646 Core Muscle Injuries (Athletic Pubalgia, Sports Hernia)
Core Muscle Injuries
(Athletic Pubalgia,
Sports Hernia)
William C. Meyers, MD, and Alexander E. Poor, MD
T his chapter will help a surgeon treating someone with groin
pain and no palpable hernia. The surgeon needs to understand
details of core anatomy as well as the different types of injuries
that occur there; otherwise, the patient should expect dissatisfac-
tion. One of the most misunderstood subjects in medicine is the
musculoskeletal physiology and pathophysiology of the pelvis. The
term sports hernia not only understates this complexity, but also
leads surgeons to think mistakenly that these pains result from
tiny protuberances (i.e., occult hernias). Nothing is further from
the truth. Most of these problems arise from real musculoskeletal
disruptions and subsequent compensations. In 1 day in our clinic
we saw 14 patients with failed “hernia” repairs for these types of
problems.
While reading this chapter, assume that all groin pain in
athletes can be explained by the anatomy. Furthermore, consider
just two types of joints in the pelvis—the ball-in-socket hip joint
without muscle and the “pubic bone joint”—as the center of
the core’s muscular universe. All of the surrounding muscles,
bones, and other soft tissue structures arrange themselves sym-
metrically around the center point, the pubic bone. Perhaps for
other reasons, people generally have considered the pubic bone
to be the center of the universe. In the case of athletic injuries,
this is particularly true.
BACKGROUND: THE CORE
Core Anatomy
The muscles that originate at or insert into the fibrocartilaginous
plate covering the pubic bone play a hugely important role in pelvic
stability. This complex constitutes the harness that allows the torso
to move with the legs.
This central stability functionally anchors the pelvis so that
peripheral parts of the body can move. The rectus abdominis flexes
the trunk as it compresses abdominal viscera and forms the anchor
for considerable abduction and adduction, as well as internal and
external hip rotation. Laterally, the rectus abdominis attaches to the
oblique muscles with pure fibrous connections, enveloping com-
plexes of nerves and tiny vascular structures.
Three adductors—the pectineus, the adductor longus, and the
adductor brevis—insert into the fibrocartilage of the pubic bone
adjacent to the rectus abdominis attachment. These muscles with
central attachments play a primary role in core stability. The
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adductor magnus inserts more laterally and the gracilis attachments
are so small and posterior that these two muscles do not participate
much in core stability. Interestingly, the anterior obturator nerve
innervates all of the adductors except the magnus, consistent with
the co-operative function of these muscles at this joint.
Basic experiments with this anatomy and fresh cadavers revealed
the dynamic relationship of these structures. Cutting 30% of the
rectus abdominis results in a huge shift in the balance across the
pubic bone, and the adductors slam against the pubic bone with
greater forces than one might expect, even with completely flaccid
muscles. Dividing the rectus abdominis also causes pressure changes
within the hip joint. These relationships are not subtle and are fun-
damental in understanding core injuries.
Pathophysiology
In athletes, tremendous torque occurs at the level of the pelvis. The
anterior pelvis takes the brunt of most forces. The pubic bone func-
tionally serves as a fulcrum around which many of the forces are
connected. When one of these core muscles weakens, usually from
fraying associated with hyperextension or hyperabduction, it results
in an imbalance of forces on the pelvis. This imbalance causes disrup-
tion of the attachments to the fibrocartilaginous plate of the pubic
bone, which can cause pain, weakness, and instability. Loss of stability
leads to compensation from the other structures that cross the pubic
bone (iliopsoas, rectus femoris, sartorius), which can then become
additional sources of pain and injury.
Certain anatomic variants can predispose a person to certain
injuries and should be recognized. For example, symptomatic femo-
roacetabular impingement results in spasm of the adductors (pri-
marily adductor longus) and hip flexors (primarily rectus femoris)
as a compensatory measure to limit range of motion in the hip joint.
This places those muscles at increased risk for injury. In addition, the
differences in the male and female pelvis probably explain why males
more often develop central core muscle injuries at the pubic bone
attachments whereas females are more likely to have hip and psoas
problems. Men have thicker, heavier pelvises than women, causing
greater shifts in force and a narrower subpubic angle, which leads to
a different distribution of forces. In addition, men have a narrower
pubic symphysis disc, which leads to less pelvic flexibility, and a nar-
rower pelvis, which likely leads to less stability overall. The female
hip is more prone to injury in part because the femoral head is 30%
smaller than in the male hip, resulting in increased load on the
articular surface.
The core is made up of everything from the chest to the
midthigh (Figure 1). All of it must be considered when a patient
has groin pain. There are four components of the core: the ball-
and-socket hip joints, the back, all remaining skeletal muscles and
bones, and everything else (all other muscles, ligaments, nerves,
blood vessels, intestines, reproductive organs, genitourinary struc-
tures, lymphatic channels, etc.). This provides the basis for the
differential diagnosis of exertional groin pain, which can be lumped
grossly into the same four groups: hip, back, core muscles, and
everything else.
 H er n ia 647

BOX 1:  Differential Diagnosis of Groin Pain

in Athletes
Hip-Associated Causes
Acetabular labral tear and femoroacetabular impingement
Osteoarthritis
Snapping hip syndrome and iliopsoas tendonitis
Avascular necrosis
Iliotibial band syndrome
Visceral Causes
Inguinal hernia
Other abdominal hernias
Testicular torsion
Infectious Causes
Septic arthritis
Osteomyelitis
Pelvic inflammatory disease
Prostatitis
Epididymitis and orchitis
Herpes infection
Inflammatory Causes
Endometriosis
Inflammatory bowel disease
Pelvic inflammatory disease
Primary osteitis pubis
Traumatic Causes
Stress fracture
Tendon avulsion
Muscle contusion
FIGURE 1  Anatomic location of the core.
Baseball pitcher–hockey goalie syndrome
Developmental Causes
Apophysitis
DIAGNOSTIC APPROACH Growth plate stress injury or fracture
Legg-Calvé-Perthes disease
History and Physical Examination Developmental dysplasia
One must consider the muscles involved in the core; there are 29 Slipped capital femoral epiphysis
muscles within the core, all of which have the potential to contribute
to an injury. A compulsive history and physical examination and Neurologic Causes
appropriate imaging are necessary to arrive at a complete diagnosis. Nerve entrapment syndromes
Localized tenderness sometimes may help to confirm specific diag- Referred pain
noses, although tenderness from diffuse bony or soft tissue inflam- Sacroiliitis
mation also may cause confusion. Resistance testing and compulsive Sciatic entrapment (piriformis syndrome)
attention to the location of elicited pain can help to identify the Hamstring strain
muscles involved. Knee pain
Interpretation of each test involves three considerations: Does the
test cause pain? Does the resulting pain correlate to the muscle being Neoplastic Causes
tested? And does the resulting pain re-create the pain that is causing Testicular carcinoma
the athlete’s disability. One also must consider the potential for hip Osteoid osteoma
joint involvement. In the physical examination, this involves primar-
ily range-of-motion tests without interference from contraction of
muscles. These tests include the standard flexion–abduction–external
rotation (FABER) test and the flexion–adduction–internal rotation nation whether the problem is musculoskeletal in nature. Box 1 sum-
(FADIR) test plus other rotational or hyperflexion/hyperextension marizes the differential diagnoses for groin pain in athletes.
tests that can isolate anterior, posterior, or lateral impingements, for
example. In our practice, concurrent hip and core muscle injuries are
seen in 16% of cases, and one must be prepared to work up and treat Imaging
both conditions when evaluating a patient with groin pain. In a practical sense, history and physical examination, plain films,
Finally, one must consider that portions of the gastrointestinal, and magnetic resonance imaging (MRI) are generally the most
genitourinary, and gynecologic systems; lymphatics; blood vessels; useful modalities for diagnosing core injuries. Using specific MRI
and nerves also reside in the core. The importance of this final group techniques (“athletic pubalgia protocol”; see Figure 1), core muscle
cannot be overstated because some of these diagnoses can be life injuries can be identified with sensitivity and specificity. A conven-
threatening, but it may be obvious from history and physical exami- tional MRI of the pelvis likely may be read as normal or as showing

