathlonBasquete = BasketballRúgbi = RugbyHandebol = HandballVôlei
de praia = Beach volleyballSquash = SquashSpinning = SpinningSkate = SkateRemo = RowingPilates = PilatesHipismo = EquestrianismFutevôlei = FootvolleyBicicleta = CyclingPrincipal = MainSecundário = Secondary
Soccer was the main sport for 129 participants, followed by running and gym workout,
with 43 and 16 subjects respectively. Altogether, these 3 sports accounted for 76.7%
of the sample (188 of 245). The 3 modalities most selected as secondary or auxiliary
sports were gym workout (N = 54), running (N = 38), and soccer (N = 19), regardless
of the primary modality. Most (66.1%; 111 out of 168) athletes with pubalgia selected
these 3 modalities as secondary sports.
Most participants who primarily played soccer also practiced gym workouts (N = 32)
and running (N = 22) as secondary modalities ([Fig. 4A ]). Gym workout and running were the secondary sports for 66.7% of the participants
(54 out of 81). Among the participants who primarily practiced running, the two sports
most practiced as an auxiliary activity were gym workout (N = 9) and soccer (N = 8)
([Fig. 4B ]), accounting for up to 58.6% of secondary sports (17 out of 29). Among those who
primarily practiced gym workouts, running (N = 5) and soccer (N = 3) were the secondary
activities, representing 57.1% of the secondary sports practiced by these athletes
(8 out of 14).
Fig. 4 Secondary sports practiced by the evaluated patients. (A ) When the main sport evaluated is soccer; (B ) When the main sport evaluated is running; (C ) When the main sport evaluated is gym workouts.Esporte acessório quando o principal
é futebol = Secondary sport when the main sport is soccerEsporte acessório quando
o principal é corrida = Secondary sport when the main sport is runningEsporte acessório
quando o principal é musculação = Secondary sport when the main sport is gym workoutsMusculação = Gym
workoutCorrida = RunningTênis = TennisFutsal = Indoor soccerVôlei = VolleyballCiclismo = CyclingNatação = SwimmingSurfe = SurfFutevôlei = FootvolleyBasquete = BasketballLutas = Combat
sportsFutebol = SoccerRemo = Rowing
Evaluation of physical examinations
[Table 1 ] shows the results of the physical examination and provocative tests. The test of
adductor contraction against resistance with an extended knee (EF4) was positive in
77.6% of the evaluated patients, followed by the test of simultaneous hip and abdominal
flexion against resistance (EF2), which was positive in 76.7% of the patients. The
hamstring flexibility test (EF9) showed the lowest sensitivity, since it was only
positive in 29% of the patients.
Table 1
Physical examination
n (%)
EF1
77 (31.4)
EF2
188 (76.7)
EF3
166 (67.8)
EF4
190 (77.6)
EF5
153 (62.4)
EF6
102 (41.6)
EF7
168 (68.6)
EF8
71 (29.0)
EF9
37 (15.1)
EF10
120 (49.0)
Association with sport level, age, and time until diagnosis
Regarding the time elapsed until the diagnosis of pubalgia, 118 patients had their
diagnoses established in less than 90 days since the onset of pain, including 20 professional
athletes, 88 recreational athletes, and 10 university athletes ([Table 2 ]). Diagnostic confirmation occurred after 90 days for 127 patients (24 professional,
94 recreational, and 9 university athletes). The age range between 25 and 40 years
predominated in both groups.
Table 2
Physical examination
≤ 90 days; N = 118–n (%)
> 90 days; N = 127–n (%)
p -valueb
EF1
33 (28%)
44 (35%)
0.27
EF2
94 (80%)
94 (74%)
0.36
EF3
83 (70%)
83 (65%)
0.42
EF4
93 (79%)
97 (76%)
0.76
EF5
72 (61%)
81 (64%)
0.69
EF6
44 (37%)
58 (46%)
0.20
EF7
76 (64%)
92 (72%)
0.22
EF8
36 (31%)
35 (28%)
0.67
EF9
13 (11%)
24 (19%)
0.11
EF10
59 (50%)
61 (48%)
0.80
Age
0.88
< 25 years old
20 (17%)
25 (20%)
25-40 years old
70 (59%)
72 (57%)
> 40 years old
28 (24%)
30 (24%)
Sport level
0.88
Professional
20 (17%)
24 (19%)
Recreational
88 (75%)
94 (74%)
University/School
10 (8.5%)
9 (7.1%)
Considering the 3 main sports (soccer, running, and gym workout) alone, the most affected
age group was that between 25 and 40 years, corresponding to 57% of the total number
of athletes evaluated. Regarding gender, there was a male predominance, representing
89% of the sample. As for physical conditioning, 75% of the subjects diagnosed with
pubalgia practiced sports at a recreational level, while 18% were professional athletes,
and 7.4% were university athletes. [Table 3 ] shows these data.
Table 3
Characteristics
Total; N = 188–n (%)
Soccer; N = 129–n (%)
Running; N = 43–n (%)
Gym workout; N = 16–n (%)
p -valueb
Age
< 0.001
< 25 years old
38 (20%)
35 (27%)
2 (4.7%)
1 (6.2%)
25-40 years old
108 (57%)
72 (56%)
24 (56%)
12 (75%)
> 40 years old
42 (22%)
22 (17%)
17 (40%)
3 (19%)
Gender
< 0.001
Female
21 (11%)
0 (0%)
15 (35%)
6 (38%)
Male
167 (89%)
129 (100%)
28 (65%)
10 (62%)
Sport level
0.034
Professional
33 (18%)
29 (22%)
2 (4.7%)
2 (12%)
Recreational
141 (75%)
90 (70%)
39 (91%)
12 (75%)
University/ School
14 (7.4%)
10 (7.8%)
2 (4.7%)
2 (12%)
Discussion
The present case series evaluated athletes with pubalgia who practiced 25 different
sports, both as main or secondary activities. It is not surprising that soccer is
the sport most played by patients treated for pubalgia globally. In the present study,
however, the athletes who preferred soccer were not only more predominant, but also
those who practiced other activities more often. The discrepancy in the choice of
secondary activities is remarkable: 81 soccer players reported practicing secondary
activities, while these numbers among athletes who practice running and gym workouts
were considerably smaller (29 and 14, respectively).
Most of our patients (88.1%) were male, which is consistent with other studies.[14 ] It is believed that the gynecoid pelvis protects against lesions, probably because
it provides a greater attachment area for the abdominal musculature, increasing the
surface for force distribution.
In the first studies about pubalgia, virtually all patients were professional athletes.
But this has gradually changed over the years, and now a significant number of recreational
athletes comprise similar case series.[14 ] In the present study, 58% of the patients played sports 3 or more times a week.
According to Brunt and Barile[5 ] (2013), among professional athletes, football, soccer, and hockey account for more
than 70% of the cases of pubalgia. In the present study, soccer (60%) and running
(15%) were the most prevalent sports.
Soccer is usually the sport with the highest incidence of pubalgia, followed by rugby,[8 ] football, and ice hockey.[12 ]
[13 ] Regarding track and field, running is a sport with a low incidence of pubalgia if
we compare data from Brazilian studies with that if other series; in the present study,
its prevalence was of 15%.
Regarding the time since symptom onset until diagnosis, 55% of the subjects reported
it was longer than 6 months, and 15%, longer than 12 months. The literature[3 ] reports that the mean time between symptom onset and the definitive diagnosis ranges
from 1 to 53 months, with a median time of 6 months.
Regarding the characteristics of the pain, most patients reported symptom improvement
at rest and worsening during the practice of sports, running, and walking. Another
13% had pain during sexual intercourse, 11%, when sneezing, and 8%, when coughing.
As for specific sports movements, symptoms worsened when changing direction, during
long runs, sprints and speed training, jumps, and kicks. Most patients referred pain
in the inguinal region, adductor muscles, and pubis. Other affected sites were the
lumbar spine, the proximal thigh, the perineum, and the testes.[15 ] Patients from other countries also reported inguinal, adductor, and pubic pain.[14 ]
[16 ]
In the present study, the most prevalent positive clinical test was the adductor contraction
against resistance with an extended knee, in 190 patients, followed by simultaneous
unilateral hip and abdomen flexion against resistance, in 188 patients. This finding
is consistent with those of the literature,[15 ] as muscle contraction in adduction against resistance, trunk flexion, and inguinal
palpation were the most sensitive tests for the diagnosis of pubalgia. Although valuable
for patient assessment, inguinal palpation relies on the experience of the examiner,
especially their ability to differentiate pubalgia from inguinal and femoral hernias.
Other findings described include tenderness in the conjoint tendon, pubic tubercle,
and medial inguinal region.[12 ]
Conclusion
Most patients with suspected pubalgia are male young adults between the ages of 26
and 45 years, who practice soccer or running at a recreational level. They present
symptoms that interfere with sports performance. Their pain improves with rest and
worsens with exercises, sexual intercourse, sneezing, coughing, and specific sports
movements, such as changing direction, sprints and speed training, jumping, and kicking.
The pain was most prevalent in the inguinal region and the pubis. The most commonly
positive pain-related clinical tests were adductor contraction against resistance
with an extended knee and simultaneous unilateral hip and abdomen flexion against
resistance. For some patients, the time from symptom onset until final diagnosis took
more than 12 months.
