There are many terms that are used to label non-hip joint groin pain in athletes, including but not limited to athletic pubalgia, sports hernia, and adductor tendinopathy (see table 1 for a more comprehensive list of terms). The 2015 Doha Agreement provided a consensus of 3 classification categories: (1) defined clinical entities (adductor-related, inguinal-related, iliopsoas-related, and pubic-related), (2) hip-related groin pain, and (3) other causes of groin pain, including a true inguinal hernia and non-musculoskeletal (MSK) conditions. (Weir et al. 2015) The use of these terms is increasing within the literature, while terms such as athletic pubalgia and sports hernia are being slowly phased out.
Table 1 – Athletic Groin Pain terms in Literature (Serner et al. 2015, Omar et al. 2008, Sheen et al. 2017))
|Adductor pain/tendonitis||Adductor tear, avulsion, herniation of muscle fibers through myofascial membrane|
|Athletic Groin Injury||Undifferentiated|
|Gilmore Groin||Inguinal ligament injury/disruption|
|Hockey groin syndrome/ Hockey goalie baseball pitcher syndrome||Adductor tear, avulsion, herniation of muscle fibers through mysofascial membrane, fascial tear of external oblique|
|Incipient Hernia||Undifferentiated, groin pain with activity|
|Inguinal ligament/canal syndrome||Sprain, tear of inguinal ligament or of posterior wall or conjoint tendon|
|Groin Disruption||Undifferentiated, or could infer inguinal ligament injury|
|Osteitis Pubis||Degenerative changes of pubic symphysis (osteophytes, subchondral cysts, +- boney edema)|
|Pubic bone stress injury||Bone Marrow Edema (BME) seen on MRI|
|Pubic Inguinal Pain Syndrome||Undifferentiated, groin pain with activity|
|Sports Hernia||Undifferentiated, groin pain with activity|
|Sportsman Hernia||Undifferentiated, groin pain with activity|
|Sportsman Groin||Undifferentiated, groin pain with activity|
Figure 1 – Diagram of 2015 DOHA agreement consensus on groin pain classification (Weir et al. 2015)
The relationships between the abdominal wall, hip joint, sacroiliac joint, adductors, and pubic symphysis are complex. A significant force imbalance between the abdominal musculature and adductors causes fascial microtrauma. Classification helps identify and communicate where the microtrauma is located. For example, inguinal-related groin pain presents with pain and tenderness localized to the inguinal canal as a result of microtrauma to the posterior inguinal canal, with or without nerve compression, and Iliopsoas-related groin pain is a result of microtrauma to the iliopsoas, etc.
Hip pathology typically causes restricted range of motion (ROM). To achieve sufficient ROM for sport, there is a compensatory stretching of the surrounding musculature, which predisposes these tissues to developing microtrauma and force imbalances . The treatment of intra-articular hip pathology varies from that of extra-articular pathology, and thus hip-related groin pain is categorized separately.
Underlying pathology for non-hip groin pain: It is clear from the literature that there is significant heterogeneity in pathology from a relatively small anatomical area. (see table 2). However a 2020 JAMA Surgery review paper summarized the following pathologic origins of groin pain syndromes: Inguinal canal, Rectus abdominus and Adductor longus, pubic symphysis and finally inguinal neuralgias. These neuralgias can occur secondary to true hernias, disruption of the tranversalis fascia leading to increased pressure on the nerves, or due to scar tissue entrapment.
Table 2 – Sources of pain in Athletic groin pain (non-hip) [Intra-abdominal sources excluded]
|Pubic bone (BME/stress #)||Rectus Abdominis||Genitofemoral nerve|
|Pubic symphysis||Pubic aponeurosis/pubic ligament/Aponeurotic plate||Iliohypogastric nerve|
|Osteomas of ischium/pubis||Inguinal ligament sprain/tear||Ilioinguinal Nerve|
|Septic osteomyelitis of pubic symphysis||Conjoint tendon||Obturator nerve|
|Inguinal ring disruption|
|Hematoma (rectus abdominis, iliopsoas)|
One important anatomical point is the area of the pubis that acts as a hub for insertions and origins of rectus abdominis, adductor longus, the inguinal ligament and conjoint tendon (see Figure 1 where purple meets blue). This portion of the pubis is directly lateral to the pubic symphysis.
