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Sports Hernias, Adductor Injuries, and Hip Problems Are Linked

Bert R. Mandelbaum, MD


February 23, 2017

Everything in medicine is connected, a principle I particularly keep in mind when I'm dealing with sports hernias (or athletic pubalgia), adductor injuries, and hip problems. I like to think of the three as a single syndrome: hip and groin issues.

If you picture a Venn diagram, with each of these problems in a circle and all of the circles overlapping somewhat, you get a good image of the relationship. People may have one of these problems or two or three at the same time. So sports physicians should think of all of them when diagnosing pain or dysfunction in this area.

A whole series of problems can affect the hips, especially labral tears and cartilage issues. Then a little higher up, the ilioinguinal nerve or one of its branches can be impinged, or there may be a weakness in the rectus abdominis wall—what we call a sports hernia—which is a little different from a traditional hernia. Finally, you've got the issues that we have in terms of the adductor tendon.[1]

Hip and Groin Abnormalities in Athletes

These problems are very common in elite athletes. In a study of x-rays from professional US male soccer players, we found a prevalence of 54.7% of hip and groin abnormalities.[2]

In another ongoing study, we have so far found that 37.5% of the players on the US Men's National Soccer Team have had sports hernia surgery, and 12.5% of them have had bilateral sports hernia surgery. In 66% of these cases, they had a dual diagnosis. (Mandelbaum B, Silvers HJ, et al. Unpublished research.)

Sometimes one of these problems can evolve to affect the others. When athletes develop one of these problems, they begin to lose range of motion in their hips. Consequently, they put more force on their hips, and if they are 15 or 16 years old, they may suffer a mild slipped capital epiphysis. This gradually grows into a deformity, further restricting range of motion as they play, causing a labral tear, more weakness in the interior abdominal wall, and secondary adductor pain. This is ultimately a perfect storm!

Thus, there is a complex relationship between these problems. They stem from our evolution as quadrupeds who became bipeds dependent on the hip and the gluteus to keep us erect. Eccentric loading of muscles with torsion, load, and shear of the strong adductors may weaken the posterior abdominal wall and cause hypertrophy of the femoral neck as well as articular and labral abnormalities.

This is typically a gradual process. Hip and groin issues very rarely occur as a result of an acute injury, though occasionally the adductor pops off the pelvis and must be dealt with right away.


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