Practical Orthopaedic Sports Medicine & Arthroscopy
1st Edition

31
Occult Groin Injuries: Athletic Pubalgia, Sports Hernia, and Osteitis Pubis
Michael B. Gerhardt MD
John A. Brown MD
Eric Giza MD
Disorders of the groin and pelvis are a significant diagnostic challenge for the sports medicine specialist. While most disorders of the groin in athletes occur as a result of injury, the broad differential diagnosis includes traumatic and atraumatic etiologies. Several confounding clinical variables exist in this part of the body making it a difficult area to accurately assess. The groin involves a crossroads of multiple systems, including the musculoskeletal, gastrointestinal, and genitourinary systems, as well as a complex array of intertwining neurovascular structures. Groin pain can be the primary chief complaint in disorders involving each of these systems. Thorough evaluation is essential in order to hone in on the correct diagnosis.
Unfortunately this is not always an easy task because the pathoanatomy of groin injuries remains poorly understood.
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For example an athlete with a complaint of chronic deep groin pain may have a stress injury of the hip or pelvis, an intrarticular hip injury such as a superior acetabular labral tear (SALT lesion), a classic inguinal hernia, an upper lumbar spine disorder, or an occult groin injury. Other less common diagnostic entities such as genitourinary infections or tumors must also be kept in mind. The clinical complexity of these disorders may lead to delay in diagnosis, which is frustrating for patients and clinicians alike. Therefore it is important to have a sound general knowledge base of the various disorders causing groin pain, and to be familiar with the basic diagnostic and treatment algorithms.
The most challenging cases involve presentation after weeks or months of symptoms or when pain persists despite rest and attempted rehabilitation. Some cases present very subtle clinical signs on physical examination. We classify these disorders as occult groin injuries, and they will be the focus of this chapter (Table 31-1). Other differential diagnoses will be listed, but will be covered in detail elsewhere in the textbook.
In general, we prefer to classify these disorders into three major groups: (a) occult groin injuries, and (b) classic hernias, (c) other diagnostic entities (Fig 31-1). An occult groin injury is defined as a painful, symptomatic injury isolated to the groin or pelvis region in which no clinically obvious signs are present upon exam. This is in contradistinction to a typical groin injury, such as a classic inguinal hernia in which groin pain is accompanied by hard clinical signs, such as a reducible or possibly irreducible bowel loop demonstrable by digital exam. Classic hernias are fairly straightforward in that the physical exam often confirms the diagnosis and allows for early detection and treatment. Many other groin disorders, which we classify as other diagnostic entities, can usually be diagnosed by clinical exam with the assistance of various imaging studies, e.g., a soft tissue tumor or an avascular necrosis of the hip.
Fig 31-1. Disorders of the groin.
At this point, we do not have a well accepted classification system for occult groin injuries, and the published nomenclature is confusing and conflicting. We prefer to consider three major categories of occult groin injuries: (a) Athletic Pubalgia, (b) Sports Hernia, and (c) Osteitis Pubis. It is sometimes impossible to separate these clinical entities, as overlap exists between the three groups (Fig 31-2). However, this classification system is useful as a framework for clinical evaluation and may help guide appropriate clinical management.
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Fig 31-2. Interrelationship of occult groin injuries.
Athletic Pubalgia and Sports Hernia
Athletic pubalgia and sports hernia are debilitating groin pain syndromes that have become major focal points in the diagnosis and treatment of the professional athlete. The concept of a debilitating focal groin injury was first described by Gilmore in 1980 as a “groin disruption” (1,2). To date there has been no real consensus on the classification of the syndromes. A variety of terms has been used to describe groin pain syndromes, including Gilmore’s groin, symphysis syndrome, hockey groin syndrome, adductor gracilis syndrome, occult inguinal hernia, sportsman’s hernia, and incipient hernia (2,3,4,5,6,7,8,9) (Table 31-1).
From a conceptual basis, athletic pubalgia is based on a biomechanical model, and sports hernia is best considered from an anatomical perspective. Both syndromes are associated with a significant loss of playing time and can be career ending. However, current treatment strategies can facilitate return to an elite level of play (2,4,5,6,7,9,10,11,12,13,14,15,16).
Athletic pubalgia is defined as an injury to the rectus abdominis insertion on the pubic symphysis, often accompanied by injury to the conjoined tendon insertion and the adductor longus attachment to the pelvis (7) (Fig 31-3). We believe the hallmark feature of this disorder is subtle pelvic instability. The sports hernia is defined as an injury of the transversalis fascia leading eventually to incompetency of the posterior inguinal wall (11,15,17) (Fig 31-4).
