Athletes know the story: a collision on the field, a hard tackle, a blunt hit to the groin, and in the days and weeks that follow — persistent pain that does not resolve with rest, ice, or time. Sometimes the pain appears acutely at the moment of injury, sometimes it emerges gradually as scar tissue forms around injured nerves in the weeks and months afterward. The condition is called athletic pubalgia, sports hernia, or sportsman’s hernia, and despite the “hernia” in the name, it is not a true abdominal hernia at all — it is most commonly an injury to the ilio-inguinal and genito-femoral nerves in the groin, producing chronic abdominal and groin pain that conventional hernia surgery cannot fix. Understanding the nerve-based pathophysiology is what separates effective surgical treatment from repeated unsuccessful interventions.

Dr. John Anastasatos treats athletic pubalgia and sports hernia at his Beverly Hills practice with academic and clinical authority specifically on peripheral nerve surgery — the discipline this condition actually requires. Dr. Anastasatos presented at Plastic Surgery Grand Rounds at the University of Alabama at Birmingham on “The Microsurgical Repair of Peripheral Nerves” in October 1999, completed a dedicated Hand, Upper Extremity, and Microsurgery Fellowship at UAB covering nerve anatomy and microsurgical repair technique, and completed his General Surgery residency at Columbia-Presbyterian Medical Center in New York — providing foundational training in the abdominal wall anatomy central to this condition. Board certified by the American Board of Plastic Surgery, a Fellow of the American College of Surgeons (FACS), and named by The Luxe Insider as one of the Top 10 Plastic Surgeons in the World.

Understanding Athletic Pubalgia

Athletic pubalgia is a classic example of a condition where the anatomical framework most patients and even many physicians assume does not match the reality of what is actually injured. The name “sports hernia” suggests a hernia — an abdominal wall defect — and the pain location in the lower abdomen and groin reinforces the impression. But the majority of athletic pubalgia patients do not have a hernia at all. They have sustained blunt trauma to the peripheral nerves that travel through the groin region: specifically, the ilio-inguinal nerve and the genito-femoral nerve.

This type of blunt injury is most likely to occur in athletes performing contact sports. In Dr. Anastasatos’s practice, athletic pubalgia has presented in football players, rugby players, hockey players, and fighters — athletes whose sports involve repeated blunt trauma to the pelvic and groin region. There may be other or additional causes of athletic pubalgia, such as tears of the muscle attachments of the anterior abdominal wall muscles to the pubic bones, and some patients have combined presentations. But the major causative entity of abdominal and groin pain in athletes — the element that repeated hernia surgeries fail to address — is injury to the nerves themselves.

Another similar entity in near anatomic vicinity is blunt injury to the lateral femoral cutaneous nerve, which causes pain and altered sensation in the anterolateral thigh. The diagnostic and treatment approach for these conditions shares the same core principle: identify the injured nerve, and treat the nerve directly rather than chasing secondary symptoms.

“The reason so many athletes come to me with persistent groin pain after failed hernia surgery is that hernia repair doesn’t address what’s actually wrong. These patients don’t have hernias — they have nerve injuries. The ilio-inguinal and genito-femoral nerves have been blunt-traumatized, and in the scar tissue that forms in the weeks and months after the injury, those nerves are compressed or entrapped. Until you decompress the nerve or release the scar tissue around it, the pain doesn’t stop. My peripheral nerve repair training at UAB is exactly the discipline that treats this correctly.” — Dr. John Anastasatos

The Two Stages of Nerve Injury

Any nerve in the body can be injured after blunt trauma and subsequently cause chronic pain. This occurs in two stages — and understanding the distinction is essential to understanding why timing matters in diagnosis and treatment.

Acute Stage

In the acute stage — the stage shortly after the blunt trauma or the injury — pain in the area of the nerve’s distribution can be due to acute inflammation around the injured nerve. At this early point, the pain is primarily inflammatory, and conservative treatment with rest, anti-inflammatories, and physical therapy may be effective for some patients.

Chronic Compression Stage

In the second and later stage, scar tissue forms around the nerve. This scar tissue may compress the nerve and act as a compression neuropathy — for years. If the trauma is severe, scar tissue can even form within the substance of the nerve itself; that entity is called a neuroma in continuity, and it represents a more advanced nerve injury requiring more detailed microsurgical intervention.

If left untreated, these conditions lead to many years of chronic pain and also loss of muscle strength, muscle atrophy and weakness, and loss of sensation in the nerve’s distribution. The natural course of untreated athletic pubalgia is not improvement — it is progressive symptomatic worsening.

Symptoms of Athletic Pubalgia

Patients with athletic pubalgia typically describe some combination of the following:

• Chronic Groin Pain: Persistent pain in the lower abdomen or groin that worsens with activity and does not resolve with rest.
• Pain With Sport-Specific Movements: Twisting, cutting, kicking, and sudden directional changes that reliably provoke the pain.
• Pain That Resists Conservative Treatment: Pain that does not meaningfully respond to rest, anti-inflammatories, and physical therapy over weeks to months.
• Failed Prior Hernia Surgery: Patients who have undergone conventional inguinal hernia repair without relief, often because the underlying nerve injury was not addressed.
• Loss of Muscle Strength: Weakness in the abdominal or adductor muscles served by the affected nerves.
• Altered Sensation: Numbness, burning, or tingling in the groin, lower abdomen, or medial thigh distribution of the affected nerve.

