Groin pain in athletes and sports enthusiasts, Athlete's hernia, Groin problem, Pubic joint, Symphysis, Pubic bone pain, Pubic and groin pain syndrome, Ice hockey player's syndrome, Overuse, Load-bearing pain
Groin pain that worsens during exertion is a common issue among young athletes. This condition is especially prevalent in sports that involve repeated use of the lower abdominal muscles and the inner thigh muscles. Such sports include soccer, ice hockey or endurance running to name a few. However, groin issues can also arise from injuries, as complications after surgery or during pregnancy and childbirth.
Osteitis pubis refers to a situation where pain or inflammation occurs in the pubic bone, the pubic joint, or in the surrounding structures. Typically initiated by overuse, this condition manifests as inflammatory changes visible in MRI scans. Symptoms include pain and tenderness around the pubic bone area that get aggravated by situations involving increased strain. In some cases, Osteitis pubis might arise as a complication of an invasive procedure done in the pelvic region.
The primary approach for managing Osteitis pubis and other groin pains is conservative. Conservative treatment involves rest, modification of loading habits, physical therapy, gentle stretching, possible anti-inflammatory medication and, if necessary, local corticosteroid injections. Surgery is considered only if conservative treatment fails or proves insufficient.
Epidemiology and etiology
Groin pain most commonly arises in sports involving powerful kicks, rotations, turns or sudden changes in direction. Groin pain related to overuse and Osteitis pubis mainly affects men under 40 years old. This can be explained by the fact that men generally engaging more in sports that expose them to groin injuries. Additionally, women have stronger muscle attachments around the pubic joint, allowing them to withstand more strain in proportion. Another reason might also be that women have wider pelvises than men, potentially redirecting forces away from the groin area during load-bearing activities. The anatomical and biomechanical differences in a womans pelvis might contribute to stabilizing the groin area and reducing the risk of groin pain.
An imbalance in muscle activity between the hip adductors and abdominal muscles can contribute to the onset of groin pain, making restoration of muscle balance a vital part of the rehabilitation procedure. The pubic joint acts as a fulcrum for the anterior part of the pelvis, and structures contributing to groin pain are closely related to this pivotal point.
The tendon fibers of the rectus abdominis, internal and transverse oblique abdominal muscles, along with the external oblique abdominal muscles, unite to form a continuous aponeurotic tendon. This, in turn, merges with the aponeurotic tendon formed by the thigh adductor muscles, creating unified support for the anterior pelvic region. A significant portion of the force generated during sports is directed precisely at the front of the pelvis, where the pubic joint serves as its center.
The hip adductors act as a direct counterforce to the force produced by the rectus abdominis in the pelvic region and this disproportion is believed to contribute to the development of groin pain. Contraction of the rectus abdominis lifts the front of the pelvis upward, while contraction of the hip adductors lowers it downward. This continuous back-and-forth motion can result in increased load, which over time transforms into an inflammatory reaction and pain in the pubic bone or its joint.
Imbalance in the muscles of the pelvic area can also lead to instability in the pubic joint and cartilage degeneration.
Groin pain associated with overuse can also develop secondarily due to increased compensatory movement. In such cases, movement is often restricted elsewhere in the kinetic chain, leading to heightened compensatory movement in the pubic joint. These situations can occur, for instance, due to hip impingement or Ischiofemoral impingement syndrome, but also other challenges in the hip and lower extremities can lead to greater stress in the pubic region.
On the other hand, groin pain and Osteitis pubis can also develop without an overuse background. In such cases, there is often an underlying factor such as:
Pregnancy or childbirth
Urological or gynecological surgery
Trauma
Psoriatic arthritis
Ankylosing spondylitis
Symptoms
Groin pain and Osteitis pubis often start as a deep or sharp pain felt unilaterally in the lower abdomen or groin fold. The pain worsens during load-bearing activities and gets better while resting. Occasionally, the pain can radiate to the upper thigh, lower back, lower abdominal muscles or testicles. Coughing or sneezing can exacerbate the pain, while rest usually provides relief.
The pain gradually appears and recurs in similar situations or activities. These situations often involve excessive extension of the back, significant abduction of the hip or other movements that subject the pubic bone area to significant traction or shear forces.
Pain often eases if the load on the pubic region can be regulated or reduced. Many find relief by decreasing the stretching load on the anterior part of the pelvis, which often leads to a slightly forward-leaning posture. Standing and moving around in an upright position might feel more challenging than moving slightly hunched.
