Athletic Pubalgia

Over the last year I have seen more and more athletic pubalgia in the clinic.  Some of this is because of the population of athletes I have seen and some of this is because of the sports medicine doctors I work with. Athletic pubalgia (also known as sports hernia) is also defined as non-specific referral of groin pain. This injury can be complex to treat or very straightforward depending on the severity.  Understanding how to determine if this is a AP and how to effectively treat it to return back to sport is crucial for the sports clinician. 
 
Typical presentation of athletic pubalgia includes: 

• Pain located in the deep groin/lower abdominal area
• Tenderness over the pubic ramus at insertion of the rectus abdominus
• Pain with resisted sit-up
• Pain with resisted hip adduction (0ften at 0, 45, and/or 90 degrees of hip flexion)
• Pain with cutting or sprinting

 
Other pathologies to consider:

• Osteitis pubis
• Hernia
• Hip OA
• Labral pathology 
• Testicular referred pain
• Piriformis syndrome
• Fracture

 
One of the key points to make with AP is that despite the term “sports hernia”, AP is not a hernia. Furthermore, this injury can be chronic in nature.  With all that in mind, there are many conservative treatment options.  
 
From a conservative standpoint, treating AP has some non-negotiables.  The first phase as many pathologies require, it to control the pain and symptoms.  The length of this phase will be determined by severity, sport demands, and previous injury history.  However, there are many other things you can do during this phase away from the site of injury to keep the athlete in shape.  It is crucial to maintain cardiovascular endurance and strength elsewhere to give the athlete the best chance of returning without another injury later.  
 
Following the first phase you can you can start to work on more advanced core strengthening with “neutral spine”.  I say neutral for the purpose of discussion and because most research articles advocate neutral spine but understand that everyone’s “neutral” is different.  Another important point to consider during this phase is the influence of the lumbar spine.  As with almost all hip injuries, we MUST consider the influence of the lumbar spine.  Make sure full ROM is achieved and good control over the stability of the lumbar spine as it will influence the pelvis. More often than not, we can indirectly influence AP with lumbar spine treatment. Lastly, slowly adding adductor specific exercises from isometric in nature to more dynamic is important to add proper strength back to this athlete.  I like the Copenhagen plank for a good isometric exercise vs squeezing a ball because it is hard to quantify the “squeeze”.  There are many different forms of Copenhagen exercises and I would urge you to watch youtube videos, try them yourself, and determine if and when each variation can assist (or not) with your athlete’s rehabilitation.  
 
Finally, as with all injuries, proper return to sport criteria MUST be measured.  While hip return to sport tests are few, there is good research on some tests and more importantly, a proper “battery” of tests must be put together.  There is no one approach for return to sport and for those of you who have gone through our “Sports Management for the Orthopedic Clinician” course, you already learned how to put your own battery of tests together for various hip pathologies and how to properly construct return to sport testing.  
 
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS
Board Certified Sports Physical Therapist

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