In a large number of active individuals and of course in athletes of all disciplines and in particular in the sport that interests us very closely, Athletics, we are forced to see more and more micro traumatic injuries from overwork , of which at least one, pubalgia, deserves this clarification, because its diagnosis is often delayed and its management neglected.
Remember that according to the French conception, a real pubalgia (which wreaks real havoc among footballers) corresponds to a syndrome of painful overwork of the pubic crossroads located at the level of the groin fold and point of convergence of many lines of force, d stretching and contraction of muscles and their tendinous insertions, canals, and numerous nerves and covers three very distinct anatomo-clinical entities which can be perfectly intertwined in the event of diagnostic delay and/or inappropriate management:
It should be noted from the outset that the diagnosis of pubalgia should not be an easy diagnosis and that there are a certain number of false pubalgias which clinically approach true pubalgia, but which in reality have different causes (between 14 and 18 years in an athletic adolescent who presents with inguinal pain, before making the diagnosis of pubalgia, the possibility of epiphysiolysis must first be considered).
A- Real pubalgia
Remember that according to the French conception, a real pubalgia (which wreaks real havoc among footballers) corresponds to a syndrome of painful overwork of the pubic crossroads located at the level of the groin fold and point of convergence of many lines of force, d stretching and contraction of muscles and their tendinous insertions, canals, and numerous nerves and covers three very distinct anatomo-clinical entities which can be perfectly intertwined in the event of diagnostic delay and/or inappropriate management:
1 - tendinopathy of the adductor muscles or that of the rectus abdominis
2 - pubic osteoarthropathy
3 - abdominal parietal pathology.
These 3 entities have a common lesion mechanism: the weakness of the posterior part of the inguinal canal . It should be noted from the outset that the diagnosis of pubalgia should not be an easy diagnosis and that there are a certain number of false pubalgias which clinically approach true pubalgia, but which in reality have different causes (between 14 and 18 years in an athletic adolescent who presents with inguinal pain, before making the diagnosis of pubalgia, the possibility of epiphysiolysis must first be considered).
A- Real pubalgia
For our beautiful French school of sports traumatology and especially that of the Pitié Salpétrière of my masters, Prs Gérard Saillant and Jacques Rodineau, pubalgia covers three very distinct anatomo-clinical entities, but which can also be perfectly intertwined in the event of diagnostic delay and/or inadequate treatment:
1 - tendinopathy of the adductor muscles or that of the rectus abdominis
2 - pubic osteoarthropathy
3 - abdominal parietal pathology.
These 3 entities have a common lesional mechanism, the weakness of the posterior part of the inguinal canal, which in addition to facilitating the formation of hernias with prolapse of organs outside the abdominal cavity, is at the origin of tensions on the pubis , tendon pain at their bony insertions and nerve irritation of the genital branch of the genito-femoral nerve, causing pain in the inner thigh and scrotum.
But intellectual honesty obliges, Anglo-Saxons and Scandinavians do not share the point of view of the French school and their “Hip and snout Pain” corresponds to a broader vision of the etiologies which include, for example, hip damage.
What you need to know, especially in a high-level athlete, if you want to avoid surgery to correct this anatomical weakness using the Nésovic/Jaeger or Bordeaux Reboul technique, which will have to be offered at the 4th month, in case of failure of a well-conducted medical treatment, it is imperative to consider the pubalgia as a medical emergency, very quickly eliminate a hip problem by comparative examination of the crossed flexions (unilateral decrease in mobility in flexion-adduction-internal rotation, on the painful side) or a spinal cause of pubalgia (by painful dysfunction of the thoraco-lumbar hinge of Robert Maigne with pains which project into the fold of the groin; this spinal dysfunction which can perfectly co-exist with true pubalgia,will be a source of failure of the medical or surgical treatment if it is not taken into account in the medical treatment which must be implemented as early as possible.
This medical treatment, whatever the anatomo-clinical form of pubalgia, should ideally be as close as possible to that proposed by the CERS of Capbreton, which has largely proven its worth: pain management, improvement of mobility internal rotation (IR), stabilization of the lumbo-pelvic region, correction of abdominal/adductor and hip adductor/abductor muscle imbalances and planning for sports recovery without medication.
I - Phylogenesis of the adductor muscles of the thigh
Since the dawn of time and very exactly since the first vertebrates emerged from the water to reach terra firma, the thigh has always been the most developed segment of the limb both in terms of muscle and bone. This phenomenon is found in all genera (amphibians, birds, mammals, reptiles) and has only disappeared in vertebrates that have lost their limbs during evolution (ophidians, cetaceans, pinnipeds). In primates, the thigh is the most powerful segment of the propelling limb, with the essential function of propulsion being added in bipeds to the anti-gravity struggle.. In Primates, the external obliquity of the femur at the origin of the varus of the knee, conferred on the adductor muscles an important anti-gravity role, this position ensuring these muscles a very great force of adduction. Conversely, in permanent bipeds, including humans, the straightness of the thigh and leg, which moves back the axis of the vertical forces generated by gravitation, places the bone structures practically in the axis of these forces and considerably modifies the biomechanics of the body. this region, the contraction of the adductors for example generating a practically vertical force with a very weak horizontal adductor component. This phylogenetic particularity explains the great vulnerability of these adductor muscles, their physiological difficulties in managing the constraints imposed by sporting activity which varies from one sport to another and therefore their exposure to tendino-muscular accidents . Lower pubalgia (adductor disease) is only the reflection of an inability to resist the various tractions on the pre-pubic tendon network.
