Physical Therapy Guide to Athletic Pubalgia — Core Muscle Injury
Athletic pubalgia (core muscle injury) is often misleadingly called a sports hernia. It is a condition that mainly affects athletes who play soccer, hockey, football, and rugby, and who run track. It is more common in males than in females. A full 94% of these injuries occur gradually from unknown causes. A specific traumatic incident, such as being checked from behind while playing hockey, cause the other 6%. Stress from repetitive twisting, kicking, and turning at high speeds is a potential cause of this injury. But casual exercisers and nonathletes also can experience core muscle injury. Physical therapists help people with core muscle injury improve strength and flexibility in the abdominal muscles and hips, and help them safely return to their desired sport or activities. If surgery is required, physical therapists help people before and after surgery, to prepare for and recover from the surgical procedure.
Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.
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What Is Core Muscle Injury?
Core muscle injury occurs when the deep layers of the abdominal wall weaken or tear. There is no defect of the abdominal wall or protrusion of abdominal contents outside the normal cavity, as with a hernia. Instead, the injury occurs where the abdominal muscles attach in the pelvis, and can cause tears in the tendons and muscles in the area. Nerve irritation also can occur and contribute to uncomfortable symptoms of numbness or tingling.
Repetitive hip and pelvic motions typical in sports can cause injury to the lower abdominal area. Imbalances between the hip and abdominal muscles can, over time, cause overuse and injury. Weakness in the abdominals and lack of conditioning also might contribute to the injury. Aggressive and unsafe abdominal exercise programs can cause or aggravate a core muscle injury.
How Does It Feel?
Chronic groin pain is a hallmark symptom of core muscle injury. It occurs in 5% to 18% of athletes. Sharp groin pain with exertion is also a typical symptom.
Pain often occurs with intense sprinting, kicking, twisting, or cutting, and decreases rapidly with rest. However, basic tasks, such as sitting up in bed, can be painful. Athletes can lose a significant amount of training and competition time due to core muscle pain or related groin pain.
With core muscle injury, you may experience:
- Sharp or stabbing pain in the groin or lower abdominal region that occurs mainly with running, sprinting, cutting, pivoting, kicking, or twisting.
- Pain felt while doing situps.
- Pain on one side of the groin.
- Pain or numbness that radiates into the inner thigh.
- Pain in the groin when coughing or sneezing.
- Little to no pain in the groin when resting, sitting, or sleeping.
- Tenderness to touch or pressure put on the lower abdominal area.
Note: If you have groin pain that isn’t relieved with rest, you could have another potentially serious medical condition involving the digestive, urinary, or reproductive systems. Consult your physician
How Is It Diagnosed?
If you see a physical therapist first, they will conduct a thorough evaluation that includes taking your health history. They may ask whether you:
- Experience groin pain while sprinting, twisting, or kicking.
- Have had any injuries to your hip, low back, or groin.
- Recently completed any intense abdominal or core strengthening exercises.
- Get significant relief from your groin pain if you rest or don’t participate in your regular sport or exercise routine.
- Feel pain in your groin when coughing, sneezing, or bearing down.
- Recall a particular movement or incident when you first felt pain in the area.
- Experience groin pain that limits your desired level of sports performance.
Your physical therapist also will conduct standard strength tests of your hip muscles, and perform other tests to measure the flexibility of your hip and thigh muscles. They will assess how well you can isolate or contract specific muscles. They also will conduct a thorough examination of your hip and low back movements.
Your physical therapist may use additional tests to determine if you have any other hip joint, knee joint, or lumbar spine injuries.
To reach a specific diagnosis, your physical therapist may collaborate with a sports medicine doctor or other health care provider. Your doctor may order further tests (MRI, ultrasound, or X-rays) to rule out other injuries to your hip, low back, or pelvis, and further confirm the diagnosis of a core muscle injury.
How Can a Physical Therapist Help?
Conservative treatment of core muscle injuries includes changes to your activities and physical therapy. Your physical therapist will use treatments to target the problems found during their evaluation. They will design a personalized treatment program for you based on your condition that focuses on your goals to help you safely return to your sport or normal activity levels.