One study, by Falvey et al.in 2016, of 382 male patients with athletic groin pain, mainly gaelic footballers, found that bone marrow edema was present in 68 % of athletes and the pubic aponeurosis was abnormal on 52.6% of MRIs. Nearly a ⅓ of patients had 3 or more findings on MRI.
The pubic aponeurosis, has been further recognized to contain a pubic ligament complex by Shiclder et al. 2017. The ligament is positioned horizontal and midline with communications with the pyramidalis tendons, adductor tendons and external oblique aponeurosis, just superficial to rectus abdominis.
Part of the goal of assessment of groin pain – is to rule out various diagnoses through systematic assessment and examination to narrow the differential. The heterogeneity even within non-hip joint pain athletic groin pain is highly suggestive of a multifocal cause to groin pain.
Figure 3 – Pubic aponeurosis/aponeurotic plate in relation to rectus abdominis and adductor longus
Figure 4 – dermatome mapping of Iliohypogastric, ilioinguinal, and genitofemoral
Important factors on History:
Location of pain (see Figure 5): Pain should be focused around 2 (medial 1/3rd), 3, 4, and/or 5
Nature of pain:
History of prior abdominal surgery esp. hernia/sport hernia surgery with mesh: Increases risk of a nerve entrapment.
Non-Hip: Hernias (direct, indirect, femoral, spigelian, obturator) genitofemoral nerve impingement, iliohypogastric nerve impingement, ilioinguinal nerve impingement, obturator nerve impingment, kidney stones, osteitis pubis, psoas bursitis, pubic stress fracture, inguinal ligament sprain/tear, intra-pelvic pathology, intra-abdominal pathology, rectus sheath hematoma, testicular pathology.
Hip: Femoral acetabular impingement, labral tear, osteoarthritis, avascular necrosis femoral head, osteomyelitis, septic arthritis, snapping hip syndromes
A comprehensive examination for groin pain (inguinal-related, pubic-related, adductor-related and psoas-related) must involve examination to exclude intra-articular hip pain, inguinal, femoral, and spigelian hernias, as well as the pubic bone (superior and inferior ramus), pubic symphysis, and other soft-tissues injuries.
Table 3 – Examination for undifferentiated musculoskeletal groin pain in athletes
|Area of interest||Examination||Interpretation of findings||Imaging|
|Hip||Range of motion, log roll, FADIR, FABER, scour||+ve testing reduces probability of athlete having non-hip groin-related pain, especially if remainder negative||Xray: (AP pelvis, Dunn view, lateral)
MRI Hip: Groin pain protocol will comment on hip pathology)
|Hip Flexors, Psoas (4 and between 1 and 4)||Direct palpation over anterior hip AIIS, Thomas test, AROM
Psoas stretch and Rectus femoris: stretch and activation v. resistance
|+ve testing in keeping with psoas or rectus femoris related pain, especially if remainder negative||Xray: AP pelvis if concern for avulsion fracture
US: hip/groin (hip flexors on requisition)
MRI: Either hip or groin pain protocol
|Inguinal Ligament and conjoint tendon||Direct palpation||US: hernia
MRI: groin pain protocol – with and without valsalva
|Pubic symphysis (3,6) and Pubic bone||Direct palpation for reproduction of patient’s pain||Xray AP pelvis
MRI groin pain protocol – with and without valsalva (+ve cleft sign)
|Rectus Abdominis||Palpation of the distal rectus femoris and its insertion for pain.
A dynamic version includes either a head and leg lift or a sit-up with localized pain in area 5 (see Fig 5), along with amplification with palpation of the area
Dynamic Ultrasound for Sport hernia – to assess inguinal ring and conjoint tendon
MRI groin pain protocol
|Adductor Longus Tendon||Swelling, tender to palpation, pain with stretch, pain with activation||US
MRI groin pain protocol
|Hernia testing||Palpation with valsalva for indirect and direct hernias||-ve testing essential for a diagnosis of athletic groin pain||US abdomen (inguinal hernias)
Dynamic abdominal US – to assess inguinal ring and conjoint tendon
MRI groin pain protocol – obturator hernia
|Nerves||Can be referred for US or CT guided nerve blocks – see Figure 4||US abdomen
MRI groin pain protocol
Figure 5 – Surface anatomy for groin-related pain examination
Assessment: The bottom line is narrowing down the differential diagnosis as this will aid in guiding treatment as well as with prognostication. We recommend localizing the area of pain into following categories:
Estimating prognosis can be difficult given the heterogeneity of the issue. A review of return to play reported by both surgical and rehabilitative methods ranged from 2 weeks up to almost 30 weeks (King et al. 2015). For pubic-related pain, rehabilitation recovery was significantly faster than surgical by ~12 weeks. However, little difference was noted between surgical and rehabilitative treatments for abdominal-located or adductor-located pain and return to play. The mean return to play was 13 weeks across all studies in a 2015 systematic review. (King et al. 2015). It should be noted, from experience, that age is a predictor of prognosis, with younger patients in their 20’s recovering faster than patients over 40. A prospective trial, by Paajanen et al. in 2011, following 60 athletes found that 53% of the non-operative group still had symptoms at 1 year, despite 2 months of physio, +/- corticosteroid and/or oral anti-inflammatories. However, other studies have suggested shorter periods (references). The presence of bone marrow edema or “osteitis pubis” on MRI typically results in longer (>3 months) times to return to sport. (Jardi et al. 2014).
