Prefer to watch? 4-minute lesson13 slides · same content, shorter

1 · SNAPSHOT

Athletic Pubalgia / Inguinal-Related Groin Pain body chart — Illustrative, not diagnostic. Canva body chart for Athletic Pubalgia / Inguinal-Related Groin Pain.

Who: Field and court athletes — soccer, AFL, rugby, hockey.
What: Inguinal-related groin pain, the fourth Doha entity.
How it behaves: Gradual lower abdominal, inguinal or groin pain with sprinting, cutting, kicking and sit-ups. Pain with coughing, sneezing, or getting out of bed. Eases with rest. Often long-standing, vague, and hard to localise.

The one thing to take from this page:

It is not a hernia. There is no defect to repair — it is a load-sharing problem across the pubic and inguinal region. The argument about the name is in the published literature, and the reason it matters is that "hernia" tells everyone there is something to fix surgically.

Not a hernia

True inguinal hernia	Inguinal-related groin pain
A palpable bulge	No bulge
Cough impulse	Pain with cough — not a bulge with cough
A defect	No defect — obliques, transversus, rectus and adductors sharing load at the pubis
A surgical diagnosis	A load problem. Surgery is a late conversation

⚠️ One randomised rehabilitation trial exists on this whole page, and a systematic review found high variation in terminology, surgical technique and preoperative diagnosis across the literature. Results are hard to pool. Do not quote them as consistent.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. This is the vaguest of the four groin entities — expect the patient to struggle to localise it, and treat that vagueness as information.

MAIN PROBLEM

"It's deep, somewhere in my groin and lower belly."
"Sprinting and sit-ups both do it."
"Coughing catches me."

BODY CHART

Lower abdominal, inguinal, and groin — often a hand rather than a finger.
Mark the pubic tubercle and the inguinal canal.
Mark the adductor origin and the symphysis too. They coexist constantly.
Any lump or bulge? Mark it, then examine for it.

BEHAVIOUR

	Fits inguinal-related	Points elsewhere
Aggs	Sprinting, cutting, kicking, sit-ups	Cutting with adductor tenderness only → adductor-related
Severity	VAS 0–10 at best / at worst / right now	—
Signature	Cough, sneeze, getting out of bed	Central symphyseal with sit-up → pubic-related
Onset	Gradual, long-standing	A bulge appearing → true hernia
Localisation	Vague, hard to pinpoint	Sharply localised → reconsider
Age	Adult athlete	Adolescent → unfused pubic physis, different diagnosis

HISTORY

How long? This one is usually months, sometimes seasons.
Sprint, cut and kick volume; sit-up and core programme volume.
Has anyone said "hernia"? Find out what they think is wrong with them — it shapes everything.
Any previous groin surgery, including on the other side?
Contralateral symptoms? Don't forget across-the-line contributions.

SPECIAL / SCREENING QUESTIONS

Any lump or bulge, especially on coughing or straining?
Testicular, scrotal or urinary symptoms?
Can they weight-bear and hop? Night pain, RED-S profile?
Skeletally mature? In an adolescent this is a different structure.

Assessing this region? Download the Hip & Groin assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Adductor-related groin pain	Tender adductor origin, squeeze positive, cough and sit-up negative. Coexists constantly.
Pubic-related groin pain	Central symphyseal tenderness, squeeze and sit-up positive.
Hip-related pain (FAI, labral)	FADIR, reduced IR in flexion — and athletic pubalgia imaging findings have been described in patients with FAI [1].
Iliopsoas-related pain	Tender deep to the inguinal ligament, pain on resisted hip flexion.
Referred urological or abdominal pain	Not reproduced by musculoskeletal loading; testicular or urinary symptoms.

The two that outrank the table

A true inguinal hernia. A palpable bulge or a cough impulse. That is a surgical diagnosis and it is not this one — clear it explicitly.

An adolescent with an unfused pubic physis. Read further: the unfused pubic physis in paediatric athletes [2]. Different structure. Do not apply the adult model.

And the reason this is called a potpourri

Inguinal-related groin pain has been described in the literature as "a pathological potpourri" [3]. That is the honest framing — several structures around one region, sharing load, with imaging that rarely settles anything.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
A palpable bulge or cough impulse	True inguinal hernia	Surgical review. Do not rehabilitate it
A tender, irreducible lump	Incarcerated or strangulated hernia	EMERGENCY
Adolescent athlete, skeletally immature	Unfused pubic physis — a different diagnosis	Paediatric imaging and review
Sudden testicular pain	Testicular torsion	🚑 Emergency, now
Other testicular or scrotal pain or swelling	Urological pathology	Urgent medical review
Urinary symptoms, fever, feeling unwell — or acute groin pain with fever	Infection, including infective osteitis pubis or pubic osteomyelitis	Medical review. A normal X-ray, CT or even a first MRI doesn't clear it — repeat the MRI if suspicion stays (Yanagita et al. 2023) [21]
Unable to weight-bear or hop	Pubic ramus or femoral neck stress fracture	Urgent imaging
RED-S profile — low energy availability, menstrual disturbance	Bone stress injury	Image and refer
Night pain, weight loss, cancer history	Malignancy	Medical review

The rule: long-standing, load-related lower abdominal and inguinal pain with no bulge, in a skeletally mature athlete who can hop and is systemically well, is yours. A bulge, an adolescent, anything testicular, or an inability to weight-bear is not.

