Athletic Groin Pain—Beyond the Pubic Symphysis

Summary: Expanding your search field from nipples to knees ensures accurate diagnosis, helping athletes avoid unnecessary surgery and return to peak competition faster.

Mimic Me: Athletic groin pain is oft misattributed to the classics—a hernia or lesion that delays return-to-play or speeds up surgical referral. In pro sports especially, the concept of the core extends far beyond the pubic symphysis—from the nipples to the knees, front and back, Adam C. Zoga, MD, reiterated at ARRS26. Did that MRI at the pubic symphysis come back negative? Time to evaluate your surroundings…

• Tennis Tear: Forceful contraction during the follow-through of an overhand serve can cause lower rectus abdominis tears.
• Knee to Know: An NFL quarterback diagnosed on the field with pubalgia actually suffered a distal adductor strain further down the thigh (requiring 2 weeks rest, instead of surgery.)
• Outfielder’s Back: A rare quadratus lumborum strain caused by tracking fly balls, presenting as diffuse pelvic pain.
• Weird Flex: A gymnast with suspect hernia was found to have a grade 2 iliacus muscle strain. Sartorius strains masquerade as core injuries, too.
• Hip Pointer: Direct impact to the anterior pelvis in quarterbacks, which represents an external oblique avulsion.
• SuperSonics: An NBA player flown across the country for specialized core surgery really had a rectus femoris avulsion from the AIIS.

Because standard pelvic protocols are blinded on the periphery, Dr. Zoga moves the phase-array torso coil directly over the localized area of maximal pain, rather than centering strictly on the pubic symphysis.

• Run both fat-suppressed and non-fat-suppressed sequences to delineate subtle avulsions and straining.

Postop Points:

• Aponeurotic Reinforcement: Verify structural support along the lateral margin of the rectus abdominis and external oblique aponeurosis.
• Cleft Sign & Osteitis Pubis: Confirm size reduction of the former, as well as improvement in the latter.
• Adductor Hematoma? If an adductor muscle release was performed, don’t be surprised to see a hematoma within that compartment.