Sports Hernia: Symptoms, Types, Causes and Treatment

A sports hernia is a complex and often misunderstood injury that strikes athletes across a variety of sports, especially those that involve sudden twisting, turning, or kicking. Unlike traditional hernias, sports hernias do not involve a visible bulge or a true hernia, making diagnosis and management uniquely challenging. This article explores the symptoms, types, causes, and treatments of sports hernia, providing a comprehensive, evidence-based guide for athletes, clinicians, and anyone interested in the science behind this debilitating injury.

Symptoms of Sports Hernia

Recognizing a sports hernia can be tricky, especially since its symptoms overlap with many other causes of groin pain. This section introduces the key signs and symptoms to look out for, helping athletes and clinicians differentiate sports hernia from other injuries.

Symptom	Description	Typical Onset	Source(s)
Deep groin pain	Unilateral, deep pain often worsened by activity	Insidious or acute	1 3 5 4
Pain on movement	Aggravated by twisting, kicking, sprinting, or sit-ups	During sports	4 5 2
Tenderness	Palpable tenderness over pubic ramus or inguinal canal	On examination	1 5 4
Relief at rest	Pain subsides with rest or lay-off	After activity/rest	1 2 5

Table 1: Key Symptoms

Common Clinical Features

The hallmark of a sports hernia is chronic, deep groin pain that often begins insidiously, typically affecting one side. Unlike a classic hernia, there is no visible bulge, making physical examination and patient history crucial for diagnosis. The pain is usually exacerbated by specific movements such as:

• Twisting or turning at speed
• Kicking
• Sprinting
• Sudden directional changes

Athletes frequently report that symptoms worsen during play but improve with rest, only to return upon resumption of activity 1 2 3 5.

Physical Examination Findings

On examination, clinicians may observe:

• Tenderness at the superficial inguinal ring or posterior inguinal wall 1 5
• Palpable tenderness over the pubic ramus
• Pain that is reproduced by resisted hip adduction or abdominal curl-ups 5
• Occasionally, a subtle bulge or medial inguinal bulge may be detected on ultrasound, though this is not always present 2

Associated and Overlapping Conditions

Sports hernia can be part of a broader syndrome known as “groin disruption injury,” which may include:

• Osteitis pubis
• Adductor tendinopathy
• Conjoint tendon injury
• Obturator nerve entrapment 2 3 4

Because symptoms often overlap with other groin injuries, thorough evaluation is vital to avoid misdiagnosis.

Types of Sports Hernia

Although the term "sports hernia" is widely used, the injury itself is not a true hernia. Instead, it represents a spectrum of injuries involving the abdominal wall, inguinal region, and associated structures. This section highlights the main types and classifications found in the literature.

Type/Descriptor	Main Feature	Prevalence/Notes	Source(s)
Athletic pubalgia	Pain from abdominal wall/adductor muscle injuries	Common in athletes	4 7 10
Inguinal disruption	Abnormal tension/tearing at inguinal ligament	Preferred nomenclature	10 7
Posterior wall defect	Weakness/tear in posterior inguinal wall	Classic sports hernia	1 2 8
Concomitant pathologies	Adductor, tendon, nerve, or pubic bone involvement	Frequently co-occurring	2 3 4

Table 2: Types/Classifications of Sports Hernia

Athletic Pubalgia

Athletic pubalgia, often used interchangeably with "sports hernia," involves pain originating from injury to the abdominal wall muscles or the adductor tendons where they attach to the pubic bone. It does not require the presence of a true hernia and often includes radiating pain toward the perineum or proximal adductors 4 7.

Inguinal Disruption

Many experts now prefer the term "inguinal disruption" to describe cases where there is abnormal tension or microscopic tearing at the inguinal ligament or external oblique aponeurosis, without a true hernia sac being present 10. This term better captures the spectrum of injuries and tissue disruptions seen in athletes.

Posterior Wall Defect

The classic form of sports hernia involves a weakness or tear in the posterior wall of the inguinal canal, sometimes described as an "occult hernia" because there is no visible bulge but athletes experience significant pain 1 2 8. Surgical repair often targets this defect to restore stability.

Coexisting or Related Pathologies

Sports hernia may not occur in isolation. Frequently, it is part of a broader “groin disruption injury” complex that may include:

• Osteitis pubis
• Conjoint tendon injuries
• Adductor muscle or tendon tears
• Obturator nerve entrapment
• Femoroacetabular impingement (FAI) 2 3 4 9

Understanding these overlapping pathologies is crucial for effective diagnosis and management.

Causes of Sports Hernia

Why do some athletes develop sports hernias while others don’t? This section explores the underlying mechanisms and risk factors that contribute to the development of this injury.

Cause/Risk Factor	Mechanism/Description	At-Risk Population	Source(s)
Repetitive loading	Shear forces at pubic/inguinal attachments	Soccer, hockey, football players	2 3 7
Muscle imbalance	Poor balance between adductors and abdominals	Athletes with weak core	2 7
Pelvic instability	Excess motion at symphysis pubis, ligamentous laxity	Athletes, limb length discrepancy	2 7
Reduced hip mobility	Limited range of motion increases stress on groin	Those with FAI	2 9

Table 3: Common Causes and Risk Factors

Repetitive Athletic Movements

Sports hernias are most commonly seen in athletes who perform repetitive, high-intensity movements involving twisting, turning, kicking, and sudden acceleration or deceleration. These actions place repeated stress on the attachments of the abdominal muscles and adductors at the pelvis and pubic bone, leading to microtrauma and eventual tissue failure 2 3 7.

