Sports Hernia: Diagnosis

and Therapeutic Approach

Adam J. Farber, MD Abstract

John H. Wilckens, MD
Dr. Farber is Chief Resident,
Department of Orthopaedic Surgery,
Johns Hopkins Hospital, Baltimore, MD.
Groin pain is a common entity in athletes involved in soccer, ice
hockey, Australian Rules football, skiing, running, and hurdling.
An increasingly recognized cause of groin pain in these athletes is a
sports hernia, an occult hernia caused by weakness or tear of the
posterior inguinal wall, without a clinically recognizable hernia,
that leads to a condition of chronic groin pain. The patient
typically presents with an insidious onset of activity-related,
unilateral, deep groin pain that abates with rest. Although the
physical examination reveals no detectable inguinal hernia, a
tender, dilated superficial inguinal ring and tenderness of the
posterior wall of the inguinal canal are found. The role of imaging
studies in this condition is unclear; most imaging studies will be
normal. Unlike most other types of groin pain, sports hernias rarely
improve with nonsurgical measures; thus, open or laparoscopic
herniorrhaphy should be considered.

Dr. Wilckens is Chairman, Department of
Orthopaedic Surgery, Johns Hopkins
Bayview Medical Center, and Assistant
Professor, Department of Orthopaedic
Surgery, Johns Hopkins University,
Baltimore.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Farber and Dr. Wilckens.
Reprint requests: Dr. Wilckens, c/o
Elaine P. Henze, BJ, ELS, Medical Editor,
Department of Orthopaedic Surgery,
Johns Hopkins Bayview Medical Center,
4940 Eastern Avenue #A672,
Baltimore, MD 21224.
J Am Acad Orthop Surg 2007;15:507-
514
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.
G
roin pain is a common entity in
athletes, especially in those en-
gaged in sports that require specific
use (or overuse) of the proximal
musculature of the thigh and lower
abdominal muscles (eg, soccer, ice
hockey, Australian Rules football,
skiing, running, hurdling).1 Ren-
ström and Peterson1 found that groin
injuries represent approximately 5%
of all soccer injuries; Ekstrand and
Hilding2 reported that groin injuries
account for 8% of all injuries in soc-
cer players.
Despite the high prevalence of
groin pain in athletes, the cause of
groin pain can be difficult to eluci-
date because of the complex local
anatomy and the multitude of differ-
ential diagnoses. The anatomic and
biomechanical considerations for in-
juries in these areas are among the
most complex in the musculo-
skeletal system, making the diagno-
sis and management of these injuries
challenging. In addition, the condi-
tions responsible for groin pain in
the athlete often have diffuse, insid-
ious symptoms and nonspecific pre-
sentations. Complicating matters is
the fact that many athletes with
chronic groin pain may have more
than one diagnosis that accounts for
their symptoms.3
The most common musculo-
skeletal causes of chronic groin pain
are adductor muscle strains and os-
teitis pubis.4 Other orthopaedic
causes of groin pain include ilioin-
guinal neuralgia, tearing of the ace-
tabular labrum, avulsion injury,
stress fracture of the pubic ramus or
femoral neck, sports hernia, ilio-
psoas muscle strain or bursitis, rec-
tus femoris muscle strain, obturator
nerve entrapment, osteonecrosis of
the femoral head, slipped capital
femoral epiphysis, and snapping hip
syndrome. Pain also may be referred
from the lumbar spine, the abdomi-

Volume 15, Number 8, August 2007 507

Sports Hernia: Diagnosis and Therapeutic Approach
nal and pelvic viscera, and genitouri-
nary problems.
An increasingly recognized cause
of chronic groin pain in athletes is
sports hernia. Sports hernia is one of
the more difficult diagnoses to make
when evaluating a patient with groin
pain. This condition is poorly under-
stood, not well-defined, and difficult
to evaluate by physical examination
and imaging modalities. Still, it is
possible to outline a diagnostic and
therapeutic treatment approach that
can be used for patients with this
suspected diagnosis.
