The pain that takes the player off the field

Athletic pubalgia — chronic pain in the pubic symphysis region — is one of the most feared injuries among soccer players, runners, and athletes in sports involving sudden changes of direction, repetitive kicking, and acceleration/deceleration. The patient describes a deep, poorly localized pain that worsens with kicking, running, changing direction, or simply getting out of bed in the morning. Rest partially relieves it, but the pain returns at the first effort.

The pathophysiology involves mechanical overload at the insertion of the adductor longus and the lower rectus abdominis on the pubic symphysis, generating enthesopathy (inflammation of the tendinous insertion) and myofascial trigger points in the involved muscles. Treatment with direct needling of trigger points in the adductors and lower rectus abdominis, combined with electroacupuncture, may contribute to pain relief and to gradual return to sport within a progressive rehabilitation plan coordinated by the physician.

Pubalgia biomechanics and trigger points

  1. Adductor–abdominal conflict at the pubic symphysis

    The pubic symphysis is the convergence point of opposing forces: the adductors pull downward and laterally, while the rectus abdominis pulls upward. In activities involving kicking and running, this biomechanical "seesaw" overloads the tendinous insertions, generating repetitive microtrauma and chronic inflammation in the symphysis.

  2. Trigger points in the adductor longus

    The adductor longus is the muscle most frequently involved in pubalgia. Its trigger points refer deep pain to the inguinal region and the inner thigh. The referred pain may simulate testicular, urinary, or hip joint pathology — leading to unnecessary investigations when the myofascial component is not recognized.

  3. Lower rectus abdominis — the forgotten component

    Trigger points in the lower rectus abdominis refer pain to the suprapubic region and the lower abdomen. In athletes with pubalgia, involvement of the rectus abdominis is almost universal, but frequently underdiagnosed. Needling of these points is essential for complete resolution of the picture.

  4. Deep needling and electroacupuncture

    Needling of trigger points in the adductors longus and lower rectus abdominis with elicitation of a twitch response promotes immediate deactivation of trigger points. Electroacupuncture 2 Hz potentiates the local analgesic and anti-inflammatory effect, accelerating recovery from enthesopathy at the pubic symphysis.

Clinical data on pubalgia

5–18%
OF SPORTS INJURIES
correspond to pain in the inguinal/pubic region — pubalgia being one of the most prevalent injuries in soccer, hockey, and long-distance running
4:1
MALE-TO-FEMALE RATIO
reflects the male predominance, probably related to pelvic anatomy and greater participation in kicking and direction-changing sports
3–6
MONTHS OF LEAVE
is the average time described in the literature for return to sport with conventional conservative treatment; multimodal approaches including myofascial needling and structured rehabilitation are under investigation as possible adjuncts to optimize this process
85%
RETURN TO SPORT
is achieved with appropriate conservative treatment (including myofascial needling and progressive rehabilitation), avoiding the need for surgical intervention in the great majority of cases

Recognizing pubalgia

Critérios clínicos
07 itens

Athletic pubalgia \u2014 typical clinical pattern

  1. 01

    Deep pain in the pubic symphysis region, worse with kicking or running

  2. 02

    Pain that radiates to the inner thigh (adductor territory)

  3. 03

    Pain when getting out of bed or off the couch in the morning — morning stiffness

  4. 04

    Worsens with changes of direction, acceleration, and deceleration

  5. 05

    Tenderness on palpation of the pubic symphysis and the adductor insertion

  6. 06

    Pain when performing sit-ups or with Valsalva (coughing, sneezing)

  7. 07

    Relative improvement with rest, return of pain at the first effort

Myths and facts about pubic pain

Myth vs. Fact

MYTH

Pubalgia always needs surgery

FACT

The great majority of cases of athletic pubalgia respond to appropriate conservative treatment. Surgery (repair of the posterior wall of the inguinal canal or adductor tenotomy) is reserved for refractory cases after 4–6 months of optimized conservative treatment. Needling of trigger points in the adductors and rectus abdominis, combined with progressive rehabilitation, resolves most cases without need for surgery.

MYTH

Pubic pain in the athlete is always pubalgia — just rest

FACT

The differential diagnosis of pubic pain includes stress fracture of the pubic ramus, inguinal hernia, hip pathology (femoroacetabular impingement), infectious osteitis pubis, and urinary pathology. Careful clinical examination by the physician — and when necessary, MRI — is essential to exclude causes that require specific treatment.

MYTH

Intense stretching of the adductors resolves pubalgia

FACT

Aggressive stretching of adductors with active trigger points can actually worsen the pain and perpetuate the cycle of irritation. The correct approach is first to deactivate the trigger points with needling, then gradually introduce eccentric strengthening exercises and, finally, progressive mobility. The order matters: first treat, then strengthen, then stretch.

The pubic seesaw no one examines

Treatment protocol

Assessment and differential diagnosis
1st visit

Clinical exam: palpation of the pubic symphysis, resisted adduction test, squeeze test. Exclusion of inguinal hernia, stress fracture, and hip pathology. Pelvic MRI when necessary. Mapping of trigger points in the adductors, lower rectus abdominis, and iliopsoas.

Needling of the adductors and rectus abdominis
Sessions 1–4

Deep needling of trigger points in the adductor longus (proximal insertion and muscle belly), gracilis, and lower rectus abdominis. Electroacupuncture 2 Hz for local analgesic effect. Avoidance of activities involving kicking and running during this phase — pool exercise allowed.

Progressive rehabilitation
Sessions 5–8

Introduction of eccentric strengthening exercises for the adductors (adapted Copenhagen protocol). Strengthening of the deep abdominal core (transversus abdominis). Maintenance needling as needed. Initiation of straight-line running with gradual progression.

Return to sport and prevention
Sessions 9–12

Progression to training with change of direction and kicking. Prevention program: strengthening of the adductors and abdominal core 3x/week. Monthly maintenance sessions during the competitive season. Full return to sport is authorized when the athlete is asymptomatic in all sport-specific activities.

Clinical pearl: the squeeze test

Scientific evidence

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 03

Frequently Asked Questions

Activities that reproduce the pain (kicking, running, changes of direction) should be temporarily suspended during the initial phase of treatment. Pool exercises, stationary cycling without load, and upper-body strengthening are generally well tolerated. Return to sports activities is progressive and individualized by the physician.

With optimized treatment including myofascial needling and progressive rehabilitation, most athletes return to full training in 6–10 weeks. The return criterion is functional: absence of pain in all sport-specific activities, including maximum-intensity kicking and sudden changes of direction.

Without appropriate treatment, pubalgia can become chronic and lead to prolonged absences. Factors that favor chronicity include: early return to sport before complete resolution, failure to treat the myofascial component (trigger points in the adductors and rectus abdominis), and failure to correct the adductor/abdominal strength imbalance. Early and complete treatment is the best prevention.