Groin pain in the athlete · Inguinal wall · Clinical synthesis

In French, “pubalgie” names no disease. It is an umbrella, and under that umbrella the Doha agreement placed five distinct clinical entities that are not treated in the same way. This article deals with the one of the inguinal wall, what the English-language literature calls sports hernia, athletic pubalgia or inguinal disruption. An entity whose commonest name refers to a lesion that does not exist: there is no hernia.

Why does the word “pubalgie” name no precise disease?

In this chapter: why an umbrella term held research back for thirty years, what the 2015 Doha agreement settled, what the 2014 Manchester consensus rejected, and the table of the five entities with their exact diagnostic criteria.

“Pubalgie” is a convenient word and that is its whole flaw. It names a painful region, not an injury mechanism; it gathers under one label an insertional tendinopathy, bony distress of the symphysis, involvement of the lower abdominal wall and sometimes a hip joint condition. The authors of the Doha agreement put it in one sentence: the heterogeneous taxonomy of groin injuries adds confusion to an already complicated field. That imprecision is not merely a problem of vocabulary: it made studies incomparable with each other for decades.

What the Doha agreement settled

On 4 November 2014, twenty-four experts from fourteen countries met in Doha for a day of work preceded by a Delphi questionnaire and systematic reviews. The result, published in 2015 in the British Journal of Sports Medicine, is a unanimous agreement on a three-level classification (Weir 2015, PMID 26031643) :

1. The defined clinical entities : adductor-related, iliopsoas-related, inguinal-related, pubic-related pain.
2. Hip-related groin pain (hip-related groin pain), dealt with separately because it calls for a different diagnostic approach.
3. The other causes : orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical.

The decisive point is methodological: these definitions rest solely on history and physical examination. None requires imaging. That is what makes them usable in the clinic on the day of the first consultation, and it is also what makes them fragile if the examination is poorly conducted: we return to that in chapter 5.

What the Manchester consensus rejected

Two years before Doha, the British Hernia Society brought together in Manchester surgeons, a musculoskeletal radiologist and a physiotherapist to settle the question of surgical vocabulary. Their conclusion, published in 2014, is explicit: the term adopted is inguinal disruption, and the terms sportsman's hernia and sportsman's groin are rejected, on the grounds that no true hernia exists (Sheen 2014, PMID 24149096).

The group described massive agreement on the existence of abnormal tension in the groin, particularly around the insertion of the inguinal ligament, with frequent findings of a detachment of the external oblique accompanied by small tears, and tissue oedema. It recommended a multidisciplinary approach with tailored physiotherapy as initial treatment, surgery consisting of releasing the tension of the inguinal canal then reinforcing it with mesh or suture.

You have to gauge what that implies in practice. A patient who is told they have a “sportsman's hernia” understands that they have a hole in their abdomen, which will have to be closed. The word makes the prognosis in the clinician's place, and it steers towards the operating theatre a condition that the consensus recommends treating first with rehabilitation. That is why this vocabulary deserves to be corrected with the patient at the first consultation.

And what about “athletic pubalgia”?

The term athletic pubalgia remains widely used, especially in the North American literature and in imaging, where it most often refers to involvement of the insertion of rectus abdominis and of its common aponeurosis with adductor longus on the pubis. It is therefore not an exact synonym of inguinal disruption : the two terms refer to neighbouring but distinct anatomical anchor points, the first centred on the pubic insertion, the second on the inguinal canal. In French practice, both are met under the name “pubalgie du sportif”, which brings us back to the original problem.

What happens in the inguinal wall, if it is not a hernia?

In this chapter: the anatomy of the inguinal canal and of the structures that cross it, the loading mechanism that explains the footballer's pain, the share taken by the nerves, measured at 96 % in one surgical series, and why the word “weakness” is more accurate than the word “hernia”.

The inguinal canal is an oblique passage of four to six centimetres cut through the thickness of the anterior abdominal wall, just above the inguinal ligament. It transmits the spermatic cord in men, the round ligament in women, and the ilioinguinal nerve and the genital branch of the genitofemoral nerve. Its anterior wall is formed by the aponeurosis of the external oblique, its floor by the inguinal ligament, its roof by the arching fibres of the internal oblique and transversus, and its posterior wall by the transversalis fascia reinforced medially by the conjoint tendon.