Sports Hernia
Background and
Epidemiology
The pathologic entity known as
sports hernia (also called sports-
man’s hernia or athletic pubalgia) is
an occult hernia caused by weakness
or tear of the posterior inguinal wall,
without a clinically recognizable
hernia, that leads to a condition
of chronic groin pain.4-9 This condi-
tion occurs almost exclusively in
men.5,8,10-15 There often is a pro-
longed course before diagnosis be-
cause of its insidious onset, nonspe-
cific symptoms, and lack of clinical
findings. The sports hernia is a com-
mon injury in athletes who partici-
pate in sports that require repetitive
twisting and turning at speed.
Therefore, this injury occurs most
commonly in individuals involved
in ice hockey, soccer, Australian
Rules football, tennis, and field
hockey.4,9,14,16-18
The exact incidence of sports her-
nia is not known, but several studies
suggest that it is quite common in
athletes with chronic groin pain
recalcitrant to nonsurgical treat-
ment.4,6,17 Lovell4 reviewed 189 cas-
es of chronic groin pain in athletes
and found that a sports hernia was
the primary diagnosis in 50% of
them. Kluin et al6 found sports her-
nia to be the cause of chronic groin
pain in 39% of their patients. Pol-
glase et al17 found deficiency of the
508
posterior wall of the inguinal canal
present in 85% of athletes who un-
derwent surgical exploration for
chronic groin pain of unknown
cause.
Pathoanatomy and Etiology
Numerous studies have described
a variety of pathologic findings in pa-
tients with sports hernia, including
attenuation or tearing of the trans-
versalis fascia or conjoined tendon,
abnormalities at the insertion of the
rectus abdominis muscle, avulsion
of part of the internal oblique mus-
cle fibers at the pubic tubercle, tear-
ing within the internal oblique
musculature, or abnormality in
the external oblique muscle and
aponeurosis.5,10,12,13,17-22 These ana-
tomic injuries result in a dilated and
weak internal inguinal ring.
There are several theories regard-
ing the cause of sports hernia; most
implicate overuse.5,16 Hip range of
motion and resultant pelvic motion,
often from trunk hyperextension and
thigh hyperabduction, lead to shear-
ing across the pubic symphysis.11,12
Theoretically, the shearing forces are
more prominent in athletes with an
imbalance between the strong ad-
ductor muscles of the thigh and the
relatively weak lower abdominal
musculature.23 These forces place
stress on the inguinal wall muscula-
ture, which ultimately leads to at-
tenuation of local soft tissues.
History and Physical
Examination
The patient with a sports hernia
typically presents with an insidious
onset of unilateral, deep groin pain,
but sudden-onset groin pain or bi-
lateral groin pain may occur in
some patients (Figures 1 and
2).4,5,10,12,13,18,20,21,24 The hallmark of
the pain is that patients are asymp-
tomatic with inactivity and the pain
returns with activity.5,11,12,21,24,25 The
pain may radiate into the adductor
region, perineum, rectus muscles, in-
guinal ligament, and testicular area.
Typically, it is aggravated by sudden
Journal of the American Academy of Orthopaedic Surgeons
movements, coughing, sneezing, per-
forming sit-ups, sprinting, and kick-
ing.4,5,7,12,13,17,18,23 Athletes typically
report the inability to achieve a sat-
isfactory level of play.13
The physical examination of a pa-
tient with a sports hernia reveals no
detectable inguinal hernia.5,10,24 The
most common physical findings in-
clude local tenderness over the con-
joined tendon, pubic tubercle, and
midinguinal region; a tender, dilated
superficial inguinal ring; and tender-
ness of the posterior wall of the
inguinal canal.1,3-5,7,8,10,11,15,18,21,22,24-26
Pain with a resisted sit-up and resist-
ed hip adduction are other common
findings on examination.5,10,12,15,20
Pain usually is exacerbated during a
Valsalva maneuver or coughing.7
Imaging
The role of imaging studies in
sports hernia is evolving. Most im-
aging studies of patients with this
condition will be normal. Accord-
ingly, imaging is useful primarily for
ruling out alternative diagnoses.24
Plain radiographs of the hips, pelvis,
and lumbar spine should be included
in the evaluation of athletes with
groin pain even though they are un-
remarkable in patients with sports
hernia.
