Πόνος στη βουβωνική χώρα: όταν η αιτία είναι το σύνδρομο του ορθού προσαγωγού

Στόχος


Υπάρχουν διάφοροι λόγοι για τον πόνο στη βουβωνική χώρα. Στους αθλητές, το σύνδρομο του ορθού προσαγωγού έχει μεγαλύτερη σημασία.

As mentioned in the previous articles, there are several reasons for groin pain. In athletes, the rectus-adductor syndrome is of most significant relevance.

WHAT IS IT ABOUT?

The rectus-adductor syndrome is a form of groin pain caused by microtraumas which consists of a chronic inflammation in the insertion point onto the pubis, that is, of the tendons of the adductors and rectus abdominis (see fig. beside). The inflammation results from a functional overuse or recurrent torsion or traction microtraumas in the region of the tendon insertions of these muscles. Indeed, the pubic region is a confluence point of considerable stress produced by both the abdominal (from above) and the adductor (from below) muscles, and functional overload is facilitated by the tiny space available.

The incidence is higher in professional male athletes that intensively practise activities involving heavy use of the lower limbs (football, running, football, tennis, rugby, fencing, athletics, riding, etc.). The problem is worsened by concurrent postural defects that create hip asymmetries such as dissymmetry of lower limbs, marked lumbar curvature, sacroiliac blocks, congenital disorders of hips, etc. Football players are most frequently affected because of the great number of technical movements they perform, which engender considerable groin stress (kicking, dribbling, sliding, changes of direction). Pregnant women frequently suffer from this disease, too.

Anyway, it should be recalled that groin pain can appear also as a consequence of changes in training exercises, unfavourable conditions of the playground (too soft or exceedingly rough) or the type of footwear used.

BIOMECHANICAL CORRELATIONS OF THE RECTUS-ADDUCTOR SYNDROME

The stability of the pelvis can only be granted by the harmonious interaction of several muscular groups, ligaments and bones. The pubic region being the fulcrum of our body, it is the meeting-conflicting point of the strengths arriving from below (impact with the ground) and from above (weight of the torso). Adductors and abdominal muscles play a major role because of their tight connections with the pubic symphysis. Their actions are antagonistic: for the abdominal muscles and the rectus in particular the direction of the force vector is superior and posterior, whereas for the adductors the direction of the force vector is inferior and anterior. (Fig. 2)

Fig:2: Meeting-conflicting forces and muscular actions

Force distribution of the force of the weight of the torso; Force distribution of the impact on the ground; 3. Abdominals force vector; 4, Adductors force vector.

Injury, weakness or dysfunction of one of the two muscles inevitably causes a functional imbalance. Moreover, in football players the ischiotibial muscles are excessively developed and shortened, so that they prevent a correct extension of the knee, for instance while running or kicking. This negatively affects the adductors that are obliged to work in a limited biomechanical space and consequently shrink and stiffen. Broad, fluid movements required by an athletic performance are hindered, the body must adopt compensating expedients, thus arising excessive stresses in a condition of passive insufficiency.

SYMPTOMS

The rectus-adductor syndrome presents as a local pain in the groin or lower abdominal region that can radiate to the hind limb medial in proximity of the abdominal wall, and less frequently the perineum. Symptoms are usually unilateral, more rarely bilateral. In the early stages pain is light, often silent, sensitive to palpation and does not hinder activity, or it appears during activity and gradually disappears once it is finished. These phases are underestimated in most cases!

In advanced stages activity is impossible, and pain arises even during walking. Social life can also be hampered.

WHAT TO DO?

If the above symptoms occur, it is important not to underestimate the disease (mainly in the early stages). Initially it is necessary to limit activity, or stop it until pain disappears completely both at rest and during activity. Should even slight pain persist, a timely specialised examination is necessary to make a diagnosis of the disease so as to shorten recovery times as much as possible.

USEFUL EXERCISES

Following exercises are useful both for the rectus-adductor syndrome prevention and rehabilitation purposes. The exercises should be performed at the end of the practise session or, in any case, after proper muscle warming. Stretching exercises will be held for 30 seconds and muscle relaxation will be promoted during expiration.

Iliopsoas muscle stretching: muscle tension is perceived as anterior at the hip;

Ischiotibial muscles stretching: tension is perceived as posterior at the thigh.

Core stability exercises: There are several variations; the two basic postures are illustrated here, to be maintained for at least 30 seconds (1-2 minutes are recommended).

Eccentric contractions of the adductors: The athlete is in the supine position, knees bent and feet flat on the pavement. The request is to contract adductors so as to bring the knees closer together. The therapist not only opposes the contraction but stretches the player’s legs apart, thus causing an eccentric contraction of the adductors. 3 series of 10-15 repeats are recommended.

Eccentric contractions of the abdominal rectus muscles: Beginning from the position illustrated in the figure the athlete extends the hip, keeping the knee extended until his heels are 5-10 cm from the ground. At this moment the therapist or a teammate brings the legs back to the starting position. 3 series of 10-15 repeats are recommended.

Bibliography

Arbasseti C. 2011, Il trattamento manuale della sindrome retto-adduttoria;
Bisciotti N. 2009, La Pubalgia dello Sportivo, Inquadramento clinico e strategie terapeutiche;
Holmich 1999; Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial;
Marcon F. 2015, Revisione della letteratura con metanalisi sull'efficacia della terapia manuale e dell'esercizio terapeutico nel trattamento della pubalgia nello sportivo.
Valent A. 2012, Insertional tendinopathy of the adductors and rectus abdominis in athletes: a review.
Weir A. 2011; Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial.