"Core muscle injury" describes a family of injuries to the muscles and connective tissue that attach around the pubic bone and lower trunk, most often involving the rectus abdominis insertion, the rectus-adductor aponeurosis and the adductor longus origin. The label is useful only when it is translated into the specific structure involved, because each pattern has a different examination, imaging question and loading plan.
Core muscle injury at a glance
Key clinical clue
Rectus insertion tenderness
with pain just above the inguinal ligament is highly suggestive
PMID 35234538
Named patterns
Four acute types
side strain, hip pointer, rectus abdominis strain and adductor-related core muscle injury
PMID 42105089
"Sports hernia" is not a true hernia. Anatomy-specific terms describe these injuries more accurately.
What core muscle injury means
Pain in the region where the abdominal muscles attach to the pubic bone has been called a sports hernia, athletic pubalgia or core muscle injury, and the diagnosis is challenging because proximal thigh muscles, the hip joint and the abdominal muscles produce overlapping symptoms (Forlizzi, 2023). Of those labels, "sports hernia" is the least accurate. It is not a true hernia, and it is easily confused with an inguinal hernia, which is a different diagnosis with a different pathway.
A 2026 imaging review described sports-related core muscle injuries as a common cause of acute and chronic groin and lower abdominal pain in athletes, particularly with cutting, kicking and rotation. It noted that variable terminology and classification add to diagnostic complexity and argued for a structured, anatomy-based approach (White, 2026). That is the approach Novo follows: name the structure, then plan around it.
The pubic "harness"
The rectus abdominis, adductor longus, pectineus and adductor brevis all attach to the pubic bone. Surgeons who treat these injuries describe them as a harness that underpins core stability and athletic performance, with the pubic attachment as a point of weakness that causes pain and lost athleticism when it is disrupted (Poor and Meyers, 2025).
At the front of the pubic bone, the rectus abdominis and adductor longus attachments blend into a shared connective-tissue region, the rectus-abdominis/adductor aponeurosis. Because the abdominal muscles pull upward and the adductors pull downward across this junction, forceful kicking, twisting or sudden changes of direction can load both sides at once. The anatomy and imaging of the adductor side of this junction are covered in detail in adductor longus and rectus-abdominis aponeurosis injuries. This article focuses on the abdominal side and on how core muscle injury is distinguished from other trunk and groin problems.
Anatomy-specific patterns
Rather than one umbrella diagnosis, current imaging literature describes distinct injury patterns (White, 2026):
- Rectus abdominis strain: injury to the muscle or its distal attachment near the pubic bone, painful with sit-ups, trunk extension and resisted trunk flexion
- Side strain: injury of the lateral abdominal wall, typically the internal oblique at the lower ribs, most often in throwing and bowling athletes
- Hip pointer: an impact or traction injury at the iliac crest, where the lateral abdominal wall muscles attach
- Adductor-related core muscle injury: injury centered on the adductor longus origin and its connection with the rectus abdominis through the aponeurosis
Earlier radiology work also emphasized that important core injuries occur away from the pubic symphysis, and that protocoled imaging helps identify them (Belair, 2016). The practical point is that "core" covers the whole trunk-pelvis junction, not one spot at the pubic bone.
Who gets core muscle injuries
These injuries cluster in activities that combine cutting, kicking and forceful trunk rotation (White, 2026). Surgeons with a large baseball practice describe them as not uncommon in that sport, where pitching and hitting load the trunk-pelvis junction repeatedly (Poor and Meyers, 2025). Recreational athletes who return to cutting sports, or who rapidly increase running, lifting or rotational training, can develop the same patterns.
How core muscle injury presents
The typical story is activity-related pain just above the groin or at the pubic bone, often on one side, that builds with sprinting, kicking, cutting, sit-ups and sometimes coughing or sneezing. Pain may spread into the lower abdomen, the inner thigh or both.
A 2023 review concluded that pain localized just above the inguinal ligament, especially with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury, and that concomitant adductor longus tendinopathy is not uncommon and should be investigated (Forlizzi, 2023). That overlap is one reason pain that responds poorly to adductor loading alone deserves a broader look.
What it is not
Several conditions mimic core muscle injury and need to be separated from it:
- Inguinal hernia: a true defect in the abdominal wall, which may or may not be palpable. A suspected hernia is referred for medical evaluation and imaging; see abdominal muscle strain vs. hernia.
- Adductor-related groin pain: pain centered on the adductor tendon origin in the inner thigh, reproduced by resisted adduction.
- Hip-related groin pain: deep groin pain with restricted or painful hip rotation, catching or locking.
- Pubic bone stress injury: focal bone tenderness with impact loading, particularly with rising training volume.
- Nerve-related pain: burning or electric pain from the ilioinguinal, genitofemoral or anterior cutaneous nerves.
- Visceral, urologic and gynecologic causes: pain linked to eating, bowel habits, urination or the menstrual cycle, or systemic symptoms.
