59: Pubalgia

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CHAPTER 59

Pubalgia

Atul T. Patel, MD, MHSA

Synonyms

Athletic hernia

Athletic pubalgia

Gilmore’s groin

Gracilis syndrome

Groin pain

Groin pull

Groin strain

Osteitis pubis

Pectineus syndrome

Sports hernia

ICD-9 Codes

727.09  Adductor tendinitis

959.19  Groin injury

789.00  Groin pain

848.8   Groin strain

848.8   Ilioinguinal strain

848.8   Inguinal muscle strain

733.5   Osteitis pubis

ICD-10 Codes

M77.9  Tendinitis NOS

S39.91  Groin injury (abdomen)

Use seventh character for the episode of care

R10.30   Groin pain (lower abdomen)

S39.011  Groin strain (abdominal muscle)

S39.011  Ilioinguinal strain (abdominal muscle)

S39.011  Inguinal muscle strain (abdominal muscle)

M85.38    Osteitis, other sites

Definition

Although there is no universally accepted definition of this condition, pubalgia is pain in the groin area that is due to musculoskeletal causes. Despite the prevalence of the condition, the literature is filled with varying causes, anatomy involved, and terminology. Pubalgia usually refers to pain in the groin or lower abdominal area, typically in athletes who engage in activities involving repetitive sprinting, kicking, or twisting movements. Most of the published studies include athletes involved in soccer, rugby, ice hockey, running, or football. It is typically a multifactorial condition initially thought to be due to weakness of the posterior wall of the inguinal canal (Fig. 59.1). These patients have no obvious hernias or symptoms, such as numbness, clicking, a lump, or dysuria, to suggest other causes. However, medical causes need to be considered and recognized before it is concluded that the pain is due to a musculoskeletal cause [1,2]. The majority of the conditions resulting in chronic groin pain in athletes are musculoskeletal in origin [3,4]. There is ample evidence that this condition is much more common in amateur and professional athletes than in the general population [57].

f59-01-9781455775774
FIGURE 59.1 The anatomic layers of the groin showing the various muscles and other structures. The rectus abdominis is seen medially. (From Drake R. Gray’s Atlas of Anatomy. New York, Churchill Livingstone, 2008.)

Symptoms

The symptoms are often vague and diffuse and in the area of the lower abdomen, groin, or medial thigh. The pain is often insidious in onset and a chronic aching type [8]. Most athletes cannot remember how or when the pain started. The symptoms are worse during and after strenuous activity and exacerbated by an increase in abdominal pressure, such as coughing or sneezing. The pain may limit the ability to stand or to sit. In men, the pain can radiate into the testicle on the involved side and to the surrounding areas of the abdomen and lower back. Women may complain of a dull ache in the groin aggravated by physical exertion or intermittent neurologic pain in the distribution of the ilioinguinal nerve [9].

Physical Examination

The findings on examination can be tenderness in the area of the pubic symphysis [10,11] and pain on contraction of the hip flexors, hip adductors, or abdominal muscles [12]. Pain and tenderness at the external inguinal ring without a frank lump may be associated with pubalgia, but the presence of a lump would indicate an inguinal hernia [13]. Tenderness and dilation of the external inguinal ring can be found in up to 94% of patients with an athletic hernia [14

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