Last Updated on Wednesday, 09 July 2014 15:15
By Dr. Rob LaPrade
http://drrobertlaprademd.com
Question: My 8-year-old son has been playing hockey for three years. He plays three days a week for one hour per game or practice. Recently, he has experienced groin pain intermittently after skating. We took him to an orthopedist who told us he has stress fractures of both pubic rami in his pelvis. What causes this and what can be done to help him return to play?
Answer: It sounds like your son has a condition called athletica pubalgia, which can lead to stress fractures where the adductor muscles of the leg attach to the pelvis. Athletica pubalgia refers to a constellation of findings that have been called many different names: osteitis pubis, slap shot gut, sportsman’s hernia, hockey groin syndrome, and core muscle injury. This condition is present almost exclusively in boys and men, and is common in sports that require repetitive hip and lower extremity motion such as ice hockey.
Determining the cause of groin pain in a young athlete can be difficult. Patients with athletica pubalgia typically present with a gradual onset of deep groin pain. The classic sign of this condition is pain that is worse with activity and goes away with rest. The pain can be localized or can radiate to other areas of the pelvis, thigh, or abdominal region. Together, these symptoms may limit on-ice activities and decrease performance. When being evaluated by a doctor, he or she may ask question about the onset, duration, and intensity of pain and push on regions of the thigh, pelvis, and lower abdominal area to try to localize the source of discomfort.
Imaging is also an important part of diagnosing athletica pubalgia. Plain x-rays should be obtained of the hip, pelvis, and lumbar spine to evaluate for bony abnormalities. Magnetic resonance imaging may also be required to look at muscle, tendon, ligament, and other soft tissue changes that may be contributing to the pain. These imaging studies help not only to diagnose the cause of groin pain, but also to assist with developing the best treatment plan.
Treatments include non-operative and operative options. Non-operative treatment consisting of rest, cross-training, heat or ice, massage, and physical therapy is recommended as a first line treatment for athletica pubalgia. Physical therapy should focus on building core muscle strength and restoring balance to muscles in the hip and pelvis. One physical therapy regimen sometimes used to reduce symptoms of athletica pubalgia includes a four part program consisting of message and stretching (Phase 1), abdominal muscle strengthening (Phase 2), return to functional activities (Phase 3), and sport-specific rehabilitation (Phase 4). While non-operative measures work in some players, surgery may be necessary in those who fail to improve with conservative treatment after 6 to 8 weeks. Operative treatments are rare but may include sports hernia surgery or surgery to treat femoral acetabular impingement.
Most hockey players are able to return to sport after several weeks of non-operative treatment if symptoms improve. For patients who require surgery, return to play typically takes anywhere from 2 weeks to 6 months depending on the type of surgery received. In short, your son will in all likelihood be able to return to play if appropriate treatment measures are taken under the guidance of his physician.
Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it toeditor@letsplayhockey.com.
