Jan 29, 2015Groin Pains
Whether you call it a sports hernia or athletic pubalgia, recurring pubic-area pain can be a major hindrance for athletes. These authors devised a specialized training program for the Cornell University men’s hockey team aimed at addressing and preventing groin injuries.
By Dr. Paul R. Geisler & Ed Kelly
Paul R. Geisler, EdD, ATC, is an Assistant Professor and Director of Athletic Training in the Department of Exercise & Sport Sciences at Ithaca College, and has over 20 years of experience as an athletic trainer and sports performance specialist working with high school, college, and professional athletes. He can be reached at: [email protected]. Ed Kelly, MS, ATC, is in his 14th season as Athletic Trainer for the Cornell University men’s hockey and sprint football teams. He can be reached at: [email protected].
In the past few years, the term “sports hernia” has shown up with growing frequency in both athletic medicine circles and mainstream media coverage of sports injuries. For those of us in the business of treating athletes, the sudden surge in popularity leads to one obvious question: Are more athletes suffering this type of injury than in the past, or have we simply developed a new term for an old condition?
Unfortunately, there is no simple answer. For one thing, despite how often the term is used, there’s no universally accepted definition for a sports hernia. It’s sometimes applied as shorthand for virtually any condition affecting an athlete’s lower abdominal region and groin area, though some researchers believe there are specific symptoms and pathologies that must be present to warrant the diagnosis. Furthermore, there’s a basic misnomer involved–in a clinical examination, no actual “hernia” by common medical definition (the trademark bulge of tissue through muscle) is usually found. A more appropriate term is athletic pubalgia, though this is much less frequently heard.
Whatever you call it, the condition can pose serious problems for athletes. When a rash of athletic pubalgia struck the Cornell University men’s hockey team two seasons ago, we decided to take the opportunity to design and implement a proactive approach to treat the injuries, and more importantly, reduce the likelihood they’d crop up again in the future. As you’ll see, we achieved significant success, and in the process, we learned much about this poorly understood area of sports medicine.
NOT EASILY DEFINED
Various researchers have complicated the subject of athletic pubalgia in published literature by defining it strictly in terms of the anatomical structures and precise pathology involved, often contradicting each other’s definitions and creating much confusion. For instance, one study describes a sports hernia as a “spectrum of pathology” involving the conjoined tendon, inguinal ligament, fascia transversalis, and internal and external oblique muscles, caused by a disruption of the inguinal canal without a clinically detectable hernia. Another describes it as a weakening of the posterior inguinal wall without an inguinal hernia detectable during a physical exam.
Numerous other authors have added to the disorder by introducing their own terms, such as “hockey hernia,” and listing specific body parts or symptoms that must be involved for the diagnosis to apply. For instance, varying definitions for a sports hernia may include or exclude the presence of a palpable hernia, and some incorporate the ilioinguinal nerve, while others ignore it.
So where is the common ground, and what do we really mean when we say an athlete has a sports hernia or athletic pubalgia? Despite the conflict over details, authors usually agree that a sports hernia involves a combination of injuries affecting both the groin area and the abdominal region. It’s actually more of a syndrome than a specific injury, encompassing several conditions that can be difficult to differentiate.
It has been theorized that athletic pubalgia is the result of chronic shearing forces across the pubic symphysis generated by repetitive adductor muscle activity. Over time, pubic symphysis forces indirectly cause progressive micro-stress to the posterior abdominal wall, causing a separation of the transversalis fascia and internal oblique aponeurosis from the inguinal ligament. This leads to the pain that we typically associate with pubalgia or a sports hernia.
Recently, a leading specialist who surgically treats this condition has attempted to create a more focused working definition for athletic pubalgia. According to William C. Meyers, MD, it consists of chronic inguinal or pubic area pain in athletes that is exertional only and not explainable by a palpable hernia or other medical diagnosis. Thus, since true athletic pubalgia (by this definition) does not include an occult internal-ring hernia, Meyers has called for the term “sports hernia” to be discontinued when dealing with conditions that don’t directly involve the inguinal rings.
Research into athletic pubalgia has shown the greatest incidence among soccer, football, and ice hockey players. For instance, Meyers’s study of 157 athletes who required surgery for pubalgia found that 75 percent played one of those three sports. It’s also not uncommon for the pain to affect both sides of the abdominal-groin region–in Meyers’s study, 43 percent of the athletes presented with bilateral abnormalities.