Table 31-1 Common Features of Occult Groin Injuries
Type Clinical Features Pathological Features Treatment
Sports Hernia
  • Inguinal pain
  • Lower abdominal pain
  • Posterior inguinal wall deficiency
  • Thinning/tearing of transversalis fascia
  • Conservative
  • Surgery (refractory cases only)
  • Laparoscopic vs. Open
Athletic Pubalgia
  • Inguinal pain
  • Lower abdominal pain
  • +/-Adductor pain
  • Tearing of abdominal muscle attachment to pelvis
  • Tearing of conjoined tendon
  • Adductor microtearing
  • Subtle pelvic instability/anterior pelvic tilt
  • Conservative
  • Surgery (if refractory)
  • Open pelvic floor repair
Osteitis Pubis
  • Peri-symphyseal pain
  • Groin pain
  • +/-Adductor pain
  • Peri-symphyseal inflammation
  • Conservative
  • Cortisone injection
  • Surgery (refractory cases only)
  • Curettage vs. arthrodesis
Anatomy
The pathoanatomy of athletic pubalgia and sports hernia is complex. The zone of injury includes the medial extent of the inguinal canal with the transversalis fascia posterior, the tendinous rectus abdominis and conjoined tendon anterior, and the bony pubic symphysis medial. The adductor tendons and their attachment along the anterior pelvis define the distal extent of the zone of injury (2,7). The various nerves of the inguinal region are involved commonly, which may explain the typical cutaneous pain distribution to the scrotum (ilioinguinal nerve), ipsilateral and contralateral inguinal area (genitofemoral nerve), and medial thigh (obturator nerve) (18). Fon (17) describes the “sportsman’s hernia” and proposes the cause as an incipient hernia based on the findings of a posterior bulge found in 80% to 85% of the operations. He considers this analogous to a classic inguinal hernia, where the absence of striated muscle at the posterior inguinal wall and the passage of the spermatic cord predispose the abdominal wall to weakness. In the “sportsman’s hernia” an anatomically thin transversalis fascia forms this part of the posterior wall, and is prone to injury. Similarly, Joesting (14) defines the “sportsman’s hernia” as an actual tear in the transversalis fascia in the posterior inguinal wall. The tear is located between the internal inguinal ring and the pubic tubercle, typically 3-5cm in length. Lynch and Renstrom (19) also localize the pathology to the posterior inguinal wall.
Susmallian (16) describes the entity of “sportsman’s hernia” as a result of a tear of the structures around the internal
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inguinal ring and the subsequent progressive weakness of the posterior wall. Kluin et al. (15) also define the term sports hernia as a weakness of the posterior inguinal wall resulting in an occult medial hernia. Genitsaris et al. (11) echoed this sentiment and under endoscopic visualization defined a defect in the posterior wall in Hesselbach’s triangle without forming a true hernia. Srinivasan and Schuricht (9) state the cause, in general, to be incompetent abdominal wall musculature. In his series, he subjectively noted the presence of an occult hernia in all cases. In a thorough review of the literature, Mora and Byrd (8) define the cause as a nonpalpable, small hernia with microscopic tearing of the internal oblique muscle attachments. Leblanc and Leblanc (20) state that the entity is a spectrum of injuries, principally involving the conjoined tendon, inguinal ligament, transversalis fascia, internal oblique muscle, and external oblique aponeurosis.
Fig 31-3. Proposed mechanism of injury in athletic pubalgia. Primary sites of involvement include: (A) tearing at the insertion of the rectus abdominis (arrow); (B) conjoined tendon disruption (arrow); (C) adductor microtears and/or inflammation (arrow).
Although more broadly defined, several authors describe a constellation of injuries around the groin that can also fall under the auspices of sports hernia. Macleod and Gibbon (21) define the groin pathology in terms of pain generators. They describe four general contributors to the groin pain:
  • Adductor or rectus abdominis musculotendinous strains or tendoperiosteal enthesopathies
  • Osteitis pubis
  • Disruption of the inguinal canal with tearing of the superficial ring and thinning of the posterior wall
  • Nerve entrapment of the ilioinguinal, genitofemoral, and/or obturator nerve
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Fig 31—4. Proposed mechanism of injury in sports hernia. Primarily involves injury to the transversalis fascia, resulting in eventual incompetency of posterior inguinal wall (arrow).
Similarly, Anderson (3) describes three possible sources of pain:
  • Abnormalities at the insertion of the rectus abdominis muscle
  • Avulsion of part of the internal oblique muscle fibers at the pubic tubercle
  • Abnormality in the external oblique muscle and aponeurosis
Some authors focus upon the effects of soft tissue injury and the biomechanics of the pelvis, without specific focus upon a structural hernia. This is what we broadly define as athletic pubalgia. Again, this is to serve as a generic term under which several clinical syndromes can be subclassified.
“Gilmore’s groin” is an entity that falls under the athletic pubalgia category. Gilmore describes variability in the intraoperative findings, but the main features include a torn external oblique aponeurosis, tearing of the conjoined tendon and avulsion from the pubic tubercle, and a dehiscence between the conjoined tendon and inguinal ligament. He reports no evidence of an actual hernia (1,2,6).
Martens et al. (22), in 1987, were the first to actually describe the concept of associated abdominal muscle and adductor injuries, as they described a specific entity composed of adductor tendinitis and musculus rectus abdominis tendonopathy. Subsequent articles introduced the term pubalgia, later to be amended to the term athletic pubalgia, upon which we base our current classification system (23). These are thought to involve microscopic tears or avulsions of the internal oblique muscle in the area commonly referred to as the conjoined tendon.
