INVITED CLINICAL COMMENTARY

IJSPT ATHLETIC PUBALGIA AND ASSOCIATED

REHABILITATION
Abigail A. Ellsworth, PT, DPT, CSCS, CPS1
Mark P. Zoland, MD2
Timothy F. Tyler, MSPT, ATC3

ABSTRACT
Background: Evaluation and treatment of groin pain in athletes is challenging. The anatomy is complex, and
multiple pathologies often coexist. Different pathologies may cause similar symptoms, and many systems
can refer pain to the groin. Many athletes with groin pain have tried prolonged rest and various treatment
regimens, and received differing opinions as to the cause of their pain. The rehabilitation specialist is often
given a non-specific referral of “groin pain” or “sports hernia.” The cause of pain could be as simple as the
effects of an adductor strain, or as complex as athletic pubalgia or inguinal disruption. The term “sports her-
nia” is starting to be replaced with more specific terms that better describe the injury. Inguinal disruption is
used to describe the syndromes related to the injury of the inguinal canal soft tissue environs ultimately
causing the pain syndrome. The term athletic pubalgia is used to describe the disruption and/or separation
of the more medial common aponeurosis from the pubis, usually with some degree of adductor tendon
pathology.
Treatment: Both non-operative and post-operative treatment options share the goal of returning the ath-
lete back to pain free activity. There is little research available to reference for rehabilitation guidelines and
creation of a plan of care. Although each surgeon has their own specific set of post-operative guidelines,
some common concepts are consistent among most surgeons. Effective rehabilitation of the high level
athlete to pain free return to play requires addressing the differences in the biomechanics of the dysfunc-
tion when comparing athletic pubalgia and inguinal disruption.
Conclusion: Proper evaluation and diagnostic skills for identifying and specifying the difference between
athletic pubalgia and inguinal disruption allows for an excellent and efficient rehabilitative plan of care.
Progression through the rehabilitative stages whether non-operative or post-operative allows for a focused
rehabilitative program. As more information is obtained through MRI imaging and the diagnosis and treat-
ment of inguinal disruption and athletic pubalgia becomes increasingly frequent, more research is war-
ranted in this field to better improve the evidence based practice and rehabilitation of patients.
Key Words: Adductor strain, athletic pubalgia, groin pain, rehabilitation, sports hernia transversus abdominis
Levels of Evidence: 5

CORRESPONDING AUTHOR
1
Pilates Therapy & Wellness Center of Weschester, Scarsdale, Abigail A. Ellsworth, PT, DPT, CSCS, CPS
NY, USA Pilates Therapy & Wellness Center of
2
General and Laparoscopic Surgeons of NY, New York, NY, USA
3
Nicholas Institute for Sports Medicine and Athletic Trauma Westchester, Scarsdale NY
(NISMAT) Lenox Hill Hospital, New York, NY, USA E-mail: abbyellsworth@gmail.com

