What is the best treatment approach for a young athlete with athletica pubalgia (sports hernia)?

Athletic Pubalgia (Sports Hernia): Treatment Approach

For young athletes with athletic pubalgia, initial conservative management with 3-6 months of rest and focused physical therapy should be attempted first, followed by surgical repair (open or laparoscopic inguinal floor reconstruction with or without adductor tenotomy) if conservative treatment fails, with >90% success rates expected for return to sport. 1, 2

Understanding Athletic Pubalgia

Athletic pubalgia represents a groin disruption injury resulting from functional instability of the pelvis, not a true hernia despite the common misnomer "sports hernia." 1 The condition involves:

• Weakening or tearing of the abdominal wall without evidence of a true hernia 2
• Multiple co-existing pathologies including posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis, and peripheral nerve entrapment 1
• Traction-countertraction forces between adductor muscles and weaker abdominal muscles, particularly in sports requiring pivoting, kicking, cutting, or rapid directional changes 1, 3

Clinical Presentation

The diagnosis is established by history and physical examination with these specific findings: 2, 4

• Groin and lower abdominal pain that may radiate to perineum and proximal adductors 2
• Pain exacerbated by kicking, cutting, sprinting, or athletic activity 2
• Pubic point tenderness accentuated by resisted hip adduction 4
• Symptoms reproduced during resisted sit-up or with forced cough/sneeze 2
• Pain on palpation over the symphysis pubis or surrounding structures 2

Diagnostic Workup

• MRI imaging should be obtained to rule out other pathologies and identify specific findings including rectus abdominis or adductor tendon tears/strains 2
• Evaluate for coexisting hip pathology, particularly femoroacetabular impingement syndrome, as diagnosis and treatment of this is crucial for successful return to sport 2
• Lidocaine injections can localize the pain source 2

Treatment Algorithm

First-Line: Conservative Management (3-6 months)

• Rest period with anti-inflammatories 2
• Focused physical therapy targeting pelvic stabilization 2, 5
• Conservative treatment combined with surgery achieves 94% success rate at long-term follow-up 1

Second-Line: Surgical Intervention

Surgery is indicated when conservative therapy fails to allow return to athletic activity. 2, 4 Surgical options include:

Open Repair Approach:

• Groin reconstruction with internal oblique flap reinforced with mesh 4
• Reattachment of rectus abdominis and repair/reinforcement of abdominal musculature in layers to recreate inguinal ligament anatomy 2
• Consider adductor tenotomy (performed in 25-33% of cases) for concurrent adductor pathology 1, 4
• Results show 83.3% excellent and 16.7% satisfactory outcomes with all patients returning to sport 4

Laparoscopic Approach:

• Total extraperitoneal (TEP) laparoscopic inguinal hernia repair with adductor tenotomy 3
• Mean operative time of 72.4 minutes 3
• 92.5% of patients return to athletic activity within 28 days following standardized physical therapy 3
• Low complication rate: 7.5% recurrence of symptoms (often contralateral), 2.2% urinary retention 3

Surgical Principles

The surgical approach aims to strengthen anterior pelvic soft tissues that support and stabilize the symphysis pubis. 1 Key technical points include:

• Repair of inguinal floor attenuation (most common intraoperative finding) 4
• Mesh reinforcement used in majority of cases 4
• Pelvic floor repair variations may be performed 2
• Concomitant adductor tenotomy or repair addresses the traction-countertraction imbalance 2, 3

Expected Outcomes

• >95% success rate with timely intervention and appropriate repair 5
• Return to sport within 28 days post-laparoscopic approach 3
• Long-term success rate of 94% combining conservative and surgical management 1

Critical Pitfall

Failure to diagnose and treat coexisting femoroacetabular impingement syndrome is crucial—this must be addressed for successful return to athletic activity. 2 The hip joint pathology evaluation should be part of every clinical examination for athletic pubalgia.