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648 Core Muscle Injuries (Athletic Pubalgia, Sports Hernia)
some nonspecific changes in the pubic symphysis or edema pat-
terns, leading to incorrect diagnoses such as stress fractures. Figure
2, in which a complete adductor longus avulsion is difficult to
appreciate, demonstrates this point. Because of the high incidence
of concomitant symptomatic hip pathology, magnetic resonance
FIGURE 2  In this image obtained using magnetic resonance imaging,
complete adductor longus avulsion (arrow) is difficult to appreciate
(arrowheads).
FIGURE 3  Magnetic resonance arthography of the hip.
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(MR) arthrography of the hip often also plays a role (Figure 3).
Imaging should be tailored to what is suspected based on the history
and physical examination. Imaging also may include plain films,
ultrasound, or computed tomography scans (CT scans).
Ultrasound can be useful to achieve detailed visualization of
structures, but its use to identify hernias can be misleading. The
close proximity of the inguinal canal to the caudal rectus abdomi-
nis attachment creates some of the confusion and explains why
the term sports hernia exists. Normal inguinal fat occurs in the
spermatic cords or round ligament. Likewise, retroperitoneal fat
extending into the inguinal canal is commonly observed on MRI
but typically should not be considered a true hernia. If a true
hernia is suspected, prone imaging and dynamic sequences with
either MRI or ultrasound can be used. Definitive diagnosis requires
the presence of true intraperitoneal structures (not simply fat)
outside the peritoneal cavity or sliding within the inguinal canal.
Bone scan does have limited usefulness in the diagnosis of osteitis
pubis. Figure 4 outlines the categories of differential diagnoses
associated with groin pain and the likely appropriate imaging
modalities.
MANAGEMENT
Nonoperative Management
For certain peripheral injuries, nonoperative management is a
first-line treatment. In many cases, it is also required because of
special considerations in athletes. These personal factors—the
timing within a season, concerns about coaching or front office
decisions, and the influence on contract negotiations—in addition
to the clinical factors, must be considered in deciding when to
use aggressive temporizing procedures versus permanent solutions.
In general, the first treatment of groin pain involves rest; ice;
anti-inflammatories; and, depending on the resources available,
manual therapy, ultrasound, infrared, and the like. This treatment
is often performed before surgical consultation, but increasingly
astute athletic trainers and athletes are seeking treatment for

Core pain
History and physical examination
Hip joint Back
• X-ray • X-ray
• MR • MR
arthrogramphy arthrogramphy
• 3D CT • CT
• Diagnostic • Diagnostic
injections injections
FIGURE 4  Differential diagnoses and imaging modalities for groin pain. CT, Computed tomography; MR, magnetic resonance; MRI, magnetic resonance imaging.
injuries earlier than has been the case historically. Classically, these
injuries improve with rest, but the pain returns upon resuming
activities. This period of rest is not a required component of the
diagnostic workup, however, and a person with signs and symp-
toms of a core muscle injury need not wait for definitive repair.
The mainstay of nonoperative treatment is physical therapy to
strengthen the lateral and posterior core muscles to offload the
injury and stabilize the pubic joint. This is analogous to strength-
ening the quadriceps and hamstrings after an injury to the anterior
cruciate ligament (ACL).
Core muscle injuries involve a large number of muscles but for-
tunately tend to occur in predictable patterns (we often refer to 29
core muscles but, in reality, this number is too low). As a general rule,
injuries that involve the central pubic bone attachments leave an
athlete with instability that, as with an ACL tear, cannot be corrected
until normal anatomy is restored. More peripheral injuries, however,
often can be managed nonoperatively, and compensatory measures
are more effective.
There are also percutaneous interventions, with varying degrees
of evidence supporting their use for temporizing core muscle inju-
ries. We prefer corticosteroid injections administered directly into
the areas of injury and inflammation and recently reviewed this
treatment. Overall, 79% of athletes with core injuries returned to
high-level play for the duration of their seasons, and delaying defini-
tive repair did not adversely affect postoperative outcomes. Other
factors, however, such as the timing of the injection and the pres-
ence of clinically significant hip pathology, may play important roles.
Some have been using platelet-rich plasma (PRP) as a form
of temporizing treatment. We do not advocate its use because
of its ineffectiveness and the newly identified risk of heterotopic
ossification (HO).
Operative Management
Surgical management of core muscle injuries involves a number of
procedures that mobilize the involved muscles to restore normal
anatomy and balance without tension (Table 1). The procedures
require the surgeon to expose, mobilize, and repair the injured
muscles without damaging what remains intact and without tension.
They do not involve simply dividing muscles or nerves or treating
occult hernias. Mesh-related inguinodynia is becoming an increas-
ingly recognized concern and should be reason enough to refrain
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H er n ia 649
Core muscles Other
• MRI • CT
• Diagnostic • Ultrasound
injections • MRI
• Other
from placing mesh unless a true hernia is identified. If you are con-
sidering doing a hernia repair on a patient with inguinal pain in the
absence of a palpable hernia, stop that line of thinking. Learn the
different specific causes of pain and how they are fixed.
Postoperative Management
Surgery can be performed as an outpatient procedure, and early
ambulation and activation of the repaired core muscles is key, as
adhesions and scar tissue are the biggest hindrance to recovery. Care-
fully monitored resisted contraction of the repaired muscles begins
on the day after surgery and should continue daily until the patient
has returned to full activity. After the first week, massage also plays
an important role. Depending on the muscles involved, the extent
of injury and repair, and the degree of appropriate rehabilitation,
most patients can expect a return to full activity in 3 to 6 weeks
postoperatively.
Complications
Complications are uncommon. Wound infections and hematomas
are the most serious complications. Hematomas may limit the
patient’s ability to return to full activity in a timely fashion; therefore
they usually are treated aggressively with surgical evacuation and
drain placement. Scar tissue is the most common postoperative
problem and occasionally requires additional surgery. One must take
care to identify any predisposing factors (such as symptomatic femo-
roacetabular impingement) that result in compensatory muscle
damage before proceeding with surgery.
RECOMMENDATIONS
1. Learn the anatomy.
2. Become familiar with the different types of procedures that can
fix core muscle injuries.
3. Understand the roles of physical therapy, temporizing, and defini-
tive interventions.
4. Beware the misnomers (sports hernia, sportsman’s hernia, Gil­
more’s groin) associated with this large and diverse collection of
injuries.
650 Core Muscle Injuries (Athletic Pubalgia, Sports Hernia)

