In athletes the most frequent causes of GPS must be classified into articular causes, musculotendinous causes, and pubic symphysis-related causes.

In the first category (i.e., articular causes), we must underline the importance of cam-FAI syndrome that can not only cause labrum tear and cartilage damage (Zhang et al. 2015) but also be the “starter” of inguinal disease, as we will discuss later (Larson et al. 2011). Furthermore, hip pathology includes also extra-articular disease like iliopsoas bursitis, trochanteric bursitis, external snapping hip syndrome, and stress fracture (Zhang et al. 2015).

In the second category (i.e., musculotendinous causes), the most frequent clinical frameworks are adductor muscle injuries and adductor tendinopathy especially at adductor longus tendon level (Harr 2016). Nevertheless, it is important to note that radiological signs of adductor longus tendinopathy are present in 71% of asymptomatic football players in comparison to a 72% of incidence in a population of symptomatic football players (Branci et al. 2015). For this reason it is paramount to distinguish a “true” adductor longus tendinopathy causing GPS from a simple functional adaptation.

In the last category (i.e., pubic symphysis-related causes), it is important to remember that the source of pain should be divided in to three zones of focal pain:

The clinical presentation of GPS must be very different especially regarding both the etiopathogenesis (by traumatic or by overuse origin) and the temporal length of the symptoms reported by patients. Basing on these two aspects, we propose (Bisciotti et al. 2016) to subdivide the GPS into the following three categories:

The typical patient who complains LSGP is a subject with a long history of groin pain (more than 3 months) that has already performed several clinical and imaging assessments and that, above all, has already performed unsuccessfully many types of conservative treatments. In this case it must be strongly suspected an inguinal disease (Bisciotti et al. 2015; Gilmore et al. 2014). With the term “inguinal disease,” we mean a series of clinical conditions like true hernia, occult hernia, weakness of the inguinal canal posterior wall, micro-tear at conjoint tendon, inguinal ligament, and Cooper ligament level (Bisciotti et al. 2015; Gilmore et al. 2014) that often can cause a situation of “groin disruption” (Garvey and Hazard 2014). In the most part of the cases, this situation of groin disruption is caused by the presence of a cam-FAI syndrome (Bisciotti et al. 2015; Rambani and Hackney 2015; Griffin et al. 2016). Cam-FAI is an abnormal conformation of femoral head. In other words, cam-FAI is an osteochondral bump at femoral head-neck junction leading to a diminution of the normal femoral head-neck offset (Economopoulos et al. 2014; Satpathy et al. 2015; Fairley et al. 2016). Cam-FAI syndrome is identified by measuring the alpha angle on the Dunn view X-ray, as showed in Fig. 25.1. An alpha angle measuring 55° or greater is considered radiographic evidence of cam-FAI (Beck et al. 2005). Cam-FAI syndrome can cause both hip articular cartilage and labral lesion (Griffin et al. 2016) and limitation of hip joint intra-rotation (Hammoud et al. 2012; Hammoud et al. 2014). Recently cam-FAI has been shown to be associated in GPS especially in young high-level athletes (Hammoud et al. 2012; Philippon et al. 2007; Philippon et al. 2010; Kapron et al. 2011; Weir et al. 2011; Siebenrock et al. 2011; Larson et al. 2013).

This association may be explained by the fact that in the athlete suffering from cam-FAI syndrome, the functional range of motion (ROM) required in athletic competition is often greater than the limited physiologic motion (Hammoud et al. 2012, 2014). This limitation of ROM can be compensated by an iper-mobility of the symphyseal articulation. This iper-mobility of the symphyseal articulation can stress the posterior inguinal wall and favor the onset of inguinal pathology (Bisciotti et al. 2016; Hammoud et al. 2012, 2014). The inguinal pathology shows a low rate of positive outcome with conservative treatment (Omar et al. 2008; Ahumada et al. 2005); in these cases it is necessary to consider a surgical treatment. Nowadays, the most utilized surgical treatment in inguinal pathology is Shouldice repair, open all-suture repair technique, Lichtenstein repair, transabdominal preperitoneal (TAPP) repair, total extraperitoneal (TEP) repair, transinguinal preperitoneal repair (TIPP), minimal repair, and inguinal ligament release procedure (Muschaweck and Berger 2010; Lange 2016; Lloyd 2016).

Sometimes this procedures may be completed with a single or double tenotomy at longus adductor level and/or a triple or selective neurectomy of ilioinguinal, iliohypogastric, and genital branch of femorogenital nerves (Harr 2016; Muschaweck and Berger 2010; Rossidis et al. 2015; Santilli et al. 2016). Following surgical repair, independently by the surgical technique used, most of the series report that >90% of athletes return to full sport activity within 2–4 months after surgery (Rossidis et al. 2015). In any case this high number of techniques used demonstrates that the pathophysiology of GPS is still controversial.