Pubalgia

Pubalgia, commonly referred to as athletic pubalgia or a sports hernia, is a clinical syndrome characterized by chronic groin pain in athletes resulting from injury to the soft tissues at the pubic region, including the rectus abdominis–adductor aponeurosis interface, the conjoint tendon, and the surrounding inguinal canal structures. It is not a true hernia. Repetitive twisting, kicking, or rapid directional changes seen in sports such as soccer, hockey, and running are common contributing factors. Associated conditions can include osteitis pubis and adductor tendon pathology.

Symptoms are typically unilateral and worsened by resisted hip adduction, sit-ups, sprinting, kicking, or directional changes, with relief at rest. On examination, clinicians may find point tenderness at the pubic tubercle, weakness or pain with resisted sit-up, and pain with Valsalva. Differentiation from inguinal hernia, osteitis pubis, and femoroacetabular impingement is important in evaluation.

Diagnosis is primarily clinical, supported by imaging when needed. Magnetic resonance imaging (MRI) can delineate soft tissue injuries at the pubic region and rule out other causes; ultrasound may aid dynamic assessment; plain radiographs can identify related bony abnormalities or osteitis pubis.

Management typically starts with conservative treatment. This includes activity modification and a structured physical therapy program focusing on core stabilization, abdominal–adductor strengthening, and gradual return to sport, along with nonsteroidal anti-inflammatory drugs as needed. Injections may be considered for refractory pain. If symptoms persist after several months of rehabilitation, surgical repair is considered, aiming to restore integrity of the pubic aponeurosis and address any concomitant adductor pathology, with open or minimally invasive approaches and possible reinforcement of the posterior inguinal canal. Postoperative rehabilitation emphasizes gradual loading and sport-specific training, with return to play commonly occurring over several months. Prognosis improves with accurate diagnosis and adherence to a comprehensive rehab program.