What is a Sports Hernia (Athletic Pubalgia)?
A sports hernia, more accurately termed "athletic pubalgia," is chronic lower abdominal and groin pain caused by weakening or tearing of the abdominal wall musculature without an actual hernia present 1, 2.
Definition and Pathophysiology
Athletic pubalgia represents a set of pelvic injuries involving the abdominal and pelvic musculature around the pubic symphysis 3. The condition develops from:
- Muscle imbalance and continuous sports-related microtrauma to the groin area 4
- The pubis acting as a pivot point between abdominal muscles and lower-extremity adductors, creating mechanical stress 1
- Progressive injury that starts localized in groin soft tissues (sports hernia phase) and can advance to involve the pubic bone (athletic pubalgia phase) 4
This is NOT a true hernia - there is no fascial defect or protruding tissue 1, 2.
Clinical Presentation
Primary Symptoms
- Groin and lower abdominal pain that can radiate toward the perineum and proximal adductors 1
- Pain exacerbated by athletic activities: kicking, cutting, sprinting 1
- Symptoms may appear acutely or insidiously 1
Physical Examination Findings
- Tenderness over the pubic symphysis or surrounding structures 1
- Pain reproduced with resisted sit-up 1
- Pain with forced cough or sneeze 1
- Pain with resisted hip adduction 5
- Absence of palpable hernia 5
Critical Diagnostic Consideration
You must evaluate for coexisting femoroacetabular impingement (FAI) syndrome, as hip-related pain frequently coexists with athletic pubalgia and both must be addressed for successful return to sport 6, 1. The 2020 British Journal of Sports Medicine consensus guidelines emphasize that hip-related pain can be difficult to distinguish from other groin pain causes and often coexists 6.
Diagnostic Approach
Clinical history and physical examination remain the cornerstone of diagnosis 4, with imaging serving as an auxiliary tool:
- MRI helps rule out other pathologies and can identify rectus abdominis or adductor tendon tears/strains 1
- However, MRI findings may be present in asymptomatic athletes, so clinical correlation is essential 4
- Lidocaine injections can localize the pain source 1
Common Pitfalls
- Misdiagnosing as a true inguinal hernia when none exists
- Failing to identify coexisting FAI syndrome, which will prevent successful return to sport even after pubalgia repair 1
- Over-relying on imaging findings without strong clinical correlation 4
- Referring for hernia surgery based solely on imaging-detected inguinal abnormalities when musculoskeletal pathology is the actual cause 7