Meyers et al. (7,24) refined this definition of athletic pubalgia as injury to the rectus abdominis tendinous insertion onto the pubic symphysis with associated adductor longus related pain. They emphasize that no true hernia is present. In general, Meyers defined the injury localized to the flexion-adduction apparatus of the lower abdomen and hip, and theorized that pelvic instability secondarily occurs as a result of imbalance between the rectus and adductor muscles. Other authors agree, as evidenced by Biedert’s claim (5) that pelvic instability plays a major role in the etiology of occult groin injuries. He uses the phrase “symphysis syndrome” as a means to describe the combination of weak groin, abnormalities of the rectus abdominis at its small attachment area on the pubis, and chronic adductor pain from overuse. In his proposed model, the symphysis pubis represents the center of the different local or referred pains.
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The end result of these injuries is an imbalance of the pelvic anterior stabilizing musculature, with the strong adductors overpowering the torn rectus muscles anteriorly, allowing for subtle anterior tilt of the pelvis (7). This anterior tilt leads to further abnormalities in the biokinetic chain, which ultimately causes more pain around the anterior groin, resulting in the athlete’s inability to compete at a high level.
Holmich (25) focuses on the adductor component of the groin pain and correlates the pathophysiology with the poor blood supply at the tendon/bone interface combined with local muscular imbalance. A traumatic event or multiple microtraumas result in injury and pain in the adductor region, which is richly innervated with nociceptive fibers. Ashby (4) localizes the origin of pain to be at the medial insertion of the inguinal ligament onto the pubic symphysis; essentially an enthesopathy of the inguinal ligament.
Athletic pubalgia and sports hernia have also been described in terms of sport specific syndromes. Meyers et al. (24) describe the Hockey goalie/Baseball pitcher syndrome in which there is a localized infolding of the adductor muscle fibers between the torn fibers of the epimysium. Pain is related to the muscle entrapment that occurs. Leblanc and Leblanc (20) describe an associated entity, a subset of sports hernia, called Hockey player’s syndrome or slap shot gut. Anatomically, this may represent a tear in the external oblique aponeurosis associated with inguinal nerve entrapment. Irshad et al. (26) describe the “hockey groin syndrome.” All patients were reported to have tearing of the external oblique aponeurosis with branches of the ilioinguinal nerve emanating from the tear. He considers the entrapment of the nerve as the causative agent in the persistent pain.
A potential source of pain in these syndromes includes the cutaneous nerves that pass through the inguinal region. Akita et al. (18) performed a study in which they examined the cutaneous branches of the inguinal region in 54 halves of 27 male adult cadavers. The ilioinguinal nerve and cutaneous branches were present in 49 of 54 and genitofemoral cutaneous branches were present in 19 of 54. The cutaneous branches of the ilioinguinal nerve wind around the spermatic cord and also are distributed to the skin of the dorsal surface of the scrotum. The ilioinguinal nerve and the genital branch of the genitofemoral nerve probably play important roles in chronic pain associated with occult groin injuries. Pain resolution after “sports herniorraphies” may indeed be due to nerve decompression during the surgical procedure.
Biomechanics
The biomechanics of the pelvis are not completely understood. Sports hernias may stem from an athletically induced tear during an episode of aggressive hip abduction and extension, such as occurs with lateral cutting in a football running back or the aggressive kick in soccer (9,11,15,16). The results are an incompetent abdominal wall, usually localized to the posterior inguinal canal, where the transversalis fascia resides. This theory does not address the adductor symptoms that frequently accompany inguinal pain.
Pelvic pathomechanics can be a useful conceptual basis of athletic pubalgia. Proponents consider the initial injury event, the subsequent propagation of pain, the eventual chronicity, and the final disability as a continuum related to changes in the biomechanics of the pelvis, localized to the region of the pubic symphysis (2,5,7,22,23,24). The initial insult occurs at the tendinous attachments that stabilize the pelvis.
With this theory, the pubic symphysis is considered a single large joint. Along the superior edge of the symphysis are the attachments of the rectus abdominis, external oblique, internal oblique, and transversus abdominis. Along the inferior edge are the attachments for the adductor group, namely the adductor longus, pectineus, and gracilis. The theoretical mechanism of injury seems to be an overuse syndrome due to repetitive hip hyperextension and truncal rotational movements leading to wear and tear and eventual failure (acute or acute on chronic) of the abdominal musculotendinous attachments to the pelvis (6).
More specifically, hip adduction/abduction and flexion/extension with the resultant pelvic motion produces a shearing force across the pubic symphysis leading to stress on the inguinal wall musculature. In combination, pull from the adductor musculature against a fixed lower extremity causes shear forces across the hemipelvis (3). Once the injury has progressed to the point of pelvic microinstability, the rectus attachment is incompetent and allows the pelvis to tilt anteriorly. Theoretically, the anterior tilt and the unopposed adductor muscle group results in increased pressure in the adductor compartment, possibly creating an “adductor compartment syndrome” with resulting adductor pain (7). With time, the failure of the support mechanism on one side of the pubis creates an overuse type scenario for the contralateral rectus and adductor group, resulting in the same problem on the opposite side. It is emphasized that the problem is not related to a classical inguinal hernia mechanism.
Clinical Evaluation
History
The athletic pubalgia/sports hernia occurs most frequently in professional, high performance pivoting athletes. In the United States, NFL football players and NHL hockey players are most commonly affected (7,24), while in Europe professional soccer players are at highest risk (2,11). It may occur in recreational athletes; however, treatment of this group is much less predictable (7,14).
These syndromes occur almost exclusively in males (7,15). Women who present with a clinical history consistent with athletic pubalgia or sports hernia should be scrutinized carefully. Routine laparoscopic evaluation is recommended for females being worked up for an occult groin injury (7).
