Purpose With increasing availability of radiological services, recent times have seen widespread use of ultrasound to characterise inguinal hernias. Anecdotally, ultrasound often detects hernias which are not responsible for the patient's symptoms. If the patient subsequently undergoes hernia repair, their source is not solved, and there is risk of chronic groin pain. Being a common encounter in clinical practice, this study aims to review the literature and provide recommendations regarding the role of ultrasound in clinically occult inguinal hernias. Method A literature review was performed in PubMed using combinations of the keywords: "occult", "equivocal", "inguinal hernia", "groin hernia", "ultrasound" and "sonography". Results Seventeen studies were included. There was significant heterogeneity. Overall, studies report that ultrasound had a high average positive predictive value of 89.3%. It had an average sensitivity of 78.8% and specificity of 78.0%. MRI has superior sensitivity and specificity, reportedly over 90%. There were two observational studies examining outcomes of surgical repair of clinically occult, radiologically evident inguinal hernias; outcomes were similar between surgically and conservatively managed groups. Conclusion Ultrasound may have a role in detection of clinically occult hernias. However, this does not necessarily guide appropriate management. If imaging is indicated, MRI would be the preferred imaging modality to distinguish inguinal hernias from musculoskeletal causes of groin pain. While MRI is more costly than ultrasound, it may prevent unnecessary surgery, which entails more costs and risk of morbidity for patients.