The primary reason why clinical evaluation, diagnosis, and treatment for pubalgia are so challenging is that several contributing or co-existing factors have been reported in the literature as being associated with the condition (see Table One at the end of this article). Also, several differential diagnoses must be considered before concluding that athletic pubalgia is the cause of an athlete’s pain (see Table Two at the end of this article for the most common examples).
By all accounts, the diagnosis of athletic pubalgia is clinically difficult because no condition-specific test exists, and there is no one clear indicator that can confirm the diagnosis. Many factors may contribute to pain in the hip, groin, and abdominal regions, and the list of historical findings and clinical signs and symptoms is also quite extensive (see Table Three at the end of this article for examples).
Nonetheless, there are a few key things we know for sure about pain and stress to this area of the body. The pubic symphysis functions as a pivot point for force transfer between the lumbo-pelvic and femoracetabular joints. As it is subjected to chronic strain and shearing forces, this can lead to micro-tears of the rectus abdominis muscle or its tendon at the pubic insertions. Movement of the femurs during athletic activity, and subsequent activation of the adductor muscles, may add to the stress.
Conceptually, there is a “chicken or egg” phenomenon in considering whether adduction forces affect the pelvis, or if pelvic forces affect the femoral adduction component. Either way, however, tears of the tendinous insertion of the rectus abdominis will undoubtedly alter the function of the pelvis, which then impacts femoral adductor function.
In addition, poor core stability can cause excessive anterior pelvic tilt, increasing tension in the adductor compartment and the femur. Likewise, poor adductor strength or flexibility will place increased stress on the pubic symphysis, thus hampering the pelvic girdle’s function and affecting various muscle attachments of the pelvis, including the obliques, rectus, and transversalis muscles, as well as the conjoined tendon.
During the 2006-07 season, the Cornell men’s hockey team suffered what you might call an outbreak of athletic pubalgia. There were five confirmed cases, a rate that far exceeded historical trends within the program. Surgery is the gold standard for resolving athletic pubalgia symptoms, but because the return-to-play timeline for surgical repair is typically 10 to 12 weeks, the sports medicine team decided a renewed focus on prevention was needed.
In the spring of 2007, we developed a specialized screening tool to look for historical markers and any other factors that might increase a player’s athletic pubalgia risk. To begin, each athlete completed an injury questionnaire that focused on the past and current health of the lumbar, abdominal, pelvic, and femoral areas. Specifically, we wanted to know who had a history of pain or soreness in the lower back, abdomen, or groin areas, and who had sustained musculoskeletal strains of the abdominal, hip flexor, adductor, or hamstring muscles.
We also conducted a clinical assessment of each athlete’s core stability, hip flexibility, and strength, and took abduction/adduction muscle strength ratios with a handheld dynamometer. For core stability, the athletes performed a series of timed movements in the quadruped position while maintaining a neutral pelvis (contracting the transverse abdominals, lumbar multifidii, and abdominal obliques to do so). Eccentric muscle strength of the rectus abdominis and hip flexors was assessed with a max time contraction test, and hip range of motion was assessed manually with a goniometer, a Thomas test, and a rectus femoris tightness screening. Hip muscle strength was measured with a handheld dynamometer. Finally, each athlete completed Gray Cook’s Functional Movement Screen, which we videotaped for in-depth analysis.
Since we had already reviewed the literature on orthopedic concerns for high-level hockey players, we weren’t surprised by most of the evaluation results. Several athletes had histories of muscle strains in the abdominals, hip flexors, and adductors. Chronic episodes of lower-back pain, as well as peripubic and lower-abdominal tenderness, were common as well.
We did observe a few interesting trends. Specifically, the movement screen and other tests revealed a high incidence of restricted abdominal and hip flexor flexibility, poor core stability, hip abduction/adduction strength imbalances (with the abductors stronger than the adductors), and poor eccentric strength in the hip flexors and rectus abdominis. All five athletes with confirmed athletic pubalgia had a history of at least two of these markers.