Muscle Imbalance and Poor Core Stability

An imbalance between the strength and activation of the hip adductors and the lower abdominal muscles can contribute to excessive shear forces across the pelvic attachments. This imbalance increases vulnerability to microtears and chronic pain 2 7.

Pelvic Instability and Biomechanical Factors

Pelvic instability, often due to ligamentous laxity, disc degeneration at the symphysis pubis, or even limb length discrepancy, can predispose athletes to sports hernia. Instability results in abnormal movement patterns and increased strain on the groin region 2 7.

Reduced Hip Range of Motion and FAI

Femoroacetabular impingement (FAI) restricts hip range of motion and increases stress on the extra-articular structures of the groin. This not only predisposes to sports hernia but also means that treatment of both FAI and sports hernia may be necessary for full recovery 9.

Additional Contributing Factors

• Accelerated disc degeneration of the symphysis pubis 2
• Para-symphyseal tendon tears and periosteal stripping 2
• Overuse and inadequate rest or recovery

Many of these factors interact, creating a “perfect storm” scenario for injury in high-performance athletes.

Treatment of Sports Hernia

Treating a sports hernia requires a comprehensive and often multidisciplinary approach. While conservative management may be effective for some, many athletes ultimately require surgical intervention. This section outlines the main treatment strategies and their outcomes.

Treatment Modalities	Description/Components	Expected Outcome	Source(s)
Rest and rehab	Rest, anti-inflammatories, targeted physiotherapy	May help mild cases	4 11 12
Manual therapy	Soft tissue/joint mobilization, neuromuscular re-ed	Recovery in some athletes	11 12
Surgical repair	Open or laparoscopic repair, mesh reinforcement	High return-to-sport rate	1 6 7 8
Multidisciplinary care	Combined ortho, surgical, physio management	Best outcomes in complex cases	9 10

Table 4: Main Treatment Strategies

Conservative Management

Rest and Physical Therapy

First-line treatment for sports hernia typically involves:

• Rest from aggravating activities
• Use of anti-inflammatory medications
• A structured physical therapy program focusing on core stabilization, pelvic control, and gradual return to sport 4 11 12

Physical therapy may include:

• Manual therapy (soft tissue/joint mobilization)
• Neuromuscular re-education
• Targeted stretching and strengthening exercises

Some athletes (especially those with milder symptoms or early-stage injuries) can return to sport with conservative management alone 11.

Injections

Occasionally, lidocaine or corticosteroid injections can help localize the pain source or provide temporary relief, but these are not definitive treatments 4 12.

Surgical Intervention

Indications for Surgery

Surgery is generally considered when:

• Symptoms persist despite several weeks or months of conservative care
• There is clear evidence of posterior wall defect or inguinal disruption on examination or imaging 1 4 7

Surgical Techniques

• Open or Laparoscopic Herniorrhaphy: Repair of the posterior inguinal wall, often with mesh reinforcement, is the gold standard for classic sports hernia 1 6 7 8.
• Maloney Darn Repair: Repair of the conjoint tendon, adductor tenotomy, or nerve release may be added for complex cases 2 4.
• Biologic Mesh: Laparoscopic mesh repair offers rapid recovery and has shown high rates of return to sport 6.

Outcomes

• Most athletes return to full activity within 4–12 weeks after surgery, depending on the technique and rehabilitation protocol used 3 6 2.
• Studies consistently report high rates of symptom resolution and return to pre-injury level of sport 7 8.

Multidisciplinary and Individualized Care

For best results, especially in athletes with coexisting pathologies like FAI, a multidisciplinary approach is recommended. This may involve:

• Coordination between orthopedic surgeons, sports physicians, and physiotherapists
• Simultaneous treatment of FAI and sports hernia when indicated 9 10

Rehabilitation and Return to Sport

Structured rehabilitation is essential after both conservative and surgical management. Components typically include:

• Core stabilization exercises
• Gradual progression of sport-specific drills
• Maintenance of hip and pelvic muscle balance
• Monitoring for recurrence or residual symptoms

Return to full sport is typically expected within 6–12 weeks post-surgery, with some surgical techniques allowing even earlier return 3 6 2.

Conclusion

Sports hernia remains a significant source of chronic groin pain in athletes, with a complex interplay of anatomical, biomechanical, and sport-specific factors. Understanding its symptoms, types, causes, and treatment options is essential for optimal recovery and prevention of recurrence.

Key Points:

• Sports hernia presents with deep, activity-related groin pain, often without a visible bulge 1 2 5.
• The injury includes various types, from athletic pubalgia to inguinal disruption, often overlapping with other groin pathologies 4 10 2.
• Causes are multifactorial, including repetitive shear forces, muscle imbalance, pelvic instability, and reduced hip mobility—particularly in sports requiring rapid directional changes 2 3 7 9.
• Treatment begins with rest and physical therapy but frequently requires surgical intervention for lasting symptom relief and return to sport 4 7 1 6.
• A multidisciplinary approach and individualized care plans are key to successful outcomes, particularly in athletes with complex or overlapping injuries 9 10.

By recognizing the nuanced presentation of sports hernia and applying evidence-based management, athletes can look forward to a timely and effective return to peak performance.