Sports Hernia: Athletic Pubalgia

The athletic pubalgia syndrome includes a number of variants.  Each variant has a slightly different mechanism of injury; therefore, this accounts for the difference in symptoms.  Listed below are several, but not all, of the different variants of athletic pubalgia. 

 

Classic Athletic Pubalgia – this is the most common form of the syndrome of chronic, severe, exertional, and lateral rectus abdominus pain related to the latter muscle’s tendinous insertion onto the pubis.  Classically, a tear or an attenuation of the rectus abdominus insertion causes the syndrome as well as possibly secondary pain near the adductor insertion sites onto the pubis.

Adductor Longus Variant – adductor longus pain is a principal component of the pain.  In some cases, the adductor longus pain occurs without any rectus abdominus pain. 

Snapping Hip Syndrome – an elicitation of a “hip snap” on physical examination or with a similar maneuver.  This variant most often occurs in runners and in women.

Spigelian Variant– there is pronounced pain in the spigelian area, the same site where hernias can occur.  In this case, the pain is not due to a hernia, but to a vertical extension of the same musculofascial shredding that characterizes the more classic athletic pubalgia.

Baseball Pitcher/Hockey Goalie Syndrome – this syndrome tends to occur in the afore-mentioned athletes and primarily involves a muscular hernia through the fascia or epimysium investing the belly of the adductor longus muscle. 

Osteitis Pubis Variants – in many cases there is some degree of osteitis pubis.  Most of the time, the former pain will resolve with appropriate treatment of the athletic pubalgia.  However, in some cases, the osteitis pubis pain is so diffuse and painful that the pain takes longer to resolve.  One must also be aware of the possibility of primary osteitis pubis, which in general is more difficult to treat.

Iliopsoas Variant – pain is principally near the psoas insertion site onto the lesser trochanter.  The pain results from a psoas bursitis that is secondary to the instability caused by the weak rectus abdominus attachment.

Gracilis Variant – the gracilis is more involved than the adductor longus in the pain resulting from a compartment syndrome due to relatively unopposed action of the adductors with respect to the pubic joint.

Athlete’s Rib Syndrome – this tends to involve rowers, tennis players, and boxers.  The rectus abdominus fibers that interdigitate with the lower most intercostals muscles sublux the 11^th and 12^th ribs and/or cartilages.

Superior Rectus Variant – this syndrome is an intermediate between the spigelian and the Athlete’s Rib Variant.

Sartorius Variant – this tends to occur in women.  There is considerable pain at the sartorius insertion site in addition to lower rectus abdominus pain.

Labral Tear/Snapping Hip Variant – the symptoms and findings of these two entities can be very similar, and in fact the two problems often coexist. 

Round Ligament Syndrome – distinguishing athletic pubalgia from endometriosis can be difficult and there seems to be a definite syndrome in athletes involving exertion and pain related to the round ligament itself.

Adductor Avulsion Variants – the adductor longus can partially or completely avulse from the pubis resulting in considerable pain. 

Adductor Calcification Syndromes – We have often seen these problems most commonly in bull riders.  Often years after the injury, the calcification that results from this severe trauma ends up in severe inflammation and pain.

Iliotibilal Tract Syndromes – pain in this area can be secondary to compensation from a primary rectus abdominus problem. 

Rectus Femoris, Quadratus, or Pectineus Syndromes - pain can occur either primarily or secondarily along other insertion sites or bursae related to these muscles and tendons.