TABLE 1:  Surgical Management of Core Muscle Injuries

Structure or Syndrome Incidence (%) Defect Possibly Indicated Procedure
Unilateral rectus abdominis/ 22 Tear and compartment syndrome Repair and compartmental
unilateral adductor (CS) decompression
Adductor longus 16
Pectineus 22
Adductor brevis 8
Pure adductor syndromes 21 Usually CS Compartmental decompression
Bilateral rectus abdominis/ 17 Aponeurotic plate disruption; tear
bilateral adductor and CS
Unilateral rectus abdominis 16 Tear Repair
Bilateral rheumatoid arthritis 15 Tears Repair
Severe osteitis variant 8 Usually tears, CS, and bone edema Repair, compartmental decompression,
and steroid injection
Unilateral/bilateral 7 Combination tear(s) and CS Repair(s) and compartmental
decompression(s)
Iliopsoas variant 4 Impingement and bursitis Lengthening procedure
Baseball pitcher–hockey goalie 4 Adductor tear and adductor muscle Compartmental decompression
syndrome belly CS
Spigelian hernia 4 Tear Repair
Rectus femoris variant 3 Impingement Compartmental decompression
High rectus abdominis variant 2 Tear Repair
Female variant 2 Medial disruption with lateral thigh Repair(s) and compartmental
compensation decompression(s)
Round ligament syndrome 1 Inflammation with tear Repair and excision
Dancer’s variants <1 Obturator internus/externus Compartmental decompression(s)
Rower’s rib syndrome <1 Subluxation Excision and mesh
Avulsions Usually acute adductor injury Repair(s) and compartmental
decompression(s)
Adductor/rectus abdominis <1 Chronic avulsion Excision, compartmental
calcification syndromes decompression
Midline rectus abdominis variant <1 Tears and muscle separation Repair(s)
Anterior ischial tuberosity <1 Posterior perineal inflammation, Compartmental decompression
variant gracilis, hamstrings
Adductor contractures <1 Often associated with hip pathology Compartmental decompression and
hip repair
More uncommon variants 2 Eg, gracilis, quadratus, iliotibial band Variable
Modified from Meyers WC, McKechnie A, Philippon MJ, et al. Experience with “sports hernia” spanning two decades. Ann Surg. 2008;248:656-665.

Meyers WC, Yoo E, Devon O, et al. Understanding “sports hernia” (athletic

SUGGESTED READINGS
Byrd JWT. Gross anatomy. In: Byrd JWT, ed. Operative Hip Arthroscopy. New
York: Springer; 2005:100-109.
Hammoud S, Bedi A, Magennis E, et al. High incidence of athletic pubalgia
symptoms in professional athletes with symptomatic femoroacetabular
impingement. Arthroscopy. 2012;28:1388-1395.
Meyers WC, Kahan DM, Joseph T, et al. Current analysis of women athletes
with pelvic pain. Med Sci Sports Exerc. 2011;43:1387-1393.
Meyers WC, McKechnie A, Philippon MJ, et al. Experience with “sports
hernia” spanning two decades. Ann Surg. 2008;248:656-665.
pubalgia): the anatomic and pathophysiologic basis for abdominal and
groin pain in athletes. Op Tech Sports Med. 2007;15:165-177.
Palisch A, Zoga AC, Meyers WC. Imaging of athletic pubalgia and core muscle
injuries: clinical and therapeutic correlations. Clin Sports Med. 2013;32:
427-447.
Zoga AC, Kavanagh EC, Meyers WC, et al. MRI findings in athletic pubalgia
and the “sports hernia.” Radiology. 2008;247:797-807.

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