Abdominal pain is not one diagnosis, and only some of it comes from the abdominal wall. Symptoms can arise from the rectus abdominis, the external and internal obliques, the attachment of the abdominal muscles near the pubic bone, a hernia or a cutaneous nerve. Abdominal pain can also come from the digestive, urinary or reproductive organs, so the first step is determining whether the presentation is appropriate for musculoskeletal care at all.
Once visceral and other medical causes have been considered, Novo localizes the pain source. At our Denver Tech Center clinic, Dr. Scott King examines how the pain started, trunk flexion and rotation, Carnett’s test, focal tenderness, the groin and inguinal region, the adductor and hip, neurologic features and whether ultrasound or MRI is needed.
Treatment is then selected according to the diagnosis and may include progressive trunk loading, manual soft-tissue treatment, selective shockwave therapy, imaging or medical referral. Diagnosis comes first; treatment comes second.
When Abdominal Pain Needs Medical Evaluation
Abdominal wall pain should be diagnosed only after the presentation is consistent with a mechanical source. Pain that is related to eating, bowel habits, urination or the menstrual cycle, or that comes with systemic symptoms, needs medical evaluation first.
Seek medical care first for fever, vomiting, blood in the stool, urine or vomit, black stools, yellowing of the skin, unexplained weight loss, pain linked to eating or bowel habits, a painful or tender bulge that will not go back in, a rigid or swollen abdomen, pain during pregnancy or with abnormal bleeding, testicular pain or swelling, pain after a significant impact, or sudden, severe or worsening pain.
Most abdominal wall pain seen in a soft-tissue clinic is mechanical, but screening comes first.
Abdominal Wall Muscle Pain
The rectus abdominis runs vertically down the front of the abdomen to the pubic bone. The external and internal obliques and the transversus abdominis wrap around the sides, linking the lower ribs to the pelvis. Together they flex, rotate and stabilize the trunk and transfer force between the legs and arms during throwing, swinging, kicking and lifting.
Abdominal wall muscle pain typically behaves mechanically: it follows a loading event, sits in a relatively localized area and is reproduced by contracting, stretching or rotating the trunk. Typical mechanisms include sit-ups or crunches, throwing, golf and tennis swings, rowing, kicking, heavy lifting and a forceful cough or sneeze.
- Rectus abdominis strain: pain at the front of the abdomen, often toward its lower attachment, with sit-ups, trunk extension or getting out of bed.
- Oblique or side strain: pain along the side of the abdomen or the lower rib margin, provoked by rotation and side bending. In throwing and bowling athletes, side strain typically involves the internal oblique at the lower ribs, usually on the side opposite the throwing arm.
- Lower abdominal and pubic attachment: pain just above the groin that overlaps with core muscle injury and adductor-related groin pain.
Is It the Abdominal Wall? Carnett’s Test
Carnett’s test helps decide whether tenderness comes from the abdominal wall or from deeper organs. The examiner presses on the tender spot, then asks you to tense the abdominal muscles. Tenderness that stays the same or increases suggests the abdominal wall; tenderness that eases suggests a visceral source. Carnett’s test localizes pain to the abdominal wall but does not identify the tissue: a muscle strain, a nerve entrapment, a hernia or a rectus sheath hematoma can all produce a positive result. Its value for acute abdominal pain is limited.
Strain or Hernia?
A hernia is a defect in the abdominal wall through which tissue can protrude. It may produce a bulge that appears with standing, coughing or straining, but a small or occult inguinal hernia may not be felt at all. Because a hernia and a muscle strain can both hurt with coughing and lifting, a suspected hernia is referred for medical evaluation and imaging rather than treated as a strain. An expert panel of surgeons and radiologists agreed that dynamic ultrasound is a good first confirmatory imaging choice for suspected occult inguinal hernia. The differences are explained in abdominal muscle strain vs. hernia.
“Sports Hernia” and Core Muscle Injury
“Sports hernia” is not a true hernia. The label has been applied to chronic athletic groin and lower abdominal pain involving the rectus abdominis insertion, the rectus-abdominis/adductor aponeurosis and the inguinal region. Newer imaging literature describes specific core muscle injury patterns instead, such as rectus abdominis strains, side strains, hip pointers and adductor-related core muscle injuries. Novo uses those anatomy-specific terms whenever possible. See core muscle injury and the rectus-adductor aponeurosis, and when the inner thigh is involved, adductor and groin pain.
