The internal oblique aponeurosis splits at the lateral border of the rectus abdominis to contribute to both the anterior and posterior rectus sheath above the arcuate line. Below the arcuate line it passes entirely anteriorly. Medially it joins the aponeuroses of external oblique and transversus abdominis to form the conjoint tendon at the pubis.
The internal oblique aponeurosis is the key layer in laparoscopic inguinal hernia repair (TEP and TAPP), where the preperitoneal space between internal oblique and transversalis fascia must be developed. Athletic pubalgia involves avulsion or microtrauma of the internal oblique aponeurosis at its pubic attachment. The aponeurosis is reinforced in open hernia repair (Shouldice, Bassini techniques).
Aponeurotic microtrauma at the pubic attachment of the internal oblique in kicking athletes producing chronic groin pain with resisted hip flexion and adduction.
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