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In one study, 17 of 20 females, who were suspected of having athletic pubalgia underwent diagnostic laparoscopy, and all but one of these women were found to have another cause for the pain, with endometriosis being the most common diagnosis (7).
Typically, these athletes present with a long standing history of lower abdominal pain with exertion. Though the pain may be insidious, often the athlete recalls a specific injury event (2,9,14,24). The pain is localized to the inguinal region, just medial to the external inguinal ring, near the insertion of the rectus abdominis on the pubic tubercle. It usually is unilateral, but can present bilaterally (6,13,24). Pain may be localized to the tendon and insertional region of the adductor longus. Radiation of the pain into the scrotum, laterally in the upper thigh, or to the opposite groin can also be present (8,18). The pain is aggravated by sudden movements such as running, lateral cutting, kicking, shooting a slap shot, pushing off with ice skates, and other activities that involve torso rotation and abdominal stress during intense physical activity. Pain is usually absent or minimal at rest. A common early symptom is that the athlete will have pain getting out of bed in the morning (2). The syndrome is often refractory to conservative management (2,9,24).
Physical Findings
The first goal of the physical exam is to first rule out a classic hernia. After that, the work up of athletic pubalgia or sports hernia is fairly straightforward. The exam is surprisingly consistent (2,3,5,20,24), and in fact, in one study it was shown that the majority of tests for pain, strength, and flexibility of the adductor, iliopsoas, and abdominal muscles are reproducible (27).
Gross observation is important to document any evidence of mass, bruising, or other soft tissue lesions of the groin. Testicular masses must be ruled out. The inguinal canal is examined next and is best done supine with the hip slightly flexed and externally rotated. Examination of the unaffected side should be performed first to establish a baseline (2,6,14). The tip of the 5th digit is inserted through the scrotum into the external inguinal ring to a depth of approximately 2 to 3 cm. In the sports hernia, there may be slight enlargement of the inguinal ring along with tenderness of the posterior wall of the canal. Sometimes a subtle defect can be appreciated in the transversalis fascia as it makes up the posterior wall (2,14). A cough impulse may be evident as well. These findings are not consistently found in athletic pubalgia.
In athletic pubalgia, adductor tenderness is quite common. Maximal points of tenderness in the adductor region are located along the adductor tendons near the pubis with the patient in full passive abduction (5,7,24). Provocative maneuvers such as sit-ups, resisted hip adduction, and Valsalva will oftentimes reproduce the symptoms. Diffuse tenderness over the pubic tubercle and the peripubic region is common. Clinical exam of the hip joint is usually normal with supple range of motion and normal gait.
Imaging
Imaging is particularly important for ruling out other forms of pathology in the differential diagnosis of athletic pubalgia and sports hernia. Most of the important diagnoses listed as “other diagnostic entities” will be evident with imaging studies.
Magnetic Resonance Imaging
MRI is a useful tool to help rule out serious diagnoses in the differential diagnosis, however, only 9% of the scans show discrete musculotendinous injury in the region of concern (7). More recently, an MRI study of athletes with surgically confirmed athletic pubalgia reported that the authors were able to identify several common findings (28):
  • Increased signal within one or both pubic bones
  • Attenuation or asymmetry of the abdominal wall musculofascial layers
  • Increased signal within one or more of the groin muscles
Attenuation of the abdominal wall musculofascial layers was seen most often (27 of 30 patients). MRI can assist in creating a more precise preoperative plan, in particular, whether to do unilateral or bilateral repair.
Overdeck recommends the use of MRI as the modality of choice. STIR and T2-weighted sequences are recommended (29). Close scrutiny should be applied to the abdominal wall, groin, symphysis, pelvic viscera, scrotum, proximal femur, inguinal region, sacroiliac joints, and hip. Robinson also recommends the use of intravenous gadolinium enhanced MR. He demonstrated that in patients with chronic adductor complaints, the extent of the abnormal MRI signal at the adductor longus insertion correlated with the athlete’s current symptoms (30).
Currently, absence of MRI findings should not dissuade one from surgical intervention as long as the clinical signs and symptoms are consistent. In fact, the majority of patients do not have positive MRI findings suggestive of rectus or inguinal canal disruption. However, as knowledge of the pathoanatomy improves, associated MRI findings are likely to be better-delineated.
Ultrasound
Orchard et al. (31) looked at a group of Australian Rules Football players with clinically evident sports hernia. They determined that dynamic ultrasound examination was able to detect inguinal canal posterior wall insufficiency in young males with no clinical signs of hernia, and thought this modality could improve decision making for associated hernia repair. Many groin specialists in Europe, including Dr. Urlike Muschaweck from Germany, consider ultrasound as the diagnostic modality of choice for evaluating occult groin injuries.
In experienced hands, ultrasound may help visualize a weak, bulging posterior wall. As technology and clinical
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acceptance evolve, ultrasound may become the modality of choice in identifying pathology in the inguinal region for those presenting with unresolved chronic groin pain.