II - Anatomical singularities of the pubic crossroads
The pubic crossroads presents some singularities which it is necessary to know:
- the fusion at the level of their junction, between the rectus abdominis muscle and the contralateral adductor longus muscle in order to form one and the same structure. This anatomical concept, now shared by all, does not yet clearly explain the mode of transfer of forces and loads through this pre-symphyseal aponeurosis.
- the insertion of the adductor magnus muscle on the ischio-pubic branch is different from that of the other adductor muscles. It is both muscular (on average 60%) and tendon (on average 40%). Ihe high frequency of damage to this muscle suggests a mode of operation that makes it very vulnerable and it is up to ultrasound to highlight these variations in insertion and to specify whether the damage is indeed located at the level of the long adductor and if it is an insertion enthesopathy, a tendon fissure or a myotendinous attack, prognosis and treatment are then totally different.
III - Physiology of the thigh muscles
The antero-posterior and internal/external muscular imbalances of the thigh muscles and between the abdominals and adductors and the resulting pathologies depend on the importance of the variable muscular stimulation from one sport to another and the interest that the subject is to maintain this balance. While the quadriceps is especially challenged when performing thigh leg extensions and weighted squats, the hamstrings are used to propel the body forward when moving quickly (running) or to flex the leg during flexion/extension movements in cycling. As for the adductors, they are very sensitive to sudden lateral displacements and micro-traumas caused by poor quality plantar support during running. They are also subjected to excessive stretching in many physical activities practiced in flexibility (dance, gymnastics).
The pubic crossroads presents some singularities which it is necessary to know:
- the fusion at the level of their junction, between the rectus abdominis muscle and the contralateral adductor longus muscle in order to form one and the same structure. This anatomical concept, now shared by all, does not yet clearly explain the mode of transfer of forces and loads through this pre-symphyseal aponeurosis.
- the insertion of the adductor magnus muscle on the ischio-pubic branch is different from that of the other adductor muscles. It is both muscular (on average 60%) and tendon (on average 40%). Ihe high frequency of damage to this muscle suggests a mode of operation that makes it very vulnerable and it is up to ultrasound to highlight these variations in insertion and to specify whether the damage is indeed located at the level of the long adductor and if it is an insertion enthesopathy, a tendon fissure or a myotendinous attack, prognosis and treatment are then totally different.
III - Physiology of the thigh muscles
The antero-posterior and internal/external muscular imbalances of the thigh muscles and between the abdominals and adductors and the resulting pathologies depend on the importance of the variable muscular stimulation from one sport to another and the interest that the subject is to maintain this balance. While the quadriceps is especially challenged when performing thigh leg extensions and weighted squats, the hamstrings are used to propel the body forward when moving quickly (running) or to flex the leg during flexion/extension movements in cycling. As for the adductors, they are very sensitive to sudden lateral displacements and micro-traumas caused by poor quality plantar support during running. They are also subjected to excessive stretching in many physical activities practiced in flexibility (dance, gymnastics).
IV - Etiopathogenesis of pubalgia
The mechanism of injury (ML) +++
ML in pubalgia corresponds to a weakness of the posterior wall of the inguinal canal and a retraction of the rectus abdominis muscle, causing tension on the pubis, tendon pain at the bony insertions and nerve irritation of the genital branch of the genitofemoral nerve causing pain in the inner thigh and scrotum (Minnich, AJSM, Sport hernia, V39, 6 , 2011).
Risk factors ++
They are of both intrinsic and extrinsic origin:
Intrinsic factors:
- history of trauma to the adductors or the abdominal wall.
- limitation of hip mobility in internal rotation.
- loco-regional biomechanical factors with dynamic instability of the pelvis: lumbar hyperlordosis, anteversion of the pelvis, sacroiliac dysfunction. In this dynamic instability of the pelvis, the lumbopelvic region plays a primordial role in the transfer of stresses between the trunk and the lower limbs, with anticipated muscular contraction of the multifidi, transverse and internal oblique muscles. In case of pain, the contraction of these muscles and of the gluteus maximus is delayed with the impossibility of stabilizing the pelvis during movements of the lower limbs (Tyler: Clin Sports Med. 29, 2010).
- delayed activation of the transverse abdominis muscle with anticipated contraction of the abdominal wall muscles (Transverse, Internal Oblique) when movements of the lower limbs disturb the balance of the pelvic ring (Cowan: Med.Sci. Sports Exerc. , V36, No. 12, 2004).
- constitutional or acquired hypotonia of the oblique muscles of the lower abdominal wall with consequences: thinning, dehiscence, pre-hernial state.
- deficiency of the internal orifice of the inguinal canal: dilated, in a pre-hernial state.
- asymmetrical stresses body weight-reaction of the ground.
- hip dysplasia or any other intra-articular hip pathology leading to reduced hip mobility: the reduction in internal rotation (on cam lesion of anterior hip impingements or by retroversion of the femur) leads to constraints on the pelvis during physical activity with antero-inferior opening of the pubic symphysis (Birmingham- AJSM- V40-5-2012). Involvement of femoroacetabular impingements in the genesis of pubalgia (Larson/Arthroscopy/2011).
