Instructional Course Lecture No. 105:
Groin Pain in Soccer Players

Ramon Cugat
ISAKOS Congress
May 11-16, 1997 Buenos Aires, ARGENTINA

Manel Llusa, Pau Golano, Pau Forcada, Domingo Ruano
Departmento de Ciencias Morfologicas.
Facultad de Medicina
Universidad de Barcelona

Jordi Ballester, Francisco Biosca, Alberto Garcia-Fojeda
Hospital del Mar
Universidad Autonoma de Barcelona
Instituto Nacional de Educacion Fisica, Lleida

Ramon Cugat, Xavier Cusco, Montse Garcia, Xavier Juan,
Juan Carlos Monllau, Angel Ruiz-Cotorro, Jaime Vilaro, Jaime Zuloaga
Federacion Catalana de Futbol, Barcelona, SPAIN
Mutualidad de Futbolistas Espanoles, Barcelona, SPAIN

The dynamic osteopathy of pubis (D.O.P.) is, at the outset, an enthosopathy of insertion tendonitis of the adductor longus tendon and/or of the abdominals which at an advanced stage causes a degenerative arthropathy of the pubic symphysis.

The syndrome was described in 1932 by SPINELLI as "the fencers' groin pain" and in 1949 BANDINI related it to soccer players.

Therefore, the D.O.P. is pathology caused by micro traumatisms, which in at its initial stage affects the muscle-tendon-insertion complex. The adductor longus and the gracilis are generally affected and in few cases there are the rectus abdominis, the pyramidalis and the lateral aponeurosis of the obliquus externus abdonini.

Symptoms usually arise with a dull pain located in the tendon-muscular union of in the muscular belly resulting from the practice of certain sports; soccer being one of them. Symptoms mentioned appear right after physical effort of hours later.

If the factor or factors unfolding the symptology are not treated, symptoms may trigger off an entesopathy of the adductor longus and the gracilis at its insertion in the anterior side of the pubic between the spina and the pubic symphysis. At this stage, the athlete refers to an intensive pain in the groin region appearing during sporting activity of minutes after. This pain unables him/her to realize the abduction-flexion combined movement of the hip or the adductors' test (1). Pain disappears with rest or with non-steroid antiinflammatories 12/24 hours later. But if pain persists an arthropathy appears owing to the progressive deterioration of the pubic symphysis.

Pubic symphysis arthropathy is distinguished by sporting activity total incapacity. It is a clinical symptom of constant pain of the insertions of one or both adductors and gracilis, or the pubic symphysis. It usually radiates the internal surface of both muscles and the ischium through the abdomino-genital or/and the obturator nerves.

In some cases pain is felt in the inguinal rings when performing the Valsalva's maneuver. It is located in the suprapubic region of one or both sides and it radiates towards the inferior part of the abdomen. Examination shows that the inguinal channel, which in most of these lesions is dilated uni or bilaterally, is very sensitive but doesn't reach the hernia stage.

In lesions affecting the upper level of the crural arch, Dr. B. NESOVIC states that most athletes suffering from such lesions present the Malgaigne's sign (2).

1. The adductors' test: is performed with the patient in supine decubitus position, hip flexed at 80 degrees and abducted. The examiner requests that an active adduction be performed while resisting. At that moment the patient feels a sharp and intense pain in the crural-inguinal region.
2. Malgaigne's sign: is performed through examination in orthostatic position. A spindle-shaped protuberance in the lateral and inferior zone of the abdominal wall is observed.

Applied Anatomy
The applied anatomy of the soccer player's dynamic osteopathy of pubis makes necessary the revision of the pubic regions both crurobturatic and inguinoabdominal as they aref all, one way or the other, involved in the etiopathology of this syndrome with participation of the bone, tendinous and muscular structures.

The Pubic Region
The pubic symphysis is an amphiarthrosis in which the articular surfaces are linked by a fibrocartilagenous disk reinforced by a series of ligaments named - owing to their location - superior pubic ligament and inferior pubic ligament. These ligaments cling to the fibrocartilagenous disk to the point that fibers intermix with it.

Besides, there are two other anterior and posterior ligaments at the peripheral level not always differentiated in anatomical texts. The anterior ligament is thicker and made of tendinous fibers of the pyramidal, rectus abdominis, obliquus externus, gracilis and thigh adductors muscles.

