What Is Pubalgia?

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Pubalgia, also called a sports hernia, is an injury to the groin, most often resulting from sports or activities that involve sudden directional changes or twisting motions.

This article will describe causes and symptoms of pubalgia, how it is diagnosed, and treated. 

Back pain and sports

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Pubalgia Symptoms

The rectus abdominis and oblique muscles of the abdomen where they attach to the pelvis are the most impacted by pubalgia. The tendons of the adductor muscles of the inner thighs that also attach to the pubic bone can be strained or torn with pubalgia.

Symptoms of pubalgia include pain and tenderness to the touch in the affected areas. Onset of pain is usually insidious without a specific cause that increases over time and occurs on one side of the body in the lower abdomen, groin, and upper portion of the adductor muscles.

Pubalgia pain can also radiate into the inner thigh, testes, and rectum, and generally improves with rest and worsens with activity, especially twisting, cutting, and kicking movements. Coughing and sneezing can also aggravate symptoms due to increased abdominal pressure.

Unlike an abdominal hernia where the muscles in the mid portion of the abdomen become torn and produce a visible bulging out of tissue, pubalgia typically does not produce any protrusion of tissue into the strained area. Over time, however, pubalgia can lead to an inguinal hernia, where abdominal organs can press into the weakened area and protrude out into the lower abdomen.

Causes

Pubalgia most often results from sports and activities that involve pivoting motions or sudden directional changes with a planted foot. This twisting motion of the lower body can cause a tear in the soft tissues of the lower abdominals or groin that are attached to the pelvis. This injury often occurs from the shearing force on the pelvis that results from the strong pull of the adductors on the pelvis and lack of abdominal strength to provide stabilization.

Running, kicking, and rapid acceleration and deceleration can also increase the likelihood of injury. The most common sports that can cause pubalgia include:

  • Hockey
  • Soccer
  • Football
  • Wrestling

Pubalgia is also more common in men due to differences in pelvic anatomy.

Diagnosis

Pubalgia is diagnosed through a physical examination. Your healthcare provider will ask you to either do a sit-up or lift your shoulders and upper torso from a lying-down position against physical resistance. With pubalgia, either of these motions typically reproduce symptoms.

At least three of five clinical signs should be present to confirm a diagnosis of pubalgia. These include:

  1. Tenderness at the pubic tubercle where the conjoint tendon attaches
  2. Tenderness to the touch of the deep inguinal ring
  3. Pain at the external inguinal ring without sign of hernia
  4. Pain at the origin of the adductor longus tendon
  5. Dull, diffuse pain in the groin that can radiate to the perineum and inner thigh

An MRI can also be useful for confirming a diagnosis of pubalgia by demonstrating partial or complete tear of the rectus abdominis, conjoint tendon, or adductor tendons. An MRI can also rule out other types of groin pain including:

Fluoroscopic or ultrasound-guided intra-articular anesthetic injections (shots placed directly into a joint) into the hip joint can also help rule out other hip conditions that can cause groin pain. Pain from problems within the hip joint will likely improve after intra-articular injections but will remain unchanged if pubalgia is present.

Treatment

Pubalgia is treated with rest at first within the first seven to 10 days after injury, along with ice and nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease pain and inflammation. Physical therapy is usually initiated two weeks later to improve the strength and flexibility of the muscles of your abdomen, groin, and hips to rehabilitate them back to proper functioning after injury. 

In more severe cases of pubalgia that do not recover well, surgery may be performed to repair the torn tissues around the groin and abdomen. Occasionally an inguinal neurectomy, a surgical procedure where the inguinal nerve within the groin is cut, is performed to relieve pain from pubalgia.

Surgery may also be needed in cases where a prior case of recovered pubalgia re-tears. If inner thigh pain continues after surgery for pubalgia, an additional surgical procedure called an adductor tenotomy may be performed. With an adductor tenotomy, the adductor tendons that attach to the pubis is cut, allowing the tendons to heal and increase in length, thereby releasing tension at the groin and improving range of motion with decreased pain.

Prognosis

Many cases of pubalgia recover within four to six weeks of physical therapy, but return to sports may take up to 10 to 12 weeks. Resting from sports and aggravating activities is crucial for allowing the injured area in the groin to heal properly, followed by gradual strengthening and conditioning  exercises to return to physical activity. If significant symptoms persist over time, a cortisone injection into the affected area may be delivered to decrease inflammation at the injury site.

Summary

Pubalgia, characterized by pain in the groin, is caused by a strain to the tendons of the abdominal muscles and sometimes the adductor muscles of the inner thigh where they attach to the pelvis. Pubalgia most often results from sports and activities that involve pivoting motions or sudden directional changes with a planted foot, causing the tissues in the groin to tear. Pubalgia has a good prognosis to heal well with rest and physical therapy, but surgery is sometimes needed for severe or recurrent cases that do not recover with conservative measures.

A Word From Verywell

Pubalgia can be a frustrating diagnosis since a break from most physical activity is needed in order to allow the strained or torn areas to heal. Working with a physical therapist will be especially important to gradually progress your tolerance for physical activity and to help correct a muscle imbalance between your abdominals and adductors that likely contributed to your injury. Staying patient is key as careful rest from activity and skilled rehabilitation establish a good likelihood that pubalgia will heal without requiring further treatment. 

2 Sources
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  1. American Academy of Orthopedic Surgeons. Sports hernia (athletic pubalgia).

  2. Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323. doi:10.1177/1941738116653711