Athletic Pubalgia (Sports Hernia)

Up to 25% of athletes with athletic pubalgia have concurrent FAI. If the FADIR test is positive or the patient has limited internal rotation of the hip, hip-specific imaging (MRI with hip protocol) is mandatory before any groin surgery. Operating on the pubic aponeurosis when the primary pain generator is the hip will fail. The two conditions can coexist and may require sequential treatment — address the intra-articular hip pathology first.

The secondary cleft sign on MRI is the most specific finding for athletic pubalgia. It appears as a curvilinear fluid signal extending inferolaterally from the pubic symphysis, representing a tear of the aponeurotic attachment. It is seen in approximately 70-80% of surgical cases. Pubic bone marrow oedema is non-specific and can be present in both athletic pubalgia and osteitis pubis — do not rely on this finding alone to differentiate the two conditions.

The groin packs several potential pain sources within centimetres, and athletic pubalgia, FAI, osteitis pubis and adductor pathology frequently coexist - so when MRI shows multiple abnormalities (or symptoms and imaging do not match), image-guided diagnostic local-anaesthetic injections are a powerful tool to identify the dominant generator before committing to surgery:

• Intra-articular hip injection: significant (greater than half) pain relief implicates the hip joint (FAI/labrum) as the primary source and predicts a good response to hip arthroscopy - operate on the hip first.
• Pubic symphysis / secondary-cleft injection: relief localises pain to the pubic aponeurotic plate / symphysis (athletic pubalgia / osteitis pubis).
• Adductor enthesis injection: relief localises to adductor-related pathology.

Each injection should be ultrasound- or fluoroscopy-guided with documented pre- and post-injection pain scores during a provocative manoeuvre. The principle mirrors the "treat the source, not the scan" rule: a positive hip injection in a patient with both cam morphology and a rectus tear tells you to address the hip first.

Exam point: when groin imaging shows more than one abnormality, use targeted image-guided anaesthetic injections (hip vs symphysis vs adductor) with recorded pain response to identify and treat the dominant pain generator - this is the practical safeguard against the number-one error of operating on the wrong source.

Q: What is athletic pubalgia? A: A core muscle injury involving disruption of the rectus abdominis–adductor longus aponeurotic plate at the pubic symphysis. It is NOT a true hernia — no visceral structure protrudes and no palpable inguinal mass is present. The pathology is a tear or attenuation of the aponeurosis due to repetitive shear forces from twisting and kicking.

Q: What is the gold standard imaging for athletic pubalgia? A: MRI of the pelvis with an athletic pubalgia protocol. Key findings include: rectus abdominis tear or oedema at the pubic attachment, adductor longus tendinopathy or partial avulsion, and the secondary cleft sign (fluid cleft extending inferolaterally from the symphysis). Dynamic ultrasound can exclude true hernia but is less sensitive for core muscle injury.

Q: How do you differentiate athletic pubalgia from osteitis pubis? A: Athletic pubalgia is typically unilateral, with pain reproduced by resisted sit-up or adduction, and MRI shows a rectus tear or secondary cleft sign. Osteitis pubis is typically bilateral, with direct symphysis tenderness, and MRI shows marked pubic bone marrow oedema and symphyseal sclerosis. Osteitis pubis is managed with rest and anti-inflammatories — it is NOT a surgical condition.

Q: What is the first-line treatment for athletic pubalgia? A: Structured physiotherapy for 6-12 weeks comprising: pain control, lumbopelvic stabilisation (transversus abdominis and multifidus), progressive adductor strengthening (Copenhagen adduction programme), and sport-specific functional rehabilitation. The Copenhagen programme has level 1 evidence for treatment and prevention of groin injuries. Surgery is reserved for patients who fail conservative management.

Q: When is surgery indicated for athletic pubalgia? A: Surgery is indicated after failure of a minimum 6-12 weeks of structured, supervised rehabilitation in a compliant athlete with MRI-confirmed core muscle injury and excluded hip pathology. Options include laparoscopic mesh repair, open repair, or combined repair with adductor release. Return-to-sport rates are 85-95% in experienced centres. The number one cause of surgical failure is incorrect diagnosis (missed FAI).