Pubalgia (Sports Groin Pain)

Introduction

Pubalgia, also known as sports groin pain, is a complex and often poorly defined cause of chronic groin pain in athletes.

It is not a single disease entity, but rather a spectrum of disorders involving:

• Muscles
• Tendons
• Pubic symphysis
• Hip joint
• Inguinal region

The condition is particularly challenging because multiple pathologies may coexist in the same athlete.

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Epidemiology

Pubalgia is commonly seen in athletes involved in:

• Football (soccer)
• Running
• Hockey
• Pivoting sports

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Incidence

• Approximately 0.5–6.2% of athletes develop groin pain per season.
• Up to 58% of football players experience groin pain during their careers.
• Pubalgia accounts for nearly 8% of all sports injuries.

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Pathophysiology

Sports groin pain develops because of repetitive stress across the:

• Pubic symphysis
• Adductor complex
• Lower abdominal musculature
• Hip joint

Biomechanical imbalance, overuse, and reduced hip mobility contribute significantly to symptom development.

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Classification of Pubalgia

Pubalgia can be broadly classified into several major pathological groups.

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1. Sports Hernia (Athletic Pubalgia)

Definition

Sports hernia, also called:

• Athletic pubalgia
• Sportsman’s hernia

refers to weakness or tearing of the posterior inguinal wall without a true hernia.

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Pathology

Common structures involved include:

• Posterior inguinal wall
• Transversalis fascia

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Clinical Features

Patients commonly complain of:

• Chronic groin pain
• Pain radiating to the:
  • Perineum
  • Medial thigh

Pain is often aggravated by:

• Sprinting
• Twisting
• Kicking
• Sudden directional changes

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Diagnosis

Diagnosis is based on:

• Local tenderness
• Pain reproduced during resisted movements
• Dynamic ultrasound
• MRI evaluation

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Treatment

Conservative treatment may include:

• Rest
• Physiotherapy
• Core strengthening

Persistent cases often require:

• Surgical posterior wall repair

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Outcomes

Surgical treatment produces excellent outcomes, with:

• Approximately 95–98% return to sport

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2. Adductor Longus Pathology

Types of Injury

Adductor-related pubalgia may present as:

• Tendinopathy
• Musculotendinous injury
• Partial tear
• Complete rupture

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Mechanism of Injury

A classic mechanism is:

• Sudden forceful contraction during kicking

This is commonly seen in football players.

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MRI Findings

MRI may demonstrate:

• Pre-pubic aponeurosis injury
• Secondary cleft sign

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Treatment

Most cases are treated conservatively with:

• Physiotherapy
• Activity modification
• NSAIDs
• Occasionally corticosteroid injections

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Surgical Treatment

Resistant cases may require:

• Adductor tenotomy

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3. Pubic Symphysis Pathology

Conditions Included

Pubic symphysis pathology includes:

• Osteitis pubis
• Symphyseal instability

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Common Patient Groups

Frequently seen in:

• Athletes with repetitive overtraining
• Postpartum females

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Clinical Features

• Local pubic tenderness
• Pain during running and cutting movements
• Pain during single-leg stance

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Imaging Findings

MRI and CT may show:

• Bone marrow edema
• Symphyseal instability
• Degenerative changes

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Treatment

Conservative Management

• Rest
• Physiotherapy
• Activity modification
• Injections

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Surgical Treatment

Rarely required, but severe instability may require:

• Pubic symphysis arthrodesis

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4. Bone Stress and Overload Injury

Pathophysiology

Repetitive overuse may produce:

• Bone marrow edema
• Stress reaction around the pubic symphysis

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Treatment

Management involves:

• Load reduction
• Activity modification
• Gradual rehabilitation

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5. Pubalgia Associated with Femoroacetabular Impingement (FAI)

Most Important Clinical Concept

One of the most important modern concepts in sports groin pain is the:

• Relationship between FAI and pubalgia

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Hip–Pubis Relationship

Reduced hip range of motion caused by FAI increases stress on:

• Pubic symphysis
• Adductor complex
• Lower abdominal structures

This creates abnormal biomechanical loading and contributes to chronic groin pain.

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Types of FAI Associated with Pubalgia

• Cam deformity
• Pincer deformity
• Mixed impingement

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Clinical Insight

A very important clinical principle is:

“If pubalgia is not improving, evaluate the hip.”

Failure to recognize underlying FAI may lead to:

• Persistent symptoms
• Failed groin surgery
• Incomplete recovery

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Diagnostic Approach

1. History

Important historical points include:

• Activity-related groin pain
• Sudden versus gradual onset
• Sporting activity involvement
• Aggravating movements

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2. Physical Examination

Examination should include assessment for:

• Adductor tenderness
• Pubic symphysis tenderness
• Hip impingement signs
• Abdominal wall weakness

Hip examination is essential in all patients.

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3. Imaging

X-Rays

Should include:

• Pelvis
• Hip views

to evaluate for:

• Cam lesions
• Pincer deformity
• Symphyseal abnormalities

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MRI

MRI is useful for evaluating:

• Labral tears
• Adductor injuries
• Aponeurotic injuries
• Bone marrow edema

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Dynamic Ultrasound

Especially useful for:

• Sports hernia evaluation
• Dynamic inguinal wall assessment

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Treatment Principles

Conservative Management

First-line treatment typically includes:

• Rest
• Physiotherapy
• NSAIDs
• Core strengthening
• Activity modification
• Injections when indicated

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Physiotherapy Goals

Rehabilitation focuses on:

• Core stability
• Hip mobility
• Adductor strengthening
• Pelvic control

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Surgical Treatment

Surgery depends on the underlying pathology.

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Outcomes

Outcomes are generally excellent when:

• The correct pain generator is identified
• Associated hip pathology is recognized
• Treatment is individualized

More than:

• 90% of athletes return to sports

with appropriate management.

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Important Clinical Pearls

• Pubalgia is a spectrum of disorders, not a single diagnosis.
• Hip pathology and groin pathology frequently coexist.
• FAI is strongly associated with sports hernia and adductor pathology.
• Failure to address underlying hip impingement may lead to persistent symptoms.
• Dynamic ultrasound is useful for sports hernia assessment.
• MRI is valuable for evaluating soft tissue and bony pathology.
• Successful treatment depends on identifying the primary pain generator.

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Final Take-Home Message

Pubalgia is a complex and multifactorial cause of groin pain in athletes.

Accurate diagnosis requires:

• Careful history
• Thorough physical examination
• Appropriate imaging
• Recognition of associated hip pathology

Modern understanding emphasizes the close relationship between:

• Femoroacetabular impingement
• Adductor pathology
• Pubic symphysis overload

Comprehensive evaluation and individualized treatment provide excellent outcomes and high return-to-sport rates.