A sports hernia, also known as athletic pubalgia or core muscle injury, is a painful injury to the soft tissues of the lower abdomen and groin. Unlike a traditional hernia, there is no visible bulge — the injury involves tears or strains of the muscles, tendons, or ligaments that attach to the pubic bone, creating a chronic source of groin pain that is notoriously difficult to diagnose without dedicated imaging.
Sports hernia is one of the most challenging groin pain diagnoses to establish because its symptoms overlap significantly with those of osteitis pubis, hip labral tears, and femoroacetabular impingement (FAI) — and these conditions frequently coexist in the same athlete. Studies suggest that up to 90% of athletes with a sports hernia have concurrent FAI, as the restricted hip motion from impingement forces the pelvis to compensate with excessive rotation, overloading the pubic attachments. Ischiofemoral impingement and iliopsoas bursitis can produce similar anterior groin pain and must be considered in the differential. MRI of the pelvis is the only study that can reliably evaluate all of these structures simultaneously.
Causes
Sports-related causes.
Sports hernias most commonly occur in athletes who perform repetitive twisting, cutting, kicking, and rapid changes of direction under high load. Hockey, soccer, football, rugby, tennis, and track and field athletes are most commonly affected — all sports that demand repeated explosive hip rotation against a planted foot. The fundamental injury mechanism is an imbalance between the powerful hip adductors and the comparatively weaker lower abdominal wall muscles at their shared attachment to the pubic bone — the adductors generate far greater force than the abdominals can counteract, creating a shear stress at the pubic symphysis that progressively tears the rectus abdominis-adductor aponeurosis. Men are affected far more commonly than women, likely reflecting differences in pelvic anatomy and adductor-to-abdominal force ratios.
Other causes.
A single violent episode of hip hyperextension combined with trunk rotation — such as a collision, a slide tackle, or a sudden deceleration — can acutely tear these tissues even in an athlete without a prior history of groin pain. Underlying femoroacetabular impingement is increasingly recognized as a significant predisposing factor: by restricting normal hip rotation, FAI transfers rotational forces from the hip joint to the pubic symphysis and lower abdominal wall, subjecting those tissues to loads they are not designed to absorb. Correction of FAI may be necessary for a sports hernia repair to succeed in these patients.
Symptoms
Patients typically report a deep, sharp groin or lower abdominal pain that worsens with sudden explosive movements — sprinting, cutting, kicking, and change-of-direction maneuvers — and with activities that raise intra-abdominal pressure including sit-ups, coughing, and sneezing. Pain often improves substantially with rest but returns reliably as soon as high-intensity activity resumes — this rest-activity cycle is a hallmark of athletic pubalgia that distinguishes it from a muscle strain. Unlike a traditional inguinal hernia, there is no palpable bulge in the groin. Some patients describe pain radiating to the inner thigh, perineum, or testicular area along the distribution of the genitofemoral nerve. In many athletes, the diagnosis is delayed for months because the condition is mistakenly managed as a recurring adductor strain or hip flexor injury.
Diagnosis
A physical exam includes careful palpation over the pubic tubercle and the insertion of the adductor longus tendon to reproduce tenderness, and provocative maneuvers including resisted sit-ups (which stress the rectus abdominis attachment) and resisted hip adduction in extension (which stresses the adductor longus origin). A traditional inguinal hernia is excluded by examination of the inguinal canal. An MRI of the pelvis is the imaging study of choice, providing the only reliable non-invasive visualization of the rectus abdominis-adductor aponeurosis, pubic bone marrow edema, adductor tendon integrity, and the posterior inguinal wall. MRI characterizes which specific structures are torn — rectus abdominis, adductor longus, or both — the severity of injury at each site, and the presence of osteitis pubis at the pubic symphysis. Crucially, a pelvis MRI simultaneously evaluates the hip joints for FAI morphology and labral tears that are driving or perpetuating the injury — information that is essential for determining the complete surgical plan when operative treatment is warranted.
Classification
Core muscle injury is classified by the specific anatomic structures involved, as identified on MRI and confirmed surgically.
- Rectus abdominis injury: Tearing or avulsion of the lower rectus abdominis from its pubic attachment. Presents with lower abdominal pain and tenderness along the midline at the pubic crest.
- Adductor injury: Strain or partial tear of the adductor longus or other adductor tendons at the pubic origin. Presents with medial groin tenderness and pain with resisted adduction. May occur as an isolated injury or as part of a combined pattern.
- Combined rectus-adductor injury: The most common and clinically significant pattern — tearing of the shared aponeurosis where the rectus abdominis and adductor longus converge at the pubic bone. MRI demonstrates injury on both sides of the pubic symphysis.
- Posterior inguinal wall disruption: Weakness or tearing of the transversalis fascia forming the posterior wall of the inguinal canal — the anatomic basis of what was historically termed "Gilmore's groin."
Treatments
Treatment depends on the severity of injury, the specific structures involved, the presence of concurrent hip pathology, and the athlete's desired return-to-sport level and timeline.
Conservative care: Initial relative rest from all aggravating high-intensity activities, anti-inflammatory medications, and a structured physical therapy program form the foundation of non-operative management. Rehabilitation focuses on progressive core strengthening — targeting the deep stabilizers including the transversus abdominis and pelvic floor — pelvic stabilization, hip abductor and adductor rebalancing, and a graduated return to sport-specific movements. Most athletes without a complete tear who commit fully to 6–8 weeks of dedicated rehabilitation achieve meaningful improvement, though return to elite sport without surgical repair is less reliable in athletes with complete aponeurotic disruptions.
Injections
Image-guided corticosteroid or platelet-rich plasma (PRP) injections targeted at the adductor longus origin or pubic symphysis can provide meaningful pain relief for persistent adductor tendinopathy or osteitis pubis that does not resolve with physical therapy alone. PRP is increasingly preferred for tendon injuries given its regenerative mechanism. Injections serve both a therapeutic and diagnostic role — pain relief following a targeted injection confirms the anatomic source and guides the surgical planning when operative treatment is under consideration.
Surgery
Surgery is the definitive treatment for competitive athletes who fail conservative management and require return to high-level sport. The most widely performed procedure involves open or laparoscopic repair of the disrupted posterior inguinal wall and reattachment of the torn aponeurotic structures to the pubic bone — analogous in concept to a hernia repair but targeting the posterior wall specifically. Adductor tenotomy (release of the adductor longus from the pubic origin) is added when adductor pathology is a significant component. When concurrent FAI or a labral tear is identified on MRI, hip arthroscopy to address these findings is performed in conjunction with the hernia repair — either staged or simultaneously depending on the surgical team's approach. Return to full sport typically occurs 8–12 weeks after isolated repair and 4–6 months when hip arthroscopy is combined.
Get an MRI to Confirm Your Diagnosis
Before surgical planning or starting treatment, a clear MRI diagnosis ensures the right path forward. First Look MRI offers self-pay Pelvis MRI scans — no doctor's order or insurance required — at our locations in Georgia, Texas, and Colorado.