Conventional Radiography/Computed Tomography/Bone Scan
Plain radiographs should be completed as the first line of imaging. In athletic pubalgia and sports hernia, this exam will be nondiagnostic except to rule out other causes of the pain or in cases of associated osteitis pubis. If there is any question of a bony abnormality, computed tomography (CT) scan should be obtained as it has proven superior to plain film radiography for its demonstration of the extent of both osseus and soft-tissue injury (29). Bone scan may also be used, again, mainly to rule out other causes of the pain.
Herniography
Some authors advocate herniography to rule out occult hernias (32,33,34). It is performed by injecting contrast material into the peritoneal cavity followed by fluoroscopy to visualize the path of the dye. Any extraperitoneal extravasation is consistent with an occult hernia (32,33,34). However it is not a risk-free procedure. Complication rates of 5% to 6%, including bowel perforation and peritonitis have been reported (15,17,32).
The current literature remains mixed in regard to the indications for this study. Leander et al. (34) compared the use of MR and herniography and concluded that herniography should be the primary diagnostic tool for diagnosing hernias. Kesek et al. (33) reviewed a group of 51 athletes all with unexplained groin pain who underwent herniography as part of the workup. A quarter of these athletes were found to have a hernia. They concluded that herniography should be included as part of the diagnostic workup. Gwanmesia et al. (32) report the results of 43 herniograms for occult groin pain with a true positive rate of 90.5% and a true negative rate of 100% and conclude that herniography is an effective tool in the workup of occult groin pain. Some believe that herniography is associated with unreasonable risks (4%-6%) such as bradyarythmias, peritonitis, and small bowel and bladder injection (15,32). The risk/benefit ratio has to be carefully considered in regard to how the results of the test will change treatment decisions for a particular patient. Other less invasive tests such as MRI or ultrasound may provide similar information without posing risk to the patient.
Decision Making Algorithm and Classification
A treatment algorithm has been developed for sports hernias and athletic pubalgia (Fig 31-5). Nonoperative treatment is initiated first, since a significant number of patients improve with a forced period of rest. During this initial phase, the basic work up includes plain radiographs and/or CT to rule out any acute bony injury.
Upon return to the playing field, if the injury recurs then a more aggressive work-up should begin. Imaging studies, as outlined in the previous section, may be obtained to confirm the diagnosis and to rule out other pathoetiologies. MRI, ultrasound (US), and (perhaps) herniography can also be useful for pre-operative planning. Failure of conservative treatment may justify surgical intervention.
The management of adductor pain can be challenging. Isolated adductor pain is treated with typical conservative measures such rest, ice, anti-inflammatories, and physical therapy for stretching and muscle balance. The most commonly involved tendon is that of the adductor longus. Treatment of adductor pain in the face of athletic pubalgia can be quite difficult. The literature is largely empiric as described by Meyers et al. (7); however other authors present similar findings (2,5).
Adductor pain with minimal to no pubalgic type pain is treated conservatively. If the adductor pain persists, despite conservative treatment, adductor release in conjunction with an open pelvic floor repair should be performed. The adductor symptoms are considered a consequence of pelvic microinstability and therefore both need to be addressed. Adductor pain with pubalgia symptoms is also initially treated conservatively. If, after conservative treatment the pubalgic pain and adductor pain persists, then a pelvic floor repair and adductor release is performed. If the pubalgic pain persists, but the adductor pain completely disappears, then the adductor can be left alone. The threshold for releasing the adductors has significantly decreased and in most cases, if any adductor pain remains, the adductor is released. This seems to avoid a second operation for adductor release in the future (Fig 31-6). The concept of adductor release still remains highly controversial.
Surgical Treatment
If pelvic instability is suspected then an open procedure that reconstitutes the pelvic attachment of the abdominal musculature should be performed. Meyers et al. (7) describe a modified Bassini herniorrhaphy pelvic floor repair. Of 157 high level athletes who underwent the repair, 152 (97%) returned to their previous level of play after this type of procedure. In addition, the study included 12 athletes who had undergone previous hernia type repairs for “occult hernia.” These athletes continued to have a clinical picture of athletic pubalgia. Following the pelvic floor repair, 11 of 12 of these athletes had complete relief of their symptoms with return to their desired levels of athletic performance.
Joesting (14) describes repair of the transversalis fascia with mesh augmentation. He argues against the laparoscopic technique because it fails to address the true pathology. In 40 patients, 36 returned to full, pain-free activity. Irshad et al. (26) report on the results of 22 NHL hockey players with debilitating groin pain, who underwent open operative exploration. All patients were reported to have tearing of the external oblique aponeurosis with branches of the ilioinguinal nerve emanating from the tear. Treatment consisted of reinforcement of the external oblique aponeurosis with mesh
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and ablation of the ilioinguinal nerve. All 22 were able to return to hockey with 19 of 22 resuming their career.
Fig 31-5. Treatment algorithm for athletic pubalgia and sports hernia.
Gilmore describes open restoration of the anatomy with meticulous repair of the affected structures without mesh. Exploration is carried out through a 6 cm incision. The principles of the repair include reconstitution of the posterior inguinal wall, repair of the rectus abdominis and external oblique, and reattachment of the conjoined tendon to the pubic tubercle (1,2,6). In his report of 915 cases, 887 (97%) were successful (1,2).