- imbalance of the very powerful Adductors/weaker Abdominals balance, but also of the Adductors/Abductors ratio < or = 80%.
Extrinsic factors
Sports at risk
Pubalgia is a pathology of young athletes, almost exclusively male, which affects 5-18% of athletes, all sports combined.
- Football+++ (schoot, side passes, dribbling) with 58% of footballers having a history of pubic pain, is the most exposed sports discipline. The incidence of pubalgia is 1/1000 Hours of play and represents between 11% and 16% of injuries. In a Norwegian study of 508 footballers, players with a history of abdominal wall injuries were twice as likely, those with a deficit on the adductors were 4 times as likely (Engebretsen, AJSM, V20, 10, 2010).
- Hockey: in this sport, adductor strength is 18% lower in players who have a history of adductor injuries. The adductor/abductor strength ratio is 95% in healthy players and 78% in injured players. The risk of adductor injury is 17 times higher if the ratio is less than 80% (Tyler et al. Adductor Muscle Strains in Hockey Players, AJSM, V29, 2, 2001).
- Athletics in a majority of disciplines (walking, combined events, pole vault, long-distance and middle-distance races, steeplechase, hurdles, etc. -
Rugby (opener; goalscorer), Tennis, Fencing, Dance, Gymnastics, etc.
- Dystraining : excess, neglected stretching, badly conducted weight training, unsuitable equipment: hard ground, too long crampons.
The mechanism of injury (ML) +++
ML in pubalgia corresponds to a weakness of the posterior wall of the inguinal canal and a retraction of the rectus abdominis muscle, causing tension on the pubis, tendon pain at the bony insertions and nerve irritation of the genital branch of the genitofemoral nerve causing pain in the inner thigh and scrotum (Minnich, AJSM, Sport hernia, V39, 6 , 2011).
Risk factors ++
They are of both intrinsic and extrinsic origin:
Intrinsic factors:
- history of trauma to the adductors or the abdominal wall.
- limitation of hip mobility in internal rotation.
- loco-regional biomechanical factors with dynamic instability of the pelvis: lumbar hyperlordosis, anteversion of the pelvis, sacroiliac dysfunction. In this dynamic instability of the pelvis, the lumbopelvic region plays a primordial role in the transfer of stresses between the trunk and the lower limbs, with anticipated muscular contraction of the multifidi, transverse and internal oblique muscles. In case of pain, the contraction of these muscles and of the gluteus maximus is delayed with the impossibility of stabilizing the pelvis during movements of the lower limbs (Tyler: Clin Sports Med. 29, 2010).
- delayed activation of the transverse abdominis muscle with anticipated contraction of the abdominal wall muscles (Transverse, Internal Oblique) when movements of the lower limbs disturb the balance of the pelvic ring (Cowan: Med.Sci. Sports Exerc. , V36, No. 12, 2004).
- constitutional or acquired hypotonia of the oblique muscles of the lower abdominal wall with consequences: thinning, dehiscence, pre-hernial state.
- deficiency of the internal orifice of the inguinal canal: dilated, in a pre-hernial state.
- hip dysplasia or any other intra-articular hip pathology leading to reduced hip mobility: the reduction in internal rotation (on cam lesion of anterior hip impingements or by retroversion of the femur) leads to constraints on the pelvis during physical activity with antero-inferior opening of the pubic symphysis (Birmingham- AJSM- V40-5-2012). Involvement of femoroacetabular impingements in the genesis of pubalgia (Larson/Arthroscopy/2011).
- imbalance of the very powerful Adductors/weaker Abdominals balance, but also of the Adductors/Abductors ratio < or = 80%.
Extrinsic factors
Sports at risk
Pubalgia is a pathology of young athletes, almost exclusively male, which affects 5-18% of athletes, all sports combined.
- Football+++ (schoot, side passes, dribbling) with 58% of footballers having a history of pubic pain, is the most exposed sports discipline. The incidence of pubalgia is 1/1000 Hours of play and represents between 11% and 16% of injuries. In a Norwegian study of 508 footballers, players with a history of abdominal wall injuries were twice as likely, those with a deficit on the adductors were 4 times as likely (Engebretsen, AJSM, V20, 10, 2010).
- Hockey: in this sport, adductor strength is 18% lower in players who have a history of adductor injuries. The adductor/abductor strength ratio is 95% in healthy players and 78% in injured players. The risk of adductor injury is 17 times higher if the ratio is less than 80% (Tyler et al. Adductor Muscle Strains in Hockey Players, AJSM, V29, 2, 2001).
- Athletics in a majority of disciplines (walking, combined events, pole vault, long-distance and middle-distance races, steeplechase, hurdles, etc. -
Rugby (opener; goalscorer), Tennis, Fencing, Dance, Gymnastics, etc.
- Dystraining : excess, neglected stretching, badly conducted weight training, unsuitable equipment: hard ground, too long crampons.
V - The three clinical forms of pubalgia
1/ TENDINOPATHY OF THE ADDUCTORS AND LARGE RIGHS OF THE ABDOMEN
a/ Adductor tendinopathy (lower pubalgia)
In the tendinopathy of the adductors, it is the tendon of the Great Adductor especially and that of the Middle adductor which are preferentially affected, either in full body of the tendon, or at the myotendinous junction, or at the level of the enthesis (bony insertion tendon, corresponding to enthesitis).
