What is the recommended treatment for an individual with a stress reaction at the symphysis and athletic pubalgia/strain injury at the adjacent adductor attachment?

Treatment of Stress Reaction at the Symphysis and Athletic Pubalgia/Adductor Strain

For combined symphyseal stress reaction and athletic pubalgia with adductor involvement, initiate conservative management with relative rest, progressive exercise therapy focusing on adductor and core strengthening, and consider surgical intervention only after 3 months of failed conservative treatment, targeting the specific injured structures identified on imaging.

Initial Conservative Management (First-Line Treatment)

Conservative therapy should be attempted for at least 3 months before considering surgical options 1. This approach prioritizes:

• Relative rest with activity modification: Avoid activities that reproduce pain, particularly running, cutting maneuvers, hip adduction against resistance, and rectus abdominis loading 2
• Progressive exercise therapy: Begin within 48-72 hours focusing on range of motion, followed by strengthening and proprioception training 3
• NSAIDs for pain control: Use ibuprofen, naproxen, diclofenac, or celecoxib for short-term pain and swelling reduction (<14 days) 4

Specific Exercise Prescription

Adductor strengthening should be the cornerstone of rehabilitation, as reduced lower extremity muscle strength is associated with higher BSI risk 3. The program should include:

• Eccentric adductor exercises: These address the microtrauma at the adductor longus musculotendinous junction commonly seen in athletic pubalgia 5, 6
• Core and proximal hip strengthening: Address excessive hip adduction during activity, which predicts tibial stress injuries and likely contributes to symphyseal overload 3
• Progressive loading: Advance from isometric to concentric to eccentric exercises as tolerated 6

Addressing the Stress Reaction Component

For the symphyseal stress reaction specifically, incorporate bone-protective strategies:

• Resistance training: Essential for producing osteogenic effects and protecting bone during healing 3
• High-impact plyometric training (advanced stages only): Consider after initial healing, as running alone may not provide sufficient osteogenic stimulus 3
• Avoid complete immobilization: Prolonged rest delays recovery without improving outcomes 4

Diagnostic Imaging and Monitoring

MRI is the preferred imaging modality to confirm the diagnosis and guide treatment decisions 1, 2. Key findings include:

• Rectus abdominis stripping injury at pubic insertion (seen in 26% of cases) 5
• Adductor longus musculotendinous junction strain 5
• Parasymphyseal bone edema indicating stress reaction 2
• Note: 20% of patients may have normal MRI despite clinical symptoms 5

Surgical Intervention (After Failed Conservative Treatment)

If conservative management fails after 3 months, surgical intervention should target only the specific injured structures identified on imaging and clinical examination 1. This "à la carte" approach produces excellent outcomes with mean return to play of 112±38 days 1.

Surgical Options Based on Pathology

For isolated adductor involvement:

• Adductor longus tenotomy alone
• Return to play: 101.7±42 days 1

For isolated abdominal wall involvement:

• Abdominal wall repair only
• Return to play: 91.1±21 days (shortest recovery time) 1

For combined pathology (most common):

• Laparoscopic totally extraperitoneal hernia repair with synthetic mesh PLUS ipsilateral adductor longus tenotomy 5
• Return to play: 132.5±39 days 1
• Success rate: 92.6% return to previous level of play 1

Surgical Technique Details

The laparoscopic approach with mesh reinforcement and targeted tenotomy allows early return to activity (mean 24 days to full sports activity in some series) with minimal complications 5. This addresses:

• Posterior transversalis fascia weakness and inguinal floor bulging 5
• Rectus abdominis microtears at pubic insertion 5
• Adductor longus antagonizing forces contributing to symphyseal overload 5

Important Clinical Considerations

Differential Diagnosis Pitfalls

Do not miss concurrent femoroacetabular impingement (FAI), which may produce pathologic transfer stress to the pubic symphysis through constrained hip flexion causing posterior pelvic tilting 7. Some patients may require:

• Concurrent or isolated FAI treatment in select cases 7
• Assessment of hip range of motion in all patients with pubalgia 7

Common Mistake to Avoid

Avoid routine bilateral adductor tenotomy when only unilateral pathology is present 1. The traditional approach of combining abdominal wall repair with routine bilateral tenotomy increases morbidity without improving outcomes 1.

Prognosis and Follow-Up

Athletic pubalgia treated surgically has excellent outcomes with 92.6% returning to previous level of play and no recurrence at 1-year follow-up when surgery is confined to injured structures 1. However:

• Pain progression is common without treatment: Athletes may become unable to sustain high-level activity 2
• Conservative management should not be abandoned prematurely: The 3-month threshold is critical before considering surgery 1