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Sports Hernia: who to see and what helps

Sports Hernia · Kitchener, Waterloo & Cambridge

A sports hernia is a painful soft-tissue injury low in the abdomen and groin, seen in sports with hard twisting, turning and kicking. Despite the name there is no true hernia and no bulge. The British Hernia Society recommends tailored physiotherapy first, with surgery when rehabilitation fails. Severe pain at the moment of an injury, and groin pain that came on with running or hard training without a sudden sprint, kick or twist, need medical care first (see the warning signs below). Otherwise the first visit at CARESPACE is with a physiotherapist, who assesses and treats that day.

What a sports hernia is

The injury is where the abdominal muscles and the inner-thigh (adductor) muscles attach to the pubic bone. The oblique abdominal muscles and their tendons are affected most often, and the adductor tendons are often stretched or torn as well.

Nobody agrees on the name. American orthopaedic surgeons prefer athletic pubalgia. The British Hernia Society chose inguinal disruption, because no true hernia exists. An international agreement on groin pain in athletes uses inguinal-related groin pain and chose not to recommend “sports hernia” as a term. A true hernia, where tissue bulges through the abdominal wall, is a different condition: see Hernia Rehab Before & After Surgery.

Symptoms

  • Pain in the groin near the pubic bone, sudden at the moment of an injury or building up gradually
  • Pain that eases with rest and returns with sport, especially twisting, turning, sprinting and kicking
  • Pain that is worse when you cough, sneeze or do a sit-up
  • A dull, spreading ache that can run to the inner thigh, the perineum or across the midline
  • No visible bulge

Who gets it

Athletes in sports that involve planting the feet and twisting at full effort. Ice hockey, soccer, football, rugby and wrestling are the sports named most often, and middle-distance runners are on the list too. It is predominantly a male athlete’s injury: only 1% to 3% of those affected are women. In Waterloo Region that mostly means hockey and soccer players.

How it is diagnosed

By examination, and by ruling other causes out. The British Hernia Society’s position statement makes the diagnosis when at least three of five signs are present: pinpoint tenderness where the abdominal tendon meets the pubic bone, tenderness over the deep inguinal ring, pain or widening at the external ring with no hernia, pain where the adductor longus tendon starts, and the dull spreading ache described above. It recommends imaging for everyone with the diagnosis, MRI for preference, mainly to exclude other causes, because no scan finding is unique to this injury. A physician or nurse practitioner arranges imaging.

Its neighbours are told apart by where they hurt. A Groin Strain is tender along the inner-thigh muscle. Pubic Pain & Osteitis Pubis is tender on the pubic joint in the midline, and the two can occur together. Hip joint problems such as Hip Impingement (FAI) must be considered as well.

When groin pain is an emergency

Nobody at CARESPACE can rule out an emergency. These signs come from the NHS (the UK’s health service), Alberta’s and British Columbia’s health services and the US National Institutes of Health, in Ontario terms; where they differ, the more cautious instruction is used.

A hernia that changes suddenly. Call 911 or go to an emergency department right away if you have a hernia, or a lump in your groin or at your belly button, and any of these: the lump is suddenly larger than before; the area over it has turned red or become tender to touch, or the skin around it has changed colour; it no longer goes back in, or you cannot push it back with gentle pressure while lying down; sudden or severe pain around it, or very bad belly pain that does not go away; feeling sick, vomiting (including blood, or vomit that looks like coffee grounds) or being unable to keep food down; a bloated belly, or being unable to pass stool or gas; a fever or high temperature, or feeling hot, cold or shivery; or sudden confusion. Do not drive yourself. A trapped hernia can lose its blood supply (a strangulated hernia), which is life-threatening and needs surgery right away.

Sudden testicle pain. Call 911 or go to an emergency department right away if you have sudden, severe pain in a testicle, testicle pain together with feeling sick, vomiting or belly pain, or testicle pain that has lasted more than an hour or continues when you are resting. Do not drive yourself: ask someone to drive you or call 911 for an ambulance, and bring any medicines you take. It can mean a twisted testicle (testicular torsion), and the testicle can be lost if this is not treated quickly.

After a fall or injury. Call 911 or go to an emergency department if you have severe hip or groin pain, you cannot move your leg, walk or put weight on it, or you have tingling, numbness, weakness or loss of feeling in your groin, hip or leg. Do not drive yourself.

