{"id":10885,"date":"2023-12-11T06:00:02","date_gmt":"2023-12-11T05:00:02","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=10885"},"modified":"2023-12-02T21:40:39","modified_gmt":"2023-12-02T20:40:39","slug":"groin-pain-into-the-bermuda-triangle-part-4","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2023\/12\/11\/groin-pain-into-the-bermuda-triangle-part-4\/","title":{"rendered":"Groin Pain: Into the Bermuda Triangle Part 4"},"content":{"rendered":"

Diagnosing, managing & rehabilitating injuries in the Bermuda Triangle<\/i><\/b><\/p>\n

Keywords<\/b>: <\/span>Groin Pain; Pubic Pain; Pubalgia; Rehabilitation<\/b><\/p>\n

Introduction<\/b><\/p>\n

This final blog in the series covers Pubic Related Groin Pain (PRGP) <\/span>(1)<\/span><\/a>.\u00a0 Earlier parts to the series can be found by following: <\/span>Part 1 Adductor Related Groin Pain (ARGP)<\/span><\/a>; <\/span>Part 2 Iliopsoas Related Groin Pain (IRGP)<\/span><\/a> and <\/span>Part 3 Inguinal Related Groin Pain (IgRGP)<\/span><\/a>.\u00a0 In keeping with most other musculoskeletal (MSK) sporting injuries, history of previous groin injury puts the athlete at greater risk of further episodes <\/span>(2)<\/span><\/a>.\u00a0 For athletes involved in team sports exposed to acceleration, deceleration or dynamic directional changes, overload can result in in PRGP <\/span>(2)<\/span><\/a>, <\/span>(3)<\/span><\/a>, <\/span>(4)<\/span><\/a>, <\/span>(5)<\/span><\/a>, <\/span>(6)<\/span><\/a>, <\/span>(7)<\/span><\/a>, <\/span>(8)<\/span><\/a>, <\/span>(9)<\/span><\/a>, <\/span>(10)<\/span><\/a>, <\/span>(11)<\/span><\/a>, <\/span>(12)<\/span><\/a>, <\/span>(13)<\/span><\/a>, <\/span>(14)<\/span><\/a>, <\/span>(15)<\/span><\/a>, <\/span>(16)<\/span><\/a>, <\/span>(17)<\/span><\/a> & <\/span>(18)<\/span><\/a>.\u00a0 In endurance, artistic or aesthetic sports PRGP may occur due to Relative Energy Deficiency in Sport (REDs) (Figures 1 and 2) <\/span>(19)<\/span><\/a>.<\/span><\/p>\n

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Figure 1 Relative Energy Deficiency in Sport (REDs) Health Conceptual Model <\/b>(<\/b>Mountjoy M, Ackerman K, Bailey DM, <\/b>et al<\/i><\/b>. <\/b>2023) <\/b>(19)<\/b><\/a><\/p>\n

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Figure 2 Relative Energy Deficiency in Sport (REDs) Performance Conceptual Model <\/b>(<\/b>Mountjoy M, Ackerman K, Bailey DM, <\/b>et al<\/i><\/b>. <\/b>2023) <\/b>(19)<\/b><\/a><\/p>\n

Pubic Related Groin Pain (PRGP)<\/b><\/p>\n

PRGP is defined <\/span>as <\/span>local tenderness of the pubic symphysis and the immediately adjacent bone <\/span>(1)<\/span><\/a>. \u00a0 No particular resistance tests specifically test for PRGP, although the \u201csqueeze test\u201d would appear to be most relevant <\/span>(1)<\/span><\/a> & <\/span>(20)<\/span><\/a>.<\/span><\/p>\n

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) <\/span>(21)<\/span><\/a>.\u00a0 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 <\/span>(22)<\/span><\/a>.\u00a0 Monitoring of training load is a complex process, with an element of chronic training load being argued by Gabbett (2016) <\/span>(23)<\/span><\/a> to avoid injuries from acute increases in load encountered by athletes; for example, during an intense competition schedule such as during a championship.\u00a0 Gabbett (2016) <\/span>(23)<\/span><\/a> argues for a so-called \u201csweet-spot\u201d for acute:chronic workload ratio to avoid injury (Figure 3).<\/span><\/p>\n

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Figure 3 Likelihood of Subsequent Injury versus Acute:Chronic Workload Ratio (Gabbett TJ 2016) <\/b>(23)<\/span><\/a><\/p>\n

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).\u00a0 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 <\/span>(24)<\/span><\/a>.<\/span><\/p>\n

The following video summaries some key concepts such as Wolff\u2019s Law, types of bone loading and rate of bone loading relating to BSI:<\/span><\/p>\n

DPT 7120 Chapter 2 Bone Stress Injuries YouTube<\/span><\/a> (25)<\/span><\/a><\/p>\n

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 <\/span>(26)<\/span><\/a>.\u00a0 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 <\/span>(26)<\/span><\/a> &<\/span> (27)<\/span><\/a> .\u00a0 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 <\/span>(28)<\/span><\/a>, <\/span>(29)<\/span><\/a>, <\/span>(30)<\/span><\/a>,<\/span> (31)<\/span><\/a>,<\/span> (32)<\/span><\/a>, <\/span>(33)<\/span><\/a>, <\/span>(34)<\/span><\/a>, <\/span>(35)<\/span><\/a> & <\/span>(36)<\/span><\/a>.\u00a0 The Copenhagen Hip and Groin Outcome Score (HAGOS) <\/span>(37)<\/span><\/a> is a potentially useful tool to monitor athletes\u2019 progress.\u00a0 For those athletes wanting to return to sport the Strategic Assessment of Risk and Risk Tolerance <\/span>(StARRT)<\/span><\/a> Framework established in 2016 <\/span>(38)<\/span><\/a> could be a good starting point for making return to play decisions post PRGP.\u00a0 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 <\/span>(39)<\/span><\/a>.<\/span><\/p>\n

Conclusions<\/b><\/p>\n