Sports hernia (sportsman's groin): symptoms, diagnosis and treatment

Despite the name, a sports hernia is not a hernia in the usual sense. In a standard inguinal hernia, tissue pushes through a weak area of the abdominal wall to produce a lump. A UK NHS clinical pathway explains that in a sports hernia there is no classical herniation; the term is used for pain thought to arise from injuries to the abdominal wall and pelvic muscles, causing a weakness of the back wall of the inguinal canal.

A private hospital group describes the condition as occurring when the muscles or tendons of the lower abdominal wall are weakened as a result of repeated micro-injuries, in the same area where inguinal hernias occur but without an actual hernia. It says this makes the problem difficult to diagnose and treat because of the interplay between the hip joint, nerves, muscles, tendons and ligaments, so very similar symptoms can have different causes.

A review by surgeons at a UK NHS trust notes that consensus meetings have agreed the terms inguinal disruption and inguinal-related pain to describe groin pain in an athlete where no true hernia exists, while the exact origin of the pain remains debated and is probably a combination of several pathologies.

The pathway describes patients who complain of one-sided or both-sided groin pain that is difficult to localise but is described as being above the inguinal ligament. Pain can radiate to the scrotum and the inner thigh and can cross the midline. It occurs on exertion.

Signs the clinician looks for include tenderness over the pubic bone and over the outer opening of the inguinal canal, increased pain on pressure over that area when you raise your straight leg, and pain with resisted sit-ups. The pathway says there are no red flags in the presentation unless there are palpable firm masses, which may be lymph nodes.

• Groin pain on one or both sides that comes on with exercise.

• Pain that can spread to the inner thigh or scrotum.

• Pain with sit-ups, sprinting, kicking or twisting.

• No visible bulge, unlike a typical inguinal hernia.

Groin pain in an athlete is usually an overuse injury, but a lump or sudden severe pain should not be assumed to be a sports hernia. The NHS says that if you have a hernia and develop pain in or around it, a bloated tummy, feel sick or are being sick, are constipated, have a high temperature, feel hot, cold or shivery or have suddenly become confused, you should get help from NHS 111, and it describes pain in or around a smaller hernia as possibly a sign of strangulation. Swelling or pain in the testicle also needs prompt assessment.

See a GP if groin pain persists beyond a couple of weeks, keeps coming back or stops you training, so that other causes, including hip problems and true hernias, can be considered.

There is no single test. The diagnosis is mainly clinical, based on history and examination, with imaging used to exclude other conditions. The pathway says that other pathologies and a true hernia can be excluded with an ultrasound scan or MRI. The NHS surgeons' review adds that after clinical assessment and exclusion of other pathology with MRI, surgery to the inguinal canal has been recommended in selected cases.

Because the hip joint, adductor tendons and pubic bone can all cause groin pain, the Doha agreement, an international consensus published in the British Journal of Sports Medicine, classifies groin pain in athletes into defined entities such as adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain, and hip-related groin pain. A clinician may use this framework to explain which structure is the most likely source.

The pathway recommends a non-operative trial for 6 to 12 weeks, including rest from the aggravating activity, physiotherapy and anti-inflammatory medicines, with a careful graded return to sport. The surgeons' review describes management strategies including physiotherapy to improve core stability, adductor strengthening, and other non-operative measures such as platelet-rich plasma and steroid injections.

If this fails, surgery to reinforce the back wall of the inguinal canal is considered. The pathway says techniques are based on variations of standard hernia repairs and may use mesh, and can be carried out by open or laparoscopic approaches. The review notes that no significant differences between open and keyhole repairs have been reported, and that an inguinal ligament release and an open minimal repair were selected as operations of choice by surgeons at a specialist congress.

The pathway cites a randomised trial of 60 patients in which 90 per cent of the operative group returned to sport within 3 months compared with 27 per cent of those treated non-operatively, and 97 per cent against 50 per cent at 1 year. These results come from one small trial and should be read with caution.

After surgery, a private hospital group says recovery depends on fitness beforehand, and it is normally advised that it will take 6 to 8 weeks to be back to normal, with physiotherapy to aid rehabilitation. Procedures are generally done under general anaesthetic and may need an overnight stay, according to that group.

Whether you have surgery or not, returning to sport in stages, rather than all at once, is the consistent advice. A physiotherapist can set criteria for progress, such as pain-free strength and sprint tests, so that you do not return too early and aggravate the injury.

On the NHS, sports hernia is usually managed in primary care and physiotherapy first. The pathway says a referral should include evidence that 6 to 12 weeks of non-operative management has been completed and failed, along with relevant history, medication, BMI and smoking status, and that an ultrasound is needed if a true hernia is suspected.

Private sports medicine and surgical services also treat sports hernia. Because opinions differ on terminology and on which operations work best, it is reasonable to ask what the diagnosis is based on, what the evidence is for the proposed operation in someone like you and what rehabilitation follows.