Pubalgia: causes, symptoms and remedies

Pubalgia rather than an illness is considered a syndrome, for which the number of cases (epidemiology, in scientific terms) is difficult to calculate, as are the relative causes and symptoms, above all due to the anatomical complexity of the groin region and frequent overlapping features of other types of disorder.

In general, pubalgia refers to chronic pain in the groin, in particular in the lower area where we find the tendons inserting the adductor muscles, even though in some cases it can affect the upper area inserting the Rectus abdominis, informally known as the abs muscle. Not by chance Pubalgia is also known as rectus-adductor syndrome.

The sports most at risk of pubalgia are football, hockey, rugby and long-distance running. However, increasing numbers are now also being seen in sports such as basketball and volleyball, skiing, tennis and light athletics. It isn’t limited to just professional athletes either; in fact, we are seeing ever more frequent cases among occasional and amateur sports people too.

The groin: anatomical notes on joints and muscles

The pubic bone is one of the bones that make up the pelvis, together with the ilium, ischium and sacrum. We have two pubic bones, one on the right and one on the left, which join at the centre to form a joint known as symphysis pubis. In addition, the exterior of the public bone contributes to forming the acetabulum, which is part of the hip joint.

The pubis is a particularly delicate anatomical area because it allows the insertion of muscles and ligaments that are essential for walking and pelvic stability. Among the most important muscles that insert into the pubis are the adductor longus, the adductor brevis, the adductor magnus, the gracilis and pectineus muscles, the abdominal muscles and those of the pelvic floor.

How many types of pubalgia are there and what are the causes?

Pubalgia differs according to where the pain is felt. There are therefore three types that can be summarised as follows:

1. Pubalgia of the abdominal wall, affecting the lower area of the abdomen muscles and anatomical elements of the inguinal canal;
2. Pubalgia of the adductor muscles, mainly affecting the adductor longus muscles and the pectineus muscle;
3. Pubalgia of the symphysis pubis.

The causes are often difficult to identify, but the most frequent are attributable to:

• Insertional tendinopathy;
• Imbalance of adductor muscles and abdominal muscles;
• Muscle injuries;
• Excessive stiffness of muscles in the posterior chain;
• Calcification;
• Inguinal hernias;
• Stress fractures;
• Dysfunction of the symphysis pubis;
• Stiffness of the hip;
• Trapped nerves;
• Visceral dysfunctions.

Symptoms of pubalgia

Classic symptoms of pubalgia are:

• Pain in the inner groin area, where the adductor muscles are inserted;
• Pain in the pubis area;
• Pain in the lower abdomen;
• Pain spreading from the above areas to the inner thigh.

These symptoms are normally most intense on waking, or when moving after a period of inactivity, such as after sitting for some time. In less serious cases, the pain tends to lessen after adequate heating and the start of physical activity.

Most people suffering from pubalgia complain of progressive pain, with symptoms that vary from simple aches through to acute pain, of such intensity that it can hinder daily activities such as walking, dressing, going up and down stairs.

Diagnosis and treatment

Diagnosis by a doctor is essentially clinical. From an objective point of view, the patient complains of pain on touch or feeling pulled/strained muscles. It is important to understand how these symptoms arise and to observe how the patient moves, walks and undresses.

As regards image diagnostics, it is always recommended to perform an X-ray of the pelvis, to evaluate the situation of symphysis pubis and possible signs of arthrosis or disorders of the coxofemoral joint. On the other hand, an ultrasound scan can be useful in the case of a suspected inguinal hernia or possible muscular lesion. Lastly, an MRI can provide detailed information on the condition of the bones and joints, as well as that of the tendons or muscles.

Once the cause has been identified, treatment is normally provided by a sports physiotherapist or expert in muscular-skeletal disorders. In collaboration with the sports doctor or physiatrist, the physiotherapist will decide on a work protocol, which is usually made up of the following stages:

• Abstention from sports activities and functional rest;
• Physical Therapies to reduce inflammation and regenerate tissues, such as LASER, TECAR or impact waves;
• Manual therapy techniques to correct the stiffness of some segments such as symphysis pubis, the hip or sacro-iliac joint;
• Manual and/or osteopathic techniques to treat any visceral and/or neurodynamic dysfunctions;
• Therapeutic Exercise to correct imbalance between adductor muscles and abdominal muscles, and/or between extensor and flexor muscles;
• Postural exercises to restore normal flexibility of muscles in the posterior chain;
• Gradual return to physical activity, increasing loads under the supervision of a professional.

As there are so many variables to consider, recovery times can vary from a few weeks to several months.

In more serious cases, and normally among sports professionals, surgical intervention may be an option, obviously performed by an orthopaedic specialist with mini-invasive techniques.

Useful exercises for pubalgia

Given the large variety of causes that may lead to pubalgia, there are no standard exercises for all patients. For this very reason, the recovery plan must always be personalised on the basis of the clinical case in hand.

However, we can confirm that usually muscle stretching postures, in particular for tightened muscles in the posterior chain, can lead to some benefits also if performed independently. For example, a useful exercise consists in stretching the posterior chain at right angles with the legs against the wall. In this case, we need to find the medium tension of the rear muscles of the thigh and hold this for 3 to 4 minutes, performing this at least twice daily.

Other exercises should be decided on together with the physiotherapist.

Pubalgia in pregnancy: how this happens, how to alleviate symptoms and how to prevent it

Pubalgia during pregnancy is normally due to an inflammation of the tendons of the muscles that are inserted in the pubis, due to the increased tension on the symphysis pubis and increased muscular elasticity of the abdominals. This is no cause for concern but can cause discomfort and pain for the mother-to-be. It generally tends to disappear immediately after birth.

To prevent pubalgia, regular physical activity is essential during pregnancy, to maintain muscle tone and support the increase in weight. For example, the recommended physical activities include yoga, water exercises, courses in low-impact exercises, etc.

In the case of particularly painful pubalgia, we recommend seeking the assistance of an experienced physiotherapist, who can use appropriate techniques to restore the balance of the pelvis and draw up a programme of suitable exercises to be continued independently at home.