What is a groin strain (aka pubic overload or osteitis pubis)?
Feeling a groin strain when you run or play sport?
Maybe you’ve been told that you have a ‘groin strain’, but the ache you feel after exercising just isn’t going away?
Perhaps you’ve tried physiotherapy, rest or stretching, and it still isn’t getting better?
Many people (especially runners and people who play football) may experience pain in the groin.
This might be happening to you, and you may be wondering if it’s a pulled or torn muscle (e.g. an adductor muscle tear).
Many of the patients I meet who have pain in their groin, turn out to have a problem with the hip such as FAI (femoroacetabular impingement). This may come as a surprise, as the hip joint often isn’t what people think it is (it’s deep in the groin, not on the outside area of the hip).
Often groin pain isn’t so much about damage or changes to muscle. It’s really about excessive loading or shearing forces across the front of the pelvis where tendinous attachments, the pubic bones and the ‘pubic symphysis all meet.
We give pain in this area various names (such as ‘osteitis pubis’, ‘pubic overload’ and ‘athletica pubalgia’, but they are essentially referring to the same condition.
What else can cause groin pain?
Hip conditions such as FAI and hip arthritis can cause groin pain, but so too can a bony stress fracture of the pubic bones. This may occur when the pubic overload becomes extreme or constant, much like a runner might get a stress fracture in a metatarsal bone.
Some people are concerned that they may have a ‘sportsman’s hernia’ aka ‘Gilmore’s groin’. This is a condition which has caused much controversy over the years. Rather than a bulging lump in the abdominal wall, the concept of the Gilmore’s groin is that there is a weakness in an area of the lower abdominal wall, but no be defect or hole in the tissues.
A few years ago it was common place for this diagnosis to be made, and many operations where undertaken to correct the supposed weakness. These days, with improved imaging, we would probably make a diagnosis of pubic overload, and rarely ever would surgery be needed.
It’s possible to have underlying intra-abdominal conditions which can mimic the pain of pubic overload, such as ovarian diseases, uterine prolapses, endometriosis, diverticular disease of the bowel and even prostate problems. Very occasionally, pain referred from the lumbar spine (such as a disc bulge) can be the issue.
This is why a detailed history, examination and investigations are key in defining the diagnosis (and therefore treatment) accurately.
What are the symptoms of pubic overload:
Typically, you may feel pain which is in your lower abdominal /pubic symphysis area, which is central, although it may may be felt a little more to the right or the left.
You may find that your pain is brought on by running, playing football, kicking or cutting movements, or sprinting. The pain may hang around for a few days until it abates sufficiently for you to return to your favoured activity. (I often meet people who find themselves trapped in a cycle of football on a Tuesday, followed by pain which lingers until the weekend, when they are once again comfortable enough to play a match).
Often, any activity which activates your abdominal wall (e.g. sit ups or setting up in bed when you’re waking up) will bring on the pain. Over time this pain can become constant.
You even might be fulled into thinking you have a hernia because it hurts when you cough or sneeze, but this is really common in pubic overload (aka osteitis pubis).
Many patients will describe feeling stiff in their adductor muscles and ‘needing to stretch’ out their groin, even though stretching may worsen the irritation.
3. Weakness and clicking.
Occasionally you might notice a clicking sensation in your lower abdomen, and you might find that you are losing power when you try to flex up your hip, or push off when running.
She’s fabulous. Really friendly and puts you at ease straight away, Really knowledgeable and made me feel like a top-class athlete with the explanation and recommendations for next steps.
How is pubic overload diagnosed?
A big part of the diagnosis making is in the history of your symptoms and what we find on examination.
I’ll be looking to rule out other conditions (e.g. by examining your tummy, your hips and lumbar spine), and I’ll be watching how you walk and control certain movements.
You’ll like be tender over the pubic symphysis area, and you might have some mild restriction in your hip movements.
I’ll be looking to reproduce your pain when squeezing together with your knees (aka ‘the squeeze test’), and I might also measure your strength on squeezing using a blood pressure cuff.
Depending on those findings, I’m likely to recommend that we carry out an MRI scan to help confirm the diagnosis, and help plan your treatment.
What are we looking for on the MRI scan?
The MRI scan will help exclude other conditions (such as hip osteoarthritis), and we’ll be looking for some classic features such as:
•Bony oedema (aka bone marrow oedema) of the pubic bones (which shows up as a brightened area within the bones).
•Fluid within the symphysis joint, or signs of shearing (aka ‘cleft’ sign).
•Oedema (inflammation) in the soft tissues and muscles located around the symphysis.
What is the treatment for Pubic Overload?
The first thing you need to know about the treatment for pubic overload is that it’s going to take a bit of time, and a fair bit of patience.
The good news is, the vast majority of people make a full recovery, get back to sport, and without the need for surgery.
It’s really important if you have pubic overload that you don’t keep ‘poking the beast’ by trying to continue to exercise when you have pain. We’re aiming for your pain to fully settle, and for you to have regained good strength and stability before you return to sport. If you try to rush this process, it will take longer to recover. This means desisting from doing the activities which wind it up.
Sometimes the pain is so extreme and horribly unpleasant that we might need to help in settling things down with an ultrasound-guided corticosteroid injection. This is purely a short-term measure and not a long-term strategy.
Physiotherapy and osteopathy to rebalance and restore the function across the lumbar pelvic area (and pelvic floor) are the mainstay of treatment. We might measure your progress with squeeze test monitoring or using a dynamometer, and whilst you’re doing the rehab work, you may be able to cycle to keep your fitness up. It’s not particularly helpful to keep stretching those adductors, and as a minimum, you can expect it’s going to take a good three months or more before you can return to sport.
Once you’re back and being active, it’s important to maintain your strength and control, and pilates can be very helpful in keeping you robust.
Dr Spencer Smith is a very nice, caring and comprehensive doctor.