What is the treatment for athletic pubalgia?

Treatment of Athletic Pubalgia

Athletic pubalgia should be treated initially with conservative management for 3-6 months, including relative rest, physical therapy with eccentric strengthening and hip stabilizer exercises, and NSAIDs; surgical intervention is reserved for patients who fail conservative therapy and typically involves open inguinal repair with mesh reinforcement, often combined with adductor tenotomy. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be attempted for 3-6 months before considering surgical options 2, 3:

• Relative rest and activity modification to prevent further damage to the weakened abdominal wall and strained adductor complex 4
• Physical therapy focusing on eccentric strengthening exercises and hip stabilizer strengthening to address the traction-countertraction imbalance between adductor muscles and weaker abdominal muscles 4, 1
• NSAIDs (such as naproxen 500mg twice daily) for acute pain relief and anti-inflammatory effect 4

Important caveat: Professional athletes who have already undergone physiotherapy during their competitive season may proceed directly to surgery at season's end rather than waiting the full 3-6 months 2. This reflects real-world practice where timing considerations affect treatment decisions.

Diagnostic Imaging Before Treatment

While not explicitly a "treatment," proper diagnosis is essential before proceeding:

• MRI is the definitive imaging study for evaluating suspected athletic pubalgia, as it can assess all peritrochanteric structures, abdominal wall integrity, and adductor pathology 5, 4
• Plain radiographs should be obtained first to exclude osseous pathology, arthritis, or structural abnormalities 5, 4

Surgical Management (For Failed Conservative Treatment)

Surgery is indicated when conservative management fails after 3-6 months 2, 3:

Surgical Approach

The most effective surgical treatment combines open inguinal repair with mesh reinforcement and adductor tenotomy 1, 2, 3:

• Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy demonstrates excellent outcomes with 92.5% of patients returning to athletic activity within 28 days 1
• Open inguinal repair using an internal oblique flap reinforced with mesh effectively addresses the anterior pelvic soft tissue weakness 3
• Adductor tenotomy should be performed concurrently to address the traction-countertraction relationship between adductor muscles and abdominal wall 1, 3

Surgical Outcomes

The evidence strongly supports surgical intervention for refractory cases:

• Mean operative time is approximately 72 minutes for the combined laparoscopic approach 1
• Return to full athletic activity typically occurs within 28 days following standardized physical therapy 1
• Long-term success rates are excellent: 94% combined success rate for conservative and surgical treatment at 13-year follow-up 2
• Surgical results show 83.3% excellent and 16.7% satisfactory outcomes 3

Postoperative Complications

Complications are relatively uncommon 1:

• Recurrence of pain/symptoms (7.5%), often on the contralateral side
• Urinary retention (2.2%)
• Pain along adductor magnus/brevis with extraneous activity (1.1%)
• Adductor brevis hematoma (1.1%)

Alternative/Emerging Treatments

Ultrasound-guided needle tenotomy with platelet-rich plasma (PRP) injection may be considered for distal rectus abdominis tendinopathies, though evidence is limited to case reports 6. This represents a less invasive option but lacks the robust evidence supporting surgical repair.

Ultrasound-guided corticosteroid injection into the peritendinous region can provide both diagnostic confirmation and therapeutic benefit in patients who fail initial conservative treatment, though this is typically a temporizing measure 4.

Critical Clinical Pearls

• Athletic pubalgia represents a "groin disruption injury" resulting from functional instability of the pelvis, not a true hernia 2
• Multiple co-existing pathologies are common, including posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis, and peripheral nerve entrapment 2
• The mechanism involves large forces across the bony pelvis during pivoting on a single leg or sudden directional changes at speed 2
• Most common intraoperative findings include nonspecific attenuation of the inguinal floor and cord lipomas 3

Treatment Algorithm Summary

1. Initial presentation: Confirm diagnosis with MRI after plain radiographs 5, 4
2. First 3-6 months: Conservative management with rest, physical therapy, and NSAIDs 2, 3
3. If conservative treatment fails: Proceed to surgical repair with mesh reinforcement and adductor tenotomy 1, 2, 3
4. Postoperative: Standardized physical therapy regimen with expected return to sport in 28 days 1