It is that posterior wall that draws the attention. Farber and Wilckens described it as early as 2007 as the site of an occult hernia caused by weakness or tearing of the posterior inguinal wall, with no clinically recognisable hernia, leading to chronic groin pain (PMID 17664370). The word “occult” says a lot about the embarrassment: a hernia is postulated that no examination shows.

The mechanism: a crossroads of opposing forces

The pubic region is the point where two antagonistic muscle systems meet. Above, the abdominal muscles (rectus abdominis, obliques, transversus) pull the symphysis up and back. Below, the adductors, and adductor longus first among them, pull down and forward. Those two forces meet on a common aponeurosis inserted on the pubis.

The at-risk sporting movement combines hip extension, trunk rotation and violent abdominal contraction: the shot, the change of direction, the throw, the skating stride. Repeated, it imposes on that crossroads shearing forces that neither bone nor aponeurosis fully dissipates. The Manchester consensus draws from it the most cautious and probably the most accurate formulation: what is found is abnormal tension in the groin, particularly around the insertion of the inguinal ligament, with sometimes a detachment of the external oblique and small tears, and tissue oedema.

The share taken by the nerves, long underestimated

The series by Gerhardt et al. covers 51 athletes operated on for groin pain between 2009 and 2015, with a mean follow-up of 4.42 years. What the surgeons found on opening is telling: nerve entrapment in 96.2 % of cases, involving the ilioinguinal nerve in 92.5 %, the iliohypogastric in 30.8 % and the genitofemoral in 13.2 %. Attenuation of the posterior inguinal wall was present and repaired in 79.3 % of cases, and scar tissue surrounding the adductor origin required debridement in 56.7 %.

A 2025 review devoted to neuropathic causes confirms that shift of attention: the anatomical variability of the nerve courses and the overlap of their sensory territories complicate diagnosis, and the clinical distinction between neuropathic pain (burning, electric shock) and nociceptive pain (dull, aching) becomes an orientation element in its own right. The authors are a reminder that conservative treatments remain first line, surgery being reserved for persistent cases (Vuckovic 2025, PMID 40032740).

Who is affected, and what place does the inguinal entity occupy?

In this chapter: the real weight of groin injuries in professional football over fifteen seasons, the place of the inguinal entity among the causes operated on, the profile of patients and why the published figures depend first of all on where you count.

The prospective study of UEFA elite clubs provides the most solid measure available. Across 47 European teams followed between 2001-2002 and 2015-2016, that is 268 team-seasons, hip and groin injuries account for 1,812 injuries out of 12,736, that is 14 % of the total, at a rate of 1.0 injury per 1,000 hours of exposure. Adductor-related injuries alone make up 63 % of them (Werner 2019, PMID 29691289).

The most interesting result of that study lies elsewhere. Over fifteen years, the rate of hip and groin injuries fell by 2 % a season, and that of adductor injuries by 3 %. But the burden, the number of days lost per 1,000 hours, did not move (p = 0.40). In other words: people get injured slightly less often, and stay out just as long. For a condition whose management is reputed to be difficult, the finding is worth pondering.

The place of the inguinal entity depends on who is counting

One difficulty must be stated frankly: there is no single prevalence figure for the inguinal entity, and the published proportions vary with the population recruited. Three measurements, three populations, three results:

• Among 100 athletes attending a specialist multidisciplinary centre, the adductor entity dominates at 61 % and the pubic entity brings up the rear at 4 %, with 44 % of multiple causes (Taylor 2018).
• Among 207 patients followed before the Doha agreement and classified into three patterns, rectus abdominis involvement accounts for 10 %, but it was isolated in only 2 cases out of 20 (Hölmich 2007).
• Among 4,655 athletes operated on, inguinal pathology accounts for 10 % of indications, behind femoroacetabular impingement (32 %), athletic pubalgia in the sense of the pubic insertion (24 %) and the adductors (12 %), de Sa 2016, PMID 27153868.

Those figures do not contradict each other: they count different things. The last describes only the patients who made it to theatre, which by construction excludes everyone whom rehabilitation was enough to cure. That is the classic bias of surgical series, and it means never reading an operative success rate as a measure of how common the disease is.