The interpubic disk frequently presents a inner tiny articular notch in age degeneration (or after pregnancy and delivery).

From the vascular view, it is worth mentioning that irrigation of this area depends on small vessels originating in the adjoining arteries: the internal pubenda, obturator, inferior epigastric, medial femaoral circumflex and the external pubenda.

The Crurobturator Region
The thigh adductor muscles lie from their origins in the pubis and the ischiopubic ramus to the femoral linea aspera. They appear stratified in such way that the most superficial one is the adductor longus followed by the adductor brevis and in depth, the adductor magnus.

The adductor longus is inserted in the pubis angle and in the inferior side of the pubic spine, it is covered by the femoral aponeurosis forming the internal rim of the Scarpa Triangle. At proximal level, it is worth remembering the link of this muscle with the inferior external pubendum artery. It is innervated by the obturator nerve (anterior and posterior rami).

Anatomy texts note that it has an adduction, external rotation and anteversion of the thigh role. However, at clinical level, various pathology texts involve these adductor muscles in deformities in internal rotation of the thigh that can be observed in some spastic patients in whom adductors tenotomy solves the problem.

The adductor brevis muscle originates in the anterior side of the pubic body, in the ischiopubic ramus. As already said, it is subjacent to the adductor longus. It is mainly related to the obturator nerve which anterior and posterior rami are in front (between the former and the adductor longus) and behind respectively. It is innervated by the obturator nerve (anterior and posterior rami), adducts and externally rotates the thigh.

It has a double innervation receiving at the front part nervous fibers of the obturator and, at the back, a collateral ramus of the sciatic nerve.

The gracilis muscle originates in the pubis and the symphysis to distally end inserted in the tibial side, together with the sartorius and the semitendinous, creating the superficial goose-foot. It is a biarticular muscle which acts as the thigh adductor and knee flexor. It is innervated by the anterior ramus to the obturator nerve.

Because of its proximity and likeness to the adductor brevis, the pectineus muscle can be considered as part of the muscular obturator complex but its innervation depends of the femoral nerve. It departs from the pecten, where it joins other tendinoaperoneurotic structures to form the Cooper's ligament to the trifurcation line of the linea aspera and up to the lesser tronchanter (pectineus line). It acts as the hip flexor and external rotator, with a slight adduction component.

The external obturator muscle is the deepest adductor muscle. Its fibers converge from the external surface of the obturator membrane and the pubis and ischium bone limits to surround the hip inferior capsule and steer through the posterior side to its insertion in the tronchanteric fossa. The obturator nerve coming out from the obturator channel shows its anterior division ramus, between the obturator and the pecten and the posterior division in the thickness of the muscle. It is an external rotator of the hip and in theory, and adductor although in practice its action is very partial.

The adductor muscular complex can present some variations and muscular anomalies. Muscular fusions between the adductor brevis and longus or the pecten are not uncommon. The so-called adductor minimus has also been described as the superior fibers of the adductor magnus starting independently in the pubis inferior ramus.

The Inguinoabdominal Region
The external oblique muscle is inserted at the pubis level, between the spine and the superior angle of the pubis through the aponeurotic fibers to form two columns called, external column, inserted in the spine and expanding on the tendon adductor brevis muscle and the internal column inserted in the pubis symphysis and crossing with homonymous fibers of the opposite side to reach the upper edge of the pubis calling this component Colles' ligament or posterior column. The orifice or superficial inguinal ring is defined between these columns and is reinforced on the top by interspine fibers jumping from the internal or external column. In normal conditions, this ring allows the strait duct of the spermatic cord in males and the round ligament in females, being thus the extension of the inguinal channel. The floor of the latter corresponds to the inguinal ligament (Poupart's ligament), the conjoint tendon of the internal obliquus and transversus abdominis muscles (falx inguinalis) form the roof, the tendon of insertion of the external obliquus create the anterior wall and the fascia transversalis with its reinforcements (Henle's ligament and Hesselbach's ligament) form the anterior wall.

Clinically, it is worth mentioning that the Malgaigne's line is linked in depth with the inguinal ligament. And also that the relation of the deep inguinal ring of the inguinal duct with the inferior epigastric artery, at the origins of the femoral artery, is an important reference.

Finally, it has to be bore in mind that, medially, the spermatic cord doesn't lay directly on the inguinal ligament but is related to the insertion of the conjoint tendon and Gimbernat ligament (aponeurotic fibers going from the inguinal ligament to the medial area of the pectineus crest).