Examples of symptoms associated with the pubic joint or Osteitis pubis:
Deep or sharp pain in the groin or lower abdominal area
Pain worsening during specific activities like sprints, kicks, direction changes or abdominal muscle-focused exercises
Pain alleviated by rest
Sensitivity to touch around the pubic joint or the tendons of the rectus abdominis and hip adductors
Pain intensifying during resisted hip adduction
Pain escalating during resisted contraction of the abdominal muscles
Treatment
The primary treatment for groin pain and Osteitis pubis is conservative care. This involves rest, anti-inflammatory medications, potential corticosteroid injections, cold therapy, and progressive physiotherapy and exercise.
Recovery times for Osteitis pubis are often lengthy. Nevertheless, only about 5-10% of athletes require surgical treatment.
Any specific criteria for the failure of conservative treatment hasn't been given and a precise timeline for recovery has not been defined. Generally, conservative treatment is continued for at least six months before considering surgery as an option for addressing the issue.
Physiotherapy
Physical therapy always begins with a thorough assessment of background factors, enabling the creation of an individualized and progressive exercise program to enhance functionality and reduce perceived discomfort. When dealing with athletes, their level of performance, expected return to the field and the timing of the sports season must also be taken into consideration. Physical therapy involves a blend of manual therapy, therapeutic exercises, as well as encouragement and education about the issue and background factors.
The treatment includes periods of rest, manual soft tissue manipulation, joint mobilization and manipulation techniques, and progressive exercises. These aim to achieve improved mobility, reduced muscle tension, enhanced control and increased power output in the area of pain.
In the initial stages, the goal often focuses on enhancing mobility by addressing any movement limitations. Subsequently, efforts concentrate on improving control and movement quality throughout the kinetic chain. Exercises involve practicing the activation and control of deep muscles with and without movement. Weaknesses in the abdominal, lumbar, pelvic, and lower limb muscles are addressed through progressive strengthening exercises. Dynamic stretching is employed to boost flexibility and enhance the load-bearing capacity of tendon tissues by gradually increasing force over time. Coordination and proprioceptive exercises are also crucial before returning to one's sport.
The design of physical therapy is always individualized based on the clinical assessment and takes into account the patient's preferences and background.
Self care
Rest and Activity Modification: Avoid activities that excessively worsen the pain. Mild to moderate pain that occurs during activity but subsides fairly quickly afterward is acceptable, but performing activities with severe pain often exacerbates the situation. Give your body time to heal from existing damage by taking things a bit easier.
Cold Therapy: Cold treatment helps reduce pain and potential inflammation. Wrap an ice pack or cold pack in a towel and apply it to the painful area for 15-20 minutes at a time. Repeat cold therapy 4-5 times a day for at least 4 days.
Medication: Over-the-counter pain and anti-inflammatory medications like ibuprofen or acetaminophen can provide temporary relief from pain and inflammation. Follow recommended dosages and instructions and consult a doctor regarding the duration and dosage of the medication.
Gentle Stretching and Mobility Exercises: Gentle stretching and mobility exercises can help maintain flexibility and prevent muscle stiffness. However, avoid prolonged and intense stretching.
Engage in Regular Exercise: Physical activity improves circulation and reduces muscle tension. Recommended forms of exercise include cycling, swimming, or water aerobics.
Improve Body Control through Training: Poor or weakened body control can increase strain in the groin area and worsen symptoms. Practice body control and kinematics through balance and body control exercises. Movements that enhance core support can also help balance load peaks in the pelvic region and groin area.
Avoid Heavy Load: Activities involving sudden movements or repetitive impact, such as running or jumping usually worsen groin pain.
Massage: Light soft tissue manipulation often reduces pain and enhances tissue circulation. Light massage can be done daily, but more intense manipulation is best limited to 1-2 times a week.
Gradual Return to Active Life: When the groin pain begins to improve, you can slowly return to your hobbies. Remember to gradually increase your activity level so your body has time to adapt to changes in load and recover.
Nutrition and Hydration: Adequate hydration and a balanced diet support the healing process and provide essential nutrients for recovery.
Remember that these tips are meant as general guidelines and do not replace medical advice from a professional. Your situation may require an individualized approach, so consult a healthcare professional for accurate assessment and recommendations.
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