The profile

The systematic review by Hatem et al., which brings together 47 studies and 2,737 patients operated on for chronic groin pain, gives the broadest portrait: 94 % men, mean age of 27.8 at the time of the operation (range 12 to 65), and a mean symptom duration of 13.1 months before the operation. Football dominates by far (71 %), followed by rugby (7 %), Australian rules football (5 %) and ice hockey (4 %): PMID 34541009.

That thirteen-month delay is the most telling figure in the series. It does not say that the condition takes a year to declare itself: it says that a year passes between the onset of symptoms and the procedure. Part of that delay is legitimate rehabilitation time; another part is diagnostic wandering, and it is that part the Doha framework seeks to reduce.

How do you recognise inguinal pain on clinical examination?

In this chapter: the two mandatory Doha criteria, the palpation and resistance tests named one by one, their measured inter-examiner agreement (from κ = 0.01 to κ = 0.72) and what the absence of a perfect test means for how the consultation is run.

The Doha definition comes down to one sentence, and every one of its terms counts: “Pain localised to the region of the inguinal canal AND tenderness of the inguinal canal. No palpable inguinal hernia is present.” The probability increases if the pain is worsened by a test of abdominal muscle resistance, or by a Valsalva, a cough, a sneeze.

Two practical consequences follow. First, palpation of the canal is mandatory : pain of inguinal location without tenderness on palpation does not meet the criterion. Second, looking for a palpable hernia is an exclusion criterion, not a diagnostic argument: if you feel a hernia, you are dealing with a hernia, and the patient needs a surgical opinion, not this framework.

The tests, one by one

The study by Heijboer et al., conducted at Aspetar hospital between March 2019 and October 2020, standardised the examination in 44 male athletes aged 18 to 40 with long-standing groin pain, that is 61 symptomatic sides. Two independent examiners, blind to each other, carried out the same protocol (PMID 36643406). The protocol included:

• Palpation of the pubic tubercle, the inguinal ligament, the superficial inguinal ring, the conjoint tendon and the posterior wall;
• Scrotal invagination with a Valsalva manoeuvre, which allows the superficial ring and the posterior wall to be reached transcutaneously;
• Abdominal resistance tests : straight sit-ups at 0° and at 45°, cross tests and oblique sit-ups.

The test most often positive in athletes classified as having a defined inguinal entity is the reproduction of recognisable pain on palpation during scrotal invagination under Valsalva: 79 %. The abdominal resistance tests, for their part, were positive in only 21 to 49 % of cases depending on the test, which is enough to disqualify the idea that a negative resisted abdominal test rules out the diagnosis.

What “no perfect test” changes in the consultation

A κ of 0.01 for judging the consistency of the posterior wall means that two trained clinicians, examining the same patient on the same day, agree at the level of chance. That is not a criticism of the examiners: it is the measure of a limit intrinsic to a manoeuvre that consists of judging a deep structure “firm or soft” through skin, subcutaneous tissue and scrotum.

The consequence is direct. The diagnosis of the inguinal entity is built by convergence : location of the pain, reproduction on palpation of the canal, worsening with Valsalva or abdominal resistance, absence of a palpable hernia, and above all reasoned elimination of the neighbours. Basing the decision on a single test (particularly on the perception of a bulge, whose agreement is poor) invites error.

It should be added that the reliability of groin examination is not uniformly poor. Hölmich et al. measured in 2004, in 18 athletes examined twice by two doctors and two physiotherapists, intra-observer kappas above 0.60 in 11 tests out of 14, and inter-observer kappas above 0.60 in 8 of the 10 pain tests. The only test without acceptable reliability was the iliopsoas strength test (PMID 15273182). It is therefore the deep palpation manoeuvres of the wall that are fragile, not groin examination in general.

The examination approach these data suggest

1. Localise : have the patient point to the area with one finger. Pain in the groin crease points one way; midline pain over the symphysis points to the pubic entity; pain in the adductor muscle belly points elsewhere.
2. Palpate the canal : pubic tubercle, inguinal ligament, superficial ring, conjoint tendon. Look for reproduction of pain the patient recognises , a formulation that counts for more than mere tenderness.
3. Provoke : Valsalva, cough, then abdominal resistance (straight and oblique sit-ups). A positive test strengthens; a negative test does not rule out.
4. Rule out a true hernia : look for a mass or a reducible bulge, standing and on Valsalva.
5. Examine the neighbours systematically : adductors (palpation and resisted adduction), iliopsoas (resisted flexion, stretching), symphysis (palpation), hip (FADIR, FABER, ranges). That is the only way to spot the 44 % of mixed presentations.