Cross-links: Adductor-related groin pain · Pubic-related groin pain · Iliopsoas-related pain · Femoroacetabular impingement

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No treatment guideline exists.

Anchored to the Doha agreement (Weir et al. 2015, PMID 26031643), which makes inguinal-related groin pain the agreed term, and to the current understanding and assessment review from the same research group (Thorborg et al. 2025, PMID 41710221).

PubMed Source

No guideline, no Australian document, and one randomised trial of rehabilitation on the whole page. A systematic review found high variation in terminology, surgical technique and preoperative diagnosis across this literature — so results are hard to pool and should not be quoted as though they were consistent.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2020Varada et al. (2020). The prevalence of athletic pubalgia imaging findings on MRI in patients with femoroacetabular impingement. Skeletal radiology, 49(8), 1249-1258. https://doi.org/10.1007/s00256-020-03405-z
2024Bixby & d'Hemecourt (2024). Athletic pubalgia in pediatric athletes: implications of the unfused pubic physis on diagnosis and outcome. Pediatric radiology, 54(8), 1281-1283. https://doi.org/10.1007/s00247-024-05957-x
2022Vuckovic et al. (2022). Inguinal-related groin pain in athletes: a pathological potpourri. BMJ open sport & exercise medicine, 8(3), e001387. https://doi.org/10.1136/bmjsem-2022-001387
2023Heijboer et al. (2023). Clinical examination for athletes with inguinal-related groin pain: interexaminer reliability and prevalence of positive tests. BMJ open sport & exercise medicine, 9(1), e001498. https://doi.org/10.1136/bmjsem-2022-001498
2020Bou Antoun et al. (2020). High insertion of conjoint tendon is associated with inguinal-related groin pain: a MRI study. European radiology, 30(3), 1517-1524. https://doi.org/10.1007/s00330-019-06466-4
2019Abouelnaga & Aboelnour (2019). Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial. Annals of rehabilitation medicine, 43(3), 305-313. https://doi.org/10.5535/arm.2019.43.3.305
2025Thorborg & Sheen (2025). Inguinal-Related Groin Pain and/or Disruption in Athletes: Current Understanding, Assessment and Management Strategies. Open access journal of sports medicine, 16, 510774. https://doi.org/10.2147/OAJSM.S510774
2025Dudai & Paajanen (2025). Narrative Review and Clinical Recommendations for Sportsman's Hernia and Athletic Pubalgia Based on 30 Years of Expert Experience. Journal of abdominal wall surgery : JAWS, 4, 15394. https://doi.org/10.3389/jaws.2025.15394
2020Gerhardt et al. (2020). Outcomes following surgical management of inguinal-related groin pain in athletes: a case series. Journal of hip preservation surgery, 7(1), 103-108. https://doi.org/10.1093/jhps/hnz068
2023Meuzelaar et al. (2023). Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort. Hernia : the journal of hernias and abdominal wall surgery, 27(5), 1179-1186. https://doi.org/10.1007/s10029-023-02815-x
2020Drager et al. (2020). Athletic Pubalgia (Sports Hernia): Presentation and Treatment. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 36(12), 2952-2953. https://doi.org/10.1016/j.arthro.2020.09.022
2024Rezaie et al. (2024). Outcomes and Proportions of Subsequent Contralateral Sports Hernia Repair Following Primary Unilateral Repair. The American journal of sports medicine, 52(3), 653-659. https://doi.org/10.1177/03635465231221496
2026Ayhan et al. (2026). Groin Pain Syndrome: Analysis of Surgical and Nonsurgical Outcomes Between Athletes and Nonathletes With "Sports Hernia" Using a Standardized Management Algorithm. Orthopaedic journal of sports medicine, 14(1), 23259671251405430. https://doi.org/10.1177/23259671251405430
2021Kraeutler et al. (2021). A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 37(7), 2377-2390.e2. https://doi.org/10.1016/j.arthro.2021.03.049
2023Neuville et al. (2023). Risk Factors for Athletic Pubalgia in Collegiate Football Student-Athletes: A Retrospective Cohort Study. Sports health, 15(5), 760-766. https://doi.org/10.1177/19417381221121127
2015Weir et al. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British journal of sports medicine, 49(12), 768-74. https://doi.org/10.1136/bjsports-2015-094869
2020Zuckerbraun et al. (2020). Groin Pain Syndrome Known as Sports Hernia: A Review. JAMA surgery, 155(4), 340-348. https://doi.org/10.1001/jamasurg.2019.5863
2020Zuckerbraun & Mauro (2020). Use of Sports Hernia to Describe Groin Pain in Athletes-Reply. JAMA surgery, 155(9), 895-896. https://doi.org/10.1001/jamasurg.2020.1767
2020Thorborg & Hölmich (2020). Use of Sports Hernia to Describe Groin Pain in Athletes. JAMA surgery, 155(9), 895. https://doi.org/10.1001/jamasurg.2020.1759
2021Dempsey et al. (2021). Nomenclature for groin pain in athletes. The British journal of radiology, 94(1126), 20201333. https://doi.org/10.1259/bjr.20201333

Mapped to this pattern

HAGOS
Copenhagen Hip and Groin Outcome Score
hip and groin pain in athletes · 37 items · 10 min

Generic measures that also apply

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