Athletic Groin Pain (Sports Hernia/Athletic Pubalgia)

Athletic groin pain (also termed athletic pubalgia or sports hernia) describes chronic groin pain in athletes that interferes with sport participation. The term "sports hernia" is a misnomer - most cases do not have a true hernia but rather musculotendinous injury or pubic symphysis pathology.

Key epidemiological features (prospective surveillance):

• Burden: hip/groin injuries are 12-16% of all time-loss injuries in men's professional football, with a consistent incidence over time (UEFA injury studies — Werner 2009, PMID 19945984; Werner 2018, PMID 29691289)
• Commonest entity: adductor-related injury accounts for ~63% of hip/groin injuries in elite football (Werner 2018, PMID 29691289)
• Sports: soccer/football, ice hockey, rugby codes, Australian Rules Football and other change-of-direction sports
• Mechanism: kicking, rapid acceleration/deceleration, change of direction
• Chronicity: often insidious onset, chronic by the time of presentation; mean absence ~15 days per injury with ~15% re-injury in elite football (Werner 2009, PMID 19945984)

The Doha Agreement (2014):

The Doha agreement on terminology and definitions in groin pain in athletes established a standardized classification system to replace the confusing historical terminology (Gilmore's groin, sportsman's hernia, hockey groin syndrome, etc.).

Relevant anatomy:

The pubic symphysis is the fibrocartilaginous joint connecting the left and right pubic bones. It experiences significant shear and compression forces during athletic movements.

Key muscular insertions:

• Adductor longus - Primary pain generator (inserts on anterior pubic body)
• Gracilis - Medial aspect of groin
• Rectus abdominis - Superior pubic insertion
• External oblique - Forms anterior inguinal canal wall
• Transversalis fascia - Posterior inguinal canal wall

Biomechanics of kicking:

During the soccer kick:

1. Wind-up phase: Hip extension, adductors eccentrically control abduction
2. Acceleration phase: Rapid hip flexion, adductors co-contract
3. Deceleration phase: Peak adductor load - eccentric lengthening to control leg
4. Follow-through: Continued eccentric adductor demand

The deceleration phase generates the highest forces on the adductor longus enthesis.

The Doha agreement (2014) established a clinical entity-based classification system for groin pain in athletes.

The four tabs above mirror how athletic groin pain is usually taught, but the Doha agreement actually defines four clinical entities — adductor-, iliopsoas-, inguinal- and pubic-related — alongside the separate hip-related and "other" categories. Iliopsoas-related pain is the entity most often omitted, yet in the seven-season UEFA surveillance it was the second most common specific diagnosis after adductor-related injury (iliopsoas-related injuries were the next most frequent diagnostic group; Werner 2009, PMID 19945984). It is included here to complete the taxonomy because it changes the examination and is a common reason a "treated" adductor or pubic case fails to settle.

History taking:

Physical examination sequence:

Differential diagnosis of groin pain in the athlete:

The Doha categories sit within a wider differential. Beyond the four musculoskeletal entities, the surgeon must actively exclude non-musculoskeletal and serious causes — many a "groin strain" has turned out to be a femoral neck stress fracture, hernia or intra-abdominal pathology.

Recurrent groin pain:

The most common "complication" is recurrent or persistent groin pain. Causes include:

• Inadequate rehabilitation (did not complete Copenhagen protocol)
• Premature return to sport (return before strength normalized)
• Missed hip pathology (FAI driving adductor overload)
• Wrong diagnosis (another cause of groin pain)
• Chronic pubic pathology (osteitis pubis takes months to resolve)

Prevention strategies:

• Structured return to sport criteria
• Ongoing maintenance strengthening
• Training load monitoring (acute:chronic ratio less than 1.5)
• Biomechanical assessment and correction
• Early recognition and treatment of recurrent symptoms

General rehabilitation principles across all procedures:

Conservative management outcomes:

Surgical outcomes:

Primary prevention in athletes:

Return to sport criteria:

Objective criteria before full return:

1. Pain-free with all sport-specific movements
2. Adductor strength greater than 90% of contralateral
3. Adductor:abductor ratio greater than 80%
4. Functional tests passed (sprint, cut, kick)
5. Graded training progression completed without symptoms

Athletic groin pain is a global problem of multidirectional field and court sports. The strongest epidemiological data come from prospective football (soccer) surveillance, but the principles apply to ice hockey, rugby codes, Australian Rules Football, Gaelic games and other change-of-direction sports.

Global epidemiology (PMID-backed):

Across these datasets the message is consistent: hip and groin complaints account for roughly one in eight time-loss injuries in men's professional football, adductor-related pain is by far the most common single diagnosis, and the burden has not fallen despite a modest decline in incidence — making prevention and accurate sub-classification a priority worldwide.

Where guidance converges and diverges:

There is broad international agreement on the core pathway: unified terminology (Doha), active exercise rehabilitation first, imaging to characterise rather than screen, and surgery only after a failed adequate conservative trial. Genuine practice variation centres on: (1) the threshold and technique for surgical repair of inguinal-related (so-called sports hernia) pain — open minimal repair, modified open repair, or laparoscopic/endoscopic repair, with no high-level head-to-head RCT establishing superiority; and (2) the role of adductor tenotomy, which remains controversial with variable reported outcomes.

Registry note: unlike arthroplasty, athletic groin pain has no implant joint registry. The closest registry-grade evidence is prospective injury surveillance (UEFA Elite Club Injury Study and similar national datasets), which functions as the field's outcome registry and is the source of the epidemiology above.

Global practice variation and resource setting: