A sports hernia, medically termed athletic pubalgia, is a common injury primarily affecting athletes, causing persistent pain in the lower abdomen and groin. Despite its misleading name, the condition typically does not involve a true hernia—the protrusion of an organ or tissue through a muscle wall opening. Instead of a visible bulge, a sports hernia represents a soft tissue injury, specifically a strain or tear, to the muscles and tendons of the lower abdomen and groin. This injury is a major cause of chronic groin pain in sports involving intense physical exertion.
Understanding the Anatomy of the Injury
The injury occurs in the complex anatomy surrounding the pubic bone, a meeting point for several powerful muscles and tendons. This area is where the abdominal muscles, particularly the obliques, and the inner thigh muscles, known as the adductors, attach. A sports hernia involves damage to the integrity of the posterior wall of the inguinal canal, an area composed of the transversalis fascia and the conjoint tendon.
The conjoint tendon is the common insertion point for the internal oblique and transversus abdominis muscles. When excessive force is applied, this posterior wall can weaken or tear, a process sometimes called inguinal disruption. Unlike a true inguinal hernia, which involves abdominal contents pushing through a hole, a sports hernia is a tear within the soft tissues themselves, explaining the absence of an external bulge.
The forceful opposition between a strong adductor group, which pulls downward, and a comparatively weaker abdominal group, which pulls upward, creates significant shear stress across the pubic symphysis. This imbalance causes the tendons of the oblique muscles, which insert onto the pubic bone, to become especially vulnerable to strain or tearing. The tendons of the adductor muscles, which attach the thigh to the pubis, are also frequently stretched or torn in conjunction with the abdominal injury.
How Sports Hernias Develop and Manifest
Sports hernias result from chronic, repetitive trauma and high-stress movements that place extreme tension on the musculotendinous structures of the lower abdomen and groin. Activities that require forceful and explosive core contractions, twisting, kicking, and sudden changes in direction are common culprits. This mechanism explains why the injury is seen frequently in athletes participating in sports like ice hockey, soccer, rugby, and football.
The primary symptom is chronic, deep pain in the groin or lower abdomen that often develops gradually over time. This pain is typically made worse by physical exertion and is alleviated with rest. The discomfort can be sharp or burning and may radiate to the inner thigh, the testicles in men, or across the midline of the body.
Pain is commonly reproduced by actions that increase intra-abdominal pressure, such as coughing, sneezing, or performing a sit-up. This chronic pain distinguishes the condition from an acute muscle pull or strain, which usually resolves within a few weeks. The persistent symptoms resulting from the continuous cycle of micro-trauma often hinder an athlete’s ability to perform.
Why Diagnosis Can Be Difficult
Diagnosing a sports hernia can be challenging because the symptoms overlap with many other causes of groin pain, and there is no single definitive test. The diagnosis relies heavily on a thorough clinical assessment, including a detailed history of the injury mechanism and a physical examination. The clinician will typically perform maneuvers that reproduce the patient’s pain, such as resisted adduction or a sit-up against resistance, to pinpoint the affected area.
A physical examination is also performed to rule out a true inguinal hernia, as a palpable bulge is absent in a sports hernia. Imaging studies, such as Magnetic Resonance Imaging (MRI), are often used, not necessarily to confirm the sports hernia, but to exclude other pathologies that mimic the symptoms, including osteitis pubis, hip flexor strains, or labral tears. An MRI is the most effective imaging for soft tissues and can sometimes reveal subtle tears or inflammation in the tendons near the pubic bone.
However, imaging results can sometimes appear normal despite the patient experiencing significant pain, which contributes to the difficulty in diagnosis. The injury often involves functional problems and subtle micro-tears that may not create the clear structural changes easily visible on a standard scan. This highlights the necessity of a clinical diagnosis, where the patient’s history and physical findings are considered paramount.
Options for Treatment and Rehabilitation
Initial management of a sports hernia typically focuses on conservative measures to reduce pain and inflammation. This includes a period of rest from the aggravating activities, the application of ice, and the use of non-steroidal anti-inflammatory drugs (NSAIDs). Following the initial rest phase, a targeted physical therapy regimen begins, focusing on improving strength and flexibility.
Physical therapy aims to strengthen the core muscles, including the abdomen and lower back, and improve the flexibility of the adductor and hip muscles to correct the underlying muscle imbalance. While conservative treatment can resolve symptoms for some, particularly when the injury is mild, it frequently fails to provide a lasting solution for high-level athletes who need to return to intense activity.
If conservative treatment spanning several weeks does not resolve the pain, surgical repair becomes the most reliable option. The goal of surgery is to reinforce the weakened posterior wall of the inguinal canal and repair any torn tendons in the area. Procedures can be performed using either an open or a minimally invasive laparoscopic technique.
Following successful surgery, a structured rehabilitation program is required before an athlete can return to sport. Most athletes can expect a full return to their sport or activities within six to twelve weeks after the procedure. Rehabilitation involves gradually increasing the intensity of exercises to rebuild muscle strength and endurance, ensuring the repaired area can withstand the high forces of athletic competition.