Nuclear medicine studies, such as
a technetium Tc 99m (99mTc) tripha-
sic bone scan, also usually are unre-
markable in the presence of a sports
hernia without other associated ab-
normality. These scans may show
increased uptake at the superior pu-
bis, especially when a conjoined ten-
don injury has occurred, or may re-
veal uptake in the pubic symphysis
or adductor tendon origin.27 Howev-
er, bone scans are limited by a lack
of specificity. Therefore, as with
plain radiographs, bone scans do not
help establish this diagnosis but can
be useful for ruling out other condi-
tions, such as osteitis pubis, sym-
physeal instability, osteoarthritis,
and tumor.
Magnetic resonance imaging
(MRI) typically reveals nonspecific
 Adam J. Farber, MD, and John H. Wilckens, MD

Figure 1 Figure 2

Typical sites of pain from multiple causes in the same general Anatomy of the posterior inguinal area (left side). (Adapted
anatomic region. (Adapted with permission from Lacroix VJ: with permission from Genitsaris M, Goulimaris I, Sikas N:
A complete approach to groin pain. Phys Sportsmed Laparoscopic repair of groin pain in athletes. Am J Sports
2000;28:66-86.) Med 2004;32:1238-1242.)

findings, but it is also useful for rul-
ing out other causes of groin pain, es-
pecially stress fractures, osteonecro-
sis of the femoral head, adductor
strains, and osteitis pubis.11,18,24,28,29
MRI findings may include a broad-
ened and irregular pubic symphysis
and, often, a characteristic pattern of
low signal intensity on T1-weighted
images and high signal intensity on
T2-weighted images localized in the
superior pubic ramus at a distance
from the pubic symphysis.29 Albers
et al30 obtained MRI scans on 32 ath-
letes with sports hernias confirmed
during surgical exploration. The
most common MRI findings were
increased signal within one or both
pubic bones or within one or more
groin muscles (including the rectus
abdominis, pectineus, and adductor
muscles) and attenuation or bulging
of the musculofascial layers of the
abdominal wall. However, such MRI
findings lack specificity, and many
patients with sports hernia have no
pathologic findings on MRI.
Dynamic high-resolution ultra-
sound can be a useful noninvasive
modality for evaluating sports her-
nia.9 As the patient actively strains
during the procedure, ultrasonic
findings can be seen at the level of
the superficial inguinal ring as a con-
vex anterior bulge and ballooning of
the inguinal canal.9 In one study,
surgical findings correlated well
with ultrasound findings, although
no control subjects were available
for comparison.9 However, there was
a high prevalence of abnormal find-
ings in asymptomatic athletes. Fur-
thermore, the quality of dynamic
high-resolution ultrasound is lim-
ited by the fact that it is oper-
ator-dependent.9,31 Despite these
drawbacks, ultrasound may offer a
noninvasive modality for assessing
whether the patient with chronic
groin pain may benefit from surgical
repair.9
Herniography (plain radiographs
obtained after an injection of radi-
opaque dye into the peritoneal cavi-
ty) has gained popularity in Europe
for the evaluation of chronic groin
pain in athletes who are considering
undergoing surgical exploration.