Our findings suggested that muscle imbalances and functional deficiencies were part of an acquired pattern for elite hockey players–and these problems challenged the dynamic balance between the lumbo-pelvic and femoracetabular joints and muscles. Given the physical demands of hockey, especially the biomechanics of movement and specific muscular stresses involved in the sport, this was hardly surprising. The data we collected helped us set priorities for the new program we would now begin to design.
TRAINING FOR PREVENTION
Although there has been very little high-quality research to date on treatment and rehabilitation programs for athletic pubalgia, authors who have tackled the subject have focused mainly on the active tissues involved. For instance, one study showed that an active pelvic stabilization program was effective for treating adductor tendinopathy, while another revealed that rest and trunk stability exercises were effective in treating chronic groin injuries. And multiple studies have found that strengthening the pelvic floor and transverse abdominal muscles results in faster recovery and return to play. Still, no quality randomized and controlled studies or systemic reviews looking at non-surgical treatment of athletic pubalgia have yet been published.
The available research, our clinical experience, and the evaluations we performed with the hockey team led us to a few conclusions. First, it’s clear that the hip adductors, hip flexors, and lumbo-pelvic stabilizers are part of an intricate functional relationship that controls the position and movement of the lumbar spine, pelvis, and femur. Imbalances between the control (timing), strength, endurance, and flexibility of these muscles directly impact the type and magnitude of forces on the pubic symphysis, femoracetabular joint, lumbar spine, posterior abdominal wall, and pelvic floor.
In addition, long-term participation in sports like hockey, soccer, and football tends to create certain muscle imbalances due to repetitive activity. If these are not addressed in a training program, the resulting concentric and eccentric strength and flexibility imbalances can leave an athlete more prone to lower abdominal and groin injuries, including athletic pubalgia.
Hip flexor and adductor strains are also very common in sports that require cutting and quick acceleration and deceleration movements. Muscle strains heal via scar tissue that decreases tensile strength and elasticity, so the treatment and rehabilitation of those injuries is paramount for maintaining the dynamic relationship between muscles in the lumbo-pelvic region. Anatomical and postural abnormalities, such as increased lumbar lordosis or kyphosis and hip anteversion or retroversion, can also affect this dynamic functional relationship and increase athletic pubalgia risk.
To translate these conclusions into a training program, we decided to isolate several key weaknesses or movement limitations, then set training priorities that would correct them. With this approach, we hoped to address the most important factors that predispose an athlete to athletic pubalgia and other related injuries. Below is a list of the key factors, followed by the exercise focuses we used to address them:
Poor core stability. For athletes with this deficiency, we sought to improve control and endurance of the transverse abdominals, abdominal obliques, lumbar multifidii, and quadratus lumborum muscles through a comprehensive core stabilization program. To be effective, core stabilization concepts needed to be incorporated throughout the athletes’ entire strength and conditioning program.
This meant going back to the basics of teaching athletes to maintain a neutral pelvis and spine, and activating the transverse abdominals in simple supine, sitting, and standing positions. We then gradually progressed toward more functional exercises utilizing these essential principles. We incorporated exercises with progressive resistance using plyo balls, tubing, and a physio ball with rotational and diagonal movements as well as other functional patterns. We also added lateral and prone plank exercises with hip abduction, flexion, and extension perturbations to reinforce neutral pelvic and lumbar positioning.
Poor eccentric strength of the hip and trunk flexors. We discontinued concentric hip and abdominal flexion exercises for these athletes in an attempt to address the flexibility and eccentric strength imbalances, which we theorized were partly caused by concentric training. We then prescribed exercises that focused on building eccentric strength and improving control of the hip and trunk flexors, using slow, controlled movements and sometimes a four-way hip machine.
To ensure maximum benefit, we were careful to not allow anterior or posterior pelvic tilting during the exercises. We were concerned that such tilting might excessively activate the powerful hamstrings and hip flexors, thus overpowering the local fine-control muscles such as the transverse abdominals and external obliques.
Weak hip adductor muscles. We focused on building hip adduction strength (eccentric and concentric), and de-emphasized concentric hip abduction exercises until the athletes’ abduction/adduction ratio approached 1:1. This was accomplished using a standard four-way hip machine, but we also could have used exercises incorporating pulleys, cables, and even therapeutic exercise bands or cords.