The pain is under the pubis , radiating to the inner thigh caused by certain sporting gestures (schoot from the inside, side pass, etc.).
The clinical evaluation highlights the classic symptomatic triad of any tendinopathy: pain on resisted contraction, on stretching (and more on external stroke than on internal stroke, on palpation).
Imaging (X-rays, echography, MRI) is not very contributive and sometimes highlights slight bone changes on the ischiopubic branch.
The clinical evaluation highlights the classic symptomatic triad of any tendinopathy: pain on resisted contraction, on stretching (and more on external stroke than on internal stroke, on palpation).
Imaging (X-rays, echography, MRI) is not very contributive and sometimes highlights slight bone changes on the ischiopubic branch.
b/ Tendinopathy of the rectus abdominis muscles (upper pubalgia)
It is similar to the previous one, except that the pain is above the pubis and affects rather the tendinous insertion (enthesis).
It is similar to the previous one, except that the pain is above the pubis and affects rather the tendinous insertion (enthesis).
2/ PUBAL OSTEO-ARTHROPATHY (median pubalgia)
This is the real pubalgia that affects the pubic symphysis by overworking the joint and muscular imbalance of the Adductors/Abdominals ratio.
The pain is pubic and may radiate down the inner thigh or up the lower abdominal wall. It is first felt mainly during exercise and then in everyday life. Clinical evaluation found pain on palpation of the symphysis and its gentle mobilization.
Imaging shows an aspect of pseudo arthritis on the radiograph without clinical radio correlation that our colleagues Durey, Boeda and Rodineau have classified into 4 stages.
The favorable evolution is done approximately in 3 months with often joint restitution ad integrum.
Imaging shows an aspect of pseudo arthritis on the radiograph without clinical radio correlation that our colleagues Durey, Boeda and Rodineau have classified into 4 stages.
The favorable evolution is done approximately in 3 months with often joint restitution ad integrum.
Frontal radiograph of the pelvis of pubic osteoarthropathy: widening of the joint space, bristling and condensed appearance of the symphyseal edges
Frontal X-ray of the pelvis: irregular and bristling aspect of the symphyseal edges, with amputation of the angles and detachment of a bone fragment at the level of the left symphyseal angle.
3/ ABDOMINAL PARIETAL PATHOLOGY
This is generally a congenital pathology of the inguinal canal; it can sometimes be acquired. The pain is supra pubic and radiates to the pubis and the testicle. Gradually onset, it is impulsive to coughing, sneezing and defecation.
The clinical evaluation sometimes finds a sudden start signifying the post traumatic origin, for example a volley, a kick in the void in football, a clearance at the foot, a drop goal, the shooting of a penalty in rugby , after accelerating while jogging on uneven, greasy or hard ground with unsuitable studs.
The physical examination is all the more sensitive as it is carried out after effort and carried out first standing, then lying down:
The physical examination is all the more sensitive as it is carried out after effort and carried out first standing, then lying down:
- highlighting of a curvature of the abdominal wall ( Malgaigne's sign ) next to the inguinal canal and which is increased by posturing the injured person in hyperlordosis.
- palpation of the inguinal ring in search of a dehiscence or a point of hernia, pain caused by the lower abdominal wall, a dilated and tender ring; all this increases when the injured person is made to cough.
The pain sometimes radiates to the front of the thigh, the testicle and the perineum. On examination, palpation of the deep orifice of the inguinal canal, following the spermatic cord, reveals this pain above the crural arch (Gilles Reboul).
- pain on isometric contraction of the abdominals.
- negativity of the examination of the symphysis and the symptomatic triad of the tendinopathy of the adductors.
Imagery contributes little.
It should be noted that in a certain number of rebellious cases, the painful symptomatology of the inguinal canal is linked to a canal syndrome of the ilioinguinal or hypogastric nerves with sensory disturbances found in the inguinal region and which can radiate to the pubis for the ilio-inguinal nerve. hypogastric and towards a labia majora or a testicle.
The ilio hypogastric and ilio inguinal nerves arise from the L1 root, descend behind the parietal peritoneum over the quadratus lumborum muscle and perforate the transverse abdominis muscle, traveling between transverse and small oblique. The iliohypogastric nerve travels inside the anterosuperior iliac spine, to divide into an abdominal branch which insinuates itself between the two oblique muscles as far as the pubic insertion of the rectus and pyramidal muscle of the abdomen, and into a branch genital which accompanies the genital branch of the ilioinguinal nerve.
The two genital branches run through the inguinal canal to become subcutaneous at the level of the superficial orifice and distribute to the inguinal region, the pubis, the anterior surface of the scrotum and the middle part of the upper end of the thigh. .
The lateral cutaneous branch born just before crossing the transverse muscle, only becomes superficial near the crest either through a purely aponeurotic orifice, or by digging into the iliac crest. This branch ends a few centimeters below the iliac crest innervating a sensory territory.
These entrapment syndromes are treated by scanno-guided infiltrations of Hydrocortancyl 125 mg.