Despite offering this anatomical introduction it shouldn't be forgotten that what is dealt here is a dynamic syndrome with mechanic characteristic, produced by an overload that worsens with exercise and betters with rest. From the anatomopathology view it is related to the tendinoperiostitis. The different clinical presentations: adductors syndrome, inguinoabdominal syndrome and dynamic osteopathy of pubis confirm the participation of the anatomic structures mentioned in this clinical entity.

Biomechanics
The pubic area with the pubic symphysis is an area of the abdominal and thigh muscles crossing which is submitted to shearing on normal walk. These shearing forces increase considerably in the practice of certain sports movements, the kick being probably the generating the biggest tensions at this level.

When analyzing the kinematics of the pelvis and the inferior limbs during the practice of the kick, it can be observed how in the first phase, or kick preparation, the limb kicking moves in extension, abduction and slight external rotation at the hip level, while the knee flexes. At the same time, the support limb has a sensible pelvic inclination with the hip flexed and the thigh in adduction.

In the second phase or kick performance, the kicking limb does an internal rotation and a hip flexion with adduction of the entire extremity while the knee is in extension. The support limb starts the extension while the inferior limb adduction is maintained.

In the third phase or reducing speed, the kicking limb is in an unstable position of maximum internal rotation and adduction while the support limb is placed in internal rotation, the adduction being maintained.

In order that the kinetic chain of the kick be developed in a harmonious way without any disturbances, a correct strength balance between abdominal and adductors muscles is indispensable, so as a correct elasticity of the pubic symphysis which allows a displacement movement in shearing up to 2 mm. and rotations up to 3 degrees.

To verify the electromyographic behavior of the different muscular groups interacting in the kicking procedure, a lab monitoring of the abdominal muscles, adductors muscles, vastus medialis, femoral biceps and lumbar muscles of a professional soccer-player was carried out, The inability to move the ball in a closed room of the laboratory showed a distortion in the kicking performance, in particular in relation with the movement of reducing speed of the limb.

To eliminate this, it was then proceeded to realize a synchronized study of a normalized teleelectromyography and a tridimentional kynematic analysis of professional soccer players. The study consisted in analyzing, previous to monitoring the cited muscles, running, reducing speed, direction changes and kicking.

The objective conclusions of the EMG simultaneous analysis and 3D filming were:

• the angular speed of the trunk when reducing speed and kicking was initially negative (extension to pass on to flexion) when speed is high and muscle contraction very energetic.
• adductors and abdominals maximum electric activities do not correspond simultaneously but overlap harmoniously.
• the recorded electrical activity is high in quantity in the adductors muscles.

It can therefore be deduced that there is an asynchronic mill arm movement with predominance of inferior traction overlapping with maximum contraction peaks of both muscle group on the pubic symphysis. This asynchronic movement requires to be correctly performed, a good elasticity and mobility of the pubic symphysis. The superiority of the adductors strength of the examined athletes confirms the necessity of strengthening the abdominal muscles to rebalance them, as a profilactic measure indispensable in the groin pains prevention.

To verify the relation between pubic rigidity and the soccer player groin pain the biomechanic study of the pubic symphysis mobility pre and post-op was carried out on 12 professional soccer players on whom surgery was performed because of non response to conservative treatment. (Dr. Perez-Castanedo's Doctoral thesis)

According to Walheim's technique extensiometric gauges, a source of continuous electrical power and a CM4 amplifier of the gauges' signal were used.

The extensiometric gauge was placed before surgery using Kirschener's needles in both pubis. Once balanced the affected hip was flexed at 90 degree keeping the other hip in total extension and slight abduction. A new record was obtained in this position. The same test was carried out for the other hip. Once the adductor tendon resectioned the same test was repeated.

In all the operated patients, a limitation of pubic symphysis mobility in relation with measurings in normal individuals was observed. Further to adductors resection an increase of mobility with values between 0.89 and 1.85 mm was verified.

Conclusions of this second study were:

• the evidence of a direct relation between the limitation of the articular range of motion of the pubic symphysis and groin pains.
• the pre-op hypomobility together with the mobility increase following the brevis adductor tendon resection states that the enthesopathy is the main source of pain instead of the bone disturbances or of the articular pathology of the symphasis.