When Abdominal Wall Pain Is Nerve Pain
Anterior cutaneous nerve entrapment syndrome, or ACNES, occurs when a small sensory nerve branch is irritated where it passes through the abdominal wall, often at the edge of the rectus abdominis. It typically causes a small, sharply localized painful spot, sometimes with altered or heightened skin sensation, and can produce a positive Carnett’s test. ACNES is a nerve problem, not a muscle strain. It is managed through a nerve-focused pathway, which may include diagnostic injection and specialist care, and it is not treated with shockwave. Thoracic spine and lower intercostal nerve irritation can also refer band-like pain into the abdominal wall, and lower-rib problems are covered on rib, thoracic and intercostal pain.
What We Examine
- A visceral, urinary, gynecologic and general health screen before attributing pain to the abdominal wall
- How and when the pain began, including any twist, throw, swing, lift, cough or impact
- Exact pain location: rectus, oblique, lower rib margin, inguinal region or pubic attachment
- Carnett’s test and focal tenderness
- Resisted trunk flexion, rotation and side bending, and coughing
- A check for a bulge or hernia signs with standing and straining
- Adductor, hip and pubic testing when pain sits near the groin
- Neurologic features such as burning, tingling or skin sensitivity
The goal is not simply to reduce tenderness. The abdominal wall has to tolerate trunk rotation, lifting, coughing and the patient’s actual sport or work.
How Treatment Is Selected
Progressive Trunk Loading
For rectus and oblique muscle injuries, loading is the foundation. A typical progression moves from pain-free bracing and breathing to isometric trunk work, controlled flexion, rotation and side bending, anti-rotation exercise, loaded rotation and finally throwing, swinging, kicking or lifting.
Manual Soft-Tissue Treatment
Manual treatment may improve local tissue mobility when the diagnosis is muscular or restricted soft tissue after injury. It does not close a hernia, release a trapped nerve or substitute for medical evaluation. Manual Adhesion Release may be part of the plan for selected chronic restriction, and persistent tissue changes after injury are discussed in muscle fibrosis after a strain.
Shockwave
Radial shockwave may be considered only for selected superficial abdominal-wall muscle or myofascial conditions after hernia, nerve entrapment and visceral causes have been excluded. Direct abdominal-wall evidence is limited. Shockwave is never directed through the abdominal wall toward the organs beneath it. See the shockwave and manual therapy evidence review.
Imaging or Medical Referral
Arranged for a suspected hernia, a significant tear or hematoma, suspected core muscle injury near the pubic bone, nerve entrapment, an unclear diagnosis or any visceral concern.
You do not need to decide which treatment you need before your visit. All four tools are compared on the services page, and shockwave at Novo is explained on shockwave therapy in Denver.
What Research Says
- How common: abdominal wall pain syndromes, including ACNES, myofascial pain and muscle strain, account for up to 30% of chronic abdominal pain cases and remain under-recognized (Thomas, 2026).
- Carnett’s test: a simple point-of-care test that helps distinguish abdominal wall from visceral pain, with limited value in acute abdominal pain (Sun, 2024).
- Occult inguinal hernia: an expert panel agreed that dynamic ultrasound is a good first confirmatory imaging choice (Henderson, 2024).
- Core muscle injury: pain above the inguinal ligament with tenderness at the rectus abdominis insertion is highly suggestive, and adductor longus involvement is common (Forlizzi, 2023).
- Myofascial shockwave: a meta-analysis of 27 randomized studies reported lower pain and better function than control conditions, with high heterogeneity (Avendaño-López, 2024).
- Abdominal-wall shockwave: no abdominal-wall-specific clinical trial was identified.
This is why Novo treats abdominal wall pain as a localization problem, after medical screening, before it becomes a treatment problem.
Strain vs. hernia → · Core muscle injury → · Shockwave and manual therapy evidence →
Sources: Thomas et al., Trop Doct 2026 · Sun et al., Curr Pain Headache Rep 2024 · Henderson et al., Hernia 2024 · Forlizzi et al., Am J Sports Med 2023 · White et al., Skeletal Radiol 2026 · Avendaño-López et al., Am J Phys Med Rehabil 2024
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