Anatomical diagram of the deep course of the inguino-femoral nerves:
Ilioinguinal nerve
2G: Genital branch
3CL: Lateral cutaneous nerve of the thigh 3F: Gluteal branch
A & P: Anterior and Posterior terminal branches
4GF: Genito-femoral nerve
4F: Femoral branch 4G: Genital branch
5: Superficial orifice of the inguinal canal
4F: Femoral branch 4G: Genital branch
5: Superficial orifice of the inguinal canal
6: Psoas muscle
7: Square muscle of the loins
8: Iliac muscle
9: Transverse (deep) and external oblique muscle
7: Square muscle of the loins
8: Iliac muscle
9: Transverse (deep) and external oblique muscle
10: Tensor fascia lata muscle
11: Sartorius VI muscle
- Treatment of pubalgia
Place of surgery
- projected pain of thoraco-lumbar spinal origin (Robert Maigne Syndrome) of T11-T12 origin , especially T12-L1, and sometimes L1-L2. It is therefore necessary in front of any pubalgia, not to forget to examine the thoracolumbar spine, the two pathologies can even co-exist, a false pubalgia on Maigne's syndrome can make the bed of a real pubalgia and complicate its management. .
- dysplasia and anterior impingement of the hip and its cam lesion (see the specific articles on hip osteoarthritis or coxarthrosis and anterior hip impingement) because of their pain which projects into the fold of the groin, can be confused with pubalgia and think first of epiphysiolysis +++ in sporty adolescents between 14 and 18 years old.
- pudendal neuralgia of sacred origin.
- fatigue (stress) fractures of the pubic rami.
I- Referred pain of thoraco-lumbar spinal origin T12/L1 (Robert Maigne Syndrome) :
See in the summary, the specific article devoted to the syndrome of the thoraco-lumbar hinge.
These referred pains are of origin T11-T12, especially T12-L1, and sometimes L1-L2. It is therefore necessary in front of any pubalgia, not to forget to examine the thoracolumbar spine, the two pathologies can even co-exist, a false pubalgia on Maigne's syndrome can make the bed of a real pubalgia and complicate its management. .
II- Hip dysplasia and anterior impingement of the hip and its cam lesion
See the summary for specific articles on hip osteoarthritis or coxarthrosis and anterior impingement of the hip ; because of their pains which project into the fold of the groin, they can be confused with pubalgia.
III- Epiphysiolysis in adolescent athletes between 14 and 18 years old
Definition of epiphysiolysis
The superior epiphysis of the femur corresponds to the upper end of the femur. In growing children and adolescents, this upper epiphysis is separated from the neck and the rest of the femur by growth plate. Epiphysiolysis corresponds to a detachment of this upper epiphysis which slides backwards or inwards, acutely, brutally or more slowly in a chronic, insidious manner. It is growth dystrophy related to physical activity.
Anatomy
The pudendal nerve arises from the anterior branches of the 2nd, 3rd and 4th sacral spinal nerves which merge behind the ischial spine. Exit from the small pelvis through the intra-piriform canal, bypassing the ischial spine under the sacrospinous ligament. Descends into the aponeurotic tunnel formed by the aponeurosis of the obturator internus muscle and the sacrotuberous ligament, called Alcock's canal.
The pudendal nerve divides just below the lesser ischial notch into two terminal branches: the perineal nerve and the dorsal nerve of the penis or clitoris, giving sensory and motor innervation to the perineal region.
- Treatment of pubalgia
It is medical above all and leads to a cure in 80 to 85% of cases.
Sports rest is unavoidable and can go up to 3 months, with total exclusion of the sporting gesture triggering the pain.
Pain management depends on the anatomo-cinic form (analgesic physiotherapy is widely used).
Physiotherapy occupies a place of choice, its objective will be to identify early patients responding to rehabilitation treatment within a short period of 4 to 6 weeks (in any case always less than 3 months) in order to avoid the transition to chronicity and consider a surgical solution. It will seek to improve hip mobility in internal rotation (IR) and the other loco-regional biomechanical disorders mentioned above (lumbar hyperlordosis, anteversion of the pelvis, sacroiliac dysfunction), to stabilize the lumbopelvic region, to correct any imbalances abdominal muscles/adductors and adductors/hip abductors, to reprogram motor control and to plan sports recovery without medication (Marc Bouvard).
A study in footballers demonstrated the interest of 8 weeks of specific strength training on the hip adductors, using elastic bands. This type of training made it possible to increase by 13% (and therefore significantly) the maximum eccentric strength of the adductors.
A study in footballers demonstrated the interest of 8 weeks of specific strength training on the hip adductors, using elastic bands. This type of training made it possible to increase by 13% (and therefore significantly) the maximum eccentric strength of the adductors.
Interest of PRP injections , effective in acute or chronic tendon lesions as well as in osteo-arthropathy by allowing better healing by early collagen synthesis. These injections will be followed by a functional treatment which must begin a few days after the injection and continue for several weeks.
Parietal surgery of the inguinal canal by lowering the broad muscles of the abdomen and putting them under tension should be offered more or less quickly (after the 3rd month for some); Bassini -type intervention modified by Nésovic and distributed in France by JH Jaeger . It should also be noted that the Bordeaux surgeon Reboul has acquired internationally renowned expertise in the surgical management of pubalgia.