Conclusions

1. The pubis and pubic symphysis create a crossing point in the kinematic chain of the kick, being submitted to shearing forces by the overlapped asymmetric sequence contraction of the abdominal and the adductors muscles.
2. The correct balance between the abdominal muscles and adductors is absolutely necessary in order to avoid the pathology.
3. The range of articular motion of the pubic symphysis is important to the correct functioning of the kinematic chain.
4. Mechanical factors altering the biomedical characteristics of the pelvis such as the hyperlordosis, pelvic anterversion, coxa valga, etc. must be considered as risk factors in the pathology.
5. The surgical treatment is based on the re-establishment of the forces balance at pubic level (adductor resection) and/or on the increase of the insertional surface (Nesovic).

The appearance of groin pain is basically due to physical activity, most of all in soccer, hockey, basketball…In all of the cases mechanisms of directional changes, braking and acceleration are performed.

Typical characteristics (morphotype) ease the appearance of such pathology (pubic anteversion, hyperlordosis, coxa vara…) And also, different etiopathologenetic symptoms which can cause differentiated clinical symptoms but with always a common pain denominator in the pubic zone and related to physical activity.

Different etiologies, clinical symptoms, and treatments were described… But they all agree in indicating the potentiality of the abdominal anterior wall muscles, the gracilis and obliquus as groin pain prevention. Furthermore, literature also agree that origin and symptoms initiation of the groin pain are caused by the increase of adductors work.

An in depth eletromyogram study with record of the adductor longus and the anterior rectus was carried out where professional soccer players were asked to perform different abdominal exercises they usually do: high abdominals, low abdominals with flexion, with resistence, etc. This was filmed simultaneously (EMG record plus players movements).

The conclusions were:

1. Whenever abdominals are in motion, there is an eletrical activity of the adductors.
2. Groin pain preventive exercises (abdominals strengthening) must be systematic in higher risk sports before clinical symptoms are suspected.
3. When groin pain clinical symptoms are suspected or detected, abdominal strengthening exercises should be stopped since clinical symptoms could worsen.
4. Only abdominal isometric exercises in supine decubitus position should be recommended.

A normalized telelectromyography was also carried out and a tridimensional analysis with two cameras (3D INEF Lleida-Software crono 2 and 3D-1 reference system), all of it synchronized. The population was composed of professional soccer players to whom surface electrodes were placed on the adductors longus (right-left), abdominals (right-left) and lumbars (right-left). While running in a racetrack, they were asked to reduce speed at acoustic stimulation, turn right or left and beat a leg. Running, reducing speed, direction changes and leg beating were analyzed.

Further to simultaneous EMG and 3D analysis, the conclusions were that:

1. The trunk angular speed at reducing and beating is initially negative (extension to pass on to flexion) when speed is high.
2. Adductors and abdominals maximum electric activities don't correspond simultaneously.

It was therefore concluded that there is an asynchronized movement with predominance of inferior traction.

Diagnosis
Clinical diagnosis will be based on a precise anamnesis which will include:

1. Patient's age
2. Duration of sporting activity
3. Type of sport
4. Duration of symptoms
5. Symptoms relation with the effort: during, after and continuously

Patient will then be examined realizing:

1. Static Study
   1. Alignment of inferior limbs (hips and knees varus-valgus)
   2. Torsion alterations (especially femoral)
   3. Pelvic spacial location (anteversion, retroversion)
   4. Lumbar spine (scoliosis, hyperlordosis, spondylolisis)
2. Dynamic Study
   1. Hips mobility (flex, ext, int rot, ext rot, adb, add)
   2. Lumbar spine mobility
   3. Presence or lack of short hamstrings
   4. Adductors and abdominals isometry
   5. Muscular elasticity testing
3. Palpation
   1. Adductors muscles and tendons
   2. Pubic symphysis
   3. Inguinal folds and superficial inguinal rings
   4. Ischium
   5. Valsalva's maneuver (cough) associated to inguinal rings palpation

X-Ray Exam
It can be of great help to diagnose and prognose pubic osteopathy although it is important to highlight this pathology big clinico-radiological disassociation. Another important factor is the fact that with ever-decreasing ages to start sporting activity and ever-increasing medico-sporting society education, it is rare to find advanced stages of the pubic degenerative arthropathy.