This study is intended to decrease
the number of unnecessary hernior-
rhaphies performed; herniography
can detect the presence of a sports
hernia or exclude this diagnosis (by
the absence of a hernia) in the pa-
tient who is considering surgical
exploration after failure of nonsurgi-
cal treatment. However, some clini-
cians believe that herniography is
inadequate for detecting many
sports hernias.4 Others think that
the false-positive rate is unaccept-
ably high.24,32,33
Recent studies on the efficacy of
herniography have yielded controver-
sial results. Lovell4 reported herniog-
raphy to have a sensitivity of 82%, a
positive predictive value of 89%, but
a specificity of only 64%. Sutcliffe et
al34 reported a sensitivity of 96.6%
and a specificity of 98.4%. Hamlin
and Kahn35 performed herniographies
in 333 patients who had symptoms of
groin pain but inconclusive or nega-
tive physical examinations. Of these

Volume 15, Number 8, August 2007 509

Sports Hernia: Diagnosis and Therapeutic Approach
patients, 57 underwent herniorrha-
phy; surgical findings were concor-
dant with the herniography in 56 pa-
tients (98%).35
Potential risks of herniography
include hollow viscus perforation,
vasovagal reactions, infections, ab-
dominal wall hematomas, and reac-
tions to contrast agent; complication
rates range from 3% to 6%.34-36 Con-
sequently, herniography is contro-
versial for the diagnostic work-up of
sports hernia and is rarely used in
the United States.24
Overall, no diagnostic imaging
modality is sensitive and specific for
the diagnosis of a sports hernia. A
variety of clinical and imaging tests
mentioned above is obtained in the
work-up of the patient with chronic
groin pain and may show pathologic
findings suggestive of a sports her-
nia. More importantly, these tests
are useful in ruling out other sourc-
es of chronic groin pain.
Treatment
Nonsurgical
Like most other conditions that
cause groin pain in the athlete (eg,
adductor muscle strain, osteitis pu-
bis), sports hernia is treated initially
with nonsurgical modalities, includ-
ing anti-inflammatory medications,
deep massage, heat or ice, and pro-
longed rest followed by gradual re-
turn to activity.10 Physical therapy is
effective occasionally; the emphasis
of therapy should be on core
strengthening and resolving the im-
balance of the hip and pelvic muscle
stabilizers.10,11,22
Larson and Lohnes11 outlined a
four-phase rehabilitation protocol
for athletes with chronic groin pain.
Phase 1 (weeks 1 and 2) focuses on
massage and stretching. Phase 2
(weeks 3 and 4) emphasizes abdom-
inal muscle strengthening. In phase
3 (week 5), functional activities, in-
cluding running, are initiated. In
phase 4 (week 6), the athlete returns
to sport-specific activities. Unlike
most other causes of groin pain,
which typically respond to nonsurgi-
510
cal treatment, sports hernias rarely
improve with such measures.5,23
Surgical
Surgical exploration and repair
should be considered when nonsur-
gical treatment of 6 to 8 weeks has
failed and when careful history and
physical examination have ruled
out other potential sources of the
pain.6-8,11,16,26 Surgical repair of the
weak posterior inguinal wall with
conventional or laparoscopic tech-
niques leads to excellent results,
usually with success rates of 80%
to 97%.5,6,8,10,12,15,17-19,22,24-26 Further-
more, in light of the potential under-
lying pelvic muscle imbalance,
treatment of a contracted or over-
developed adductor muscle should
not be neglected. Therefore, when
symptomatic adductor abnormality
cannot be corrected preoperatively,
some clinicians recommend adduc-
tor tenotomy combined with her-
niorrhaphy.10-12,15,37
Kumar et al19 reported the results
of 35 patients (34 males, 1 female)
who underwent surgical repair of
suspected sports hernia. Surgery
consisted of an open repair of the
tear in the external oblique apo-
neurosis (when present) and darn or
mesh repair of the posterior inguinal
canal. In this cohort, 93% of patients
returned to normal athletic activi-
ties at preinjury level.
Polglase et al17 reported the re-
sults of 64 athletes (62 males, 2 fe-
males) with chronic groin pain who
underwent open surgical repair of
the posterior wall of the inguinal ca-
nal by a standard Bassini repair or by
plication of the transversalis fascia.