Which diagnoses must be ruled out before settling on the inguinal wall?

In this chapter: femoroacetabular impingement and the real value of the FADIR, the true inguinal hernia, the non-musculoskeletal causes the Doha agreement requires you to consider, and a sorting tree usable in the clinic.

The inguinal entity is a diagnosis of convergence, but also, in part, a diagnosis of exclusion. Three families must be ruled out: the other Doha entities, hip pathology, and what the consensus places under “other causes”.

Femoroacetabular impingement

It is the commonest and the most misleading neighbour. In the review by de Sa et al. covering 4,655 athletes operated on for groin pain, femoroacetabular impingement is the leading cause, at 32 % of indications: ahead of athletic pubalgia (24 %). Intra-articular and extra-articular causes are equal there, which makes it impossible to treat the hip as a secondary hypothesis.

The screening test is the FADIR (flexion-adduction-internal rotation). Its benchmark meta-analysis credits it with a pooled sensitivity of 0.94 - 0.99, but with diagnostic odds ratios whose confidence intervals cross unity, and the authors conclude that these tests have only screening value (Reiman 2015, PMID 25515771). In practice: a negative FADIR makes impingement unlikely and that is its whole value; a positive FADIR does not confirm it. For the full approach, see our articles on femoroacetabular impingement and hip labral tear.

The true inguinal hernia

The distinction is simple in principle and decisive in practice: a true hernia can be palpated. The Doha definition explicitly excludes the inguinal entity in the presence of a palpable inguinal hernia. Examination standing, at rest then on Valsalva and coughing, looks for a mass or a reducible bulge. A genuine hernia warrants a surgical opinion straight away, without going through rehabilitation.

The rarity of true hernia in this population deserves emphasising one last time: in the series by Zoga et al., of the 102 patients whose images could be compared with the operative findings, only two had a hernia. That is what justifies the consensus rejecting the term.

The non-musculoskeletal causes

The Doha agreement does not stop at a list: it calls for a high level of clinical suspicion, because these causes do not reveal themselves on musculoskeletal examination. The categories retained are orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical.

In practice, in an athlete referred for “groin pain”, you have to be able to consider testicular disease, a urinary infection, prostatitis, endometriosis in women, gastrointestinal disease in the iliac fossa, early spondyloarthritis, since sacroiliitis can refer to the groin, and a stress fracture. What these situations have in common is that they resist rehabilitation without the physiotherapist understanding why, which should in itself be a signal.

What can imaging really show?

In this chapter: the measured performance of MRI against operative findings, what dynamic ultrasound brings and at what price, why normal imaging rules nothing out, and the rule that follows from all this.

The classic position is that of Farber and Wilckens: the role of imaging in this condition is unclear; most investigations will be normal (PMID 17664370). Twenty years later, that sentence remains largely true for the inguinal entity in the Doha sense, whose definition contains no imaging criterion. But it deserves qualifying by the quantitative data available.

What MRI sees, and with what accuracy

The reference study is that of Zoga et al., which retrospectively compared the MRIs of 141 patients referred for groin pain with the operative findings in 102 of them, with a control group of 25 asymptomatic men (PMID 18487535). The results are mixed:

• 138 patients out of 141 (98 %) had an MRI abnormality capable of explaining the pain;
• for a tear of the rectus abdominis tendon: sensitivity 68 %, specificity 100 % ;
• for a tear of the adductor tendon : sensitivity 86 %, specificity 89 % ;
• these lesions were significantly more frequent in patients than in controls (p < 0.001);
• and, as said, only two patients had a hernia at operation.

The specificity of 100 % for rectus abdominis is the usable figure: when MRI states a rectus abdominis insertion tear, it is right. The sensitivity of 68 % is the symmetrical warning: an MRI that shows nothing misses nearly a third of those lesions. Zoga also noted that patients with involvement of the rectus abdominis insertion were the most likely to go on to surgical repair of the pelvic floor.