The pelvis routine radiology in antero-posterior projection and both hip joints (preferably in bipedestation) is indispensable. For a better vision of the symphysis it is recommended to perform a projection with the patient in supine decubitus position and a slight inclination of the x-ray tube in the caudo-skull direction focusing the pubis.

In 1964, RISPOLI described 4 stages related to radiological disturbances which appear all through the symptoms evolution. Basing themselves on their experience, the authors have added one more state which they have called stage 0.

X-Ray Stages:

STAGE 0: x-ray exam within normality, symptomatology and other positive complementary tests (bone scan compatible with pubic osteopathy).

STAGE 1: x-ray exam with osteolitic changes around the adductor longus, adductor brevis of gracilis muscles insertions uni or bilaterally. It is also possible to see symphasis erosions.

STAGE 2: x-ray exam with deeper and asymetric erosions.

STAGE 3: x-ray showing an even more deformed symphasis with an established osteoarthritis and very developed erosions.

STAGE 4: x-ray exam showing ectopic calcifications in the adductor longus, brevis and gracilis muscles tendinous insertions. It is also possible to see areas of calcific hyperdensity which would correspond to the cure of osteolitic lesions of the former stages.

D.O.P. Isotopic Scan
This nuclear medicine technique consists in obtaining skeleton images after the fixation of a tracer to the bone tissue. The radiopharmaceutic used has an intense affinity with the mineral ionic replacement, fixing itself to the hydroxyapaptite crystals surface through an absorption and further ionic exchange mechanism.

A quantified scan examination is performed following the three phases method. The disphosphate methyl marked with Tecnecium-99 (Tc-99) is used as tracer.

The images of the first and the second phases correspond to the arterial passage of the radiopharmaco (1st phase) and to its circulation flow distribution, obtaining the images of the vascular pool (2nd phase) and are made immediately after the tracer injection in the elbow or forearm flexure vein. Should a pubic osteopathy be suspected, the images are obtained from the passage of the tracer in the pubic and pelvis region usually storing the information which will allow further on to configurate a dynamic sequence of the tracer passage in the concerned region named "arterial of vascular phase". The static images collected after the first passage of the tracer are called "vascular pool phase". These two early first phases inform of the presence of anomalies in the vascularization and/or the presence of hyperemia areas. The images obtention is performed by means of a 30' 1/30" sequence after the injection.

The bone phase (3rd phase) images and data are obtained 120' post-injection. These images are static and show the radiopharmaco distribution in the skeleton. The pubic region being the one of major interest, it is recommended that the patient empties the bladder remaining urine before taking this image sequence. Images of the whole skeleton are taken and in particular the pelvic region in AP and PA projections. These static images are called "bone phase".

The image interpretation is quantified in four degrees for all the phases:

DEGREE 0: no significant activity is detected

DEGREE 1: slight + uptake

DEGREE 2: moderate ++ uptake

DEGREE 3: intense +++ uptake

Asymmetries in the uptaking degree between both pubic rami are also taken into consideration. The presence of hyperuptakes or assymetries in any of the three scan phases performed are considered as abnormal placing special emphasis on the "bone phase" which usually shows (96% of the studied cases from + to +++) unspecified changes with regard to the metabolism increase or local bone turn over produced in the pubic branches. In the vascular phase no telling results are obtained as far as positivity is concerned (around 45% don't show any activity increase, 50% approximately show a slight activity and only 5% show an intense activity). This is because the "vascular phase" reflects a blood flow increase, characteristic of the acute inflammation processes and therefore, pubic osteopathy has, by definition, a chronic background.

To conclude, one could say that the isotopic scan is a highly sensitive test but of low specification to the pubic osteopathy which results suggest the presence of a reactive aseptic osteitis.

Differential Diagnosis

1. Pull up or avulsion fractures of:

• Rectus femoris inserted in the antero inferior iliac spine
• Sartorius and tensor fascia femoris inserted in the antero-superior iliac spine
• Hamstring muscles inserted in the ischial tuberosity
• Iliopsoas tendon inserted in the lesser trochanter
• Abdominal muscles tendons inserted in the ilias crest
• Abductor longus, adductor brevis and gracilis tendon inserted near the symphasis pubis

