Pain first, lump later
A hernia does not always announce itself with a bulge. Where the defect is small, or where a knuckle of fat is pressing into the inguinal canal without fully passing through, the only symptom may be an ache in the groin that builds through the day, sharpens on lifting, and eases with rest. This is sometimes called an occult hernia.
It is frequently missed because the examining doctor is looking for something to see. On examination there may be nothing visible at all — only tenderness at a specific point and a subtle impulse on coughing.
The main alternatives
- Inguinal disruption, often called sportsman's groin — injury to the muscle and tendon attachments around the pubic bone, typical in footballers, hockey and racquet players
- Adductor tendinopathy, where pain is reproduced by squeezing the knees together against resistance
- Hip joint pathology, which often refers pain into the groin and is worse on rotation rather than on straining
- Osteitis pubis, with tenderness directly over the pubic symphysis
- Referred pain from the lower back
These overlap and can coexist. The reason to see a surgeon who deals with groins routinely is that the distinction determines whether an operation will help you or waste six weeks of your season.
Getting to a diagnosis
Assessment begins with a careful history of exactly which movements provoke the pain, followed by examination standing and lying, with cough and strain. Where a hernia is suspected but not confirmed, a dynamic ultrasound — performed while you strain, rather than lying still — is the most useful next test. MRI is more helpful where tendon or bone injury is the leading suspicion.
Features that favour a hernia over a muscular injury
- Pain worse at the end of the day and after standing, not just during sport
- Aggravated by coughing, sneezing or straining on the toilet
- A dragging sensation rather than a sharp catch
- Pain radiating towards the scrotum or inner thigh
- Discomfort under a waistband or belt
Treatment and return to training
If an occult hernia is confirmed and is the source of symptoms, repair reliably resolves the pain. Keyhole or robotic repair is generally preferred in this group because it places mesh across the whole posterior wall and allows an earlier return to loaded training — typically light work at two weeks, full contact and heavy lifting at six.
If the problem is tendon rather than hernia, you will be told so, and directed towards the physiotherapy or sports medicine input that will actually help. An unnecessary hernia operation is not a neutral event.
Where to be seen
Clinics at Nuffield Health Warwickshire Hospital, Leamington Spa, with dynamic ultrasound arranged locally. Repair from £4,500, with theatre dates usually within 7 days of the consultation where surgery is indicated.
Common questions
Can you have a hernia with no lump at all?
Yes. Small or early hernias, and hernias in patients with a muscular abdominal wall, can produce symptoms well before anything is visible. Examination and dynamic ultrasound are how these are found.
Is sportsman's groin a hernia?
Not in the true sense — there is usually no defect with contents passing through it. It is an injury to the muscle and tendon attachments at the pubic bone. Confusingly it is sometimes called a sports hernia, which is why precise assessment matters.
Should I keep training while I wait?
You will not cause a rupture by training, but continuing through pain generally prolongs the problem. Reducing loaded and high-impact work until you have a diagnosis is sensible.
How long until I can return to sport after repair?
Light aerobic work at about two weeks, running at three to four, and full loaded and contact training at six weeks, assuming a keyhole or robotic repair and an uncomplicated recovery.
What if the scan is normal but the pain continues?
A normal static ultrasound does not exclude a hernia. If the clinical picture fits, either a properly performed dynamic study or, occasionally, diagnostic laparoscopy is the way to settle it.