Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

7. Groin Pain Etiology: Athletic Pubalgia Evaluation…
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For example, when the foot is planted to accelerate speed or change
of direction, the power in the legs must be balanced by the torso to move
the entire body in the same direction. As the adductor and gracilis
muscles contract, they exert pulling force on the inferior edge of the
pubic ramus and pubic symphysis. The pubic symphysis acts to stabilize
both halves of the pelvis to the opposing force vector. The rectus muscle
then contracts to bring the torso in line with the new vector force, exerting
a pulling force on the superior edge of the pubic ramus and symphysis.
If the athletic training activity promotes leg muscle development
over abdominal wall muscle development (typically the rectus muscle),
or promotes right-sided muscle development over the left, a relative
pelvic instability can develop. This allows chronic and recurring muscle,
tendon, or symphyseal trauma that is collectively known as osteitis
pubis. This injury mechanism helps to explain why certain sports and
athletic positions have a higher incidence of osteitis pubis: the football
player who stops and starts by planting the same pivot foot, the soccer
player or punter who plants the left foot and creates the burst kick with
the right foot, and the sprinter who explodes from the starting block
using the same staggered foot position.
Diagnosis The diagnosis of osteitis pubis begins with a history and
physical exam. High-intensity athletes doing year-round training in
sports like soccer, football, and track have the highest incidence of
injury for the reasons explained above [ 8 ]. Commonly, the patient will
admit to a chronic and recurring set of symptoms for which they have
self-medicated or self-limited their training to allow healing. But upon
restarting competitive training, the symptoms recur, and they seek the
surgeon to help get back to full speed.
The goal of the physical exam is to best localize the focal area of
pain. Osteitis pubis can be divided into three zones for focal pain: suprapubic,
intrapubic, and infrapubic. Suprapubic sources of pain include
injuries to the rectus muscle, rectus tendon, conjoint tendon, and the
periosteum of the pubic rami. Intrapubic sources of pain stem mainly
from injury to the pubic symphysis and its fibrocartilaginous interpubic
disk. Infrapubic sources of pain include injury to the gracilis muscle, the
adductor longus muscle, the tendinous origins of these muscles, and
periosteum of the pubic rami.
On examination, the pain can often be elicited by manual palpation.
A pubic symphyseal injury can be assessed by performing the spring
test. With the patient in supine position, the examiner places direct
downward pressure with a hand on each side the pubis. Pain with a