In that study, 93.8% of athletes
achieved excellent or good relief of
pain and improved physical perfor-
mance.
Hackney5 reported on 15 patients
(14 males, 1 female) with sports her-
nia who underwent open repair of
the external inguinal ring with plica-
tion of the transversalis fascia and
reapproximation of the conjoined
tendon to the inguinal ligament. In
Journal of the American Academy of Orthopaedic Surgeons
this cohort, 80% of patients re-
turned to normal athletic activities
at preinjury level.
Steele et al13 described 40 patients
with sports hernia who underwent
an open modified Bassini hernior-
rhaphy in which the transversalis
fascia from the deep to superficial
ring was imbricated and attached to
the inguinal ligament. There was a
full return to sport in 77% of the pa-
tients (average time to return, 4
months).
Van Der Donckt et al15 reported
on 41 male athletes with chronic
groin pain resistant to nonsurgical
treatment who underwent an open
Bassini hernial repair and percuta-
neous adductor longus tenotomy. At
final follow-up, all patients had
resumed their sports activities
(average time, 7 months); 90% (37
patients) believed they performed at
the same level as previously, and
10% (4 patients), at a lower level.
Ahumada et al10 reported the re-
sults of 12 athletes (11 males, 1 fe-
male) with chronic groin pain resis-
tant to nonsurgical treatment who
underwent open internal oblique
flap repair; 9 of those repairs were re-
inforced with mesh. Four patients
underwent additional adductor te-
notomy. At final follow-up, all 12 pa-
tients had resumed their sporting ac-
tivities. Results were excellent in
83% and satisfactory in 17%.
Meyers et al12 reported the results
of 157 athletes with chronic groin
pain resistant to nonsurgical treat-
ment who underwent open pelvic
floor repair. Surgery consisted of a
broad surgical reattachment of the
inferolateral edge of the rectus abdo-
minis muscle with its fascial invest-
ment to the pubis and adjacent ante-
rior ligaments; 36 patients (23%)
underwent concurrent adductor re-
lease. At final follow-up, 152 pa-
tients (97%) had returned to their
preinjury activity levels.
Of 44 male athletes with chronic
groin pain resistant to nonsurgical
treatment who had undergone open
repair of the posterior inguinal wall,

Malycha and Lovell8 found that 41
(93%) had returned to their preinju-
ry activity levels at final follow-up.
In that study, 75% (33 patients) rat-
ed the result as good, and 23% (10
patients), as improved.
Laparoscopic treatment offers the
potential advantage of a more rapid
recuperation and return to sport
than does open hernia repair. Ingold-
by25 compared the results of 28 pa-
tients with sports hernia who un-
derwent conventional open (14
patients) or laparoscopic (14 pa-
tients) repair. All patients returned
to their preinjury activity levels, and
none reported severe pain. Return to
sporting activity occurred in <4
weeks for 9 patients in the conven-
tional repair group and 13 patients in
the laparoscopic repair group, a sig-
nificant difference (P < 0.05). Ingold-
by25 concluded that laparoscopic re-
pair was as effective as conventional
open repair and permitted earlier re-
turn to activity.
Azurin et al26 reported that all
eight professional athletes who un-
derwent laparoscopic preperitoneal
herniorrhaphy with mesh reinforce-
ment had resolution of their symp-
toms and were able to return to their
preinjury function without pain in
<4 weeks.
Kluin et al6 reported that, of 14
athletes (13 males, 1 female) who
underwent laparoscopic extraperito-
neal herniorrhaphy with mesh rein-
forcement, 10 had full resolution of
their symptoms by 3 weeks, and 12
had full resolution of symptoms by 3
months, with return to their preinju-
ry function without pain.
Srinivasan and Schuricht38 re-
ported the results of 15 male pro-
fessional athletes who underwent
laparoscopic extraperitoneal herni-
orrhaphy with mesh reinforcement.
