Further insights in pubic-related groin pain : is an arcuate pubic ligament injury a possible cause of athletic pubalgia?

Athletic pubalgia remains one of the most challenging and poorly understood conditions in sports medicine, often described as the “Bermuda Triangle” of groin pain because of its complex anatomy, overlapping symptoms, and diagnostic uncertainty. While muscular and tendinous causes have been extensively investigated, the ligamentous structures of the pubic symphysis have historically received limited attention. This doctoral thesis investigates the hypothesis that injury to the inferior pubic ligament (IPL), also known as the arcuate pubic ligament, represents a distinct and clinically relevant cause of pubic-related groin pain in athletes. The research follows a multi-phase approach integrating clinical observation, systematic literature review, anatomical dissection, and imaging-based clinical investigation. It began with the documentation of a traumatic IPL rupture as a previously unrecognized source of athletic pubalgia, confirmed by magnetic resonance imaging (MRI) and successfully treated with targeted intervention. This observation motivated a comprehensive exploration of the anatomy and biomechanics of the pubic symphysis. A systematic review synthesized contemporary anatomical evidence and demonstrated that several long-standing assumptions regarding musculotendinous attachments are outdated. Subsequent cadaveric dissection studies provided updated topographical insights into the ligamentous and muscular architecture of the pubic region, clarifying the specific relationships of the IPL and its stabilizing role within the pelvic ring. Building on these anatomical findings, a clinical MRI study evaluated the prevalence and relevance of IPL injuries in athletes presenting with isolated pubic-related groin pain. The results revealed a substantial proportion of IPL lesions in this population, while such injuries were absent in a control group with adductor-related groin pain, supporting the specificity of IPL pathology. Furthermore, IPL injury was associated with delayed return-to-play, underscoring its functional and clinical significance. Collectively, this thesis establishes IPL injury as a distinct pathological entity contributing to athletic pubalgia. It bridges a critical gap between anatomy, imaging, and clinical practice, offering a refined diagnostic framework for pubic-related groin pain. These findings have important implications for early detection, targeted rehabilitation, and preventive strategies, and may extend beyond sports medicine to other populations with pelvic instability or chronic pubic pain. By redefining the role of pubic ligament injuries, this work advances both scientific understanding and clinical management of a complex and often debilitating condition.