Given the mechanism of injury and after 3 months of medical treatment introduced as early as possible and well conducted, surgical management should be proposed, particularly in high-level footballers, especially if they have a toned abdominal wall. and a distended and very painful superficial inguinal orifice. The technique used is that of Nésovic, often practiced by orthopedic surgeons, which retains the advantage of simplicity, more comfortable suites and more reasonable recovery times. The endoscopic techniques of simple obturation by prosthetic reinforcements, practiced by visceral surgeons, theoretically less aggressive, have not yet succeeded in making the difference. Not responding to the concern for rebalancing the pubic symphysis,
The maintenance of conservative medical treatment for 3 months, before asking a surgical indication in forms affecting the inguinal canal, is shared by many authors: - Jalal
Boukhris , Rifi Mojib, Sami Mezghani, JH Jaeger: sportsman's pubalgia of high level: place of the surgical treatment, apropos of a continuous series of 100 cases
- Wodecki specifies that the surgical treatment is addressed to the pure or predominant parieto-abdominal forms.
Boukhris , Rifi Mojib, Sami Mezghani, JH Jaeger: sportsman's pubalgia of high level: place of the surgical treatment, apropos of a continuous series of 100 cases
- Wodecki specifies that the surgical treatment is addressed to the pure or predominant parieto-abdominal forms.
- Gilmore on more than 1000 cases since 1980 recommends a surgical treatment of the sufferings of the inguinal canal after failure of a rehabilitation program of 4 weeks.
- Baquie uses surgery in a very small number of cases at the end of the painful second season only.
- Vidalin out of 72 cases, poses the surgical indication from the outset when the diagnosis of inguinal form of pubalgia is made and must be unreserved when there is a clinical pathology of the hernial orifice with pain on inguinal touch. The surgical indication must be made with reservations, in the event of associated spinal pathology T12/L1, pubic arthropathy or pathology of the adductors. But the surgical indication seems immediately the best if there is a parieto-abdominal lesion.
- Ekstrand in 2001, in a prospective randomized series of 66 cases, demonstrates the superiority of immediate or deferred surgical treatment in stubborn pubalgia linked to pain in the inguinal canal.
- Biedert in a smaller study involving 24 athletes and evaluated up to 6.6 years after the surgical procedure performed on average 17 months after the onset of symptoms also obtained excellent results. The resumption of all sports activities was possible in 23 of the 24 operated athletes. More or less often associated with a parietal treatment, a gesture on the other side of the pubic intersection, in this case the tenotomy of the adductors, is to be relegated to the background, because considered too dilapidating for top athletes, and can be a source of muscle hypotonia.
- Akermark obtained only 62.5% of good results on 16 tenotomies; this should not come as a surprise given the lesional mechanism, tendinopathy being in the majority of cases a purely functional phenomenon which does not require an indication for surgery. Renotomies should be reserved for forms with predominant symptomatology at the level of the adductors, calcifications or sequelae of strains, or in the event of persistent pain in the adductors after a Nesovic-type abdominoplasty.
Post-surgical rehabilitation must respect the healing time of the abdominal strap, which requires avoiding all untimely stresses on the wall for four weeks. Then we carry out work to soften the scars (massage and ultrasound), gentle toning of the abdominal strap which can begin with electrostimulation and isometric contractions and stretching and progressive strengthening of the adductors in eccentric. Neuromuscular reprogramming is also reintroduced before any resumption of jogging around the sixth postoperative week. The work of specific technical gestures is reintroduced around the eighth week.
- THE CERS (European Center for Sports Rehabilitation) in Capbreton and its medical director, Dr. Pierre-Louis Puig are undeniably very familiar with the medical management of pubalgia and their protocol or equivalent is recommended.
Treatment according to etiology:- THE CERS (European Center for Sports Rehabilitation) in Capbreton and its medical director, Dr. Pierre-Louis Puig are undeniably very familiar with the medical management of pubalgia and their protocol or equivalent is recommended.
- in the event of osteo-arthropathy : corticosteroid infiltrations, oral corticosteroids, mesotherapy, podiatric and osteopathic treatments. The functional treatment will focus on improving the flexibility of the hips and strengthening the internal running of the large muscles of the abdomen without ever triggering pain.
- in the event of tendinopathy of insertion of the adductors: local physiotherapy, deep transverse massage (MTP), mesotherapy, shock waves++, stretching (contracted-relaxed).
- in the event of damage to the rectus abdominis, the level of the lesion must be assessed in order to adapt the treatment: insertion tendinopathy, tendon lesion or myotendinous lesion.
- in case of muscle or musculo-aponeurotic lesions, relative rest and painless physiotherapy most often allow healing.
- in the event of a parieto-abdominal lesion , the athlete must be referred quickly for a surgical opinion and operated.
VII- Prevention- in the event of tendinopathy of insertion of the adductors: local physiotherapy, deep transverse massage (MTP), mesotherapy, shock waves++, stretching (contracted-relaxed).
- in the event of damage to the rectus abdominis, the level of the lesion must be assessed in order to adapt the treatment: insertion tendinopathy, tendon lesion or myotendinous lesion.
- in case of muscle or musculo-aponeurotic lesions, relative rest and painless physiotherapy most often allow healing.
- in the event of a parieto-abdominal lesion , the athlete must be referred quickly for a surgical opinion and operated.
It is crucial, especially in Football (the most affected sport) and must be integrated into physical preparation with the help of physiotherapists or specially trained physical trainers: long warm-up, stretching before exercise and especially at a distance from the body. exercise, eccentric muscle strengthening of the adductors with or without elastic bands and broad muscles of the abdomen, correction of technical faults, postural education. Never forget that after a trauma to the adductors, it is recommended before resuming football to recover muscle strength symmetrically between healthy and injured muscles (the deficit must be less than 10%) and to have an adductor ratio /abductor at 90% on clinical testing or dynamometer.