Return to full, unrestricted athletic
activity occurred in ≤4 weeks in 13
athletes (87%), in 6 weeks in 1 ath-
lete, and in 8 weeks in 1 athlete.
One-year follow-up revealed no ad-
verse sequelae or recurrence of
symptoms.
Volume 15, Number 8, August 2007
Susmallian et al14 found that, of
35 male professional soccer players
with sports hernia who had under-
gone laparoscopic preperitoneal
mesh repairs, 97% had returned to
their normal activities at final
follow-up (mean, 14.6 months). No
patient had pain associated with the
repair. The athletes had been al-
lowed to resume sports activity 10
days after surgery. The authors sug-
gested that patients with chronic
groin pain who have been undiag-
nosed for more than 3 months, and
for whom nonsurgical treatment
fails, are candidates for laparoscopic
groin repair.
In summary, most athletes return
to sports participation within 2 to 6
weeks after laparoscopic repair and
within 1 to 6 months after an open
repair.11,14,15,21,22,25,26,38
Gilmore’s Groin
Gilmore’s groin is a variant of sports
hernia first recognized by Gilmore39
in 1980 after the successful treat-
ment of three professional soccer
players. The pathologic features of
Gilmore’s groin include a torn exter-
nal oblique aponeurosis, a torn con-
joined tendon, a dehiscence between
the conjoined tendon and the in-
guinal ligament, a dilated superficial
inguinal ring, and the lack of a clin-
ically detectable hernia.39,40
The condition is common in soc-
cer players.40 Most patients are
males who present with the insidi-
ous onset of groin pain. The pain is
typically unilateral and in the in-
guinal region, but occasionally it
may be bilateral or involve the ad-
ductor or perineal areas.40 The symp-
toms are chronic, increase with ac-
tivity, and are exacerbated by sudden
movements (eg, sprinting, kicking,
coughing) and getting out of bed the
day after a game.39,40 On physical ex-
amination, findings include a tender,
dilated superficial inguinal ring and
a cough impulse.39,40 As in the case
of sports hernia, a radiographic
work-up is not diagnostic but may
Adam J. Farber, MD, and John H. Wilckens, MD
be useful in excluding other sources
of groin pain.
Initial treatment is nonsurgical,
even though it is usually unsuccess-
ful. Surgical treatment consists of re-
storing the normal anatomy with a
detailed suture repair. Gilmore39 re-
ported a 97% success rate with this
procedure in professional soccer
players.
Hockey Player’s
Syndrome
Hockey player’s syndrome, also
called hockey groin syndrome or
slap-shot gut, is an entity that is
unique to elite hockey players.20,41,42
It results from overuse and involves
a tear of the external oblique apo-
neurosis associated with inguinal
nerve entrapment41,42 (Figure 1).
Patients present with groin pain
that may radiate to the scrotum, hip,
and back.42 The pain, which is grad-
ual in onset and muscular in na-
ture,41,42 is exacerbated by ipsilateral
hip extension and contralateral tor-
so rotation and occurs on the side
opposite to the player’s forehand slap
shot.41,42 Patients typically report
their pain as worse in the morning,
during the first few strides of skat-
ing, and during the slap-shot mo-
tion.41,42
Physical examination fails to re-
veal overt signs of hernia, but pain
often is noted on palpation of the su-
perficial inguinal ring.41,42 In addi-
tion, a palpable gap occasionally
may be felt in the external oblique
aponeurosis as the supine patient el-
evates the head or actively flexes the
hip against resistance.41 Imaging
studies, such as plain radiography,
bone scintigraphy, computed tomog-
raphy, MRI, and ultrasound, fail to
reveal the defect.41,42 Surgical explo-
ration currently is the only method
by which to confirm the diagnosis.