2. Stress fractures of:

• femoral neck
• pubic rami
• femoral dyaphysis

3. Bursitis:

• The subcutaneous trochanteric bursa is the synovial bursa on the tendon of the gluteus maximus between the skin and the mentioned muscle. This bursitis frequently afflicts goalkeepers.
• The trochanteric bursa of the gluteus maximus is the synovial bursa between the gluteus maximus and the greater trochanter.
• The trochanter bursa of the gluteus medius comprises two synovial bursa, an anterior between the tendon of insertion of the gluteus medius and the greater trochanter; and a posterior one between this tendon and the piriformis muscle.
• The trochanteric bursa of the gluteus minimus is the synovial bursa between the tendon of insertion of the gluteus minimus and the greater trochanter.
• The piriformis muscle bursa is located between its tendon of attachment and the greater trochanter.
• The ischial bursa of the obturator internus muscle. It is licated between the cartilage covered surface the lesser sciatic notch and the tendon of the obturator internus.
• The subtendinous bursa of the obturator internus muscle. Located below its insertion.
• The intermuscular bursa of the gluteal muscle. It comprises two or three synovial bursae below the attachment of the gluteus maximus to the linea aspera.
• The ischial bursa of the gluteus maximus muscle. Located between the ischial tuberosity and the inferior surface of the gluteus maximus.
• Iliopectineal bursa. It is located between the iliopsoas muscle and the pelvic bone, above the hip joint with which it often communicates.
• The subtendinous iliatic bursa is located between the lesser trochanter and the tendon of insertion of the iliopsoas muscle.
• The biceps femoris muscle is located between the origins of the biceps femoris and the semimembranous muscle.

4. Muscular lesions of:

• Adductor longus
• Rectus femoris
• Rectus abdominus
• Gracilis
• Iliopsoas
• Pectineus

5. Muscle-tendinous lesions of:

• Adductor longus
• Rectus femoris
• Rectus abdominus
• Gracilis
• Iliopsoas
• Pectineus

6. Tendo-periosteal lesions of:

• Adductor longus
• Rectus femoris
• Rectus abdominus
• Gracilis
• Iliopsoas
• Pectineus

7. Acute tendonitis

• Rheumatic
• Inflammatory
• Metabolic (uric)

8. Snapping hip: The tensor fascia lata slipping over the greater trochanter

9. Traumatic myositis ossificans:

• Adductor longus
• Iliopsoas muscle

10. Osteoarticular lesion of:

• Sacrum:
  • tumours
  • sacroileitis
• Hip:
  • epiphisiolysis
  • perthes
  • dysplasia
  • villonodular pigmented synovitis
  • traumatic synivitis
  • osteochondritis dissecans
• Lumbar spine:
  • discal lesion
  • spondylolisis
  • spondylolisthesis
• Inferior limbs:
  • dysmetria
  • referred lesion of the knee
• Abdominal wall:
  • Inguinal hernia
  • Crural hernia

11. Affections of the genitourinary tract:

• Urethritis
• Prostatitis
• Epididymitis
• Deferentitis
• Urethral calculus
• Torsion of the testis
• Varicocele
• Hydrocele
• Pubis osteitis after bladder and prostate surgeries as described by BEER in 1924.
• Postinfiltration pubis osteitis
• Hematogenous pubis osteitis

Treatment
A conservative treatment is established consisting of:

1. Rest
2. Medical Treatment
   • Non-steroid anti-inflammatories
   • Myorelaxants
   • 1-3 local infiltrations with anesthetic and/or corticoids
3. Physiotherapy
   • Massage hydrotherapy
   • Pressure massages
   • Ultrasounds
   • Short wave
   • Interferential currents
4. Rehabilitation
   • Specific stretching exercises of
     • the adductor muscles
     • the hamstring muscles
     • the iliopsoas
     • the thigh anterior muscles
     • gastrocnemius, etc.
   • Cycling and swimming according to moment and pain tolerance
   • Rectus andobliquus abdominals strengthening exercises when tolerated
5. Footwear study
   • According to field conditions, absorption orthesis, socks for the adductors.
   • Strengthening exercises of adductors should never be performed while feeling pain.
   • When results obtained with the conservative treatment are not satisfactory or in cases where the athlete requires a quick solution because of the advanced stage of the pathology, a surgical treatment will be applied.

Surgical Technique
Anesthesia: epidural of general

Patient position: in supine decubitus position with knees and hips flexed at maximum abduction.

Cutaneous incision: bilateral at 3 cm. of the inguinal fold and centered on the adductor longus.

