Quick summary: Pubalgia is an injury affecting the pubic area, common among athletes. Main symptoms include groin pain that worsens with activity, discomfort when lifting the leg, and pain during rotational movements. Physiotherapy treatment enables complete recovery in 90% of cases, with an estimated timeframe of 6 to 12 weeks depending on severity.
What is pubalgia
Pubalgia, also known as athletic pubalgia or "sports hernia," is an injury affecting the musculotendinous structures that insert into the pubic area. This condition causes groin pain and can significantly limit physical activity.
According to epidemiological studies, pubalgia accounts for between 5% and 18% of all sports injuries. It is particularly common in sports involving direction changes, sprints, and kicking, such as football, hockey, and running.
The pubic area is a meeting point where multiple structures converge: the adductor muscles (inner thigh), lower abdominal muscles, and the pubic symphysis (the joint connecting the two pubic bones). This crossroads of forces makes the region vulnerable to overload and injury.
Types of pubalgia
There are three main types of pubalgia, classified according to the affected area:
High pubalgia (abdominal)
Primarily affects the lower abdominal muscles, especially the rectus abdominis at its pubic insertion. Pain is located above the pubis and may radiate towards the lower abdomen.
Mid pubalgia (articular)
Involves the pubic symphysis, the cartilaginous joint that connects the two pelvic bones at the midline. It can cause inflammation and degenerative changes in this joint.
Low pubalgia (adductor)
This is the most common type. It affects the adductor muscles, especially the adductor longus, at their pubic insertion. Pain is located in the inner thigh and groin area.
| Type | Affected area | Pain location | |------|---------------|---------------| | High | Lower abdominals | Above the pubis | | Mid | Pubic symphysis | Centre of pubis | | Low | Adductors | Groin and inner thigh |
It's important to note that many cases present with mixed involvement, affecting more than one structure.
Symptoms of pubalgia
Pubalgia symptoms typically develop progressively. Recognising them early is essential for starting treatment and preventing the injury from becoming chronic.
Main symptoms:
- Groin pain that increases with physical activity, especially when running, kicking, or changing direction
- Discomfort when lifting the leg, both actively and against resistance
- Pain during hip rotation movements, both internal and external
- Difficulty climbing stairs or getting into a car
- Radiating pain towards the lower abdomen, inner thigh, or even the testicles
- In advanced cases, pain at rest and even at night
Typical pain progression:
- Initial phase: Mild discomfort at the end of training that disappears with rest
- Intermediate phase: Pain during exercise that limits performance
- Advanced phase: Constant pain that prevents sports activity and affects daily life
Important: If the pain is severe, appeared suddenly, or doesn't improve after two weeks of relative rest, consult a healthcare professional. Some symptoms may be confused with other conditions requiring medical evaluation.
Causes of pubalgia
Pubalgia occurs due to overloading of the structures inserting into the pubis. This overload can be caused by sporting and non-sporting factors.
Sporting causes
- Overload from repetitive movements: Kicking, sprinting, and repeatedly changing direction generates cumulative tension in the pubic area
- High-risk sports: Football (up to 10% of injuries), hockey, running, tennis, and racquet sports
- Sudden increase in training load: Increasing volume or intensity without adequate progression
- Inadequate playing surface: Hard or uneven terrain increases impact
Non-sporting causes
- Muscular imbalance: Imbalance between adductor and abdominal strength. When the adductors are stronger or tighter than the abdominals, the pubis suffers
- Lack of hip mobility: Joint stiffness forces compensation through other structures
- Poor posture and biomechanical alterations: Lumbar hyperlordosis, leg length discrepancy, flat feet
- Pregnancy: Hormonal changes and weight gain can cause pubalgia in pregnant women
Risk factors
- Previous history of groin injuries
- Weak or dysfunctional core
- Reduced adductor flexibility
- Training without adequate warm-up
- Inadequate or worn sports footwear
Diagnosis of pubalgia
Pubalgia diagnosis is fundamentally clinical, based on patient history and physical examination. Imaging tests complement the assessment.
