Sports Hernias

Ovid: 5-Minute Sports Medicine Consult, The

Sports Hernias
Aaron Lee
William W. Briner Jr.
  • The sports hernia is a syndrome of chronic pain owing to weakness or injury to the posterior inguinal canal, conjoined tendon, and common adductor origin.
  • Described as a “phenomenon of chronic activity-related groin pain that is unresponsive to conservative therapy and significantly improves with surgical repair” (1)[C]
  • Historically, it was considered to be an early direct inguinal hernia, but more recently this has been called into question because there is no palpable hernia on physical exam, and hernia has not been evident at surgery in these patients. Thus the term sports hernia may in fact be considered a misnomer (1,2,3)[C].
  • Synonym(s): Athletic pubalgia; Sportsman's hernia; Inguinal ligament sprain; Gilmore groin; Footballer's groin/hernia
  • Unknown; far more common in soccer players
  • Also described in football, hockey, and baseball players in the U.S. and rugby players abroad
  • Predominant gender: Males account for >90% of cases.
Risk Factors
Activities with high-speed twisting and turning, such as soccer and rugby
General Prevention
Strength and conditioning programs that stress flexibility, core strength and sport specific movements have been suggested. There may be a strength imbalance of musculature below the pubic symphysis over muscles above, so abdominal oblique and rectus strengthening may be beneficial, however research is currently lacking (1)[C]
Pathogenesis is unclear but:
  • May involve some aspect of congenital inguinal wall weakness
  • Likely related to overuse with some combination of muscle strength, balance, stability, or endurance inequality between the abdominal musculature and the adductor muscle group
  • A resulting tear in the rectus complex and conjoined tendon may extend into the internal or external ring of the inguinal canal, causing pain and weakness and contributing to the sports hernia.
Commonly Associated Conditions
Groin pain is often multifactorial. In particular, chronic adductor strain may coexist with athletic pubalgia.
  • Early in course, groin pain is felt after activity or toward the end of activity.
  • As condition progresses, pain is more severe and occurs earlier in activity. Decreased ability to twist, turn, or stride out is observed. Later in course, pain occurs with running and may progress to affect daily activities.
  • Pain may radiate to uninvolved side or scrotum.
  • Painful intercourse
  • Pain with coughing/Valsalva maneuver
  • Often more intense and felt more “internally” than groin strains
  • Resolves with prolonged abstinence from training but recurs with return to activity
  • Groin pain with exercise
  • Exacerbated by sudden movements
  • Usually unilateral
  • Often insidious in onset but may occur after sudden tearing sensation
  • Chronic in nature; may progress to affect daily activities, even getting out of bed
  • In soccer players, pain worse with long kicks and hard shots
Physical Exam
  • Inversion of scrotal skin and palpation along inguinal canal is the essential physical exam technique.
    • Most tender posteriorly in midinguinal canal and at pubic tubercle
    • Dilated superficial ring
    • Inguinal floor tear that may be palpable and cause tenderness inside the external inguinal ring
    • Pain worse with Valsalva or sit-ups, with minimal bulging occasionally palpable
  • Lack of palpable hernia
  • Also have tenderness of the conjoined tendon
  • Hip adductor origin tenderness and pain with resisted adduction suggest chronic adductor strain.
  • Careful hip/genitourinary exam should be performed.
  • Palpate pubic symphysis for tenderness that would be consistent with osteitis pubis.
Diagnostic Tests & Interpretation
  • There is no diagnostic imaging test for athletic pubalgia. Imaging studies likely will all be negative if this is the lone diagnosis.
  • Primarily to rule out other causes of chronic groin pain
  • Plain films to rule out fracture and pubic symphysis asymmetry
  • P.553

  • Bone scan/CT scan may identify stress fractures, osteitis pubis.
  • MRI/MR arthrography may be helpful to identify muscle, tendon, or intraarticular pathology.
  • MRI survey of the pelvis is recommended initially to identify areas of possible pathology that allow a more specific, high-resolution, small field of view study to take place (3)[C].
  • US is emerging as a diagnostic tool, particularly in Europe, but it is highly operator-dependent; allows dynamic visualization of tissues.
  • Herniography used in Europe
Differential Diagnosis
  • Inguinal hernia
  • Chronic adductor strain
  • Chronic rectus abdominis strain
  • Bursitis: Especially iliopectineal bursa
  • Ilioinguinal nerve entrapment
  • Snapping hip syndrome
  • Femoral hernia
  • Femoral neck stress fracture
  • Pubic ramus fracture
  • Osteitis pubis
  • Intraarticular hip pathology
  • Testicular/ovarian pathology
  • Referred pain from herniated disk or spondyloarthropathy
  • Chronic groin pain is often multifactorial. Sports hernia often coexists with one or more of these diagnoses owing to the close proximity of anatomic structures.
848.8 Other specified sites of sprains and strains

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