Sports Hernia (Athletic Pubalgia)

Despite its name, a “sports hernia” is not a true hernia but rather a painful soft tissue injury in the groin area. Unlike traditional hernias, it does not cause a visible bulge in the groin, and the affected tissues can vary in each case.

This injury may involve strain or tearing of any soft tissue such as muscles, tendons, or ligaments in the lower abdomen or groin. Since it is not a true hernia — that involves a protrusion of abdominal tissue (like intestine) through a weak spot in the abdominal wall — the term athletic pubalgia is often preferred for sports hernia.

Sports hernias involve a tear or strain in the groin or lower abdominal muscles, with the rectus abdominis and the adductor muscles being the most commonly affected. The rectus abdominis, located in the front of the abdomen, helps with trunk movement by attaching to the pubic bone. The adductor muscles, which extend from the pubic bone to the thigh, stabilize the pelvis and bring the leg towards the body’s midline.

In fact, the most common area of injury for “sports hernia,” is where the tendon of the rectus abdominis muscle joins the tendon of the adductor longus muscle above the pubic bone. This area, often referred to as the rectus-adductor aponeurosis, is where these tendons connect and form a shared attachment to the pubic bone. Injuries here are frequently seen in athletes due to the repetitive and forceful movements involved in sports.

A sports hernia most often happens to people who play sports that require sudden changes of direction or severe twisting movements, but you don’t have to be playing a sport to get sports hernia.

Sports hernias tend to happen in more vigorous sports like soccer, football, wrestling, and ice hockey. These sports involve twisting your pelvis when your feet are planted. This can cause the soft tissue of your groin or lower abdomen to tear.

Other situations that may cause this core muscle injury include:

• Forceful hip movements that you keep repeating. This includes, jumping, kicking, and twisting.
• Abdominal and hip exercises that are vigorous and unsafe
• Weak abdominal muscles
• Lack of proper sports conditioning
• A difference in strength between your abdominal and hip muscles

Sports hernias usually affect young men who play sports. Women get sports hernias too, but much less frequently.

A sports hernia typically causes severe and intense pain in the groin at the time of the injury.

The main symptoms of a sports hernia are the following:

• Sudden, severe groin pain: This is the primary symptom, often occurring during the injury.
• Pain relief with rest, return with activity: The pain typically subsides with rest but flares up during sports, especially with rotational movements.
• Pain on one side: The pain is more commonly felt on one side of the groin, rather than both.
• Tenderness: The affected area may be tender to the touch.
• No visible bulge (initially): Unlike inguinal hernias, a sports hernia doesn’t initially cause a noticeable bulge in the groin.
• Potential for inguinal hernia development: Over time, the weakened area can lead to a bulge as abdominal organs press against it.
• Risk of chronic pain and activity withdrawal: If left untreated, the pain can become chronic, leading to the athlete having to stop participating in sports.

A thorough medical evaluation is crucial for diagnosing a sports hernia due to the similarity of its symptoms to other groin injuries.

The diagnosis involves a patient medical history to understand the injury’s mechanism and the time frame of the injury (when it started and how it progressed), a physical examination focusing on the lower abdomen, pubic area, and legs, and potentially imaging tests such as X-rays or an MRI scan to confirm the diagnosis and rule out other conditions.

Sports hernias are treated with either conservative or surgical methods. Conservative treatment, which includes rest, ice, medication, and physical therapy, is successful in 90% of cases. If conservative treatment fails, surgery, which can be open or laparoscopic, may be necessary.

Conservative Treatment: 

• Rest: Stop physical activity for 7-10 days.
• Ice: Apply ice to the area to reduce inflammation and pain.
• Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) are used to manage pain and swelling.
• Physical Therapy: After two weeks, a physical therapy program helps restore mobility, strength, and flexibility.
• Duration: Many athletes return to sports after 8-12 weeks of physical therapy.

Surgical Treatment:

If pain persists or returns when resuming sports, surgery may be required. Surgery can be performed through open incision or laparoscopically. In some cases, a neurectomy of the ilioinguinal nerve may be needed to relieve pain. If pain continues after surgery, a partial release of the adductor tendon may be necessary.

A tailored physical therapy and rehabilitation plan is created after surgery, with most athletes returning to sports within 6-12 weeks after surgery.