Physical examination
The physiotherapist or doctor will perform:
- Palpation of structures: Identification of tender points in the pubis, adductors, and abdominals
- Specific tests: Adductor resistance tests (squeeze test), hip flexion against resistance test
- Mobility assessment: Range of motion of hips and lumbar spine
- Functional analysis: Observation of movement patterns, gait, and sporting gestures
Imaging tests
- X-ray: Shows bone alterations and irregularities in the pubic symphysis
- MRI: The test of choice. Shows the condition of muscles, tendons, and cartilage in detail
- Ultrasound: Useful for assessing tendon condition and guiding treatments
Differential diagnosis
It's important to distinguish pubalgia from other conditions with similar symptoms:
- Inguinal hernia: Unlike pubalgia, a hernia produces a palpable lump that increases with effort
- Hip involvement: Osteoarthritis, femoroacetabular impingement
- Lumbar pathology: Referred pain from the spine
- Urological or gynaecological problems: In some cases, other causes may need to be ruled out
An accurate diagnosis is essential for establishing appropriate treatment. If you have doubts, consult a professional.
Physiotherapy treatment for pubalgia
Conservative (non-surgical) treatment resolves approximately 90% of pubalgia cases. Physiotherapy is the fundamental pillar of this treatment.
Phase 1: Acute (1-2 weeks)
The goal is to reduce pain and inflammation without completely losing activity.
- Relative rest: Avoid activities that reproduce pain, but maintain gentle physical activity (walking, swimming). Absolute rest is not recommended as it can weaken the muscles
- Cryotherapy: Application of cold (15-20 minutes) after activity or when there is pain
- Manual therapy techniques: Gentle massage of peripheral muscles, hip mobilisations
- Electrotherapy: TENS, ultrasound, or anti-inflammatory currents depending on each case
Phase 2: Rehabilitation (2-8 weeks)
The goal is to restore strength, flexibility, and motor control of the area.
- Isometric work for adductors and abdominals: Exercises without joint movement to activate muscles without overloading the insertions
- Progressive stretching: Adductors, hip flexors, quadriceps
- Core strengthening: Essential for stabilising the pelvis and reducing tension on the pubis
- Proprioceptive work: Balance and postural control exercises
- Advanced manual therapy: Dry needling, myofascial techniques if trigger points are present
Phase 3: Sports readaptation (4-12 weeks)
The goal is to prepare the athlete to return to their activity safely.
- Specific functional exercises: Movements that mimic sporting gestures with progressive load
- Field training: Progressive running, direction changes, kicking (in ball sports)
- Preventive work: Exercises the athlete must maintain to prevent recurrence
- Gradual return to competition: First partial training, then complete sessions, finally matches
When to consider surgery
Surgery is reserved for cases that don't respond to conservative treatment after 6-12 months. Surgical techniques include repair of tendon insertions and, in some cases, nerve release. Post-surgical recovery also requires physiotherapy.
Important: This article does not include medication recommendations. Pharmaceutical prescription is exclusively the doctor's responsibility.
Rehabilitation exercises for pubalgia
These exercises form part of a typical rehabilitation programme. Before performing them, consult your physiotherapist to confirm they are appropriate for your recovery phase.
1. Adductor stretch (butterfly)
- Sit on the floor with the soles of your feet together and knees pointing outward
- Keep your back straight
- Gently press your knees towards the floor with your elbows
- Hold the position for 15-20 seconds
- Repetitions: 4 times, 3 times daily
2. Bridges (bridging)
- Lie on your back with knees bent and feet flat on the floor
- Raise your pelvis off the floor by contracting glutes and abdominals
- Hold for 2 seconds at the top
- Lower in a controlled manner
- Repetitions: 10-15 repetitions, 3 sets
3. Abdominal plank
- Support yourself on forearms and toes
- Keep your body in a straight line (without letting the lower back sag or raising the hips)
- Engage your abdomen as if bracing for impact
- Duration: 20-30 seconds, progressing to 60 seconds
- Sets: 3
4. Ball squeeze (adductor isometric)
- Lie on your back with knees bent
- Place a ball or cushion between your knees
- Squeeze the ball with both knees for 5 seconds
- Relax
- Repetitions: 10-15, 3 sets
5. Hypopressive exercises
- In quadruped position or standing
- Exhale all air and, without inhaling, open your ribs as if you wanted to breathe
- Hold the apnoea for 5-10 seconds
- Relax and breathe normally
- Repetitions: 3-5, once daily
Warning: These exercises are for guidance only. Progression, intensity, and exercise selection should be supervised by a professional according to your specific case.