The same day, with a hernia or a change in a testicle. Go to an urgent care clinic or an emergency department the same day if you have a hernia and pain in or around it, or belly pain, that is new or getting worse but is not sudden or severe (a hernia that has turned red or become tender to touch is on the emergency list above); a hernia and constipation (being unable to pass stool or gas is on the emergency list above); a lump or swelling in a testicle or anywhere in your scrotum; a change in the shape or feel of a testicle; one testicle that has become bigger than the other; or an ache or discomfort in your testicles that worries you.

The same day, for the hip or groin. Go to an urgent care clinic or an emergency department the same day if you have severe hip or groin pain that started suddenly without a fall or injury; new or severe pain or swelling in the groin while a strain is healing; a hip or groin that is swollen and feels hot; a groin, hip or upper thigh that is cool or pale or has changed colour; or pain together with feeling generally unwell and a high temperature (or feeling hot, cold or shivery).

Hip or groin pain that came on with running or hard training, and did not start with a sudden sprint, kick, twist or change of direction, needs medical assessment the same day, at an urgent care clinic or emergency department if you cannot reach a physician or nurse practitioner. It can be a stress fracture in the neck of the thigh bone, which can shift out of place and then needs surgery, and X-rays alone cannot rule one out. Protect the leg with crutches until the diagnosis is confirmed. Stress Fractures has more.

The emergency departments in Waterloo Region are:

  • WRHN @ Midtown (formerly Grand River Hospital), 835 King St. W., Kitchener
  • WRHN @ Queen’s Blvd. (formerly St. Mary’s General Hospital), 911 Queen’s Blvd., Kitchener
  • Cambridge Memorial Hospital, 700 Coronation Blvd., Cambridge

If you cannot get there safely, call 911.

See a physician or nurse practitioner if you have a lump or bulge in your groin or at your belly button with none of the signs above, even one that disappears when you lie down, or if groin pain is increasing or is not getting better as expected.

What the evidence says about treating a sports hernia

  • Where these points come from. The position statement, two randomized trials and a systematic review of 56 studies. The statement describes itself as a best guide, not as evidence, and the review rated its studies as mostly poor quality with a high risk of bias.
  • Physiotherapy first. The statement recommends a multidisciplinary approach with tailored physiotherapy as the initial treatment: one to two months of rehabilitation, rest and pain relief, with surgery for rehabilitation that has failed after more than two months.
  • Active exercise beat passive treatment in one small trial. Forty soccer players with at least two months of pain all had heat, friction massage, TENS, mobilization of the pelvis and hip, and stretching for two months. Half also did hip and abdominal strengthening, core stability and balance exercises. Of those, 13 of 20 returned to sport without groin pain, against 3 of 20. The exercise group received more treatment time, and nobody was followed long term.
  • For pain that had already lasted months, surgery did better in one trial. Sixty athletes with three to six months of symptoms had either a keyhole mesh repair or at least two months of active physiotherapy with corticosteroid injections and anti-inflammatory medicine. At three months, 27 of 30 in the surgery group were back at sport against 8 of 30, and 7 of the 30 treated without surgery later had the operation.
  • Across the wider research, the two routes look level. In the systematic review, which covered 3,332 athletes with every kind of groin pain, return-to-play rates after rehabilitation and after surgery were comparable for pain from the abdominal wall.
  • Not everyone needs an operation. The statement’s consensus is that, among elite athletes, surgery is required in approximately 60% of cases and must be preceded by appropriate physiotherapy. That is a view about elite athletes referred to surgeons, not a measured rate for everyone with the diagnosis. No operation has been shown to be better than another.

What a doctor may offer

CARESPACE does not provide these. A physician can arrange the MRI, advise on anti-inflammatory medicine and refer you to a surgeon if rehabilitation has not worked. The repair is open or keyhole, with mesh or stitches. The position statement expects a full return to activity four to eight weeks after surgery; American orthopaedic surgeons say six to twelve weeks for most athletes.

How each CARESPACE service treats a sports hernia

Physiotherapy

A physiotherapist can examine the lower abdomen, the adductors and the hip, including a resisted sit-up, and say when the picture calls for a physician and a scan. The rehabilitation itself is work a physiotherapist can provide: strengthening for the gluteal and deep abdominal muscles, posture and control of the pelvis in the twisting and cutting positions that set the pain off, mobility for tight muscles, and cardiovascular exercise. If you go on to surgery, the same program is the preparation, and it includes learning the post-operative exercises beforehand.

See our physiotherapy team →

Chiropractic

A chiropractor can examine the hip, pelvis and spine and can provide mobilization together with an exercise program, not in place of one. Every player in the soccer trial received mobilization of the pelvis and hip, and it was the added exercise that made the difference.

