Sports Hernia (Athletic Pubalgia)

What a sports hernia is

The pubic bone is a crossroads where the abdominal muscles pull upward and the adductor muscles of the inner thigh pull downward. Repeated twisting, kicking and rapid changes of direction put shearing forces across this area. In athletic pubalgia, the tendons, the lower abdominal wall (rectus abdominis insertion and inguinal canal floor) or the adductor tendons become strained, torn or weakened.

Unlike an inguinal hernia, there is no hole through which abdominal contents push, so there is no visible lump.

Sports hernia vs inguinal hernia

Symptoms

• deep groin pain or lower abdominal pain, usually on one side
• pain with sprinting, cutting, kicking, twisting and sit-ups
• pain that may spread to the inner thigh, or in men toward the testicle
• pain with coughing or sneezing in some
• improvement with rest, then recurrence when returning to sport
• tenderness at the pubic bone

Causes and risk factors

• sports requiring twisting, kicking and cutting: soccer, ice hockey, football, rugby, tennis, Australian rules football
• muscle imbalance between strong adductors and weaker abdominal muscles
• reduced hip range of motion, including femoroacetabular impingement
• overtraining and inadequate recovery
• male sex (much more common in men)

Diagnosis

Groin pain in athletes has many causes, often overlapping. A sports medicine doctor will:

• examine the pubic bone, inguinal canal, adductors and hip
• perform resisted sit-ups and adductor squeeze tests that reproduce pain
• check hip movement for impingement or a labral tear
• order MRI (often with an athletic pubalgia protocol) to show tendon injuries, bone edema at the pubis and hip problems
• use ultrasound to look for true hernias and dynamic changes

Other causes to consider: adductor muscle strain, osteitis pubis, hip osteoarthritis, a femoral hernia, stress fractures, nerve entrapment, and referred pain from the lower back. In men, testicular and urological causes are also considered.

Treatment

Non-surgical (first-line)

• relative rest from sprinting, cutting and kicking for several weeks
• physical therapy for 6 to 8 weeks or more, focused on core stabilization, hip and adductor strengthening, flexibility and gradual return to sport-specific movements
• ice after activity and NSAIDs such as ibuprofen at the label dose for short periods
• injections of corticosteroid in some cases

Many athletes return to sport without surgery.

Surgery

If symptoms persist after 2 to 3 months of good rehabilitation, or in elite athletes with clear structural injury, surgery may be recommended:

• repair and reinforcement of the lower abdominal wall, sometimes with mesh (open or laparoscopic)
• adductor tendon release or repair
• treatment of coexisting hip impingement when present

Most athletes return to full sport within 6 to 12 weeks after surgery, with high success rates.

Prevention

• core and hip strengthening, including adductor strengthening exercises (such as the Copenhagen adductor exercise), which reduce groin injuries in soccer players
• good warm-up and flexibility
• gradual increases in training load
• adequate recovery between sessions

Frequently asked questions

What is a sports hernia?

A sports hernia, or athletic pubalgia, is a strain or tear of the soft tissues in the lower abdomen and groin where muscles attach to the pubic bone. It causes groin pain during sports but, unlike a true hernia, usually has no visible bulge.

How do I know if I have a sports hernia?

Typical signs are deep groin or lower abdominal pain with sprinting, twisting, kicking or sit-ups, improving with rest and returning with sport, and no bulge. A sports medicine doctor can examine you, and MRI can confirm the injury.

Can a sports hernia heal without surgery?

Yes. Many sports hernias improve with several weeks of rest from aggravating activities and a structured physical therapy program focused on core, hip and adductor strength. Surgery is considered if pain persists after 2 to 3 months of rehab.

How long does a sports hernia take to heal?

With non-surgical treatment, many athletes return to sport in 6 to 8 weeks, though some take longer. After surgery, most return to full activity within 6 to 12 weeks, depending on the procedure and sport.

Is a sports hernia the same as an inguinal hernia?

No. An inguinal hernia is a weakness or hole in the abdominal wall allowing tissue to bulge through, causing a visible lump. A sports hernia is a soft tissue injury without a bulge, though the two can occur together.