Aperture of the Fascia Femoris: longitudinal to the muscle and separation allowing the adductor tendon visualization.

Careful Coagulation of vessels to avoid possible hematoma.

Selective Tenotomy of the adductor longus tendon and occasionally of the gracilis, according to symptoms. This performance is always bilateral.

In some cases 3-4 drillings are performed in the symphysis (there's no difference between results in cases with drillings and cases without).

Plain closure

Postsurgery Status:
On the first week: the position of inferior limbs in abduction is recommended during the night, when walking and when sitting.

On the second week: adductors stretching, hamstrings, quadriceps and adductors exercises are started.

On the third week after the surgery: swimming, cycling are allowed and racing progressively on the 4th week.

Eight weeks later it is allowed to come back to sport.

If, in addition, the patient presents a weakness of the abdomen inferior wall with dilatation of the deep inguinal rings, Basini's, Nesovic's or Perez-Fontana-Broggi's technique will be included.

Results
Results obtained at the Mutualidad de Futbolistas Catalana headquarters of Barcelona are:

• studied period from October 1991 to May 1995
• lesions treated: 8,401
• inguinal pain: 657 representing 7.82% and distributed as follows:
  • right adductors pathology: 239
  • left adductor pathology: 200
  • D.O.P.: 218
• 109 out of the 657 cases were operated, 107 through adductors and gracilis bilateral tenotomy when required, and 2 cases using the Perez-Fontana-Broggi's technique.

Complications occurred in the surgical cases were the following:

• 12 adherence rupture
• 2 relapses solved with conservative treatment
• 8 who 2 months after the intervention referred to slight pain of the adductor muscle and which diminished 4 months later
• 1 prostatitis postcatheterization of the bladder due to anesthesia problems
• 1 second surgical procedure

Prevention
Is based on:

1. Physical training
   1. Aerobic conditioning adapting the organism to determined sports requirements.
   2. Muscular strenthening through isotonic, isometric and isokynetic exercises.
   3. Stretching and elasticity exercises which is one of the main aims of the physical preparation since they increase the athlete's capacity to avoid tendo-muscular lesions.
   4. A correct stretching needs to:
      • be performed after a general warming-up, previous to sport activity
      • be performed when ending sport activity
      • be started smoothly and easily for 15 to 20 minutes
      • be concentrated on the part of the body that needs to be stretched
      • be increased proportionally to the stretching intensity
      • always control the recuperation
      • avoid pain when stretching
      • get a daily stretching routine
      • avoid the "snapping" movement totally harmful to the aim sought
      • it must be bore in mind that the flexibility development is a slow process that has to be introduced in the sport culture at early ages to avoid posterior risks of innecessary lesions.
   5. Specific stretching for D.O.P.
      • extensors, quadriceps
      • flexors, hamstrings
      • gluteus
      • pyramidalis
      • adductors
      • anterior abdominal rectus and obliquus
   6. The anterior abdominal rectus and obliquus must be strengthened to avoid mechanic strengths imbalance produced in theD.O.P..
2. Dietetics habits
   1. Correct diet: with high essential nutrients content, varied and balanced, avoiding hyperproteic diets and insisting on the quality of nutritive groups.
   2. Correct hydration while training, before, during and after competition. It must be bore in mind that the "sensation of thirst" happens when the organism is already partly dehydrated.
   3. It is recommended to sleep over the necessary time, 8-10 hours, to reach a good neuromuscular coordination and avoid lesions.
3. Sports Medicine controls
   They must be sufficient, carried out on a regular basis and complete to be able to detect possible factors which predispose to lesion. Such factors can be:
   • structural: non pathological articular laxity
   • morphologic and functional: vicious attitudes, growth diseases

To conclude, the Dynamic Osteopathy of Pubis prevention requires the pluridisciplinary back-up of all the health and physical preparation professionals of the athletes involved: coach, physical coach, physiotherapist, physician. It is a pathology that can and must be prevented since early ages of learning.

References

ABBE R. "Rupture of the Tendon of the Adductor Longus". Ann Surg. 2:517-519. 1895.

ABERLE-HORSTENEGG W. "Isolierter abriB der Trochanter Minor-Epiphyse und Aquivalenter MuskelriB des Iliopsoas. Zbl Chir. 58:1439-1443. 1931.

ADAMS RJ, CHANDLER FA. "Osteitis Pubis of Traumatic Etiology". J Bone Joint Surg. 35-A:685-696. 1953.

