Editorial Commentary: Managing Hip Pain, Athletic Pubalgia, Sports Hernia, Core Muscle Injury, and Inguinal Disruption Requires Diagnostic and Therapeutic Expertise.

Pubalgia means pubic pain. This is different from core muscle injury (implying muscular pathology) or inguinal disruption (different anatomic region). Athletic pubalgia includes a myriad of pathologic conditions involving the pubic symphysis, adductors, rectus abdominis, posterior inguinal wall, and/or related nerves. Moreover, growing evidence supports a link between femoroacetabular impingement (FAI) and pubalgic conditions. Constrained hip range of motion in flexion causing obligatory transitory, even ballistic, posterior tilting of the hemipelvis may produce pathologic transfer stress to not only the pubic symphysis but the sacroiliac joint, lumbar spine, and proximal hamstrings, manifesting in diverse, often-painful, conditions. In select cases of pubalgia, patients may have clinical improvement with concurrent or even isolated treatment addressing FAI. Unlike atypical posterior hip pain from FAI, which may be referred pain that might respond favorably, albeit temporarily, to an intra-articular injection, secondary pubic pain from a transfer stress pathomechanism might not be expected to benefit from such. And, it's not always FAI. Some patients who do not respond to nonoperative management may not require arthroscopic surgery and might benefit from open or laparoscopic mesh hernia repair, adductor tenotomy, primary tissue (hernia) repair, rectus abdominis repair, or even endoscopic surgery for osteitis pubis and/or pubalgia. And, finally, these may be combined with FAI surgical treatment. Refinement of definitions, pathologic conditions, technical advances, and collaboration with general surgeons will best help us treat our patients.