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INTRODUCTION AND BACKGROUND Nevertheless, inguinal disruption is meant to convey
Evaluation and treatment of groin pain in athletes is terms such as  sports hernia, incipient hernia, Gilm-
challenging. The anatomy is complex, multiple pathol- ore’s groin, groin disruption and sportsman’s groin3.
ogies often coexist, different pathologies may cause The British Hernia Society’s 2014 position statement
similar symptoms, and many systems can refer pain based on the Manchester Consensus Conference
to the groin. Many athletes with groin pain have tried delineated this group of pathologies from MRI findings
prolonged rest and various treatment regimens, and at the symphysis pubis where two observations are
receive differing opinions as to the cause of their pain.1,2 commonly noted: bone marrow edema, which often
The rehabilitation specialist is often given a non-spe- indicates injury in the area of the pubis, and “symphy-
cific referral of “groin pain” or “sports hernia.” As the sis capsular and adductor change, which involves the
vocabulary is still inconsistent, the data evolving, and anterior capsule, capsular ligaments and the enthesis
the treatment protocols progressing, understanding the of the common aponeuroses of the adductor longus
specific injury patterns at an anatomic level is the first and rectus abdominis” 3 Although exact terminology
step in creating a therapeutic protocol in both the non- is not universally agreed upon, for the purposes of
operative, and post-operative patient. clarity in this clinical commentary, the term inguinal
disruption is used to describe the syndromes which
DIFFERENTIAL DIAGNOSIS are related to the injury of the inguinal canal soft tis-
A thorough history and a physical examination is sue environs ultimately causing the pain syndrome.
needed to differentiate groin strains from athletic The term athletic pubalgia will be used to describe the
pubalgia, osteitis pubis, hernia, hip-joint osteoar- disruption and/or separation of the more medial com-
throsis, rectal or testicular referred pain, piriformis mon aponeurosis from the pubis, usually with some
syndrome or presence of a coexisting fracture of the degree of adductor tendon pathology.3
pelvis or the lower extremities. Many of these diag-
noses may exist in the active patient and present Typically athletic pubalgia is believed to be multifac-
with similar symptoms and pain patterns. Although eted, occurring with a twisting motion exacerbated by
significant data regarding the myriad of terms used planting the foot at high speeds, sudden sharp changes
to describe groin injuries was gathered in the last in direction, repetitive kicking, and lateral motion.4-6
three decades, core injury specialists, mainly sur- Diagnosis is often made by conducting an accurate
geons, are relying heavily upon new data obtained history and physical examination, and then often con-
from magnetic resonance imaging (MRI). MRI tech- firmed with MRI. Specific MRI protocols are currently
nology has advanced to the point where specific in use to assess the area to determine the degree of
injury patterns can be recognized. This imaging has aponeurotic plate disruption and adductor tendinop-
added to the understanding of, and even redefined athy. Additionally, sequences with and without the
the term “sports hernia”, and to a large degree has performance of the Val Salva maneuver can assist in
made the name obsolete. For the most part, the term assessment of the integrity of the transversalis fascia,
“sports hernia” encompasses two patterns of injury: which can be attenuated as described by Gilmore, one
inguinal disruption and athletic pubalgia. of the findings seen in inguinal disruption.

The term “sports hernia” which has been adopted Despite the fact that inguinal disruption and athletic
by the media, public, and the medical community pubalgia are separated in description, the injury often
alike, is falling out of favor with specialists who take involves both pathologies, and the symptoms can be
care of this group of injuries. The reason is twofold. very similar. Pain is often described as chronic, with
First, the injury is not a hernia, as there is no actual point tenderness near the lower abdominal insertion,
defect in the abdominal wall. Second, although the at the pubic tubercle, and can involve the adductor lon-
injury does occur frequently in the athlete, it is not gus tendon origin as well.4,7 A typical physical exam
limited to this population. The term is simply a mis- will often reveal palpable tenderness over the pubic
nomer. It does, however, have staying power, and tubercle and overall pelvic weakness in the floor as
despite many attempts by consensus conferences well as surrounding musculature. The patient will
attendees, the term remains in use. often experience increased symptoms when asked to

