Athletic Pubalgia, also referred to as “Sports Hernia,” “Gilmore Groin,” “Sportsman’s Hernia,” or “Groin Disruption,” has been used to define a particular injury in the groin area, but lacks a universal definition [25, 26]. Typically, this injury is believed to be multifaceted and can occur with a twisting motion exacerbated by planting the foot at high speeds, sudden sharp changes in direction, repetitive kicking, and lateral side to side motion [25–27]. Injury usually results from disruption of the muscular components and/or fascial attachments to the pubis area [28–30]. Diagnosis is often made with an accurate history and physical exam, and confirmed or rebutted with diagnostic imaging. A current investigator, Dr. Mark Zolan MD, at Lenox Hill Hospital in NYC is investigating the diagnostic accuracy of MRI imaging while the patient holds a Valsala maneuver to detect a tear of the posterior wall of the inguinal canal. Pain is often described as chronic, with point tenderness near the lower abdominal insertion, pubic tubercle, and can involve the adductor longus tendon origin as well [25, 30]. A typical physical exam will often reveal overall pelvic weakness with palpable tenderness over the pubic tubercle. The patient will often experience increased symptoms when asked to perform a resisted sit-up, and the abdominal area pushes outward upon execution of this movement. In addition, the patient may present with adductor and hip flexor weakness and overall pelvic instability [25]. Upon completion of a gait analysis, dysfunction can often be noted with the movement of the pelvis and femoral alignment of the lower extremities. The hallmark complaint of athletic pubalgia is a “deep” groin or lower abdominal pain with exertion. This pain tends to be deeper and more intense than an adductor or iliopsoas strain and is ipsilateral in nature. According to Kachingwe et al. [30] there are five signs that are indicative of a sports hernia: (1) a subjective complaint of deep groin/lower abdominal pain, (2) the pain is exacerbated with increased exertion such as sprinting, cutting, and sit-up and is relieved with rest, (3) palpable tenderness over the pubic ramus at the insertion of the rectus abdominus and/or conjoined tendon, (4) pain with resisted hip adduction at 0°, 45°, and/or 90° of hip flexion, and (5) pain with resisted abdominal curl up.

Nonoperative treatment of sports hernia is often advocated as the first type of intervention for treatment. There is little evidence and few research papers support the effectiveness of conservative care; however, the majority of studies that have been conducted showed significant improvement after 6–8 weeks of physical therapy intervention [30, 31]. With little evidence to guide clinicians with the differential diagnosis and effective treatment of patients with athletic pubalgia or “sports hernias,” management of this condition has been diverse. While this lack of evidence-based research may not seem like a problem with nonoperative treatment, Table 17.3 reveals various pathological injuries that may present with similar signs and symptoms with overlapping findings upon exam and evaluation [28, 30, 32].

Differential diagnosis is important to ensure that the main cause or affliction is not being overlooked and the proper treatment is being administered. There is also the possibility of coexisting injuries, where more than one affliction causes groin pain, making it difficult to establish which injury is the main contributor to the pain and which is secondary. In fact, Larson et al. [33] found that when an athlete had a sports hernia and an intra-articular hip surgery concomitantly the success rate was much better than performing surgery on just one of the pathologies. Typically the patient has experienced these symptoms for months if not longer by the time a diagnosis of athletic pubalgia is determined. Given that the majority of cases of athletic pubalgia are insidious onset, determining the mechanism of injury is difficult and the patient may experience periods of improvement and episodic exacerbations making long-term success sometimes difficult. The main commonality of this injury is typically due to increased repetitive torque on the pubic symphysis during aggressive abduction/adduction of the thigh. This motion can lead to disruption of the aponeurosis of the rectus abdominis and the adductor longus tendon [1, 2, 28].

Rehabilitation can be performed on its own or coupled with steroid injections of the pubic symphysis or the adductor tendon origins, anti-inflammatories, and rest from activity. Clinical assessment of core stability, hip strength and flexibility, and identification of muscular compensation and imbalances are crucial [32]. Treatment should target strengthening and neuromuscular reeducation regarding timing and recruitment patterns during functional motion in addition to manual therapy techniques to manage soft tissue and fascial restrictions [31]. A comprehensive rehabilitation program to develop coordination and strength of the hip adductors, flexors, internal rotators, extensors, core stabilizers and lumbopelvic spinal musculature is important for an effective recovery. Table 17.4 is a list of examples of core and proprioceptive exercises to include in the beginning stages of a rehabilitation program.