What is the treatment for athletic pubalgia?

Treatment of Athletic Pubalgia

Athletic pubalgia should be treated with a combination of conservative management initially, followed by surgical intervention if conservative measures fail. 1, 2

Diagnosis

Athletic pubalgia, also known as sports hernia or groin disruption injury, is characterized by chronic lower abdominal and groin pain without the presence of a true hernia 3. Proper diagnosis requires:

• Detailed history focusing on pain exacerbated with physical activity 2
• Physical examination revealing pubic point tenderness accentuated by resisted adduction of the hip 2
• Absence of a true hernia on examination 2
• Evaluation for common co-existing pathologies including posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis, and peripheral nerve entrapment 4

Conservative Management (First-Line Treatment)

Conservative treatment should be attempted for 3-6 months before considering surgical options 4:

• Physical therapy focusing on core strengthening and pelvic stabilization 5
• Activity modification with reduction in pivoting and cutting movements 4
• Anti-inflammatory medications for pain management 5
• Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) injection for distal rectus abdominis tendinopathies 6
• Pelvic floor physiotherapy for patients with pelvic floor dysfunction 1

Surgical Management (Second-Line Treatment)

If conservative measures fail after 3-6 months, surgical intervention should be considered 4:

• Groin reconstruction for cases with multiple pathologies 4
• Open hernia repair with or without mesh for cases with inguinal floor attenuation 2
• Sports hernia repair (Gilmore technique) for specific sports hernia presentations 4
• Laparoscopic repair as a less invasive alternative 4
• Conjoint tendon repair for cases with conjoint tendinopathy 4
• Adductor tenotomy for cases with predominant adductor involvement 4

Treatment Algorithm

1. Initial Phase (0-6 weeks):

   • Rest and activity modification 5
   • Anti-inflammatory medications 5
   • Physical therapy focusing on core strengthening 5

2. Intermediate Phase (6-12 weeks):

   • Progressive return to sport-specific activities 5
   • Consider ultrasound-guided PRP injection for persistent tendinopathies 6
   • Pelvic floor physiotherapy if indicated 1

3. Advanced Phase (3-6 months):

   • Return to sport with modified technique 4
   • Continued strengthening program 5
   • Reassessment for surgical candidacy if symptoms persist 4

4. Surgical Intervention (if needed):

   • Select appropriate surgical technique based on specific pathology identified 2, 4
   • Post-surgical rehabilitation protocol 4

Expected Outcomes

With appropriate treatment, success rates of 94% have been reported with a combination of conservative and surgical approaches 4. Most athletes can return to their previous level of activity following successful treatment 6, 2.

Common Pitfalls and Considerations

• Failure to identify and address co-existing pathologies can lead to treatment failure 4
• Premature return to sport before adequate healing can cause symptom recurrence 5
• Athletic pubalgia should be considered as a 'groin disruption injury' resulting from functional instability of the pelvis 4
• Professional athletes may benefit from earlier surgical intervention, particularly at the end of their competitive season 4