B- Falses pubalgias
A large number of pains projecting at the fold of the groin are falses pubalgias, whether: B- Falses pubalgias
- projected pain of thoraco-lumbar spinal origin (Robert Maigne Syndrome) of T11-T12 origin , especially T12-L1, and sometimes L1-L2. It is therefore necessary in front of any pubalgia, not to forget to examine the thoracolumbar spine, the two pathologies can even co-exist, a false pubalgia on Maigne's syndrome can make the bed of a real pubalgia and complicate its management. .
- dysplasia and anterior impingement of the hip and its cam lesion (see the specific articles on hip osteoarthritis or coxarthrosis and anterior hip impingement) because of their pain which projects into the fold of the groin, can be confused with pubalgia and think first of epiphysiolysis +++ in sporty adolescents between 14 and 18 years old.
- pudendal neuralgia of sacred origin.
- fatigue (stress) fractures of the pubic rami.
I- Referred pain of thoraco-lumbar spinal origin T12/L1 (Robert Maigne Syndrome) :
See in the summary, the specific article devoted to the syndrome of the thoraco-lumbar hinge.
These referred pains are of origin T11-T12, especially T12-L1, and sometimes L1-L2. It is therefore necessary in front of any pubalgia, not to forget to examine the thoracolumbar spine, the two pathologies can even co-exist, a false pubalgia on Maigne's syndrome can make the bed of a real pubalgia and complicate its management. .
II- Hip dysplasia and anterior impingement of the hip and its cam lesion
See the summary for specific articles on hip osteoarthritis or coxarthrosis and anterior impingement of the hip ; because of their pains which project into the fold of the groin, they can be confused with pubalgia.
III- Epiphysiolysis in adolescent athletes between 14 and 18 years old
Definition of epiphysiolysis
The superior epiphysis of the femur corresponds to the upper end of the femur. In growing children and adolescents, this upper epiphysis is separated from the neck and the rest of the femur by growth plate. Epiphysiolysis corresponds to a detachment of this upper epiphysis which slides backwards or inwards, acutely, brutally or more slowly in a chronic, insidious manner. It is growth dystrophy related to physical activity.
General
Around 13 to 15 years old and up to 18 years old, epiphysiolysis = epiphyseal detachment backwards or coxa retorsa, or inside: coxa vara mainly affects boys (2.5 times more boys than girls) obese or slender having grown a lot; its onset is either sudden or progressive and the evolution of this growth dystrophy is long. Role of sport (throws in athletics for example). In 30% of cases this dystrophy is bilateral, but rarely simultaneous, contralateral involvement occurs on average 18 months apart.
The slippage is most often gradual; It can be brutal and then corresponds to a true non-traumatic, acute and unstable epiphyseal detachment.
Unfortunately, the diagnosis is often made late:
Unfortunately, the diagnosis is often made late:
- pain in the fold of the groin which should not be imposing for pubalgia
- lameness which should immediately alert any conscientious doctor
- misleading forms that this condition can take: in front of pain felt in the knee which on examination appears clinically normal, always remember to examine the hip joint above.
The clinical examination of the hip on the painful side will most often highlight an asymmetry of mobility, especially in internal rotation with the knee stretched out on the plane of the examination table, or in cross-flexion (flexion, adduction, internal rotation ) knee flexed at 90°.
hip x-rays, possibly comparative will highlight the sliding of the femoral head, either backwards or inwards.
- lameness which should immediately alert any conscientious doctor
- misleading forms that this condition can take: in front of pain felt in the knee which on examination appears clinically normal, always remember to examine the hip joint above.
The clinical examination of the hip on the painful side will most often highlight an asymmetry of mobility, especially in internal rotation with the knee stretched out on the plane of the examination table, or in cross-flexion (flexion, adduction, internal rotation ) knee flexed at 90°.
hip x-rays, possibly comparative will highlight the sliding of the femoral head, either backwards or inwards.
Spontaneous progression is dominated by increased displacement and the risk of “acute” sliding occurring, which can be associated with early (coxitis, osteonecrosis, etc.) and long-term (secondary osteoarthritis) complications.
The treatment is the business of a specialized orthopedic surgeon (often a pediatric orthopedic surgeon). It aims to stop the progression of the slippage to avoid complications, the frequency of which increases with the importance of the displacement:
- in slightly displaced and stable forms, fixation in place with a cannulated screw is the method of choice and gives good results in the majority of patients.
- in unstable or large displacement forms, the treatment remains controversial. Early diagnosis remains the best prognostic factor in this condition.
EBetween the ages of 13 and 18, any athletic adolescent with progressive or sudden onset pain localized in the fold of the groin (false pubalgia) with radiation to the knee and a fortiori if this pain is accompanied by lameness, should consider epiphysiolosis. The physical examination of the flexed knee of the painful hip which highlights a functional limitation of cross flexion: flexion/adduction/internal rotation, must be considered as epiphysiolysis, with a formal ban on continuing any physical and sporting activity +++ until radiological evidence to the contrary and the opinion of an orthopedic surgeon.
