Management of Sports Hernia
Surgical repair is the most effective treatment for sports hernia, with laparoscopic techniques generally enabling quicker recovery than open repair. 1
Definition and Clinical Presentation
Sports hernia (also called athletic pubalgia) is a condition characterized by chronic inguinal/pubic exertional pain without a palpable hernia, typically affecting high-performance male athletes. It is not a true hernia but rather an injury to the rectus abdominis insertion or weakness of the posterior inguinal wall.
Key features include:
- Most common in sports involving cutting, pivoting, kicking and sharp turns (soccer, ice hockey, football)
- Insidious onset, though a specific inciting incident may be identified
- Chronic groin pain exacerbated by activity
- Pain often radiates to adductor region, scrotum, or pubic symphysis
Diagnostic Approach
Diagnosis is primarily clinical, based on:
- History of activity-related groin pain unresponsive to conservative measures
- Physical examination findings may include:
- Pain with resisted sit-ups
- Pain with resisted hip adduction
- Tenderness at the pubic tubercle or rectus insertion
- Absence of a palpable hernia
- Pain with Valsalva maneuver
Imaging studies are mainly used to exclude other conditions:
- MRI may show rectus abdominis or adductor tendon injury
- Diagnostic ultrasound can help rule out true hernias
- Radiographs to exclude pubic symphysis arthropathy
Management Algorithm
1. Initial Conservative Management (Trial of 6-8 weeks)
- Rest and activity modification
- Physical therapy focusing on:
- Manual therapy (soft tissue and joint mobilization)
- Neuromuscular re-education
- Core strengthening
- Hip adductor stretching and strengthening
- Pelvic stabilization exercises
2. Surgical Management (if conservative treatment fails)
Surgical options include:
- Rectus abdominis reattachment (preferred approach)
- May include adductor release if adductor involvement is present
- Can be performed via open or laparoscopic approach
- Laparoscopic techniques generally enable quicker recovery 1
3. Post-Surgical Rehabilitation
- Gradual return to activities
- Progressive strengthening program
- Sport-specific training
- Return to sport typically in 6-12 weeks
Treatment Outcomes
Research shows that surgery is more effective than conservative treatment for sports hernias 1. In motivated patients, after surgical repair and proper rehabilitation, approximately 95% become pain-free and able to return to competitive sports 2.
A case series found that some athletes can successfully return to sport with conservative management alone, while others require surgical intervention followed by rehabilitation 3. The decision should be based on response to initial conservative management.
Important Considerations
- Sports hernia is often misdiagnosed or confused with other causes of groin pain
- The condition may be better described as a "syndrome of muscle imbalance of the groin" 4
- Causative factors likely include posterior inguinal wall weakening from excessive shear forces through poorly balanced hip adductor and abdominal muscle activation
- Multidisciplinary approach is recommended for optimal management
The most effective approach for managing sports hernia involves an initial trial of conservative treatment with physical therapy, followed by surgical intervention if symptoms persist, with appropriate post-surgical rehabilitation to ensure successful return to sport.