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 775
perform a resisted sit-up, as the abdominal area pushes point should be able to move throughout the day
outward upon execution of this movement. In addition, conducting daily activities with little to no pain pres-
the patient may present with adductor and hip flexor ent. Patients should not have reports of deep groin
weakness with dynamic movement.5 Upon comple- pain with increase intensity but may experience
tion of an observational gait analysis, dysfunction can occasional “twinges” with new activity additions.
often be noted with the movement of the pelvis and
Non-operative rehabilitation can be performed on
femoral alignment of the lower extremities. The hall-
its own or coupled with steroid injections of the
mark complaint of athletic pubalgia is a “deep” groin or
pubic symphysis or the adductor tendon origins,
lower abdominal pain with exertion. This pain tends to
anti-inflammatories, and rest from activity. Clinical
be deeper and more intense than an adductor or ilio-
assessment of core stability, hip strength and flex-
psoas strain and is ipsilateral in nature. According to
ibility, and identification of muscular compensation
Kachingwe et al6 there are five signs that are indicative
and imbalances are crucial. Treatment should tar-
of a “sports hernia” now termed athletic pubalgia as
get strengthening and neuromuscular reeducation
seen in Table 1.
regarding timing and recruitment patterns during
functional motion in addition to manual therapy
TREATMENT OPTIONS
techniques to manage soft tissue and fascial restric-
Non-operative conservative treatment is often advo-
tions.7 A comprehensive rehabilitation program
cated as the first type of intervention. Treatment main-
to develop coordination and strength of the hip
stays include rest, abstention from the aggravating
adductors, flexors, internal rotators, extensors, core
sport and similar activities, and focused rehabilitation.
stabilizers and lumbopelvic spinal musculature is
There is little evidence supporting the effectiveness
important for an effective recovery. Table 3 provides
of conservative care, however, the majority of stud-
a list of examples of core and proprioceptive exer-
ies that have been conducted showed significant
cises to include in the beginning stages of a conser-
improvement after 6-8 weeks of physical therapy
vative rehabilitation program.
intervention.6,7 With little evidence to guide clinicians
with the differential diagnosis and effective treatment Progression to incorporation of single leg activities
of patients with athletic pubalgia or inguinal disrup- on an unstable surface activates deep pelvic and core
tion, management of this condition has been diverse. stabilization as well as developing proprioception
Table 2 outlines a typical non-operative rehabilitation and kinesthetic awareness.7,13 Active stretching of the
protocol addressing both athletic pubalgia and ingui- spine and lower extremities to ensure the preserva-
nal disruption pathologies. While this lack of evidence tion of flexibility and full range of motion should be
based research may not seem like a problem with added targeting the muscles around the pelvis. The
non-operative treatment, various pathological injuries progression to the final stage places the patient back
may present with similar signs and symptoms with into the sports specific activity that they wish to
overlapping findings upon exam and evaluation.6, 8 return to in a light and modified manner with a focus
on core stabilization and proper body mechanics.
Pain control and reduction of any edema is the focus
of phase one non-operative care. Inability to reduce Effective rehabilitation of the high level athlete to pain
or control the pain prevents the patient from pro- free return to play, requires addressing the differences
gressing to Phase II (Table 2). The patient at this in the biomechanics of the dysfunction when com-

Table 1. Five signs that are indicative of athletic pubalgia

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Table 2. Non-operative Management of Athletic Pubalgia; Table 2. Non-operative Management of Athletic Pubalgia;
Phases I-IV Phases I-IV

Phase I (1-2 weeks) • Patient should demonstrate good pelvic

• Pain and edema control stabilization and easy recruitment of the
• Education regarding sitting, standing and TA with ambulation
supine posture and neutral spine • Gait training and pelvic proprioceptive
• Transversus abdominis recruitment neuromuscular function (PNF) patterns
• Hip and lumbar spine mobilization to should continue and have a good motor
increase ROM (Grade I & II) pattern developing
• Gentle active stretching of hamstrings, • Full to functional ROM should be achieved
adductors, quadriceps, iliopsoas, and in the lumbopelvic area and hips, reduce
lumbar spine. any remaining restrictions
• Strengthening with the addition of little to • Dynamic core training with use of neutral
no weight of the Transversus abdominis spine during activity and use of unstable
and side lying hip abduction and extension surfaces
• Standing stabilization with resistance or
Phase II (2-4 weeks)
balance disturbances added, progress from
• Cardiovascular warm up bike or elliptical
double to single leg functional activity
• Gait training on pelvic motion and timing
• Continue with active stretching
for heel strike, mid-stance and push off
• Myofascial release and soft tissue work to
• Continue TA (Transversus Abdominis)
any remaining restrictions
recruitment and strengthening
o Do not progress to phase III without the
• Achieve full to functional ROM for lumbar
following being met
spine and increase hip ROM
ƒ No pain with ADL’s, ambulation, and
• Initiate static core strengthening with the
fast paced walking
ability to maintain neutral spine ƒ Full functional ROM of hips, pelvis,
• Increase recruitment of hip and pelvic and lumbar spine
stabilization, emphasizing gluteals, TA and ƒ The ability to maintain spinal
multifidus neutral with standing, sitting,
• Initiate functional strengthening starting walking, and single leg activity
with double leg exercise and progressing to with added challenges of unstable
single leg as pain and strength improves surfaces or perturbations
• Spine and hip mobilization addition of ƒ Able to recognize and correct
rotation (Grade II & III) postural dysfunction when neutral
o Do not progress to phase III without the spine is not maintained
following being met
ƒ Decreased pain with ADL’s less than Phase IV (Week 6-8)
2/10 • Cardiovascular warm up should be sport/
ƒ Full functional ROM of lumbar spine recreational activity specific
and hips • ROM should be progressed to full if only
ƒ Ability to recruit and maintain TA functional was achieved
contraction with standing and single • Active stretching interspersed with static
leg activity stretching should be implemented
ƒ No pain with ambulation • Strengthening should consist of
ƒ No trunk lateral motion concentric and eccentric strengthening
(Trendelenberg) with ambulation in a functional, isotonic, isometric and
and single leg activity isokinetic fashion.
• Manual myofascial release and soft tissue
Phase III (4-6 weeks) mobilization to rectify any remaining
• Cardiovascular warm up on bike or restrictions
elliptical with higher speed and resistance, • PNF pattern training of LE and UE/LE
use of a treadmill with fast pace walking patterns