Some cases of more severe core muscle injury may require surgery. A conservative course of treatment that includes physical therapy for four to six weeks is the first recommendation for most patients. If groin pain continues after that time, surgery may be recommended. A recent study found that 50% of patients with core muscle injury recovered with conservative treatment. If you decide to have surgery, your physical therapist can guide you in regaining your strength and flexibility after the surgical procedure.
Treatment Without Surgery
Physical therapy will focus on addressing the key problems found during your evaluation. These problems often include poor hip strength and flexibility, and a reduced ability to activate or turn the abdominal muscles to keep the pelvis stable during intense activity.
Physical therapy treatments will address your condition without causing pain or making your pain worse. Your physical therapist also will teach you to modify sport or training activities that cause groin pain or hinder your recovery. Ice may also be applied to decrease pain. Your physical therapist may advise you to:
- Avoid aggressive or painful stretching.
- Avoid kicking or sprinting.
- Avoid doing situps.
Your physical therapy treatment may include:
Icing and compression. During the early phases of injury or when you have high levels of pain, applying ice and compression to the area may decrease your pain level.
Stretching. Your physical therapist may show you how to perform hip and low-back exercises to gently stretch your muscles. They will teach you how often and how long to do these exercises to match your condition to improve muscle flexibility and decrease pain.
Muscle retraining. Your physical therapist will teach you to target and move your abdominal and hip muscles. This is a key part of your treatment, as certain muscles may not be working well due to your injury.
Strengthening. Your physical therapist will teach you targeted hip and core strengthening exercises that do not aggravate your injury once you are having less pain.
Manual therapy. Your physical therapist may perform hands-on (manual) therapy to stretch and mobilize affected soft tissue and joints based on your evaluation. Hands-on therapy can improve your hip-joint mobility and range of motion, decrease muscle pain, and improve flexibility.
Return-to-sport drills. Once you can progress without pain, your physical therapist will slowly add movements specific to your sport or activity to your treatment program. For example, you may return to running and light sport-related drills to prepare your body for the full stress of participation in your sport.
Can This Injury or Condition Be Prevented?
Core muscle injury is challenging to prevent because of the stress and strain placed on the pelvis and hips during some sports. A prevention program is recommended for people with the highest risk for a core muscle injury. Those at high risk include males and females who participate in soccer, hockey, and football. A prevention program may include:
- Abdominal and core strengthening exercises.
- Exercises to strengthen the hip muscles.
- Exercises to improve flexibility and decrease strain across the lower abdominal area, where core muscle injury often occurs.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat core muscle injuries. However, you may want to consider:
- A physical therapist who is experienced in treating athletes with a core muscle injury. Some physical therapists have a practice with a sports or orthopedic focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with a core muscle injury.
- During your first visit with a physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
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The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of sports hernia. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
K, Reiman MP, Weir A, et al. Clinical examination, diagnostic imaging, and testing of athletes with groin pain: an evidence-based approach to effective management. J Orthop Sports Phys Ther. 2018;48(4):239–249. Article Summary on PubMed .
Poor AE, Roedl JB, Zoga AC, Meyers WC. Core muscle injuries in athletes. Curr Sports Med Rep. 2018;17(2):54–58. Article Summary on PubMed.
Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768–774. Article Summary on PubMed.
Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139–144. Article Summary on PubMed .
Woodward JS, Parker A, Macdonald RM. Non-surgical treatment of a professional hockey player with the signs and symptoms of sports hernia: a case report. Int J Sports Phys Ther. 2012;7(1):85–100. Article Summary on PubMed .
Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011;150(1):99–107. Article Summary on PubMed .
Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin injuries in sports medicine. Sports Health. 2010;2(3):231–236. Article Summary on PubMed .
Unverzaqt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J Orthop Sports Phys Ther. 2008;38(2):63–70. Article Summary on PubMed .
Kachinqwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J Orthop Sports Phys Ther. 2008;38(12):768–781. Article Summary on PubMed .
Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15(8):507–514. Article Summary on PubMed.*PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
<p>Revised in 2020 by Andrew Edwin Sweeny III, PT, DPT, board-certified clinical specialist in sports physical therapy, and reviewed by James E. Zachazewski, PT, DPT, board-certified clinical specialist in sports physical therapy, on behalf of the American Academy of Sports Physical Therapy. Authored in 2014 by Andrew Edwin Sweeny III. </p>