Dynamic ultrasound

Ultrasound has the advantage of being dynamic: it allows the wall to be loaded in real time. The Manchester consensus mentions it among the useful imaging modalities. The case reported by Yang et al. illustrates its use: a 19-year-old footballer whose abdominopelvic CT was normal, and in whom dynamic ultrasound showed a direct bulge arising from the posterior inguinal wall on abdominal tensing, with the legs raised during a full inspiration. Surgery confirmed the deficiency of the posterior wall (PMID 26798621).

That case shows the value of the method and, at the same time, its limit: it is an isolated case, operator-dependent, and it should be set against the κ of 0.29 measured by Heijboer for the clinical assessment of bulging of the posterior wall. The sign is real but hard to establish reproducibly, whatever the method used to look for it.

The rule that follows

Three indications emerge, and one non-indication:

• Eliminate a competitor : stress fracture, hip pathology, bone oedema of the symphysis, tumour. That is the first reason to image.
• Document before surgery : the location of the lesion guides the procedure, and rectus abdominis involvement has prognostic value in Zoga's series.
• Settle an atypical situation : a woman, an adolescent, an unusual sport, a course that does not follow.
• What it is not for : confirming the inguinal entity in an athlete whose clinical examination already points to it. Normal imaging will not change your mind, and an asymptomatic abnormality will divert the management.

What conservative treatment should be offered first line?

In this chapter: what the consensus recommends, a methodological warning about Hölmich's protocol, what the data specific to the inguinal entity actually allow you to state, and a table of modalities with their level of evidence.

The first-line recommendation is clear and comes from the most specific consensus on the question. The Manchester group, convened by the British Hernia Society, and therefore by surgeons, recommends a multidisciplinary approach with tailored physiotherapy as initial treatment, surgery coming only afterwards (PMID 24149096). That surgeons place rehabilitation in the front line deserves emphasis.

A necessary warning about Hölmich's protocol

Hölmich's active exercise protocol is regularly presented as the reference treatment for groin pain. One has to be precise about what it establishes, because that is where the commonest error slips in.

The randomised trial published in the Lancet in 1999 included 68 athletes with adductor-related groin pain, as the title of the paper says explicitly: adductor-related groin pain, of a median duration of 40 weeks. The active programme, centred on strengthening and coordination of the muscles acting on the pelvis and in particular the adductors, allowed 23 patients to return to sport without pain against 4 in the passive physiotherapy group, that is an odds ratio of 12.7 (95 % CI 3.4 to 47.2) : PMID 9989713. The effect was maintained at 8-12 years of follow-up (PMID 21813441).

That distinction is not academic scruple. If the patient has both entities (a frequent case, as noted: 18 of the 20 rectus abdominis cases in Hölmich were associated with the adductors), then the protocol treats the adductor part with an excellent level of evidence, and the inguinal part by ricochet, with no guarantee. Knowing that changes how you announce the prognosis and how you interpret a failure.

What is available for the inguinal entity itself

The data are thin and that must be said. The systematic review by Serner et al. sifted 72 studies on the treatment of groin pain: only four were of high quality. For sportsman's hernia, the synthesis concludes to moderate level evidence in favour of surgery compared with conservative treatment (PMID 25633830).

But the same review delivers a result that must temper that conclusion: the correlation between the methodological quality of a study and the success rate it reports is moderate and inverse (r = −0.41, p < 0.001). In other words, the more rigorous a study, the less effective it finds the treatment. When the most favourable evidence comes from the weakest studies, caution is needed on both sides of the debate.

Prevention, the only ground where the evidence is solid

The cluster trial by Harøy et al. deserves to be known precisely, because it is one of the few good quality randomised trials in the field. Thirty-five Norwegian semi-professional teams were randomised: 18 teams (339 players) performed an adductor strengthening programme based on a single exercise, the Copenhagen Adduction, at three levels of progression, three times a week during pre-season (6 to 8 weeks) then once a week in season (28 weeks); 17 teams (313 players) trained as usual.

Result: a mean prevalence of groin problems of 13.5 % (95 % CI 12.3-14.7) against 21.3 % (95 % CI 20.0-22.6), that is a risk reduced by 41 % (OR 0.59, 95 % CI 0.40-0.86, p = 0.008), PMID 29891614. These are groin problems from all causes, measured by self-report questionnaire, and not the inguinal entity alone: the nuance matters but takes nothing away from the value of a programme that takes five minutes.

