This posting draws on notes I am making for a section of a new book on chronic pelvic pain that I am coediting, and part writing. It relates to the effects of particular sports on the evolution of pelvic pain…. Particularly when excessive training takes place in immature bodies – before skeletal maturity is achieved. There is significant evidence linking some athletic activities with the onset of chronic pelvic pain (CPP) (Sommer et al 2010), particularly when the activities in question are excessively pursued early in life (Antolak et al 2002).

In general however, with a few notable exceptions such as cycling, studies suggest a beneficial therapeutic effect from aerobic exercise in CPP (Giubilei et al 2007) and evidence largely supports the benefits of athletic activities, with inactivity associated with negative long-term effects, particularly in men (Orsini et al 2006). Musculoskeletal causes of CPP are many and varied, and sport and leisure activities may result in an increased risk of sustaining an injury, whether due to trauma or training intensity.

Cycling and genitourinary symptoms in men and women

In a major review paper Sommer et al (2010) report that “there is a significant relationship between cycling-induced perineal compression leading to vascular, endothelial, and neurogenic dysfunction in men, and the development of erectile dysfunction.

Research on female bicyclists is very limited but indicates the same impairment as in male bicyclists.”

Huang et al (2005) report that epidemiological data on bicycle riding, of more than 3 hours per week is an independent relative risk (RR = 1.72) for moderate to severe erectile dysfunction.

As preventive strategies they recommend that:

  • Bicycle riders should take precautionary measures to minimize the risks associated with bicycle riding by changing the saddle type to a noseless seat

  • Cycling posture should be changed to a more upright/reclining position

  • The saddle/seat should be tilted downwards

Sport and CPP in men – pudendal nerve entrapment

Antolak et al (2002) reported that the etiology of chronic pelvic pain syndrome is a puzzle that may be explained partly by Pudendal Nerve Entrapment (PNE), resulting in neuropathic pain. Post surgical onset of PNE is common in women, whereas in men, trauma and sport has been implicated (Amarenco et al 1991, Nehme-Schuster et al 2005)

In men with PNE, aberrant development, and subsequent malpositioning of the ischial spine, appear to be associated with athletic activities during youth. These aberrant changes largely occur during the periods of development and ossification of the spinous process of the ischium. Antolak et al reported that a common feature in all PNE patients was that: “flexion activities of the hip (sitting, climbing, squatting, cycling, and exercising) induce or aggravate urogenital pain, chronic pelvic pain, or prostatitis-like pain”.

Sporting activities that appear to have been etiological, or aggravating factors, in many patients with PNE, when teenagers and/or young adults, include:

  • American football
  • Weight-lifting
  • Wrestling

Antolak et al theorise that hypertrophy of the muscles of the pelvic floor, during the years of youthful athleticism, causes elongation and posterior remodeling of the ischial spine. This results in the sacrospinous ligament rotating, causing the sacrotuberous and sacrospinous ligaments to become superimposed over each other, an effect that they describe as being: “like a lobster claw, with the pudendal nerve traversing the inter-ligamentous space where it can be crushed”. They suggest that during squatting activities, or during sitting and rising, there occurs a stretching of the pudendal nerve over the sacrospinous ligament, or the ischial spine. Shearing forces on the nerve may then result.

The piriformis muscle may also be involved

Antolak et al (2002) note that:

“The pudendal nerve exits the pelvis at the inferior aspect of this muscle. In the athlete, flexion and abduction of the thigh are common motions, and they may lead to hypertrophy of the piriformis muscle, causing compression of the pudendal nerve against the posterior edge of the sacrospinous ligament. Pain that suggests this process includes …. that induced during sports activity such as that of a baseball catcher – squatting and then rising to throw the ball – motions that require extension of the gluteus muscle and abduction and extension of the hip”.

They further suggest that the same principles be investigated in women is “lest vulvodynia and other syndromes continue to be misdiagnosed and inappropriately treated”.