History of lumbo-pelvic and femoracetabular muscle strains. We worked individually with these athletes on the specific muscles that were most vulnerable to strain, exhibited the greatest inflexibility, or were most in need of recruitment. In some cases, athletes were instructed to focus more on flexibility of the adductor, iliopsoas, and/or rectus femoris muscles with side lying or supine stretches. For others, a clinician-assisted manual approach was required to address personal limitations. A few athletes had to incorporate trunk flexibility and mobility exercises into their workouts, such as prone press-ups and torso rotational patterns.
One year after implementing our program, we are pleased with the trends we have seen thus far, specifically a decrease in the number of soft-tissue injuries to the lumbo-pelvic-femoral region. The team enjoyed a 40 percent reduction in hip flexor and adductor muscle strains, and an associated 58 percent drop in days lost to injury during the 2007-08 season. There was a 17 percent reduction in lower-back pain episodes, with an associated 64 percent drop in lost days. And there were no new cases of athletic pubalgia.
Three players did suffer mild abdominal strains during the season, but each case was resolved with a conservative care program that re-emphasized the exercises that had been prescribed as part of the prevention program. Overall, we noted a significant reduction in the number of lumbo-pelvic-femoral related complaints, and saw improved return-to-play timeframes for minor strains and pain throughout the season.
So what did we learn by designing and implementing this program? First, athletic pubalgia is a complex condition involving several interrelated factors. Often confused with other orthopedic problems or lumped in with the general and poorly defined term “sports hernias,” it is in fact a specific condition unto itself, and effective prevention and rehab exercise programs must address all the right components.
Whenever an athlete experiences groin pain, several anatomical structures and biomechanical models may be in play. Because of the proximity of this area to vital parts of the digestive, reproductive, and genitourinary systems, you must take care to ensure that other potential diagnoses are ruled out before treating the condition as athletic pubalgia. It’s always a good idea to bring a physician into the picture if a correct diagnosis is elusive.
To prevent this type of injury in the first place, exercise programs should focus on individual injury histories involving the lumbar spine, abdomen, and hip joints, and also address functional core stability, which is crucial for protecting the lumbo-pelvic region. Building or restoring functional eccentric and concentric strength and flexibility balance between the hip flexors/extensors and abductors/adductors must be priorities as well. Above all, because the risk is so individualized, training programs should be specifically crafted to address each athlete’s risk factors and their underlying causes. With that approach, you can help your athletes avoid this painful and debilitating condition.
The authors wish to thank Thomas Howley, MS, CSCS, Cornell’s Assistant Director of Athletics for Athletes Performance, for his assistance with this article.
Table One: Co-Existing Factors for Athletic Pubalgia
History of abdominal muscle pathology Hip flexor and/or adductor strains Adductor tendinopathy Pubic symphysitis or osteitis pubis Lower abdominal, adductor, and hip flexor muscle imbalances Adductor/abductor strength ratio under .80
Table Two: Differential Diagnosis Considerations
Pubic symphysitis or osteitis pubis Adductor tendinopathy Obturator/ilioinguinal neuropathy Inguinal hernia (direct/indirect) Femoracetabular intra-articular lesions Femoracetabular impingement syndrome Legg-Calve-Perthes disease Avascular necrosis of the femoral head Osteoarthritis Labral pathologies Slipped capital epiphyses Osteochondritis dissecans Pubic bone/femoral stress fractures Testicular pathology Intra-abdominal/pelvic floor pathology (genitourinary, reproductive, gastrointestinal systems)
Table Three: Common History & Symptom Complaints
Lower abdominal pain with exertion Distinct mechanism w/exertion often not recalled Pain w/coughing, sneezing, or Valsalva maneuver Pain in inguinal canal near rectus abdominis insertion on pubic symphysis Pain absent/minimal at rest Pain progresses from unilateral to bilateral over time Pain with resistive adduction and/or hip flexion reported in the lower abdominals, inner thigh, and/or testicular areas Failed response to conservative treatment History of multiple hip, low back, and/or pelvic pathologies Inguinal tenderness Pain with resistive hip adduction Pain with resistive trunk flexion Peripubic tenderness Adductor longus insertional tenderness Direct pubic symphysis tenderness Lower abdominal tenderness Testicular pain Absence of palpable inguinal mass