When does surgery become legitimate, and what does it bring?

In this chapter: the randomised trial that favours surgery, the meta-analysis that finds no difference, the techniques and their results by anatomical site, and how to hold these data together without sacrificing one of them.

This is the chapter where the literature contradicts itself, and it is better to say so at the outset than to choose the source that suits. Three good-quality pieces of work give three different answers, because they do not ask the same question.

The randomised trial: advantage to surgery

Paajanen et al. conducted the only randomised trial directly comparing the two strategies in this indication. Sixty patients with chronic groin pain and suspected sportsman's hernia, defined by the authors as a deficiency of the posterior wall of the inguinal canal, were randomised after 3 to 6 months of symptoms into two groups of 30 (PMID 21549403) :

• Operated group : totally extraperitoneal repair with mesh placed behind the symphysis and the painful area.
• Conservative group : at least 2 months of active physiotherapy, corticosteroid injections and oral anti-inflammatories.

The results are clear-cut: 27 of the 30 operated patients (90 %) returned to sport after 3 months, against 8 of the 30 treated conservatively (27 %), p < 0.0001. Superiority in pain was significant from 1 to 12 months (p < 0.001). Seven patients in the conservative group (23 %) were eventually operated on because of persisting pain.

Two reservations, however. The first is that the conservative arm combined corticosteroid injections and anti-inflammatories with physiotherapy: that is not the progressive exercise programme current consensus recommends. The second is the sample size, 60 patients, and the absence of blinding, unavoidable when one arm involves an incision.

The meta-analysis: no difference in return rate

King et al. pooled 56 studies and 3,332 athletes to compare rates and timing of return to sport between surgery and rehabilitation, grouping diagnoses into three anatomical families: abdominal wall, adductors, pubis (PMID 26130700).

Their conclusion is that return-to-sport rates are comparable between surgery and rehabilitation in all three diagnostic groups. For pubic-related pain, rehabilitation even returns athletes to sport significantly faster: 10.5 weeks against 23.1 weeks. The “abdominal wall” group, the one that concerns us here, is the one that recovers fastest of the three, in both strategies.

The authors attach a severe warning to that result: the overall methodological quality is low, the evidence is mostly level IV, and the risk of bias is particularly high in the surgical studies.

The results by technique and by site

The review by Hatem et al. is the most useful for informing a decision, provided you keep in mind that it compares nothing: it describes what becomes of 2,737 patients operated on across 47 studies, of which 44 are level IV and only 2 are level 1b randomised trials. Return to the previous level or higher is:

• 92 % (95 % CI 88-95) after surgery of the inguinal region; ;
• 89 % (95 % CI 70-99) after a combined inguinal and adductor origin procedure;
• 84 % (95 % CI 47-100) after surgery of the pubic symphysis;
• 75 % (95 % CI 57-89) after surgery of the adductor origin.

Return to the previous level is therefore significantly more likely after inguinal surgery (92 %) than after adductor surgery (75 %). The confidence intervals of the other two groups are so wide that they allow no firm conclusion: that of the symphysis runs from 47 % to 100 %.

How to hold these data together

The reading that respects all three pieces of work is the following. Surgery works : return-to-sport rates after an inguinal procedure are high and consistent from one series to another. It is not for all that superior to rehabilitation in the only large-scale comparison available, and the single randomised trial that finds it superior compared surgery with a conservative arm that was not a modern progressive exercise programme.

To that is added Serner's warning: in this field, the most rigorous studies report the poorest results. A rate of 92 % coming mostly from level IV studies must be read with that implicit correction.

In practice, the elements that tilt towards a surgical opinion are: failure of a well-conducted progressive exercise programme over at least two to three months, pain that stays localised to the inguinal canal and reproducible on palpation, a clear neuropathic component, and an athlete whose season or career forces a decision. Conversely, a patient who has had only rest, anti-inflammatories and shockwave therapy has not had conservative treatment: they have had a wait.

What do concrete clinical cases teach us?

In this chapter: three published, identified cases, two treated without surgery with return to sport, and a third that shows what dynamic ultrasound brings and where it stops. What each demonstrates, and what it does not.

