Athletic Pubalgia (Sports Hernia)

Athletic pubalgia is one of the most common causes of chronic groin pain in athletes, and it is frequently misdiagnosed as a groin strain, osteitis pubis or hip pathology. Up to 30-50% of athletes with chronic groin pain have core muscle injury.

What it is. The term "sports hernia" is misleading, because there is no true hernia. The pathology is a tear or attenuation of the aponeurosis between the rectus abdominis and adductor longus at their pubic attachment. Accurate diagnosis requires MRI and a structured clinical assessment to differentiate it from intra-articular hip pathology, which demands a completely different treatment pathway.

What to call it. The Doha agreement went further than rejecting "sports hernia" alone: it retired "athletic pubalgia" as well, on the grounds that both labels assert a pathology that imaging and surgery frequently fail to confirm, and replaced them with the location the examination can actually establish, inguinal-related, pubic-related, adductor-related and iliopsoas-related groin pain, alongside hip-related and other causes. Quote the Doha entity in an exam and give the older label only as a gloss. Athletic groin pain develops the whole framework, including the iliopsoas- and hip-related entities.

Who. Incidence is 0.5-6% of athletes per year in kicking and cutting sports. Patients are overwhelmingly male, a ratio of approximately 10:1, with a peak at 20-35 years, the competitive sporting years. The sports are soccer, rugby, Australian rules football, ice hockey and tennis. 20-30% of cases are bilateral.

What it costs. The average time lost from sport is 6-12 weeks, and recurrence runs up to 20% without structured rehabilitation. The average delay to the correct diagnosis is 4-8 months. Professional athletes may require surgical intervention, and the cost in professional sport is significant because of the time away from play.

The pubic aponeurotic plate. The rectus abdominis and adductor longus share a common aponeurotic attachment on the anterior pubis. The rectus abdominis inserts on the pubic crest and symphysis, and the adductor longus originates from the inferior pubic ramus, so the two structures form a functional unit: the pubic aponeurotic plate.

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How it fails. Normally the rectus and adductor share a balanced load at the pubic aponeurosis. During twisting, kicking and cutting, opposing forces (the rectus pulling superiorly, the adductor pulling inferiorly) create shear stress at the aponeurosis, and repetitive loading from kicking, twisting and sprinting causes microtears, attenuation or frank disruption at the rectus insertion, the adductor origin, or both. The plate progressively loses integrity, and the result is pain with any activity that loads it: coughing, sit-ups, sprinting.

Why it is not a hernia. The posterior inguinal wall may be weakened, but no visceral structure protrudes. There is no true hernia.

Why it mimics other conditions. The pubic symphysis, hip joint and inguinal canal are within centimetres of one another, and athletes often have multiplanar groin pain that is hard to localise. Obturator nerve irritation from adductor pathology refers pain to the medial thigh. FAI or labral pathology and athletic pubalgia can coexist (the proportion, and what it means for surgery, is under Clinical Assessment), and pubic bone marrow oedema can be present in both athletic pubalgia and osteitis pubis.

There are two ways to classify the injury. By the structure injured, which guides surgical planning: isolated adductor pathology may respond to adductor release, while rectus tears may require direct repair or mesh reinforcement. And by the clinical pattern, which sharpens the differential: an acute adductor strain is sudden in onset and localised to the adductor longus, and osteitis pubis is bilateral, insidious and tender at the pubis.

History. The mechanism is repetitive overload from twisting, cutting, sprinting and kicking. The pain is deep in the groin and low abdomen, with perineal radiation; it is activity-related, improves with rest and recurs on return to sport. It is typically unilateral, and bilateral pain suggests osteitis pubis. Coughing, sneezing, sit-ups and resisted adduction provoke it; increased intra-abdominal pressure reproduces the pain. Ask about previous treatment: failed courses of physiotherapy, NSAIDs or rest.

Examination. There is no visible swelling and no inguinal lump, which is what separates this from a true hernia. Tenderness sits over the pubic tubercle, the rectus insertion and the adductor origin. The provocation tests are in the table below; the order in which to run them is the protocol.

The differential. Adductor longus strain is the most common athletic groin injury. The intra-articular hip causes are FAI, labral tear and early hip osteoarthritis. Nerve entrapment, obturator or genitofemoral, is the neuropathic cause and is taken separately below.

MRI pelvis, athletic pubalgia protocol. The first-line study: coronal, sagittal and axial T1 and T2 fat-suppressed sequences through the pubic symphysis and hips. Look for a rectus abdominis tear or oedema at the pubic attachment, adductor longus tendinopathy or partial avulsion, the secondary cleft sign (a fluid cleft inferolateral to the symphysis indicating capsular disruption), and the pattern of pubic bone marrow oedema. MRI is the gold standard, with sensitivity reported at 85-95% for core muscle injury.

MRI hip, FAI protocol. Add it for a positive FADIR test, limited hip internal rotation or deep anterior groin pain. Look for cam or pincer morphology, labral tear, chondral damage and ligamentum teres pathology.

Dynamic ultrasound. An adjunct: a Valsalva manoeuvre during real-time scanning of the inguinal canal assesses posterior wall deficiency and a true inguinal hernia. It is operator-dependent and less sensitive than MRI for rectus or adductor pathology; it excludes a true hernia and does not replace MRI for the diagnosis.

CT pelvis. For the patient who cannot have an MRI (pacemaker, metalwork artefact). Soft-tissue detail is poor compared with MRI, so it is less useful for the aponeurosis; its role is to exclude bony pathology, a stress fracture or pubic symphysis sclerosis.

The decision. Structured rehabilitation comes first for every patient. Surgery is for the athlete who is still in pain after that programme with the injury confirmed on MRI and the hip excluded, and the bilateral, pubic-tender athlete whose plate is intact has osteitis pubis, which is not a surgical condition.