Athletic Pubalgia

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We have recently written overviews of our current understanding of the anatomic and pathophysiologic bases for this set of syndromes.1,3 Briefly, this set of syndromes accounts for most of the surgical problems that we see in athletes. Athletes create tremendous torque that occurs at the level of the pelvis. The anterior pelvis takes much of the brunt of these forces. The attachments to the anterior pelvis play the most important roles with respect to the direct and opposing forces that are involved in this torque. However, the posterior, lateral, and medial compartments are usually also involved and need to be considered in planning therapy.

From an anatomic perspective, it is important to understand fully the pelvic anatomy that is involved. Basically, one thinks of the pubic symphysis as the fulcrum around which the forces occur. Then one thinks of the injuries as a combination of acute or chronic weakening and compensatory overuse of various insertions or attachments. In many of these injuries, one thinks in terms of an "unstable pubic joint."

Pathophysiological^, one then can think in terms of which attachments to the joint are involved either directly in the injury or conversely as compensatory mechanisms. In addition to the attachments, one may also think in terms of there being a variety of "strap muscles" or "compensatory compartments." An example of a strap muscle might be the psoas tendon, which does not insert directly into the pubis. Nonetheless, the psoas muscle and tendon do provide considerable pubic joint stability. While the anterior compartment is the most common one involved in injury, the other compartments may also be directly involved, in which case the nondirectly involved compartments become "compensatory."

One must figure out the mechanisms of the primary injuries and then determine the method of repair. The most common injury is a weakening of the rectus abdominis muscle as it inserts on the pubis, associated with compensatory overuse of the other side, the adductor longus, adductor brevis, and/or pectineus. In total, we have described more than 18 syndromes that occur relatively commonly. One should also remember that there are other parts of these muscles or attachments that can be injured in different locations. For example, the rectus abdominis muscles can fray anywhere within the anterior abdominal wall or can also cause a subluxation syndrome of the lowermost ribs or cartilages. We have seen the latter syndromes in fighters, rowers, women tennis players, and bull riders.

We classify the pathology seen at surgery associated with the preceding syndromes as grade 1, single or multiple small tears; grade 2, partial avulsion or avulsions; and grade 3, complete avulsion or avulsions or a complete avulsion associated with another partial avulsion.

There are some other "confusors." As suggested by the previous discussion, proper diagnosis of these injuries can be tricky. At this point, we just mention some of the considerations that can be confusing.

Four of the confusors are (1) identification of patients who need surgery, (2) the type of surgery, (3) the timing of surgery, and (4) the duration of rehabilitation. Briefly, surgery is indicated when joint instability is clearly demonstrated after the acute effects of injury, for example, hematoma, have resolved and physical therapy does not seem appropriate. Surgery involves a combination of tightening, loosening, or other procedures that focus on preventing persistence of pain. The specific surgery depends greatly on understanding precisely the direct and compensatory parts of the injury as well as the principal causes of the pain. Timing of surgery depends on various medical, social, and business factors such as the proper identification of the specific injury, the degree of debility that the injury causes, the possible negative consequences of playing with the injury, and the relative risks in relation to such things as the importance of upcoming games, the player's contract, the team's interests in the player, and confidence that performance will not hurt the player's overall value. Duration of rehabilitation is a particularly tricky consideration. We get most players back within 6 weeks of the injury, depending, of course, on the type of injury. There is evidence that we could get the players back even earlier, but long-term success possibly could be negatively associated with returning too quickly.

Finally, we mention two more confusors. One is that the psoas "snapping hip" syndrome can be, but does not have to be, associated with athletic pubalgia or a labral tear. Because the iliopsoas tendon glides by the hip joint so closely, one has to consider that the patient can have one, two, or three syndromes at the same time. To make things even more confusing, one can at the same time demonstrate a clear labral tear by MRI or arthroscopy, but the tear still may be totally asymptomatic.

A second confusor is the consideration of osteitis pubis. It is important that we realize that most athlete patients with this radiographic diagnosis have a secondary type of osteitis that responds favorably to treatment of the underlying joint instability. However, there still is a "primary" type of osteitis pubis that can affect athletes. The primary form of this problem involves continuous and debilitating pain that may be aggravated or ameliorated by exertion. The pain and tenderness often involve multiple bony sites in the pelvis. The primary type of osteitis pubis is difficult to treat. Fortunately, from an athletic standpoint, the primary osteitis pubis occurs much more in nonathletes. The problem is nonetheless, of course, very unfortunate for the patients involved because it is so difficult to treat. On the other hand, the syndrome does seem usually to be time limited.

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