Brannigan et al. (6) prospectively evaluated 85 patients undergoing 100 groin repairs for “Gilmore’s groin hernia”: Ninety-six percent returned to competitive sports within 15 weeks. Beidert et al. (5) describe 24 patients with symphysis syndrome, 20 of which had adductor pain. 20 patients underwent spreading of the lateral border of the rectus sheath together with an epimysial adductor release. Return to full sport occurred at 10 to 12 weeks, with 96% of athletes returning to their previous level of sport.
In patients with the diagnosis of sports hernia, the surgical repair focuses on the deficiency of the posterior wall of the inguinal canal. Both laparascopic and open procedures have been successful, however the recent literature reflects a trend toward laparoscopic intervention. Debate regarding unilateral verses bilateral repair is ongoing, without current consensus. The arguments for prophylactic repair of the unaffected side include prevention of contralateral symptoms, balanced reinforcement, and a single surgical procedure
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(9,11,16,20). Opponents of bilateral repair cite the inherent risks of surgery and the routine performance of potentially unnecessary surgery.
Fig 31-6. Treatment algorithm for adductor symptoms.
Genitsaris (11) reports on bilateral laparoscopic repair in 131 professional athletes. All patients returned to activity in 1 week with the majority back to full sport in 2 to 3 weeks. Mean follow up was 5 years with one reported failure, successfully treated laparoscopically with mesh. Kluin et al. (15) advocate endoscopic evaluation and repair in athletes as well. They report a 93% return to activity within 3 months. The only failure in this group was a female. In Srinivasan and Schuricht’s (9) series of 15 professional athletes repaired laparoscopically with mesh, all resumed unrestricted athletic activity in 2 to 8 weeks. Interestingly, they indirectly address the biomechanical issue by stating that it is “theoretically possible that this reinforcement contributes to the structural integrity of the groin in those athletes, who have an associated musculoskeletal problem.”
Complications and Special Considerations
In a review of the literature regarding athletic pubalgia and sports hernia, no serious surgical complications were reported. Minor complications included superficial wound infections, hematoma, and peri-incisional numbness. Failures in recognition of a neoplastic disorder such as a seminoma, or serious gynecologic condition such as endometriosis, would be far more devastating than the clinician’s failure to precisely recognize an occult groin injury.
Concomitant adductor pathology is a common finding in athletic pubalgia. Some surgeons advocate adductor release in this situation. This approach should minimize the chance of incomplete pain relief and potentially the need for additional subsequent surgery. However, adductor release remains controversial and further research is needed to determine if this procedure is truly indicated. Certain authors argue against adductor release and report excellent results and quicker return to play with a “minimal repair” technique as advocated by Muschaweck (34a).
Another dilemma involves surgery on the asymptomatic side. In Meyers et al. (7) review of 157 athletes, five (out of 86) patients, who had unilateral repairs returned for contralateral symptoms. Three of these five patients were subsequently repaired and did well. Two patients had tolerable symptoms, which did not require an operation. In Gilmore’s (2) series of 915 cases, 10% returned with contralateral symptoms. Meyers et al. (24) now routinely use MRI specifically to assist with the decision.
Those surgeons that perform laparoscopic repair have the option of applying the mesh reinforcement to both inguinal regions. Some, regardless of the laparoscopic findings, perform bilateral mesh reinforcement, citing the need for a balanced repair (11,16). Currently, there is no definitive test or investigation to predict whether an athlete who undergoes a unilateral repair will subsequently require a repair on the contralateral side.
A red flag should be raised when a female presents with groin pain. All other sources of potential pathology need to be
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investigated and rehabilitation exhausted before turning to a surgical solution (7,15). Similarly, caution should be exercised when considering treatment for athletic pubalgia or sports hernia in nonathletes. Both Meyers et al. (7) and Joesting (14) have demonstrated significantly less satisfactory results in nonathletes, though the explanation is not entirely clear.
Osteitis Pubis
Basic Science—Anatomy
The symphysis pubis is composed of opposed hyaline cartilage covered pubic bones with an intervening fibrocartilage disc. The articulation is supported superiorly by the suprapubic ligament and inferiorly by the arcuate ligament (35). The thickest portion of the fibrous joint is superior and anterior (36). Remodeling of the symphysis is usually complete by age 26. The adult symphysis is about 3 mm wide with sclerosis at the joint margins, with continued narrowing and sclerotic change throughout adult life, and eventual osteoarthritic degeneration (35).
There are numerous muscle attachments about the symphysis, including the rectus and abdominal musculature superiorly, and the adductors and gracilis inferiorly. The blood supply of the bones arise from a periosteal plexus and involve valveless venous outflow from the pudendal plexus (35). The innervation involves both sympathetic (L1, L2) and parasympathetic (S2-4) supply. The sympathetic fibers respond to ischemic pain and can induce muscle spasm, while the parasympathetic fibers respond to mechanical stimuli and can create referred pain to the groin, thigh, and perineum (35).
