Sports hernia

SPORTS HERNIA

Sports hernia (often described within the spectrum of rectus abdominis–adductor longus aponeurotic injuries, athletic pubalgia, “sports hernia” or core muscle injury) is a cause of chronic groin and pubic pain in athletes. It arises from overload and microtrauma at the common attachment of the lower abdominal muscles (rectus abdominis) and the adductor tendons on the pubic bone. Athletes typically experience pain in the lower abdomen, pubic region and/or medial thigh that is aggravated by sprinting, cutting, kicking, sudden trunk rotation or resisted sit-ups and adduction.

This syndrome is particularly common in sports that involve rapid changes of direction, acceleration–deceleration, repeated kicking and powerful trunk rotation, such as football (soccer), ice hockey, rugby, basketball, tennis and athletics. The Doha agreement on groin pain in athletes highlights adductor-related and pubic-related groin pain as distinct clinical entities, into which sports hernia often fits. Without a clear diagnosis and a structured rehabilitation plan, symptoms can become long-standing, with recurrent pain episodes every time training loads are increased, potentially affecting performance and availability for sport.

From overload to insertional tendinopathy

In sports hernia, the common aponeurotic plate where the rectus abdominis and adductor longus attach to the pubic bone is subjected to repetitive traction, shear forces and microtears, leading to insertional tendinopathy and, in some cases, associated osteitis pubis. Athletes often report insidious onset of pain that initially appears after intense training or competition and then gradually comes on earlier with lower loads, sometimes even during daily activities. Pain is usually localised to the pubic symphysis or slightly lateral, may radiate into the adductors or lower abdominal wall and is frequently aggravated by coughing, sneezing, resisted sit-ups, cutting and strong adduction efforts.

Clinical examination focuses on palpation of the pubic symphysis and rectus-adductor aponeurosis, resisted tests for the adductors and lower abdominals, and assessment of lumbopelvic control and hip strength. MRI and ultrasound can demonstrate signal changes and partial avulsions at the rectus abdominis–adductor longus attachment, as well as pubic bone marrow oedema or secondary cleft signs, helping to differentiate this condition from hip joint pathology, inguinal hernia or isolated adductor strains. Diagnosis is ultimately based on a combination of history, examination and imaging and cases are commonly categorised within adductor-related and pubic-related groin pain according to the Doha consensus framework.

Load management and exercise planning

Conservative management of sports hernia relies on a structured, stepwise approach combining load management, targeted exercise and, when needed, adjunctive symptom-relief strategies. Contemporary literature on groin pain in athletes recommends starting with non-operative care, focusing on strengthening the adductors and core, improving lumbopelvic control and progressively re-introducing sport-specific movements. Early stages usually involve temporarily reducing high-load activities such as sprinting, cutting and powerful kicking while introducing lower-load exercises for hip mobility, trunk stability and gentle adductor activation within a tolerable range.

As symptoms settle, rehabilitation advances to more demanding strengthening (including isometric, concentric and later eccentric work for the adductors and abdominals), dynamic lumbopelvic control drills in running and change-of-direction patterns and ultimately high-speed sport-specific tasks guided by objective progression criteria rather than time alone. For athletes who remain significantly limited despite well-delivered conservative care, options such as targeted injections or surgical repair of the rectus abdominis–adductor longus aponeurosis may be considered. In those cases postoperative physiotherapy following similar graded-loading principles is crucial for a safe and successful return to play.

Frequently Asked Questions

In simple terms, what is Sports hernia?
It is an overload-related injury at the common attachment of the lower abdominals and adductor tendons on the pubic bone, causing chronic groin pain in athletes.
In which sports is it most common?
Especially in football (soccer), hockey, rugby, basketball, tennis, athletics and other sports with frequent cutting, sprinting and kicking.
How is it different from a simple adductor strain?
A strain usually affects a single muscle acutely, whereas this syndrome involves the rectus–adductor aponeurosis and often the pubic symphysis, leading to more persistent, central groin pain.
What symptoms should raise suspicion of this syndrome?
Lower abdominal or pubic pain that worsens with sprinting, cutting, kicking, sit-ups or strong adduction and tends to linger after training.
What does physiotherapy usually involve?
A mix of core and adductor strengthening, hip mobility work and graded re-exposure to high-speed, change-of-direction and kicking tasks.
How long does conservative rehab typically take?
It often spans several weeks to a few months, depending on symptom duration, sport level and adherence to the rehabilitation plan.
Is there anything I can do to help prevent it?
Gradual load progression, maintaining strong adductors and core and managing spikes in training volume or intensity may help lower the risk.
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