The cases that follow are genuine indexed case reports , readable in full with open access on PubMed Central. They are level 4 evidence: they illustrate an approach, they demonstrate no efficacy.

Case 1: A professional golfer, treated without surgery

Presentation. A professional golfer develops lower abdominal and groin pain after a change in his physical preparation routine. The clinical picture is consistent with a diagnosis of sports hernia.

Management. A structured programme of trunk musculature retraining, organised in progression following the neurodevelopmental sequence, targeting the neuromuscular control and stability needed for return to golf.

Result. Full return to playing golf after 13 physiotherapy sessions over 4 weeks (Becker & Bullock, Int J Sports Phys Ther 2014, PMID 25383252, full text PMC4223293).

What it brings. The authors themselves note that no case of managing this condition had been reported in a golfer, and that the available data broadly favour surgery. Their conclusion is measured: a structured rehabilitation programme may be an option prior to surgical repair, allowing some athletes to return to their sport.

Case 2: A professional ice hockey player, seven weeks and seven years of follow-up

Presentation. A professional ice hockey player injures his abdomen during a game; the diagnosis retained is sports hernia.

Management. Structured conservative treatment centred on trunk control and stability, with progressively increasing peripheral demands, then functional training before return to play.

Result. Return to full competition seven weeks after the injury. A rare element in a case report: the authors specify that the player was still competing in the NHL seven years later (Woodward, Parker & van der Meer, Int J Sports Phys Ther 2012, PMID 22319682, full text PMC3273884).

What it brings. The authors point to a fundamental methodological problem: the publications favourable to surgery describe poor results of conservative treatment without ever specifying what that treatment consisted of. That is exactly the criticism that can be made of the conservative arm of Paajanen's trial, and it is an argument worth knowing when a patient arrives with a “failure of rehabilitation” in their notes.

Case 3: A 19-year-old footballer, or what dynamic ultrasound brings

Presentation. A 19-year-old footballer presents with groin pain worsened by sporting activity. The abdominopelvic CT performed in general surgery shows no abnormality; the patient is referred to rehabilitation medicine.

Approach. History and physical examination point the way, and dynamic ultrasound reveals a direct bulge arising from the posterior inguinal wall when abdominal tension is induced by raising both legs during a full inspiration.

Result. Surgery confirmed the lesion, allowing early management (Yang et al., Ann Rehabil Med 2015, PMID 26798621, full text PMC4720758).

What it brings. A normal static investigation, here a CT, does not rule out a wall deficiency that only reveals itself under load. That is the argument for dynamic imaging when the clinical picture insists and the standard work-up stays silent.

How do you apply this framework in practice?

In this chapter: the synthesis of the levels of evidence, a consultation framework, what to do in the first weeks, the referral criteria and what to tell the patient about the word “hernia”.

The consultation framework

1. Rule out the emergency and the true hernia. Red flags, palpation standing on Valsalva. A reducible mass stops the process and refers to the surgeon.
2. Have the patient localise the pain with one finger, then palpate the five territories without presuming: adductors, iliopsoas, inguinal canal, symphysis, hip. Note every positive entity, not only the first.
3. Provoke : Valsalva, cough, straight and oblique abdominal resistance. Remember that the most rewarding test is reproduction of recognisable pain on palpation of the canal.
4. Name the diagnosis correctly to the patient, and correct the word “hernia” if someone has used it.
5. Start a progressive exercise programme covering the abdominal-adductor crossroads, announcing a horizon of 8 to 12 weeks and not of a few sessions.
6. Reassess at intervals set in advance, and reopen the diagnosis in case of a plateau rather than intensifying the treatment.

What to tell the patient about the word “hernia”

It is a consultation moment in its own right, and it is short. The patient often arrives with the phrase “sportsman's hernia”, heard at the club, from a teammate or read online. That phrase carries a precise picture: a hole in the wall, which has to be closed surgically. Yet the learned society that brings together hernia surgeons has rejected that term, on the grounds that no true hernia is present; and the only series that compared imaging with operative findings found a hernia in only two patients out of a hundred and two.

Saying that is not cheap reassurance: it is correcting a belief which, left intact, steers the patient towards the operating theatre before they have received the treatment the consensus places in the front line.

Frequently asked questions