IV- Pudendal neuralgia EBetween the ages of 13 and 18, any athletic adolescent with progressive or sudden onset pain localized in the fold of the groin (false pubalgia) with radiation to the knee and a fortiori if this pain is accompanied by lameness, should consider epiphysiolosis. The physical examination of the flexed knee of the painful hip which highlights a functional limitation of cross flexion: flexion/adduction/internal rotation, must be considered as epiphysiolysis, with a formal ban on continuing any physical and sporting activity +++ until radiological evidence to the contrary and the opinion of an orthopedic surgeon.
Anatomy
The pudendal nerve arises from the anterior branches of the 2nd, 3rd and 4th sacral spinal nerves which merge behind the ischial spine. Exit from the small pelvis through the intra-piriform canal, bypassing the ischial spine under the sacrospinous ligament. Descends into the aponeurotic tunnel formed by the aponeurosis of the obturator internus muscle and the sacrotuberous ligament, called Alcock's canal.
The pudendal nerve divides just below the lesser ischial notch into two terminal branches: the perineal nerve and the dorsal nerve of the penis or clitoris, giving sensory and motor innervation to the perineal region.
JL Vansonn's drawing of the pudendal nerve in red on an anterior view
Drawing by JL Vansonn of the pudendal nerve in a posterior view
Woman: ratio 7/10
Permanent spontaneous pelvic pain, when sitting, decreasing when standing and walking.
Chronic painful background in the type of burns, of moderate intensity Intense paroxysmal attacks
Hypo or hyperaesthesia of the skin, paresthesia or feeling of numbness.
Location: following the path of the nerve or irradiation to the entire pelvis, to the external genitalia and to the anorectal region.
Predisposing factors/triggers:
Cycling, horse riding Sitting
work
Repeated automobile movements
Trauma to the ischial region
Surgical intervention: proctological, urological, gynecological, orthopedic.
Treatment of pudendal neuralgia
Scan-guided infiltration.
V - Fatigue (stress) fractures of the pubic rami
V - Fatigue (stress) fractures of the pubic rami
Faced with inguinal pain that most often appears gradually, but sometimes suddenly appears (thereby raising fears of a complication such as displacement of the focus of a stress fracture), pain which may be accompanied by lameness, the first reflex is of course and we will never repeat it enough, to eliminate an intra-articular hip problem clinically and through imaging; once a hip problem has been eliminated and before considering the diagnosis of true pubalgia, it is necessary to think in athletes of a stress fracture of the pubic branches and especially of the ischio-pubic branch whose preferential seat is close to the symphysis , while a stress fracture of the ilio-pubic branch will sit rather close to the acetabulum.
On physical examination , palpation close to the symphysis can awaken or accentuate the pain felt. Hip mobility in cross flexion is symmetrical and in principle does not cause pain, at least if the fracture line is close to the symphysis (this is less true if the line is close to the acetabulum).
It is the imaging that will specify the diagnosis and it is always necessary to start with simple X-rays which can visualize the line of fracture, if the clinical suspicion was late or hesitant. If the clinician is doing his job, the X-rays show nothing at all and will only be positive around the 3rd week at best. It is therefore better for the sportsman to prescribe an MRI, which will visualize the stress fracture early, rather than a scintigraphy which very early shows images of hyperfixation, but which nevertheless remains a non-specific and too sensitive examination.
On the therapeutic level, if rest remains unavoidable, more and more medico-surgical teams are offering athletes injections of PRP (from 1 to 3) which accelerate the process of bone consolidation.
The diagnosis of true pubalgia, which clinically presents as pain in the fold of the groin, is a real medical emergency; but beforehand four false pubalgia, real diagnostic pitfalls, must be kept in mind, one of which, Robert Maigne's thoraco-lumbar hinge syndrome is in our experience particularly frequent and co-exists most of the time with pubalgia true. More delicate, two other false pubalgias must be mentioned as a priority, these are hip pathologies (hip dysplasia, epiphysiolysis, cam lesion and early coxarthrosis) and stress fractures of the pubic branches. As for pudendal neuralgia, it is a much more confidential etiology.
The medical treatment of true pubalgia should be as early as possible if surgery is to be avoided; analgesics and/or anti-inflammatories must be used wisely and more especially in symphyseal forms; as for the return to sport, it must be done without medication.
Finally, biomechanically, the pelvic girdle must regain very good mobility, high stability and high resistance to eccentric stresses (Marc Bouvard) in order to avoid any recurrence or chronicization which would then require surgical management.
Finally
Faced with pain in the fold of the groin suggesting pubalgia, it is first necessary to rule out a hip problem (hip dysplasia, epiphysiolysis, cam lesion and early coxarthrosis) or a stress fracture of the pubic branches, then look for an intervertebral disturbance of Robert Maigne T12/L1 often present and treat it concomitantly in order to subsequently avoid any chronicization source of therapeutic failure and finally if the diagnosis of true pubalgia is retained, consider it as a medical emergency to be treated rationally for 3 months following a protocol ideally of the Capbreton CERS type which has largely proven its worth. And never forget +++ that uA joint, a muscle, a ligament, a tendon, are anatomical structures that have specific vascularization and innervation. This innervation comes from a peripheral nerve or a nerve root, the latter being directly related to the spine, many benign vertebral dysfunctions (DIM Robert Maigne) will make the bed of joint or tendino-ligamento affections - muscular which it will be imperative to detect, treat and monitor.
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