Who Is a Good Candidate for Nerve Decompression Surgery

Surgical treatment of athletic pubalgia is appropriate for patients whose presentation is consistent with nerve injury rather than simple muscular strain. Common candidates include:

• Athletes With Contact-Sport Injury History: Football, rugby, hockey, fighting sports, and similar activities involving blunt groin trauma.
• Persistent Pain Despite Conservative Management: Patients who have completed an adequate trial of rest, physical therapy, and anti-inflammatory treatment without resolution.
• Failed Prior Hernia Repair: Patients whose hernia surgery did not relieve their pain because the actual diagnosis was nerve injury rather than hernia.
• Nerve-Pattern Symptoms: Symptoms consistent with injury to the ilio-inguinal, genito-femoral, or lateral femoral cutaneous nerves rather than generalized groin musculoskeletal pain.
• Good Candidates for Outpatient Surgery: Patients medically fit for the outpatient procedure.
• Commitment to Post-Operative Recovery: Understanding that nerve function takes months to fully return after decompression.

What to Expect From Surgery and Recovery

Dr. Anastasatos performs athletic pubalgia surgery as an outpatient procedure. The operation involves identifying the injured nerve, freeing it from the scar tissue that has formed around it (a procedure called external neurolysis), and when necessary, addressing any neuroma in continuity that has developed within the nerve itself. Recovery is expeditious — patients typically return home the same day and return to light activity within days to weeks depending on the extent of the surgery.

Following nerve decompression of the scar tissue or the entrapment, nerve function takes months to return completely. The timeline is not immediate — nerves regenerate slowly, at roughly one millimeter per day — so patients should expect gradual, progressive improvement over the months following surgery rather than immediate resolution.

Critically, the sooner the problem is addressed, the higher the chances of complete recovery and symptom resolution. Patients who have lived with chronic athletic pubalgia for years have a different prognosis than patients identified and treated closer to their original injury. Early diagnosis and appropriate intervention materially affect outcomes.

Frequently Asked Questions About Athletic Pubalgia Treatment

How do I know if I have athletic pubalgia versus a true hernia?

A true inguinal hernia typically produces a palpable bulge and is identifiable on physical examination. Athletic pubalgia is not a true hernia — it produces pain without a bulge, often with specific movement patterns, and may show subtle findings on MRI. The evaluation at consultation distinguishes these clinically.

Why didn’t my previous hernia surgery work?

Because your actual diagnosis was likely athletic pubalgia with nerve injury, not a true hernia. Conventional hernia repair does not address nerve injury, so the underlying problem remains after the surgery. This is one of the most common reasons patients end up in Dr. Anastasatos’s office for nerve-focused evaluation.

How long until I can return to my sport?

The answer depends on the extent of the nerve injury, how long it has been present, and your specific sport. Most patients are progressively cleared for activity over several months, with full return to competitive contact sports typically at six months or later. Nerve function and strength continue to improve well beyond return to play.

Is nerve decompression surgery safe?

When performed by a surgeon with specific peripheral nerve training, yes. Dr. Anastasatos’s Hand, Upper Extremity, and Microsurgery Fellowship and academic presentations on peripheral nerve repair provide the specialized training this operation requires — training that general surgeons and orthopedic surgeons typically do not have.

What if my pain has been going on for years?

Treatment is still possible, but outcomes are generally better for patients treated earlier. Chronic compression and scar tissue formation within the nerve (neuroma in continuity) become more difficult to treat as time passes. The evaluation determines what stage of nerve injury exists and what surgical intervention is most likely to help.

Do all athletes with groin pain need surgery?

No — many cases of athletic groin pain resolve with conservative management. Surgery is appropriate for patients with persistent symptoms consistent with nerve injury after an adequate trial of non-operative treatment, or for patients whose prior surgical intervention did not resolve their pain.

Why Choose Dr. Anastasatos for Athletic Pubalgia Surgery

• UAB Plastic Surgery Grand Rounds on Microsurgical Peripheral Nerve Repair: Academic presentation at the University of Alabama at Birmingham specifically on the discipline this condition requires — a credential unique among plastic surgeons offering athletic pubalgia treatment.
• UAB Hand, Upper Extremity, and Microsurgery Fellowship: Dedicated fellowship training in microsurgery and peripheral nerve anatomy — the technical foundation for precise nerve decompression.
• Columbia-Presbyterian General Surgery Residency: Foundational general surgery training including abdominal wall anatomy and surgical technique relevant to the groin region.
• Board-Certified and FACS: Certification by the American Board of Plastic Surgery and Fellowship in the American College of Surgeons reflect rigorous, verified training.
• Combined Plastic Surgery and Nerve Surgery Expertise: Rare combination of training in both plastic surgery and the microsurgical nerve work specific to athletic pubalgia treatment.
• Outpatient Surgical Approach: Same-day discharge with expeditious recovery tailored to athletes’ active lifestyles.
• Experience With Athletes: Treatment experience across football, rugby, hockey, fighting sports, and similar contact-sport athletes.
• Top 10 International Recognition: Named by The Luxe Insider as one of the Top 10 Plastic Surgeons in the World.

Schedule Your Athletic Pubalgia Consultation in Beverly Hills

If you are an athlete with persistent groin or lower abdominal pain that has resisted conservative treatment — or if a prior hernia surgery did not relieve your pain — the problem is very likely peripheral nerve injury rather than a true hernia, and the surgical approach required is specifically nerve decompression rather than hernia repair. Dr. John Anastasatos welcomes patients to the Beverly Hills office at 436 North Bedford Drive, Suite 202, Beverly Hills, CA 90210, for a private consultation covering your injury history, current symptoms, appropriate diagnostic workup, and treatment options. Contact us at Los Angeles Plastic Surgery today to schedule your consultation with Dr. Anastasatos.