Groin Pain: Into the Bermuda Triangle Part 4

Diagnosing, managing & rehabilitating injuries in the Bermuda Triangle

Keywords: Groin Pain; Pubic Pain; Pubalgia; Rehabilitation

Introduction

This final blog in the series covers Pubic Related Groin Pain (PRGP) (1).  Earlier parts to the series can be found by following: Part 1 Adductor Related Groin Pain (ARGP); Part 2 Iliopsoas Related Groin Pain (IRGP) and Part 3 Inguinal Related Groin Pain (IgRGP).  In keeping with most other musculoskeletal (MSK) sporting injuries, history of previous groin injury puts the athlete at greater risk of further episodes (2).  For athletes involved in team sports exposed to acceleration, deceleration or dynamic directional changes, overload can result in in PRGP (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), (12), (13), (14), (15), (16), (17) & (18).  In endurance, artistic or aesthetic sports PRGP may occur due to Relative Energy Deficiency in Sport (REDs) (Figures 1 and 2) (19).

Figure 1 Relative Energy Deficiency in Sport (REDs) Health Conceptual Model (Mountjoy M, Ackerman K, Bailey DM, et al. 2023) (19)

Figure 2 Relative Energy Deficiency in Sport (REDs) Performance Conceptual Model (Mountjoy M, Ackerman K, Bailey DM, et al. 2023) (19)

Pubic Related Groin Pain (PRGP)

PRGP is defined as local tenderness of the pubic symphysis and the immediately adjacent bone (1).   No particular resistance tests specifically test for PRGP, although the “squeeze test” would appear to be most relevant (1) & (20).

PRGP is effectively an injury to osseous structures due to a reaction (either acute or chronic) which the structures cannot cope with; effectively it is a Bone Stress Injury (BSI) (21).  Incorporating a more holistic view of athlete health could well mitigate the progression of a BSI, with gut health emerging as an important risk factor for BSI (22).  Monitoring of training load is a complex process, with an element of chronic training load being argued by Gabbett (2016) (23) to avoid injuries from acute increases in load encountered by athletes; for example, during an intense competition schedule such as during a championship.  Gabbett (2016) (23) argues for a so-called “sweet-spot” for acute:chronic workload ratio to avoid injury (Figure 3).

Figure 3 Likelihood of Subsequent Injury versus Acute:Chronic Workload Ratio (Gabbett TJ 2016) (23)

A small sample of Australian rules football players, with a clinical diagnosis of PRGP, underwent bone biopsy of an area of the superior pubic ramus which was previously identified from Magnetic Resonance Imaging (MRI) as a region with Bone Marrow Oedema (BMO).  New woven bone was found, but poor study methodology did not allow for the researchers to conclude if this new woven bone was pathology related to a stress reaction of the bone, or part of the normal adaptation from training load (24).

The following video summaries some key concepts such as Wolff’s Law, types of bone loading and rate of bone loading relating to BSI:

DPT 7120 Chapter 2 Bone Stress Injuries YouTube (25)

Treatment for PRGP, particularly in relation to the BSI, necessitates unloading of the area followed by graduated return to loading over three to four months (26).  Whilst no weight-bearing activities involving running are allowed for three months, stationary cycling can gradually be introduced prior to carefully monitored return to running (26) & (27) .  Whilst there is no evidence-based treatment for PRGP, it is possible that interventions for ARGP, with greater evidence-base, could be used as part of the clinical reasoning in rehabilitating PRGP (28), (29), (30), (31), (32), (33), (34), (35) & (36).  The Copenhagen Hip and Groin Outcome Score (HAGOS) (37) is a potentially useful tool to monitor athletes’ progress.  For those athletes wanting to return to sport the Strategic Assessment of Risk and Risk Tolerance (StARRT) Framework established in 2016 (38) could be a good starting point for making return to play decisions post PRGP.  Some sports with repetitive actions, such as bowling in cricket, havee the potential to overload numerous structures and therefore specific interventions for prevention are needed (39).

Conclusions

  • PRGP is difficult to diagnose and manage. 
  • HAGOS is a valid tool to monitor PRGP rehabilitation.
  • Most efficacious treatment for PRGP is undefined.

Acknowledgements: Thank you to the Association Chartered Physiotherapists in Sports and Exercise Medicine @physiosinsport and British Journal of Sports Medicine @BJSM_BMJ for their support in publishing this Blog.

Competing Interests: None

Author:

Jim Scanlan NHS Fife Advanced Practitioner Physiotherapist in General Practice

Scottish Rugby Union Faculty of Medicine Member; SCRUMCAPS Tutor.

MSc; BSc (Hons); Pg Dip Ortho Med; Pg Dip Injection Therapy; IRMER Certified; 

HCPC; MCSP; ACPSEM: Silver Accreditation. 

Twitter: @jim_physio

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