Instructional Course Lecture No. 105:
Groin Pain in Soccer Players
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,
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
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
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).
- 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.
- 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.
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
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
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
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
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
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 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
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.
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
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
- adductors and abdominals maximum
electric activities do not correspond simultaneously but overlap
- 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
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
Conclusions of this second study
- 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.
- 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.
- The correct balance between
the abdominal muscles and adductors is absolutely necessary in
order to avoid the pathology.
- The range of articular motion
of the pubic symphysis is important to the correct functioning
of the kinematic chain.
- 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.
- 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
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
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:
- Whenever abdominals are in motion,
there is an eletrical activity of the adductors.
- Groin pain preventive exercises
(abdominals strengthening) must be systematic in higher risk
sports before clinical symptoms are suspected.
- When groin pain clinical symptoms
are suspected or detected, abdominal strengthening exercises
should be stopped since clinical symptoms could worsen.
- 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:
- The trunk angular speed at reducing
and beating is initially negative (extension to pass on to flexion)
when speed is high.
- Adductors and abdominals maximum
electric activities don't correspond simultaneously.
It was therefore concluded that
there is an asynchronized movement with predominance of inferior
Clinical diagnosis will be based on a precise anamnesis which
- Patient's age
- Duration of sporting activity
- Type of sport
- Duration of symptoms
- Symptoms relation with the effort:
during, after and continuously
Patient will then be examined
- Static Study
- Alignment of inferior limbs
(hips and knees varus-valgus)
- Torsion alterations (especially
- Pelvic spacial location (anteversion,
- Lumbar spine (scoliosis, hyperlordosis,
- Dynamic Study
- Hips mobility (flex, ext, int
rot, ext rot, adb, add)
- Lumbar spine mobility
- Presence or lack of short hamstrings
- Adductors and abdominals isometry
- Muscular elasticity testing
- Adductors muscles and tendons
- Pubic symphysis
- Inguinal folds and superficial
- Valsalva's maneuver (cough)
associated to inguinal rings palpation
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 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
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.
1. Pull up or avulsion fractures
- 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
- 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
- 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
- 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
- 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
4. Muscular lesions of:
- Adductor longus
- Rectus femoris
- Rectus abdominus
5. Muscle-tendinous lesions of:
- Adductor longus
- Rectus femoris
- Rectus abdominus
6. Tendo-periosteal lesions of:
- Adductor longus
- Rectus femoris
- Rectus abdominus
7. Acute tendonitis
- 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:
- villonodular pigmented synovitis
- traumatic synivitis
- osteochondritis dissecans
- Lumbar spine:
- discal lesion
- Inferior limbs:
- referred lesion of the knee
- Abdominal wall:
- Inguinal hernia
- Crural hernia
11. Affections of the genitourinary
- Urethral calculus
- Torsion of the testis
- Pubis osteitis after bladder
and prostate surgeries as described by BEER in 1924.
- Postinfiltration pubis osteitis
- Hematogenous pubis osteitis
A conservative treatment is established consisting of:
- Medical Treatment
- Non-steroid anti-inflammatories
- 1-3 local infiltrations with
anesthetic and/or corticoids
- Massage hydrotherapy
- Pressure massages
- Short wave
- Interferential currents
- Specific stretching exercises
- 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
- 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.
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
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).
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
On the third week after the surgery:
swimming, cycling are allowed and racing progressively on the
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 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
- 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
Is based on:
- Physical training
- Aerobic conditioning adapting
the organism to determined sports requirements.
- Muscular strenthening through
isotonic, isometric and isokynetic exercises.
- 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
- A correct stretching needs to:
- be performed after a general
warming-up, previous to sport activity
- be performed when ending sport
- 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.
- Specific stretching for D.O.P.
- extensors, quadriceps
- flexors, hamstrings
- anterior abdominal rectus and
- The anterior abdominal rectus
and obliquus must be strengthened to avoid mechanic strengths
imbalance produced in theD.O.P..
- Dietetics habits
- Correct diet: with high essential
nutrients content, varied and balanced, avoiding hyperproteic
diets and insisting on the quality of nutritive groups.
- 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.
- It is recommended to sleep over
the necessary time, 8-10 hours, to reach a good neuromuscular
coordination and avoid lesions.
- 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
- 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.
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