Protocols may differ based on underlying pathology. Common themes include hip range of motion and mobility training along with increasing lumbopelvic control.
Abdominal-related pain – 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks. Along with hip ROM and core mobility training. Generally a period of 4 weeks has been recommended before resuming explosive/agility maneuvers.
Adductor-related pain – avoiding aggravating activities, and gradual progression of strengthening. The program should also focus on hip range of motion and core mobility training.
Inguinal-related pain – 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks. The program should also focus on hip range of motion and core mobility training.
Pubic-related pain: 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks. The program should also focus on hip range of motion and core mobility training. Four weeks of no pain is generally recommended before resuming explosive/agility maneuvers. (Jardi et. al. 2014)
Injections: Adjunct therapies described have included NSAIDs, and injections (corticosteroids and platelet rich plasma) into pubic symphysis, or rectus abdominus muscles.
If there is nerve-like symptom description in the history or the pain transects inguinal, pubic and/or adductor areas, then there has been some promise shown in the use of both nerve blocks for treatment. These can generally be helpful as a diagnosis tool in non-hip groin pain in athletes. Radiofrequency ablation of the ilioinguinal nerve demonstrated improvement in a study of 36 patients when compared to bupivacaine with triamcinolone. (Comin et al. 2013). We have a case of iliohypogastric nerve RFA in a professional football player that was able to resume full training without pain after 4 months of discomfort. Many of the surgical techniques report including an neurectomy of the inguinal sensory nerves. (Zuckerbraun et al. 2020).
There are multiple different surgical interventions which can involve any of the following: fixation of transversus abdominus to inguinal ligament, mesh insertion (total extraperitoneal mesh placement), aponeurotic plate fixation back to periosteum with inguinal floor repair, adductor tenotomy/lengthening, rectus abdominis repair and neurectomy of associated nerves.
Adductor tenotomy alone is generally reserved for patients that report adductor localized pain. Robertson et al. 2011, reported 71% of athletes returning to their pre-injury level of sport after chronic adductor pain. The series included 109 male athletes that had chronic adductor pain with a mean of 15 months at time of operation) despite conservative management.
Laparoscopic mesh for posterior wall was used frequently. In 2 different studies, one of 35 and the other 131 patients,respectively. The authors found that 97% of patients returned to prior sporting level within 3 weeks. (Genitsaris et al. 2004, Susmallion et al. 2004).
Another option is open repair, one study of 128 patients with a minimal repair technique (posterior wall repair with decompression of genital branch of genitofemoral nerve) reported 84% returned to pre-injury level of sport at 4 weeks.(Mushaweck et al., 2010)
Complications include: bruising, bleeding, hematomas, infection, and dysthesias (Meyers et al. 2008).
Criteria for referral for Laparoscopic Repair for Sport hernia (Inguinal-related groin pain in athlete in absence of a true hernia):
1) Athletic Injury – overuse/gradual onset;
2) Worse with twisting, sprinting, change of directions, and mechanical provocation;
3) Pain greater than 6 months ( > 6 weeks if professional/elite athlete).
1) Pain over inguinal ligaments and location of external and internal rings;
2) Absence of true inguinal hernia.
1) Ultrasound – demonstrating no true inguinal hernia;
2) MRI groin pain protocol – Negative for other causes of groin pain.
It should be noted that despite promising results with surgical interventions, geographical availability can be quite limited.
Author: Dr. Jordan Anderson, MD CCFP PGY3 and Dr. Neil Dilworth (April 4, 2021 – PR AF MC updated May 5, 2021)