As with any diagnosis, the history is often the most critical subset of clinical data available to the clinician evaluating athletic groin pain. Most patients with an ultimate diagnosis of sports hernia will describe an insidious onset of the exercise-related deep, dull, and diffuse pain about the lower abdomen or groin that is typically unilateral and that has been unresponsive to exhaustive rehabilitation efforts. Sports hernia almost always occurs in athletes participating in sports involving kicking, cutting, and explosive twisting and turning at speed [8]. As mentioned previously, it is therefore most commonly seen in ice hockey, soccer, Australian or American-rules football, tennis, and field hockey. The majority of cases (around 94 %) [1] are described as insidious, however in one series, Meyers et al. found that 71.3 % of patients could recall a specific event or injury which preceded their development of symptoms [17]. They often describe radiation pattern to the perineum, inner thigh, scrotum, or occasionally to the midline [1, 6]. Typically, these symptoms are completely relieved by rest and return with the resumption of rigorous sport often lasting 2–3 days following game day. In addition to frank athletic participation, symptoms are often reproduced by sit-ups, coughing or sneezing, and other valsalva producing maneuvers. The complaint of pain with increased intra-abdominal pressure is extremely important in diagnosing sports hernia, as an intra-articular hip problem will not produce this symptom. Kachingwe et al. describe five signs and symptoms, which when present together, make sports hernia the most probable diagnosis. They include: “(1) a subjective complaint of deep groin/lower abdominal pain, (2) pain that is exacerbated with sport-specific activities such as sprinting, kicking, cutting, and/or sit-ups and is relieved with rest, (3) palpable tenderness over the pubic ramus at the insertion of the rectus abdominis and or conjoined-tendon, (4) pain with resisted hip adduction at 0, 45, and/or 90 degrees of hip flexion, and (5) pain with resisted abdominal curl-up” [18].

In addition to these positive facets of the patient’s history, there are a number of pertinent negative findings that are helpful in narrowing the differential toward sports hernia. Patients do not tend to describe a history of fever, chills, or weight loss, which could point toward a more systemic diagnosis such as infection or malignancy. Persistent rest or night pain is unusual, which could again represent hip or systemic or neoplastic processes. Although stress fractures, such as those involving the femoral neck, can produce activity-related groin pain, they are typically closely linked to a discrete increase in physical activity, which is not classically associated with the presentation of sports hernia. Sports hernia is not typically associated with changes in bowel habits, as is the case with some gastrointestinal causes of lower abdominal and groin pain such as true hernia, inflammatory bowel disease, or diverticulitis. Similarly, although many reproductive disorders such as endometriosis, ovarian cyst formation, leiomyoma, and dysmenorrhea may cause similar groin pain, sports hernia symptoms do not change with the menstrual cycle as these diagnoses do. As such, a thorough gynecologic history as well as a physical exam is necessary in the evaluation of a female athlete when sports hernia is suspected. Sports hernia patients do not tend to report dysuria, which can be associated with other groin pain-producing diagnoses such as urethritis, epididymitis, or pelvic inflammatory disease [1, 4–6, 8–10].

The assembly of these pertinent positive and negative findings should considerably narrow a clinician’s differential diagnoses to a much smaller subset of musculoskeletal pathology. Most authors suggest that the diagnoses that are most difficult to distinguish from sports hernia from a history taking perspective are true hernia, hip adductor and flexor strains or tears, osteitis pubis, peri-articular, and intra-articular hip pathology such as labral, chondral, or osseous injury. Once a patient’s history has helped to narrow the differential to these musculoskeletal diagnoses, the physical exam and certain imaging modalities can help to reliably solidify a diagnosis of sports hernia.

As described previously, a carefully taken history will have ruled out the more systemic and visceral disorders and narrowed the differential to a smaller subset of musculoskeletal diagnoses. These diagnoses include true hernia, hip adductor and flexor strains, osteitis pubis, peri-articular, and intra-articular hip pathology such as labral, chondral, or osseous injury and finally sports hernia. At this point, a clinician’s targeted physical exam, with these specific diagnoses in mind, should be able to eliminate the remaining mimickers and confidently diagnose sports hernia. One of the challenges of diagnosing sports hernia is that its pathoanatomy does not fit perfectly into one medical subspecialty, making it difficult for any one provider to adequately evaluate a patient with activity-related groin pain. The goal of this section is to provide the description of a set of physical exam maneuvers that cross over subspecialty division, allowing a single clinician to comprehensively assess the patient with suspicion of sports hernia.