Osteitis pubis (OP)

Strakowski & Jamil (2006) report on osteitis pubis, “an uncommon cause of pelvic pain in runners”. This condition presents insidiously, with pain in the hip adductors aggravated by running or pivoting on one leg.
The adductor muscles are usually noted as hypertonic, with pain on resisted hip adduction. Tenderness over the pubic symphysis will also be evident. Plain film radiographs commonly reveal sclerosis of the pubic bones; with occasional widening of the symphysis, (Harris & Murray 1974)

Overuse in sport : hip, groin and pelvic injuries

Geraci & Brown (2005) note that approximately 5% to 21% of all athletic injuries involve the hip and pelvis.
In one study, overuse accounted for 82.4% of the injuries to the hip and pelvis that presented to a general sports medicine clinic (Geraci 1994). Another investigator reported that up to 70% of runners sustain overuse injuries during any 1-year period (Hreljac 1999) Beckman and Buchanen suggest that regardless of the level of athletic competition overuse injuries to the hip and pelvic region are equally common.

The etiology of these injuries appears to be multifactorial.
An example of one of a common, yet frequently overlooked, injury in runners is gluteus medius tendinosis. It is suggested that this condition may arise as a result of a rigid supinated foot, and a tight gastrocnemius-soleus muscles, that prevent calcaneal eversion, and subsequent subtalar joint pronation. This inhibits the functional kinetic chain in internal rotation at the tibia and femur, producing reduced stimuli to the gluteus medius muscle. The athlete may then produce compensating use patterns leading to dysfunction and pathology involving gluteus maximus.

Sports in which overuse injuries are commonest

Overuse injuries are commonest where sports demand repetitive hip rotation with axial loading, for example in golf, figure skating, football, baseball, ballet, martial arts, and gymnastics. (Shindle et al 2007)
The individual’s history provides the greatest clue to the diagnosis because athletes can usually describe the motion that reproduces the pain. Philippon (2003) reports on the common occurrence of femoro-acetabular impingement (FAI) resulting from overuse and injury in participants of hockey, ballet, football and soccer.

Those affected usually present with anterior groin pain exacerbated by hip flexion. MRI commonly demonstrates an anterosuperior labral tear, and an anterosuperior cartilage defect For example in 33 competitive ice-hockey players undergoing hip arthroscopy, 27 (81%) required decompression of FAI. (Philippon & Schenker 2006)

Groin strain and football (soccer)

Injuries involving the groin account for up to 22% of injuries in professional football players in the UK, that require time off training and out of competition.
Hanna et al (2010) report that there is debate amongst experts as to the aetiology of adductor related groin pain.

Suggestions include:

• Bone stress injury (Verrall et al 2002)

• Adductor enthesopathy, enthesitis (Holmich 2007)

• Partial avulsion (Brennan et al 2005)
• A form of inguinal fascial defect Taylor et al 1991)

Ice Hockey and groin strain

Ice hockey is one of the most aggressive team sports, with enormous potential for injury. Kai et al (2010) report that groin injuries are common (5% to 7% of all ice hockey injuries), and can occur without contact. Such injuries arise from multiple etiologies, not all of which are easily identified. The term ‘‘athletic pubalgia’’ is frequently used to describe groin pain that involves refractory unilateral or bilateral groin pain that is aggravated by activity. Injury data from the National Hockey League revealed that 13 to 20 per 100 players, per year, suffer groin injuries. Such injuries are also common in amateur athletes, however they
• are usually more severe in professionals, possibly because of increased stresses and continued play, despite injury.

Groin pain in athletes has multiple etiologies that are not often clinically apparent, some of which are classified under the term ‘‘athletic pubalgia’’. (Shindle et al 2007) Athletic pubalgia is a clinical syndrome that may take on numerous forms and variations but primarily includes refractory unilateral or bilateral groin pain exacerbated by activity .The ability of MRI to depict anatomy and soft-tissue characteristics is useful in the evaluation of patients with groin pain.(Pfirrmann et al 2006)

Inactivity and CPP

A lack of adequate exercise – has been shown by Orsini et al (2006) to be a risk factor for CPP in men. This conclusion was derived from analysis of surveys involving over 30,000 men, aged between 45 and 70, in Sweden. Based on the International Prostate Symptom Score, over six thousand (23%) men were shown to have moderate or severe lower urinary tract symptoms. Those who were physically active at work, as well as during leisure time were at half the risk of lower urinary tract symptoms compared to inactive men. Long-term high inactivity (5 hours daily at age 30 years, plus currently) was also associated with a 2-fold increased risk compared with the risk in men who were more active at the 2 periods. The conclusion was that physical activity in young and late adulthood appears to be associated with a lower risk of moderate and severe lower urinary tract symptoms.

These glimpses at the causes of some pelvic pain problems will be much amplified when the book eventually appears in print – probably autumn of 2011.


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