Nonsurgical treatment, including
rest, physiotherapy, local anesthetic
injections, and corticosteroid injec-
tions, usually is unsuccessful.41,42 In
such cases, surgical repair is indicat-
511
Sports Hernia: Diagnosis and Therapeutic Approach
ed.41,42 Surgical intervention to re-
pair and reinforce the external ob-
lique aponeurosis with mesh,
combined with a neurectomy of the
inguinal nerve, is the usual defini-
tive therapy and leads to successful
outcomes in >90% of patients.41,42
Irshad et al41 reported the results
of 22 professional hockey players di-
agnosed with this condition. Non-
surgical measures had failed for all
athletes, and all ultimately under-
went open surgical repair consisting
of ablation of the ilioinguinal nerve
and repair of the external oblique
aponeurosis with mesh reinforce-
ment. Postoperatively, all 22 pa-
tients returned to playing hockey; 19
(86%) were able to continue at the
professional level. At final follow-
up, 18 (82%) had no pain, and 4
(18%) reported mild, intermittent
pain.41
In another study, Lacroix et al42
reported that 11 professional hockey
players diagnosed with this condi-
tion in whom nonsurgical manage-
ment had failed underwent open
surgical repair consisting of neurec-
tomy of the ilioinguinal nerve prox-
imal to the entrapment and concur-
rent repair of the external oblique
aponeurosis. At final follow-up, 10
of the 11 athletes (91%) were pain
free and had returned to playing pro-
fessional hockey; the remaining pa-
tient sustained a recurrence.42
Diagnostic Approach
The following diagnostic and treat-
ment approach is proposed for the
evaluation of athletes with chronic
groin pain and a suspected sports
hernia or one of its variants.
History
The initial history of an athlete
with chronic groin pain should iden-
tify the onset, location, duration, ra-
diation, and quality of the patient’s
pain. The effect of specific sport ac-
tivities (eg, kicking, pivoting, sit-
ups) or a Valsalva maneuver on the
patient’s pain should be ascer-
512
tained.20 Any changes in the training
regimen or history of injury should
be noted. In addition, the physician
should inquire about the presence of
urinary symptoms, night pain, back
pain, or systemic symptoms.4,20
Physical Examination
The physical examination is es-
sential in evaluating any patient, but
frequently it is nonspecific in the
athlete with sports hernia. The
physical examination includes a
thorough evaluation of the abdo-
men, pelvis, hips, thighs, and lum-
bosacral spine.4 Components of the
physical examination include in-
spection, palpation, range-of-motion
testing, and motor-strength testing.
Areas palpated should include the
anterior superior iliac spine, anteri-
or inferior iliac spine, superficial in-
guinal ring, pubic symphysis, abdo-
men, pubic rami, thoracolumbar
spine, and testes.4 The examination
also should include palpation and
muscle-resistance testing of the ad-
ductor muscles, rectus abdominis,
rectus femoris, and iliopsoas,4 as
well as evaluation for an inguinal
hernia.
As noted, the physical examina-
tion of a patient with a sports hernia
reveals no detectable inguinal her-
nia. The most common physical
findings include local tenderness
over the conjoined tendon, pubic tu-
bercle, and midinguinal region; a
tender, dilated superficial inguinal
ring; tenderness of the posterior wall
of the inguinal canal; and pain with
a resisted sit-up.
The physical examination is ex-
tremely useful in ruling out other
potential sources of chronic groin
pain, such as stress fracture, acetab-
ular labral tear, muscle strain, oste-
itis pubis, and avulsion injury. The
patient with stress fracture usually
has pain with axial loading of the leg
or with standing and hopping on the
affected leg.16 Pain and clicking with
passive hip range of motion is sug-
gestive of an acetabular labral
tear.16 Pain with palpation of the ad-
Journal of the American Academy of Orthopaedic Surgeons
ductor compartment and pain with
resisted adduction and passive ab-
duction of the thigh is suggestive of
adductor muscle strain.1,4,40 Similar-
ly, pain with palpation over the rec-
tus femoris and pain with resisted
hip flexion and knee extension sug-
gests a rectus femoris strain.1,4,16,40
The patient with osteitis pubis usu-
ally has tenderness to palpation of
the pubic symphysis.4,40 The patient
with avulsion fractures has focal
tenderness to palpation over the
avulsed fragment of bone and pain
with resisted activity of the offend-
ing muscle group.
