II. Epidemiology

  1. Common cause of chronic Groin Pain in athletes

III. Causes

  1. Pregnancy
  2. Sports Injury
    1. Long distance Running
    2. Soccer

IV. Pathophysiology

  1. Pregnancy
    1. Expanding pressure from growing fetus
  2. Sports-related repetitive stress injuries
    1. Overuse of hip adductors and gracilis Muscle
    2. Shearing forces on Pubic Symphysis
    3. Traction on pelvic musculature

V. Risk Factors: Predisposing factors in sports

  1. Limited internal hip rotation
  2. Sacroiliac joint fixation
  3. Lower limb biomechanical abnormalities (postulated)
    1. Leg Length Discrepancy
    2. Over-pronation
    3. Genu Varum (Varus knee deformity)
    4. Genu Valgum (Valgus knee deformity)

VI. Symptoms

  1. Groin Pain of gradual onset and progression
  2. Exercise-induced pain
    1. Adductor pain in medial thigh (80%)
    2. Pubic Symphysis pain (40%)
    3. Lower Abdominal Pain (30%)
    4. Hip Pain (12%)
    5. Referred Scrotal Pain (8%)

VII. Signs

  1. Tenderness to palpation of Pubic Symphysis
  2. Provocative maneuvers
    1. Active adduction (distal symphysis involvement)
    2. Sit-ups (proximal symphysis involvement)

VIII. Imaging (non-pregnant patients)

  1. XRay (changes often seen in asymptomatic athletes)
    1. Widened Pubic Symphysis
    2. Irregular articular surface
    3. Periarticular sclerosis
  2. Isotope bone scan
    1. Increased uptake at Pubic Symphysis
    2. Poor Test Sensitivity
  3. MRI (preferred study)
    1. Early: Marrow edema
    2. Later: Low signal uptake on T1 and T2-weighted images

IX. Differential Diagnosis

  1. See Groin Injuries in Athletes
  2. Adductor Strain
  3. Osteomyelitis of the Pubic Symphysis
    1. Spontaneous onset following surgery near Pelvis

X. Management: Athlete

  1. Avoid provocative activities
  2. Cross training with pain-free Exercise
  3. Physical Therapy
    1. Hip Range of Motion
    2. Adductor Stretching and strengthening
  4. Correct biomechanical abnormalities
    1. Leg Length Discrepancy
    2. Over-pronation
  5. Consider local Corticosteroid Injection in acute cases

XI. Prognosis

  1. Complete resolution may require 9-12 months

XII. References

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