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Table 3. Core & proprioceptive exercises for early Table 4. Post-Operative Rehabilitation Protocol
stages of conservative treatment Week 1
Examples of Beginner Lower Abdominal, Core • Activities of daily living only
Exercises • No lifting or other activities that increase
Posterior pelvic tilts with completion of exhalation abdominal pressure
Posterior pelvic tilts with exhalation and bridging • Walking on flat surfaces is starting the day
Front and side planks with exhalation and after surgery
maintaining pelvic neutral • Ice 15 minutes daily every 2 hours for the
Examples of Proprioceptive Exercises first 24-48 hours
Balance on unstable surface maintaining pelvic • Wound care
neutral
(Progress from double-leg to single leg stance) Week 2-3
Balance on unstable surface while throwing and • Palpation assessment and visual Analog
catching a ball Scale (VAS) assessment
(Progress from double-leg to single leg stance) • Beginning of light resistive exercises in
Balance on unstable surface using a BodyBlade® pool if incision healing allows
(Progress from double-leg to single leg stance) • Standing closed chain activities targeting
the muscles of the Lower extremities and
hip
paring athletic pubalgia and inguinal disruption. After o Heel raises
approximately six months, an assessment is made as o Standing hip adduction, abduction,
to whether non-operative measures have been effec- flexion, extension
tive. Beyond this point, the injury is chronic, and more • Begin local activation of TA/Multifidus/
aggressive options may be entertained. iliopsoas/ deep hip rotators
• Initiate deeps tissue massage of the
POST OPERATIVE REHABILITATION adductor muscle bellies
Post-operative and non-operative conservative treat- • Manual therapy to target the Thoracic
ments have similar guidelines and stages of recov- and lumbar spine to maintain/improve
ery. Post-operative rehabilitation following “sports mobility and ROM
hernia” repair (encompassing both athletic pubal- • Light gentle stretches
gia and inguinal disruption) should be based on the o Lateral trunk, hip extension, psoas,
physiology of soft tissue healing. It is imperative hamstrings, quadriceps
that the rehabilitation does not excessively stress the • Retro walking
repair too early. Although each surgeon has their
own specific set of post-operative guidelines, some Week 4
common concepts are consistent among most sur- • Reassessment of VAS to monitor
geons and are defined in phases (Table 4). An initial progression
rest period of four weeks is typically recommended • Proprioceptive and balance exercises
post-operatively before physical therapy is initiated. bilateral and initiation of unilateral
The main objectives and clinical milestones for pro- • Core muscle activation with monitored
gression between stages are outlined in the tables. resistance for pain and load
• Hip rotator, gluteus Maximus, Gluteus
The first week of post-operative rehabilitation is for Medius stabilization exercises
management of pain and swelling, with relative • Begin abdominal scar mobilization over
rest recommended. Daily walking on flat surfaces is incisional area as well as deep tissue
encouraged. Therapeutic massage around adductors massage and release
and surrounding tissue away from the incision site may to surrounding structures
begin as soon as two weeks after surgery and progress
to scar management over the abdominal incision area

