Athletic pubalgia

Athletic pubalgia, also called the sportman's hernia or sports hernia, Gilmore's groin or groin disruption, is a medical condition of the groin affecting athletes^[1]. Jerry Gilmore recognized the syndrome in 1980 and developed a surgical repair technique. It is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. Soccer players are affected most frequently, and both recreational and professional athletes may be affected. A hernia cannot be found on physical examination or medical imaging, and is not revealed during surgery. The term hernia thus is a misnomer^[2], but has persisted, as surgical reconstructions similar to those performed for inguinal hernias are often effective for "sports hernias" as well.

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Symptoms include pain during sports movements, particularly hip extension, and twisting and turning. This pain usually radiates to the adductor muscle region and even the testicles, although it is often difficult for the patient to pin-point the exact location.

Following sporting activity the person with athletic pubalgia will be stiff and sore. The day after a football match, getting out of bed or a car will be difficult. Any exertion that increases intra-abdominal pressure, such as coughing, sneezing, or sporting activity can cause pain. In the early stages, the person may be able to continue playing their sport, but the problem usually gets progressively worse.

As pain in the groin and pelvis can be referred from a number of problems, including injuries to the lumbar spine, the hip joint, the sacro-iliac joint, the abdomen, and the genito-urinary system, diagnosis of athletic pubalgia requires skillful differentiation and pubic examination in certain cases where there is intense groin pain.

The diagnosis of Gilmore's groin is based on the patient's history and clinical signs. The most notable clinical sign is dilation of the superficial inguinal ring on the affected side, which can be palpated by the examining doctor when the scrotum is inverted with the little finger. Typically, there is specific pain on coughing and sneezing, as well as sitting up and squeezing the legs together.

The exact lesion may differ, but common pathologic findings at operation are ^[3] :

• torn external oblique aponeurosis
• tear in the conjoint tendon
• conjoint tendon torn from pubic tubercle
• dehiscence between conjoined tendon and inguinal ligament
• tear in the fascia transversalis ^[2]
• abnormal insertion of the rectus abdominis muscle
• tear of the abdominal internal oblique muscle from the pubic tubercle
• entrapment of the ilioinguinal nerve or genitofemoral nerve^[4]

Several of these lesions may occur simultaneously. Also, many athletes have concomitant weakness or tearing of the adductor muscles of the hip.^[3]

The exact incidence of these entities is unknown: some believe it is the most common cause of chronic groin pain in athletes, while others argue that it is only rare.^[5] Conservative therapies (gentle stretching and a short period of rest^[6]) may temporarily alleviate the pain, but definitive treatment consists of surgical repair followed by a structured rehabilitation^[3][7].

Notable cases

Well-known sufferers include:

• Patriots quarterback Tom Brady^[8]
• England cricketer Ashley Giles^[9]
• Philadelphia Eagles quarterback Donovan McNabb^[10]
• Outfielders Chris and Shelley Duncan^[11]
• Los Angeles Galaxy soccer player Benjamin Benditson^[12]
• Houston Dynamo soccer player Joseph Ngwenya
• Kilmarnock F.C. midfielder Danny Invincibile^[13]
• Toronto Maple Leafs forward Kyle Wellwood^[14]
• Philadelphia Flyers forward Daniel Briere^[15]
• New York Islanders center Shawn Bates ^[16]
• Calgary Flames forward Darren McCarty ^[17]
• New England Revolution forward Pat Noonan ^[18]
• Nashville Predators winger J.P. Dumont ^[19]
• Dallas Stars defenseman Sergei Zubov
• National Kam. forward Yngve Almli
• Anaheim Ducks goaltender Jean-Sebastien Giguere and forward Samuel Pahlsson

Notes