Pathoetiology
Mobility about the symphysis is generally less than 2 mm; however, both laboratory and clinical studies have identified increased mobility associated with pregnancy (37,38). Shear forces are greatest during mid-stance, when the unsupported pelvis begins to drop (39). Osteitis pubis is probably caused by repetitive microtrauma across the symphysis leading to periosteal inflammation, osseous resorption, or osteolysis along the symphyseal margin of the inferior pubic ramus (40,41). It has also been postulated that following an initial muscle strain, a cycle of events is created, which is then exacerbated by further activity (42). Spinelli first described the condition in athletes in 1932 (43). Inciting activities include unilateral leg support, cutting, sudden acceleration-deceleration, and multi-directional cutting from sports such as soccer, rugby, ice hockey, and football (35,41,44,45,46). Osteitis pubis accounted for 3% to 5% of all injuries of a professional Mexican soccer club over a 10 year period. It was also found that a higher percentage of midfield players, who perform more multidirectional cutting than other players, suffered from the condition (45). Excessive firing of the rectus abdominus or adductors, or imbalance between these muscles can lead to inflammation across the joint (35,41,42,43). This muscle imbalance between the abdominal muscles and the adductors can lead to anterior pelvic tilt as described in athletic pubalgia. Sacroiliac abnormalities can be present, and instability of one or both joints can contribute to excessive forces across the symphysis (35,41,47,48).
Though the etiology of osteitis pubis in athletes is typically mechanical, the condition was originally described as an infectious complication of urologic suprapubic surgery (44,49). Infection of the symphysis has also been described in gynecologic surgery, intravenous drug users, and after herniorraphy, with pseudomonas aeruginosa the most common pathogen (35,44). Depending on the severity of the infection, there can be destruction of the periosteum and hyaline cartilage, with subsequent osteomyelitis of the pubic bones (35).
Coventry and Mitchell (50) reported on the histology of symphysis in seven cases of noninfectious osteitis pubis (35). They found moderate lymphocytes, plasma cells, and an inflammatory reaction along with marrow fibrosis, hyaline cartilage degeneration, and bone resorption.
Clinical Evaluation
History
The typical presenting complaint is the insidious onset of anterior pubic pain, adductor pain, or lower abdominal pain that is exacerbated by activity (43). The symptoms are often consistent with several pathologic conditions about the groin, and the variability of the presenting complaints can contribute to diagnostic delay (39,42). Patients commonly describe pain, when standing on one leg, while dressing (41). Fricker et al. (35) reported on 59 cases of osteitis pubis and found that the range of symptom onset was from 1 month to 5 years, with an average of 14.8 months in women and 9.3 months in men. A thorough history is important to exclude genitourinary related causes, obstetric related issues, and seronegative arthropathies.
Physical Findings
The most common physical sign is tenderness of the symphysis pubis. Fricker et al. (35) found pubic tenderness in 70% of male patients, adductor longus tenderness in 42%, and impairment of hip range of motion in 24%. There is often pain with resisted adduction and active abdominal muscle contracture. We have found that loading of the symphysis with external compression of the pelvis often elicits pain. The patient is placed in a lateral position on the exam table with the symphysis pubis oriented perpendicular to the floor. One hand is placed anterior to the pubis to prevent forward leaning and the other hand applies a downward pressure on the exposed iliac crest. Examination of the sacroiliac joints, lumbar spine, inguinal region, and hip are also important to exclude other causes of symptoms, and
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laboratory work up for infection or inflammatory arthropathy should be performed, if indicated.
Imaging
Radiographic evaluation of osteitis pubis begins with routine films of the pelvis. Visualization of articular surface irregularity, erosion, sclerosis, and osteophyte formation is often possible (Fig 31-7). Flamingo views of the pelvis can demonstrate symphyseal joint laxity or disruption, defined by widening of more than 7 mm or greater than 2 mm of malalignment of the upper margins of the superior pubic rami (40).
Fricker et al. (35) found that the severity of sclerosis on radiography did not reliably match symptoms and signs. For cases where exam and history are consistent with osteitis pubis, but plain radiographs are equivocal, scintography with Tc99 is useful to confirm the diagnosis. A positive scan will reveal focal accumulation of radionucleotide at or adjacent to the symphysis pubis (40). MRI may demonstrate abnormal signal at the pubic symphysis and/or symphyseal disc extrusion (40). Both CT and MRI can be helpful to identify concomitant lesions of the sacroiliac joint or pubic rami, such as stress fractures. In a retrospective review of MRI and plain radiographs, Major and Helms (48) demonstrated that 6 out of 11 patients with combined complaints of pubic pain and sciatic pain or low back pain, had secondary lesions of the sacroiliac joint.
Classification
Two types of osteitis pubis exist, infectious and traumatic. As discussed above, infectious is often secondary to direct inoculation after a surgical procedure in the vicinity of the pubis symphysis. Traumatic osteitis pubis was separated into four stages by Rodriguez et al. (45) in a retrospective cohort of 44 players:
Fig 31-7. Twenty-two year old male soccer player with 6 month complaint of groin pain. Note the unilateral resorption and fragmentation of the pubic symphysis (arrow).
  • Stage 1 included unilateral symptoms that subsided after warm-up and returns after training,
  • Stage 2 involved bilateral symptoms,
  • Stage 3 players were unable to continue playing,
  • Stage 4 players had pain and difficulty with activities of daily living.
Debate exists regarding whether osteitis pubis represents a unique disorder, or if it is part of a larger syndrome. Our impression is that it can be both. In our experience, patients can present with isolated pain at the symphysis and positive focal imaging studies. Other patients have pain in the adductor region, inguinal pain, and lower abdominal discomfort. Several authors have described osteitis pubis in addition to a larger syndrome such as athletic pubalgia or sports hernia (2,17,27,51).