Imaging
As indicated, radiographic find-
ings in patients with sports hernia
are neither sensitive nor specific for
this diagnosis. However, an imaging
work-up is a noninvasive method of
excluding other pathologic entities
in the differential diagnosis of chron-
ic groin pain. Plain radiographs, in-
cluding an anteroposterior view of
the pelvis and anteroposterior and
lateral views of the hip, should be
obtained initially. These studies can
be useful in ruling out other condi-
tions in the differential diagnosis,
including slipped capital femoral
epiphysis; osteoarthritis; stress frac-
tures of the femoral neck and pelvis;
and avulsion fractures of the anteri-
or superior iliac spine, lesser tro-
chanter, or anterior inferior iliac
spine.16,31
After radiographs are obtained, a
99mTc bone scan may be obtained. As
with radiographs, 99mTc bone scans
are more useful in ruling out other
diagnoses than in making the diag-
nosis of a sports hernia, but bone
scans can evaluate stress fractures,
osteitis pubis, osteonecrosis, and
tenoperiosteal lesions.31
MRI also is used for evaluating the
patient with chronic groin pain recal-
citrant to nonsurgical therapy. It
helps in ruling out other sources of
chronic groin pain in the athlete, in-
cluding adductor muscle strain, ace-
tabular labral tear, stress fracture, il-

iopsoas bursitis, osteitis pubis, and
osteonecrosis of the femoral head,28,43
and it is useful for the patient with
ambiguous clinical presentation.28,29
Some clinicians have suggested that
MRI may be useful for determining
which athletes may benefit from bi-
lateral herniorrhaphy in the setting
of unilateral symptoms.12,30 The role
of MRI in the diagnostic work-up of
a sports hernia is evolving.
Despite numerous reports in the
European literature regarding the
safety and efficacy of herniography,
it lacks specificity and is not recom-
mended in the diagnostic work-up of
the patient with a suspected sports
hernia.4,34,35
Treatment Approach
When no hernia is detected on phys-
ical examination but the history and
physical findings are consistent with
this diagnosis and a radiographic
work-up fails to reveal another cause
of the symptoms, then nonsurgical
treatment with rest, anti-inflam-
matory agents, and stretching and
strengthening exercises should be at-
tempted.22 The patient should un-
dergo a detailed physical therapy as-
sessment to evaluate core strength
and muscle imbalance. When symp-
toms persist for ≥3 months with
nonsurgical treatment, referral to a
general surgeon for open or laparo-
scopic herniorrhaphy should be con-
sidered.6,8,22
Summary
Sports hernia increasingly is being
recognized as a common cause of
chronic groin pain in athletes. There
are several theories regarding the
cause of sports hernia; most impli-
cate overuse. A variety of patholog-
ic findings have been described in
patients with sports hernia; these
anatomic injuries result in a dilated
and weak internal inguinal ring. Pa-
tients typically present with an in-
sidious onset of unilateral, deep
groin pain, but physical examination
Volume 15, Number 8, August 2007
reveals no detectable inguinal her-
nia. Most imaging studies will be
normal. Unlike most other causes of
groin pain, sports hernias rarely re-
spond to nonsurgical treatment. Sur-
gical exploration and repair should
be considered when nonsurgical
treatment of 6 to 8 weeks has failed
or when other potential sources of
groin pain have been ruled out. Most
athletes return to sports participa-
tion within 2 to 6 weeks after lapa-
roscopic repair and within 1 to 6
months after open repair. Addition-
al research is needed to clarify the
role of imaging studies in the evalu-
ation of a sports hernia and to eval-
uate training regimens and condi-
tioning exercises that may help
prevent this injury.
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