AKERMARK C, JOHANSSON C. "Tenotomy of the Adductor Longus tendon in the Treatment of Chronic Groin Pain in Athletes". Am J Sports Med. 20:640-643. 1992.

ANDERSON MK, HALL SJ. "Sports Injury Management". Williams & Wilkins. North Providence. 1995.

ANDRIVET R. "Une Conception Nouvelle de la Maladie des Adducteurs et ses Consequences Therapeutiques". Med. Sport. 46: 108-110. 1972.

ARNHEIM DD, ANDERSON MK. "Fisioterapia y Entrenamiento Atletico". Mosby Doyma. Barcelona. 1994.

BALDUINI FC. "Abdominal and Groin Injuries in Tennis". Clin Sports Med. 7:349-357. 1988.

BANDINI T. "Su una Sindromedei Retto-Adduttori nei Giocatori di Calcio". Rassegna Med infor Tunistica Patol Lavoro. 5:804.1949.

BEACH EW. "Osteitis Pubis: a Urologic and Roentgenographic Study". Urol Cutaneous Rrev. 53:577-584. 1949.

BEER E. "Periostitis of Symphysis and Descending Rami of Pubis Following Suprapubic Operations". Intervat J Med & Surg. 37:224-225. 1924.

BENTLEY S. "The Treatment of Sports Injuries by Local Injection". Brit J Sports Med. 15:71-74. 1981.

BROGGE TRIAS MA, SALVA LACOMBE JA. "Hernia Inguinocrural". Ed.Jims,S.A. Barcelona. pp:43-205. 1982.

BURMAN M, WEINKLE IN, LANGSAM MJ, "Adolescent Osteochondritis of the Symphasis Pubis". J Bone Joint Surg. 16:649-657. 1934.

CABOT JR, GUILLET R, DAL MONTE A. "Lesiones Cronicas en el Deporte". IV Congreso Internacional de Medicina Deportiva del "Groupement Latin de medicine Physique et des Sports". Barcelona 11-14 septiembre 1963.

CABOT JR. "Osteopatia Dinamica del Pubis". XVI World Congress of Sports Medicine. 359. 1966.

CARNEVALE V. "La Denominada Inguinocruralgia Traumatica de los Jugadores de Futbol". La Prensa Medica Argentina. 41:355-357. 1954.

CASPERSON PC. "Gron and Hamstring Injuries". Athletic Training. 17:43-45. 1982.

COCHRAME GM. "Osteitis Pubis in Athletes". Brit J Sports Med. 5:233-235. 1971.

CZIPOTT Z. "Labdarugok Pubialgiajanak Kezeleje Hydrocortisonnal". Orvosi Hetilap. 26:900-901. 1958.

DUREY A, RODINEAU J. "Les Lesions Pubiennes des Sportifs". Ann Med Phys. 19:282-291. 1976.

ECHEVARREN MM. "Ingle del Futbolista". Il Curso de la Escuela Catalana de Traumatologia del Deporte. pp:268-270. 1981.

EKSTRAND J, GILLQUIST J. "Soccer Injuries and Their Mechanisms: a Prospective Study". Med Sci Sports. 15:267-290. 1983.

FENEIS H. "Pocket Atlas of Human Anatomy Based on the International Nomenclature". Thieme Medical Publishers. New York. 1994.

GERMAIN BC. "Anatomia para el Movimiento: Introduccion al Analisis de las Tecnicas Corporales". Tomo I. Los Libros de la Liebre de Marzo. Barcelona. 1994.

GERMAIN BC, LAMUTTE A. "Anatomia para el Movimiento: Bases para Ejercicios". Tomo II. Los Libros de la Liebre de Marzo. Barcelona. 1994.

GODSHALL RW, HANSEN CA. "Incomplete Avulsion of a Portion of the Iliac Epiphysis. An Injury of Young Athletes". J Bone Joint Surg. 55-A:1301-1302. 1973.

HANSON PG, ANGEVINE M, JUHL JH. "Osteitis Pubis in Sports Activities". Phys Sports Med. 7:111-114. 1978.

HARRIS NG, MURRAY RO. "Lesions of the Symphysis in Athletes". Brit Med J. 4:211-214. 1974.

HOON JR. "Adductor Muscle Injuries in Bowlers". JAMA. 171:145-147. 1959.