Recovery time
Pubalgia recovery time varies according to severity and when treatment begins.
| Severity | Estimated time | Characteristics | |----------|----------------|-----------------| | Mild | 2-4 weeks | Pain only at the end of exercise, no functional limitation | | Moderate | 6-12 weeks | Pain during exercise, some limitation | | Chronic | 3-6 months | Persistent pain, significant limitation, possible need for advanced treatments |
Factors influencing recovery:
- Time elapsed since symptom onset: The sooner it's treated, the better the prognosis
- Treatment adherence: Following physiotherapist guidelines accelerates recovery
- Correction of risk factors: Working on muscular imbalances, improving sports technique
- Patience: Returning too early increases the risk of relapse
The good news is that 90% of cases resolve with conservative treatment without the need for surgery.
Prevention of pubalgia
Prevention is always more effective than treatment. These are the keys to reducing pubalgia risk:
- Adequate warm-up: Dedicate at least 10-15 minutes to preparing your body before training. Include hip mobility and core activation
- Preventive strengthening: Maintain a regular exercise programme for abdominals, adductors, and glutes. Force balance is fundamental
- Regular stretching: Work on flexibility of adductors, hip flexors, and posterior thigh muscles
- Correct sports technique: Good running, kicking, or direction-changing technique reduces stress on the pubis
- Adequate load progression: Increase volume and intensity gradually (10% rule: don't increase more than 10% weekly)
- Rest and recovery: Respect rest days. The body needs time to adapt
Frequently asked questions about pubalgia
How do I know if I have pubalgia?
The most characteristic symptom is groin pain that increases with physical activity, especially when running, kicking, or making hip rotation movements. There is usually also discomfort when lifting the leg against resistance. If pain persists for more than a week, it's advisable to consult a physiotherapist or doctor for an accurate assessment.
How long does pubalgia take to heal?
It depends on severity. Mild cases can resolve in 2-4 weeks with appropriate treatment. Moderate cases require between 6 and 12 weeks of rehabilitation. Chronic or long-standing cases may need 3-6 months. The key is to start treatment early and be consistent with exercises.
Can pubalgia be cured without surgery?
Yes, in the vast majority of cases. Conservative treatment (physiotherapy, exercises, activity modification) resolves approximately 90% of pubalgia cases. Surgery is reserved only for cases that don't improve after 6-12 months of properly managed treatment.
What is the difference between pubalgia and inguinal hernia?
Pubalgia is a musculotendinous injury that doesn't produce a visible lump. An inguinal hernia is a protrusion of abdominal contents through a weak point in the abdominal wall, which usually produces a palpable lump that increases when coughing or straining. Although both can cause groin pain, treatment is different. If you have doubts, consult a professional.
Can I continue doing sport with pubalgia?
It depends on the phase. In the acute phase, it's advisable to reduce activity and avoid movements that cause pain. However, absolute rest is not indicated. During rehabilitation, adapted physical activity (swimming, gentle cycling) that doesn't reproduce symptoms can be maintained. Return to sport should be progressive and guided by a professional.
Can pubalgia recur?
Yes, there is a risk of relapse if the factors that caused it are not corrected. That's why it's essential to complete rehabilitation, work on muscular imbalances, and maintain a preventive exercise programme. Athletes who have suffered pubalgia should pay special attention to warm-up and core work.
This article is for informational purposes and does not replace consultation with a healthcare professional. If you experience persistent pain, consult your doctor or physiotherapist for personalised diagnosis and treatment.
Article reviewed by Gemma Pastor Vila, Certified Physiotherapist No. 15434 at the Col·legi de Fisioterapeutes de Catalunya.
Suffering from pubalgia? We can help
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