See our chiropractic team →

Kinesiology

A kinesiologist can build the return to running (jogging, then sprints, then cutting) with the hip, abdominal and balance work underneath it; the soccer players started that progression at week six. After surgery, the position statement’s program moves from static exercises in the first week to running from the third and sport-specific work in the fourth, always within your surgeon’s instructions.

See our kinesiology team →

Other services people ask about

Massage therapy. Both groups of soccer players had friction massage, and the group that had it without the strengthening exercises did much worse. The sources give no support for massage as the treatment.

Where most people start

With a physiotherapist, who assesses and treats at the first visit. The exceptions are the two named at the top of this page, which need medical care first as the warning signs above describe. If the pain has lasted more than two months despite proper rehabilitation, see a physician about a scan and a surgical opinion.

How your team works together

The recommended team includes an orthopaedic surgeon and a hernia surgeon as well as a physiotherapist, so part of this care sits outside CARESPACE. Inside it, a physiotherapist can lead the rehabilitation, and a chiropractor or kinesiologist can add mobilization and the return-to-running program.

  1. Available this week

    Eric Bowman, BSc, MPT, PT

    Physiotherapist

    CARESPACE Weber North

    If you are looking for physiotherapy in Waterloo, you are probably not looking for a rushed appointment or a generic sheet of exercises.

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Browse by service: physiotherapists, chiropractors and kinesiologists.

What to expect at your first visit

  1. The story: one injury or a gradual build-up, which movements bring the pain on, and whether coughing or sneezing does.
  2. The examination: the lower abdomen and the area around the pubic bone, a resisted sit-up, the adductors and the hip.
  3. Where that leaves you: rehabilitation first, or a physician and a scan.
  4. Treatment at that visit and a plan to leave with: what to stop for now, the first exercises, and when progress will be reviewed.

What you can do at home

  • Rest from sport and use ice for the first 7 to 10 days after an injury.
  • Rehabilitation exercises can begin about two weeks after the injury.
  • Keep your fitness up with exercise that does not bring on the pain, such as swimming.
  • Ask a pharmacist, physician or nurse practitioner about anti-inflammatory medicine.
  • Take note of what happens when you go back to sport. Pain that returns with sport after rehabilitation is the point at which surgery is considered.

How long it takes, and whether it comes back

American orthopaedic surgeons say four to six weeks of physiotherapy resolves the pain in many cases; the position statement allows one to two months before judging that rehabilitation has failed. More than 90% of athletes who go through rehabilitation and then surgery get back to sport. Left untreated, a sports hernia can become chronic, disabling pain, and repaired tissue can tear again.

Sports hernia treatment in Kitchener, Waterloo and Cambridge

Kitchener. Physiotherapy in Kitchener, Chiropractic in Kitchener and Kinesiology in Kitchener. Locations: Victoria North, Fischer-Hallman, Westmount East and Deer Ridge.

Waterloo. Physiotherapy in Waterloo, Chiropractic in Waterloo and Kinesiology in Waterloo. Locations: Weber North, Uptown Waterloo and Waterloo GoodLife.

Cambridge. Physiotherapy in Cambridge. Location: Hespeler Road.

The city pages linked above show the locations and practitioners for each service, with their next availability.

Common questions

Is a sports hernia a real hernia?

No. Nothing pushes through the abdominal wall and there is no bulge. It may later lead to an inguinal hernia, though, and any lump in the groin should be seen by a physician or nurse practitioner.

Will a sports hernia heal on its own?

Rest eases the pain, but it typically returns with sport, and untreated it can become chronic. Rehabilitation is the first treatment.

Do I need surgery for a sports hernia?

Not always. The British Hernia Society’s consensus is that surgery is required in approximately 60% of cases among elite athletes, and only after appropriate physiotherapy; the sources here give no figure for other athletes. In the one trial of athletes whose pain had already lasted three to six months, surgery got more of them back to sport by three months.

Can I keep playing with a sports hernia?

The sources do not give a rule for playing through it. They describe rest from sport in the first 7 to 10 days after an injury and one to two months of rehabilitation, and they note that the pain tends to return with twisting and turning.

Where can I get treatment for a sports hernia in Kitchener?

Start with Physiotherapy in Kitchener. Book online or call 519-208-2273 and our Central Reception Team will find the closest location with an opening.

Do I need a referral?

No. Book online or call 519-208-2273. You pay at each visit and receive a receipt for your extended health plan. More on fees and insurance →

Sources

Related conditions

Groin Strain
Pubic Pain & Osteitis Pubis
Hernia Rehab Before & After Surgery
Hip Impingement (FAI)
Hip Pain

The CARESPACE Central Reception Team

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