Proper diagnosis and management of athletic pubalgia

Proper diagnosis and management of athletic pubalgia Blog

Each year, between 10 and 13 percent of reported sports-related injuries involve groin pain. Some of these people will be diagnosed with athletic pubalgia, which is also known as a sports hernia. These are injuries that may happen to people who run, kick or play sports that require sudden and explosive changes of direction. The proper diagnosis and management of sports hernias are important because an untreated sports hernia may end up limiting an athlete’s ability to continue participating in his or her chosen sport.

Other conditions that cause groin pain

When a patient reports groin pain, doctors should first check for other conditions that can cause the pain. There are a number of differential diagnoses, including:

  • Strained or pulled muscles
  • Muscle bruises
  • A ruptured tendon
  • Bursitis
  • Pubic instability
  • Referred pain from the lumbar spine or sacroiliac joint
  • An inguinal hernia
  • Osteoarthritis in the hip

There are several other possible causes of pain in the groin. The differential diagnoses should be eliminated as causing the pain first.

Diagnosis of athletic pubalgia

People who are suffering from athletic pubalgia often report pain in their groins and lower abdomens that may radiate down to the scrotum or inner thighs. The pain is normally intense and located on one side. People who have sports hernias are usually athletes who may not go to their doctors about their symptoms for several months because they may be able to play despite the pain.

When a sports hernia is suspected, a doctor will complete a physical exam. The patient may have tenderness on the side that is affected on or just above the pubic tubercle. He or she may also report tenderness near the rectum and pain during a resisted sit-up test. Doctors may use MRIs, ultrasounds and x-rays to rule out other problems and to confirm the diagnosis.

Management of sports hernias

Sports hernias will generally need to be surgically repaired. However, physical therapy management may be used for athletes while they are in the middle of their seasons until they complete them. They can take off four weeks to rest, and during that time period, their physical therapists may direct them to complete a closed-chain exercise program involving their lower legs. They may also be given a series of steroid injections or ones containing platelet-rich plasma. This management regimen may help to alleviate the worst symptoms and allow the athlete to return to his or her sport in order to finish out the season.

After surgery, rehabilitation will involve several things. Athletes will be able to bear weight as they can tolerate it. Patients will be told to rest for about 10 days. Physical therapy will then include a regimen of range-of-motion exercises, closed-chain exercises and core-strength exercises that begin about four weeks after surgery. The athletes will be able to start performing drills for their sports at about five weeks. Most will be able to fully return to their sports at about six weeks after their surgeries.

Groin pain is a fairly common type of injury experienced by people who play certain sports. When a sports hernia is suspected, it is important that it is properly diagnosed and treated so that it doesn’t prevent the person from being able to return to his or her sport.

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

image

Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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