In this article, Sports Hernia Specialist and Doctor William Brown (who successfully treats over 150 cases of the injury every year) covers everything you need to know regarding the dreaded groin pain:
- What it is
- How and where it happens in the body
- Proper diagnosis (and how to test for it yourself)
- Treating and curing it successfully without surgery (including a full rehab program)
A sports hernia (SH) is the term used to describe a painful injury to the soft tissues of the groin. You may also hear the terms Athletic Pubalgia (AP) or Inguinal Disruption (ID) used to describe the injury.
It occurs most often in athletes who participate in sports requiring quick changes in direction or fast twisting motions. Thus, it is very common in soccer, hockey, and rugby athletes.
Although an inguinal hernia (a “traditional” hernia) occurs in the same area, a sports hernia is a completely different injury.
- A traditional hernia is a defect in the abdominal wall that allows the intestines to pop out and created a bulge.
- A Sports Hernia is a tear or strain of the muscle, tendons, and ligaments of the lower abdominal wall, groin, and upper inner thigh. There is usually no bulge, but athletes experience pain and weakness that limits their ability to play.
Because of the complexity of the injury and lack of understanding about the injury (even by doctors and surgeons) many athletes have the injury misdiagnosed and treated inappropriately. The athlete therefore does not get better.
Understanding Where a Sports Hernia Happens
The muscles and soft tissues most commonly injured are lower abdominal wall, symphysis pubis, and the hip adductor tendons (soft tissues that attach to the inner thigh and groin).
These structures are damaged by the sheer forces involved with rapid changes in direction and twisting movements. These structures become overly stretched and even torn. This is one reason that stretching is not recommended during initial stages of rehabilitation (the proper rehabilitation method is explained further below).
What Exactly Causes a Sports Hernia?
As described above, sports that require a quick shift in direction or involve twisting at the hips are well-known to cause a sports hernia:
With that said, new research suggests that hip mobility issues, adductor (inner thigh) injuries, and sports hernias are all connected. As the muscles and tendons of the hips and inner thighs become tight, immobile, and dysfunctional, excessive stress is placed on the tendons of the pubic bone. Eventually this pressure becomes too much of a strain—and something tears.
Hip mobility issues increase the risk of a sports hernia injury. As the muscles and tendons of the hip become tight or the hip range of motion decreases because of hip impingement, the abdominal wall and adductor tendons are required to stretch further to compensate. This strains those structures makes them prone to injury. The injury can occur suddenly, but is more commonly repeated small injuries.
In other words, as athletes begin to lose mobility and a healthy range of motion in their hips, force is placed on surrounding musculature that isn’t designed to take such pressure. As the athlete continues to play, their hip “deformity” only gets worse and the much weaker abdominal wall and obliques are required to ‘pick up the slack’—but they just can’t, so they tear.
It is important to note that this is typically a slow process.
Sports hernias rarely occur due to an acute or sudden injury of soft tissues abruptly and completely tearing off of the bone.
What are the Common Symptoms of a Sports Hernia?
At the time of the actual injury, there is almost always severe pain in the groin. While the pain does usually get better with rest, it flares up again when athletes attempt to return to play. Undoubtedly, this is the most frustrating aspect for athletes—as soon as they try to begin playing again, the pain returns full force.
Unfortunately, a sports hernia does not produce any visible bulge like much more common inguinal hernias. This makes it very difficult to diagnose by medical professionals who are not specifically trained in dealing with sports injuries like athletic pubalgia. This is also a common cause of frustration as it is not uncommon for athletes to receive multiple improper or incorrect diagnoses.
Bottom line: the injury can cause chronic, unending pain that disables and prevents athletes from every playing again.
Properly Diagnosing Your Sports Hernia
There are several ways to diagnose whether or not you have a sports hernia:
- Self-test using the pubic-probe method
- Physical test performed by a doctor or physical therapist
- Imaging tests using MRI and dynamic ultrasound technology
For the first two diagnosis methods, a universal pain scale is used.
- 0 for a lack of tenderness (none)
- 1 for a slight degree of tenderness
- 2 for mild yet definite tenderness that can be reproduced
- 3 for a moderate level of tenderness (“okay, that hurts”)
- 4 for a severe level of tenderness (“that really hurts”)
- 5 for pain that is too severe to tolerate
Three areas are tested:
- Adductor tendon (inner thigh)
- Pubic symphysis (middle, lower groin)
- Inguinal floor on both sides (under the inguinal canal)
Using this scale, a sports hernia is suspected if tenderness along the inguinal floor is 3 or greater, and clearly higher than any pain felt in the adductor on the same side of the body. If the tenderness is rated at a 2 or lower, or adductor pain is clearly higher, other injuries are more likely.
While seated or standing, apply pressure to the pubic bone, inguinal area, and inner thigh. Using the scale above, determine whether a sports hernia is likely. If so, schedule a consultation with a top-rated sports doctor as soon as possible.
Physical Test Performed by a Doctor
Along with performing the “pressure point” test, a trained specialist will also evaluate other movements. Specifically, they will have you perform a resisted sit-up: a sit-up while they “push” you back down. If moderate to severe pain is felt, and pain is greater in the pubic area than in the adductors (using the pain scale above), the chance of a sports hernia is high.
There are two forms of imaging that can be used to help with the diagnosis process:
- Dynamic ultrasound
While an MRI can help to rule out other possible issues, it often requires a radiology expert trained in sports injuries to make a concrete diagnosis for AP. For this reason, an MRI alone is not typically recommended for a successful diagnosis, but rather to rule out other possibilities.
On the other hand, a dynamic ultrasound performed by a trained sports physician can help to pinpoint tears in the soft tissues of the groin. While performing the Valsalva maneuver (holding your breath and “pushing out” against your stomach), the surgeon will examine your groin and inguinal area.
Together along with a physical examination, these two imaging tests can help to provide a success diagnosis for AP with a high level of confidence.
Treating a Sports Hernia without Surgery
In some cases, treating a SH without surgery is possible. After an initial rest period of 7-10 days, a “core-focused” rehabilitation program begins. The rehabilitation program is a 10-week treatment process designed to restore balance and strength to the muscles of the hips, groin, and inner thighs.
It includes several different components:
- Myofascial release (foam-rolling)
- Static stretching and mobility exercises
- Strengthening exercises (three phases)
- Sagittal plane
- Frontal plane
- Transverse plane
Read through the complete rehabilitation program for a full break-down of the physical therapy process (and how to start it today).
Additionally, other physical therapy methods including platelet-rich plasma injections (PRP) have been shown to dramatically increase recovery times and success without the use of surgery.
Treating a Sports Hernia with Surgery
While physical therapy alone is successful at treating some cases of AP, surgery is required for others. The best way to avoid surgery is to begin the rehabilitation program immediately following initial rest after the injury. However, for some this will not be enough.
There are currently two forms of surgery:
- Minimal repair technique (Pure Tissue Repair)
While mesh is typically used for traditional hernias, it is now considered to be less ideal for the treatment of a SH. This is because there are large shearing forces in the groin—mesh is much more ideal for a “static” area such as along the abdominal wall.
On the other hand, the minimal repair technique utilizes a suture to repair the torn area. Athletes are able to return to play much quicker, and success rates are higher.
Above all else, if surgery is required make sure to select an approved sports hernia doctor that is trained at treating the injury. Many general physicians and surgeons simply are not trained to successfully treat the injury—in such cases the success rate of surgery is significantly lower.
For a complete, full-scale orthopedic review of the injury visit our clinical review page.