Table 1

Theories on the underlying pathology of inguinal-related groin pain in athletes in chronological order divided into theories on nerve irritation and musculoskeletal (MSK) injuries

Nerve irritation theoriesYear and authors
Nerve entrapment
Peripheral nerves may become entrapped after direct trauma or inflammatory conditions. The ilioinguinal nerve transmits sensation from the proximal part of the penis and the base of the scrotum. These sensations may be elicited by intensive abdominal muscle training leading to entrapment of the nerve, where it goes through the different layers of the abdominal muscles6
1980; Renstrom and Peterson6
Posterior abdominal wall weakness/bulge (‘incipient hernia’/‘sports hernia’)
  1. Insufficient strength of the fascia transversalis to withstand the repeated high intra-abdominal pressure generated by sports activities7

  2. Distension of the peritoneum or stretching of the ilioinguinal nerve8

  3. Bulge in the posterior inguinal wall consistent with an incipient direct inguinal hernia9

  4. Posterior wall bulge with or without conjoint tendon tear or internal ring dilatation10

  5. Distension of the posterior inguinal canal wall musculature, suggested by the site of maximal tenderness, painful cough impulse and operative findings (an early type of direct hernia/sports hernia)11

  6. Nerve irritation of the ilioinguinal and the genital branch of the genitofemoral nerve within the inguinal canal caused by a ‘sports hernia’. Additionally, possible entrapment neuropathy12

  7. A circumscribed weakness of the inguinal canal posterior wall causing a bulge compressing the genital branch of genitofemoral nerve during straining. Additionally, as the canal is widened, the rectus muscle is medially and cranially retracted. This retraction causes increased tension, leading to pubalgia13

  8. During muscular contraction of the abdominal wall, the conjoint tendon lowers and closes the deep inguinal ring like ‘a curtain’, decreasing its diameter. A high insertion of the conjoint tendon leaves the inguinal ring wider and uncovered, thus more exposed to repeated sports-related microtrauma, in particular, the protrusion of preperitoneal fat in the deep inguinal orifice14

  1. 1985; Smedberg et al7

  2. 1989; Gullmo8

  3. 1992; Malycha and Lovell9

  4. 1991; Polglase et al10

  5. 1993; Hackney11

  6. 1999; Akita et al12

  7. 2010; Muschaweck and Berger13

  8. 2019; Bou Antoun et al14

Tear of the external oblique
Nerve irritation caused by single or multiple tears in the external oblique aponeurosis at the site of the emergence of neurovascular bundles containing the terminal branches of the iliohypogastric nerve15 16
1995; Williams and Foster15
1999; Ziprin et al16
Musculoskeletal pathology theoriesYear and authors
Muscle imbalance causing pain and changes at pubic bones
Muscle imbalance at the level of pubic symphysis due to weak anterior abdominal wall and hypertrophic lower limb muscles causing an excessive functional overload of muscular and tendon insertions on the pubic bone17
1987; Nesovic17
Severe musculotendinous injury
Severe musculotendinous injury, such as a torn external oblique aponeurosis or conjoined tendon torn from the pubic tubercle. Dehiscence between conjoined tendon and inguinal ligament18 19
1991; Gilmore18
1998; Gilmore19
Pubic joint concept
Pain is due to an insertional shearing injury of the muscular attachments at the pubis, mainly inguinal canal, rectus abdominis and adductor muscles, causing pain at the pubic symphysis20 21
2000; Meyers et al20
2012; Meyers et al21
Inguinal ligament enthesopathy
Inguinal ligament enthesopathy at the pubic tubercle. This is due to excessive stress during lateral abdominal muscle contraction. The abdominal core muscles play a pivotal role in the cause of pain as their forces are transmitted through the inguinal ligament onto the pubic tubercle22
2008; Lloyd et al23
2009; Mann et al24
2017; Rennie and Lloyd22