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 are initiated in the next phase, as well as mild resistive
Table 4. (continued)
exercise of the lower extremities in the form of progres-
• Gentle stretches and the addition of active
sive resistive exercises (PREs). Abdominal crunches or
stretches with mild to moderate resistance
sit ups are contraindicated at his time but initial con-
• Manual therapy to improve mobility and
traction of the abdominal muscles is started in the form
ROM of hip, lumbopelvic junction, and
of activating and increasing the recruitment in the
spine
transversus abdominis muscle [Fig. 1]. Light stationary
Week 5-6 biking is introduced at this time. The following stage
• Reassessment of the VAS to monitor starts the resistive exercises. Additionally, open chain
progression and pain tolerance exercises of the lower extremities are initiated remind-
• Unilateral and bilateral balance and ing the patient to continue to contract the transversus
proprioceptive exercises abdominis muscle during the movements, ensuing
• Initiation of adductor PRE’s monitoring proximal stability for distal mobility [Figures 2-4]. Both
pain levels dynamic and static abdominal exercises are initiated
o Isometrics and sports specific movements start to enter into the
o Bent knee fall outs guidelines (Table 4).
o Resistive side steps with
The final stage is based on an 8-12 week projection for
Thera-band®
return to sport; rehabilitation may take longer in some
• Abdominal progression in the sagittal and
instances depending on the involvement, including
transverse planes
the extent of the surgical procedure and the patient’s
o 90/90 heel lowers
tolerance to recovery. Balance and proprioceptive
o Seated isometric holds
exercises are progressed to activity specific level with
o Plank off knees
the addition of perturbations and uneven surfaces.
o Plank off feet
Balance progressions on an unstable surface are per-
o Integrated functional pelvis on hips
formed in all directions [Fig. 5]. Increased emphasis
and trunk on pelvis
on dynamic and functional training with both con-
o Abdominal crunches
Week 6-8
• Cardiovascular activities for 20-30 minutes
with warm up and cool down
• Strengthening of the hip and lower
extremities continues with addition of
weights
• Jogging forwards and backwards, rope
jumping and sprinting for short distances
• Agility and coordination drills
• Cross-over cariocas and straddles
• Single leg eccentric lowers with adduction
forces using Thera-band®
• Core stabilization challenging entire body
• Plyometrics Figure 1. Posterior pelvic tilt. (A) Lying on your back relaxed
• Dynamic pelvic stabilization, lateral hip with your hands placed over the anterior superior iliac spine
and gluteal strengthening (ASIS) on each side and tips of fingers applying a slight pres-
sure to the soft tissue just medial to the ASIS. (B) Start the
motion by drawing the pubic symphysis towards the umbili-
by 3-4 weeks after surgery (when rehabilitation typi-
cus with emphasis on anterior musculature contracting. The
cally is initiated). The patient should avoid excessive fingers should feel the transversus abdominis contract equally
trunk extension and rotation.9 Neuromuscular reeduca- on each side, the rib cage should depress and the lumbar spine
tion and muscle activation and recruitment exercises should flatten with little effort applied.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 779
 Figure 3. Bridging coupled with lower extremity lift. (A) Lie
on floor and bridge from pressure applied to the lower extrem-
ities against the floor. (B) Place a physioball under the legs and
Figure 2. Hip conditioning and core stabilization exercise. apply downward pressure to the ball as the legs straighten
(A) Start sitting on a ball positioning the knees and hips at 90 allowing the pelvis to rise from the surface. (C) Once able to
degrees with hands on the hips or thighs. (B) Place knees and bridge on ball, lift one leg into the air, keeping knee extended
feet together in midline and lift one knee while trying to main- and trunk stabilized.
tain pelvic and trunk stability. (C) Once pelvic and trunk sta-
bility is achieved with the hands on the thighs, progress to
opposite upper extremity (UE) placing opposing pressure on
raised knee while other UE is raised in the air for additional
stabilization challenge.

