Pubalgia

What is pubalgia ?  

Hip and groin injuries account for 14% of football injuries but the complexity of groin pain lies in the fact that a variety of pathologies can come into play (1). Indeed, pubalgia is considered to be a progressive overuse condition. It is mostly unilateral and develops as a result of excessive muscular or articular loads, but it can also occur as a result of the repetition of traumatic gestures, such as shearing during kicking or overpowering passes. 

There are 3 main types of pubalgia : 

• Tendinopathy of the rectus abdominis 
  
• Tendinopathy of the adductors 
  
• Pubic osteoarthropathy : osseous damage often degenerative or postural imbalance at the pubis 
  

With appropriate conservative treatment and good management, pubalgia heals in 3 to 6 months depending on the case. However, a quicker recovery can be observed in high level athletes after an operation (1).

Anatomically, what does pubalgia include ?

In most cases, pubalgia is caused by the adductor muscle group. Let’s take a look at the different muscles that make up this group in order to better target the subject. The adductors are a group of 5 muscles located in the medial part of the thigh. 4 are mono articular and only one, the gracilis, is bi articular. They all originate from the pubis at approximately the same point, with the exception of the lower fascicle of the adductor magnus. 

• The pectineus : the highest and smallest of the adductors, it is also the least powerful of this group. 
  
• Adductor longus : the most superficial of all the muscles mentioned here. 
  
• Adductor brevis : a deep muscle, consisting of 2 fascicles between the adductor longus and adductor magnus. 
  
• Adductor magnus : the largest and most powerful muscle of the adductor group, it is composed of 3 bundles rolled up on themselves. Its lower fascicle inserts on the ischial tuberosity while the upper and middle ones insert on the ischio-pubic branch. Its terminations go from the acrid line of the femur to the medial condyle of the latter for the inferior bundle. 
  
• The gracilis : the only bi-articular muscle in the list, it is situated medial to all the muscles mentioned above. It ends at the level of the crow’s feet (medial side of the tibia) behind the sartorius and above the semitendinosus.

What treatment and rehabilitation is needed ?

Non-operative rehabilitation can be carried out alone or combined with steroid injections if the results after several weeks or months are not sufficient. Although there is a risk of weakening the tissues concerned, these injections can be carried out at the pubic symphysis or the origins of the adductor tendon, with anti-inflammatory medication and rest. However, it is essential to favour conservative treatment based on physiotherapy. This management should begin with clinical assessment of trunk stability, hip strength and flexibility, and identification of muscle compensations and imbalances. All of these variables are crucial as it is these imbalances that will induce new or excessive stresses to the structures mentioned above. 

During care, active stretching of the spine and lower limbs should be added to ensure that flexibility and full range of motion are maintained, targeting the muscles around the pelvis. Although all surgeons have their own specific protocol, an initial rest period of four weeks is generally recommended for surgery before starting physiotherapy (2).

An important role is also given to the fascial tissues in pubalgia rehabilitation because in this overuse condition, they tend to change their properties and become more adherent, limiting good mobility and potentially transmitting painful messages to the brain. After these initial phases of treatment, it is necessary to move on to functional rehabilitation, aiming to incorporate proprioceptive activities. Thus, single leg exercises on an unstable surface can activate the deep stabilisation of the pelvis and trunk, while developing proprioception and kinaesthetic awareness (3)(4).

The key word of this site is to raise awareness of the progressiveness of the activities, this principle obviously adapts to this pathology since it involves the notion of overuse tendinopathy. This notion applies in parallel to the notion of good body mechanics during movements so that the stresses are distributed equitably over the body structures. 

How can this condition be effectively prevented and avoided ?

The prevention of pubalgia aims to balance and strengthen the following agonist/antagonist couples : 

• Abdominal and paravertebral : Postural work on the back and front should be carried out regularly to work on the stability of the trunk, its resistance, its proprioception and its postural maintenance. It should be noted that this sheathing must be carried out dynamically and not statically in order to get as close as possible to the conditions of physical practice. 

• Adductors and abductors : it is important to vary the modalities of reinforcement while incorporating a significant eccentric load.

• Hamstrings and quadriceps : the most judicious for this couple seems to be plyometric strengthening. Indeed, the latter is closest to the muscular physiology during jumps, receptions and ball strikes, thus allowing preparation for shearing efforts, intense and numerous in matches. 

On the other hand, the notion of flexibility and mobility of the muscles surrounding the pelvis is also to be placed at the centre of the concerns. Indeed, stiffness or retractions of these muscles can modify the position of the pelvis and unbalance it in the face of stress. These morphological disturbances can be responsible for injuries, as the body is not used to and prepared for these inconvenient constraints. This is why it is necessary to start a mobility routine at hip level, allowing good relaxation of the soft tissues and to associate it with a stretching programme (adductors, abdominals, quadri-ischios). 

Daily proprioceptive hip exercises can also prepare the body for the many demands on the hip during matches. 

A good warm-up is also one of the pillars of injury prevention, it is necessary to incorporate ballistic movements, activo-dynamic stretching, eccentric contractions and to respect a progressiveness in ball strikes and intensities of changes of direction. 

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