The Doha agreement on groin pain terminology classifies athletic groin pain clinically into adductor-related, iliopsoas-related, inguinal-related and pubic-related pain, with hip-related pain and other causes as separate categories (Weir, 2015). A core muscle injury often produces findings that span more than one of those entities.
Questions the examination tries to answer
- Is the pain centered on the rectus insertion, the adductor origin, the pubic symphysis, the inguinal canal or the hip?
- Does a resisted sit-up, resisted adduction or both reproduce the familiar pain?
- Is there a palpable hernia, or a reason to suspect an occult one?
- Is the lateral abdominal wall or iliac crest involved, suggesting a side strain or hip pointer?
- Are there neurologic or visceral features that point elsewhere?
- How much trunk and adductor load can the athlete tolerate now?
- Would imaging change management?
The role of imaging
The diagnosis of core muscle injury is primarily clinical. The 2023 review noted that dynamic ultrasonography is increasingly used, and that MRI is not always diagnostic and may underestimate the true extent of injury (Forlizzi, 2023). Radiology reviews, by contrast, emphasize MRI with a dedicated protocol as the standard way to characterize the rectus-adductor aponeurosis, the pubic bone and confounders such as hip pathology (Coker, 2015; White, 2026).
Those positions are complementary rather than contradictory. Imaging answers a question the examination raises, such as whether there is an aponeurotic tear, a hernia or a hip problem. Reactive changes around the pubic bone are also common in athletes without symptoms, so an MRI finding is interpreted alongside the examination rather than on its own.
Management principles
Most core muscle injuries are managed without surgery at first. The 2023 review noted that functional rehabilitation programs can often return athletes to the same level of play (Forlizzi, 2023). A plan usually includes:
- A clear anatomical diagnosis, which explains why a generic groin or abdominal program may not be enough
- Load management, temporarily reducing the kicking, sprinting, cutting or abdominal loading that provokes symptoms without prolonged rest
- Progressive trunk and adductor loading, from isometric work to controlled flexion and rotation, adductor strengthening, then running, cutting and sport-specific loading
- Adjuncts where appropriate, such as manual treatment for clinically relevant soft-tissue restriction and, for selected chronic superficial muscle presentations, shockwave, as reviewed in shockwave and manual therapy for abdominal wall muscle injury
When surgery is considered
Surgical series confirm that rectus-adductor aponeurotic plate injury is a recognized structural diagnosis. In one series of 100 competitive athletes, surgery was offered only after 6 to 12 weeks of appropriate conservative treatment had failed (Emblom, 2018). The 2023 review suggested surgical repair be considered when symptoms persist despite 12 weeks of nonoperative treatment (Forlizzi, 2023).
Those are uncontrolled series and expert reviews, not comparative trials. Whether surgery is appropriate is a specialist decision based on the structure involved, the response to rehabilitation and the athlete's goals.
Why the label matters
Calling every lower abdominal or groin injury a "sports hernia" leads to two errors. A true hernia can be missed because the label sounds like it has already been addressed, and a muscle or aponeurotic injury can be mismanaged because it is assumed to need a hernia operation. Naming the actual structure, such as a distal rectus abdominis strain, an aponeurosis injury or an adductor origin problem, keeps both the patient and every clinician involved working on the same problem.
How Novo approaches suspected core muscle injury
We screen for medical causes, examine the rectus insertion, the lateral abdominal wall, the adductor origin, the pubic symphysis, the inguinal region and the hip, look for hernia signs, and test how each responds to load. When the pattern suggests an aponeurotic, hernia or hip problem, appropriate imaging or referral is the next step. See how we approach abdominal wall, oblique and rectus muscle pain and adductor tendinopathy and groin pain.
References
- White LM, Naraghi AM, Mohankumar R, Bleakney RR. Imaging findings of sports-related acute core muscle injuries. Skeletal Radiology. Published online 2026. PMID 42105089. (link)
- Forlizzi JM, Ward MB, Whalen J, Wuerz TH, Gill TJ 4th. Core muscle injury: evaluation and treatment in the athlete. American Journal of Sports Medicine. 2023;51(4):1087-1095. PMID 35234538. (link)
- Belair JA, Hegazi TM, Roedl JB, Zoga AC, Omar IM. Core injuries remote from the pubic symphysis. Radiologic Clinics of North America. 2016;54(5):893-911. PMID 27545427. (link)
- Poor AE, Meyers WC. Core muscle injuries in baseball players. Clinics in Sports Medicine. 2025;44(2):355-367. PMID 40021262. (link)
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine. 2015;49(12):768-774. PMID 26031643. (link)
- Coker DJ, Zoga AC. The role of magnetic resonance imaging in athletic pubalgia and core muscle injury. Topics in Magnetic Resonance Imaging. 2015;24(4):183-191. PMID 26244616. (link)
- Emblom BA, Mathis T, Aune K. Athletic pubalgia secondary to rectus abdominis-adductor longus aponeurotic plate injury: diagnosis, management, and operative treatment of 100 competitive athletes. Orthopaedic Journal of Sports Medicine. 2018;6(9):2325967118798333. PMID 30263900. (link)