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Figure 4. Pelvic stability on unstable surface progression. (A) Sitting on an air filled balance disc, place knees and feet together in
midline and find pelvic stabilizers with feet on ground. (B) With arms outstretched, maintain midline as you lift one knee towards
chest attempting to hold pelvis and trunk stable. (C) Progress to lifting both legs off and balancing for a prolonged hold. (D) Once
prolonged holds are achieved progress to the addition of a ball toss.

Figure 5. Double leg & single leg balance and proprioceptive training. (A) Standing on a 360 degree balance board (Fitter Inter-
national, Calgary, Canada) with knees and hips flexed try to maintain balance. (B) Progress to single leg activity with hips and knee
flexed once bilateral is mastered. (C) Add a ball toss once single leg balance and control is achieved.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 781
 Figure 7. Side plank. Lying on side. align shoulder, elbow,
hips and ankles and raise up into plank maintaining align-
ment.

Figure 6. Wall squat with pelvic stabilization. Place ball

behind low back and squat to 90 degrees hip flexion, holding
trunk and pelvis in place. Then, raise up one knee to lift foot
from ground.

centric and eccentric strengthening is included in

this phase [Figures 6-9]. Lastly, early stages of plyo-
metrics, integrating upper and lower extremities
are added at the end of this stage in preparation for
the athlete to return to play (Week 8-12).

The possibility of coexisting injuries exists, where

more than one affliction causes groin pain, thereby
making it difficult to establish which injury is the
main contributor to pain and which is secondary. In Figure 8. Front plank progression (A) align shoulders with
fact, Larson et al10 found that when an athlete had elbows and lift into forearm plank keeping pelvis in alignment
a “sports hernia” repair and an intra-articular hip (B) Progress to placing hands aligned with shoulders and fin-
gers pressing into surface keeping pelvis aligned with plank
surgery concomitantly the success rate was much position (C) Place hands on BOSU® (BOSU, Ashland, OH) and
better than performing surgery on just one of the balance with the body held in plank position keeping pelvic
pathologies. alignment.

The International Journal of Sports Physical Therapy | Volume 9, Number 6 | November 2014 | Page 782
 adduction. This motion can lead to disruption of the
aponeurosis of the rectus abdominis and the adduc-
tor longus tendon.1,2,8

CONCLUSION
In general, treatment and rehabilitation are designed
to relieve pain, restore range of motion, restore
strength, and return function. Although these guide-
lines are outlined for progression, not all individuals
will respond in the same manner. Clinical experi-
ence and judgment with sound clinical reasoning
should be factored in when executing a patient’s spe-
cific plan of care. Proper evaluation and diagnostic
skills for identifying and specifying the difference
between athletic pubalgia and inguinal disruption
allows for an effective and efficient rehabilitative
plan of care. Applying protocols for stages of opera-
tive and non-operative rehabilitation helps to ensure
that all aspects of function are addressed and re-
injury is prevented. As more information is obtained
Figure 9. Quadruped Training (A) Align the knees under the
hips and the hands under the shoulders and maintain pelvic through MRI imaging and the diagnosis and treat-
alignment as one leg is outstretched. (B) Once aligned extend ment of inguinal disruption and athletic pubalgia
one leg and the opposite arm maintaining pelvic and shoulder becomes increasingly frequent, rehabilitation spe-
girdle alignment. cialists are afforded a better understanding to the
mechanism of injury and the proper biomechanics
required to allow for a full recovery and return to
SUMMARY pain free function. As with any new development in
The importance of achieving the proper muscle acti- the medical and rehabilitative field, more research
vation and recruitment pattern training is crucial for is warranted to better improve the evidence based
proper recovery with both conservative and post- practice and rehabilitation of patients.
operative rehabilitation. Often patients will com-
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