Treatment
Nonoperative
Nonoperative treatment of osteitis pubis is usually effective. The first phase of recovery involves rest from all physical activity, the use of ice, ultrasound stimulation, and oral anti-inflammatory medications (35,39,41,42,43,45,50,52). Oral corticosteroids have also been used with some benefit; however, the risks of this treatment make it a second line treatment option (35,42,44). Phonophoresis with 10% hydrocortisone or topical ketoprofen can also be useful (42).
After reduction of acute pain and inflammation, a second phase of stretching and strengthening should be initiated to reduce the forces across the pelvis. Both Batt et al. (42) and Williams et al. (41) recommend stretching of all muscle groups; however, the hip flexors and external rotator muscles should be emphasized as they are the least flexible. The third phase involves a gradual return to exercise starting with low impact activities that will not stress the pubic symphysis, such as rowing and freestyle swimming. Sim et al. (53) outlined a helpful swimming rehabilitation activity, which includes the use of a flotation jacket with the legs tied together to prevent torque across the pelvis. The fourth and final phase includes a progression to biking, jogging, running, cutting, and ultimately high level sporting activities.
Recurrence has been reported to be as high as 25%, with only 25% of athletes returning to their previous level of competition; therefore, an immediate and aggressive approach to nonoperative treatment is necessary (42). Batt et al. (42) found an average of 3 to 6 months for full return to play, while Fricker et al. (35) report a range of 3 weeks to 48 months. Rodriguez et al. (45) showed that the time to symptom remission was dependent upon the stage of the condition. Stage 1 and 2 took 3.8 and 6.7 weeks, respectively, while stage 3 took 10 weeks.
Another conservative treatment modality includes corticosteroid injection into the symphysis. Holt et al. (43) recommend injection of 4 mg dexamethasone, 1 ml 1% lidocaine, and 1 ml of 0.25% bupivicaine in athletes that do
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not respond to simpler treatment modalities. In their series, seven of eight college level athletes returned to their prior level of play, and three of eight returned within 3 weeks. O’Connell et al. (40) also advocate early injection of the symphysis with 14 of 16 athletes returning to sport after 48 hours; however, only five of 16 remained completely pain free at 6 month follow-up.
Reports of other alternative treatment modalities have been reported with varying degrees of success. Maksymowych et al. (49) described the use of intravenous pamidronate infusions (two injections per month for 3 to 6 months) for refractory osteitis pubis. A total of three patients (two with idiopathic osteitis pubis and one with spondyloarthropathy), who failed conservative treatment were symptom free at 6 month follow-up, and two of three patients had negative uptake on repeat bone scan.
Operative
Up to 90% of cases will respond to nonoperative care, and operative treatment should be reserved for refractory cases and recurrences only (35) (Fig 31-8). Absolute indications for surgical treatment of the symphysis pubis include acute infection or excessive widening of the symphysis with sacroiliac joint disruption. Surgical options include wedge resection, curettage, and bone grafting with rigid fixation (50). Mullhall et al. (52) reported on two soccer players who returned to professional sport six months after open curettage and methylprednisolone injection. Williams reported on 13 professional rugby players with at least 13 months of failed conservative treatment and found that all players were pain free at an average of 52.4 months after bone grafting and arthrodesis (41).
Fig 31-8. Ostetitis pubis treatment algorithm.
There is no current consensus on the ideal operative treatment. Rigid plate fixation has been advocated for athletes with refractory osteitis pubis; however, the long term biomechanical effects are unknown at this time. The question remains as to the effects anterior arthrodesis will have on the posterior pelvic ring, specifically the SI joint. Until this issue is resolved, the indication for arthrodesis should be reserved for those refractory patients who demonstrate large osteophytes, gross instability, and complete loss of joint space. Conversely, potential problems could arise from surgical curettage of the symphysis as the possibility of increased anterior instability arises. Curettage has been shown to provide relief in elite athletes, but care should be taken to minimize dissection such that the surrounding stabilizing ligaments are not disrupted.
Conclusions and Future Directions
There is some evidence that muscular imbalance, which may be present in disorders such as osteitis pubis and athletic pubalgia, can be affected by a conditioning program. Hölmich et al. (54) investigated athletes with a mean of 40 weeks of groin pain into an active physical rehabilitation group and a physiotherapy only group. The active physical training consisted of a gradual abdominal and adductor strengthening program and the physiotherapy group underwent rest, stretching, and
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modalities. They found that 23 of 29 athletes in the active group and four of 30 athletes in the control group returned to sport after 8 to 12 weeks.
Prevention programs can have a significant impact on sporting injuries. Tyler et al. (55) found that an adductor strengthening program may be effective in the prevention of adductor strains in professional ice hockey players. Thirty-three of 58 who were identified as “at risk” on the basis of preseason hip adductor strength and participated in an intervention program, which consisted of 6 weeks of exercises aimed at functional strengthening of the adductor muscles. They found that there were three adductor strains in the two seasons subsequent to the intervention, compared with 11 in the previous two seasons (55). Similarly, a groin injury prevention program in Major League Soccer teams has been implemented in the United States and our preliminary results appear to be promising. It is our belief that these types of sport specific prevention programs will be the key to minimizing the number of missed playing hours due to groin injuries. Further research is needed to determine the precise etiology, biomechanics, and pathophysiology of occult groin injuries.
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