Athletic Groin Pain

History: groin pain related to sporting activity is the unifying feature. The Doha entity dictates the localisation - adductor-related is medial groin at the adductor longus origin; iliopsoas-related is anterior hip / groin worse with flexion activities, possibly with snapping; inguinal-related is in the canal region, worse with coughing or Valsalva, may radiate into the scrotum; pubic-related is central, often bilateral, and may suggest pubic apophysitis in adolescents.

Ask about mechanism, sport, training-load changes, previous groin injury, hip stiffness, and (in female athletes) menstrual regularity and energy availability (RED-S screening).

Examination:

• •Adductor-related: tenderness at adductor longus origin; pain on resisted adduction (squeeze test at 0, 45, and 90 degrees); pain on passive abduction
• •Iliopsoas-related: deep tenderness lateral to the femoral artery; pain on resisted hip flexion and passive extension; audible or palpable snap
• •Inguinal-related: inguinal canal tenderness; pain on coughing, Valsalva, or resisted abdominal contraction; assess for palpable hernia. No single test is definitive
• •Pubic-related: tenderness directly over the symphysis; pain on squeeze test; pain on single-leg standing or hopping
• •Hip-related: perform FADIR on every groin-pain patient. Compare internal rotation in flexion with the contralateral side. No single hip test is diagnostic in isolation

General: lumbopelvic stability, lumbar spine (L1/L2 radiculopathy), abdominal examination.

Differentials: FAI syndrome or labral tear (deep anterior groin, positive FADIR, imaging morphology); hip OA (older, reduced internal rotation, radiographic changes); femoral neck stress fracture (endurance athlete, RED-S risk factors); true inguinal hernia (cough impulse, reducible lump); nerve entrapment (obturator, ilioinguinal, genitofemoral); lumbar radiculopathy (L1/L2); avulsion fracture in adolescents (ASIS, AIIS, ischial tuberosity); pubic apophysitis in adolescents; urological or gynaecological pathology.

Groin pain in athletes is primarily a clinical diagnosis using the Doha framework.

• •Plain radiographs (AP pelvis with or without lateral hip): first-line when imaging is needed. Assess the symphysis, hip morphology, and bony avulsions. Symphyseal changes may be asymptomatic in athletes
• •MRI: second-line for unresolved or complex cases. Demonstrates pubic bone marrow oedema, adductor tendinopathy or tear, ARC pathology (secondary cleft sign), hip joint pathology, and stress fracture. Crucial caveat: pubic bone marrow oedema is present in some athletes without groin pain - interpret alongside clinical findings
• •Ultrasound: useful for dynamic inguinal canal assessment, adductor tendon pathology, and iliopsoas
• •Diagnostic injection: image-guided local anaesthetic to localise the primary pain source
• •BAMIC grading: for acute muscle strains
• •Bloods: not routinely indicated

Adductor-related groin pain:

• •Acute strain: relative rest, ice, compression. Early active rehabilitation over prolonged rest. Criteria-based return to sport. BAMIC grading guides prognosis
• •Chronic tendinopathy: exercise-based rehabilitation is the mainstay. Progressive adductor strengthening is the cornerstone, with the Copenhagen adductor exercise as a well-supported component. Address biomechanical deficits. Short-course NSAIDs. Corticosteroid injection may facilitate rehabilitation but does not address the underlying tendinopathy
• •Surgery is rarely needed - consider after 3-6 months of failed structured rehabilitation

Iliopsoas-related: physiotherapy-led rehabilitation with stretching, progressive strengthening, hip flexor load management, and lumbopelvic stability.

Inguinal-related: conservative management first - core and abdominal strengthening. If symptoms persist, refer to a clinician with specific interest in inguinal-related groin pain. Laparoscopic repair may be offered in selected refractory cases. Evidence is mixed.

Pubic-related: activity modification, progressive rehabilitation, graduated return. Often requires longer recovery. Symphysis injection may provide short-term relief. Surgical options are limited.

Hip-related: covered in the FAI syndrome topic; hip and groin pathology commonly coexist and both must be addressed.

General principles: address coexisting entities, correct modifiable risk factors, criteria-based return to sport (pain-free sport-specific activities, adequate adductor strength, adductor-to-abductor ratio).

Referral: SEM specialist or groin pain specialist service if diagnostic uncertainty, symptoms persisting beyond 3 months, suspected stress fracture, suspected FAI, or refractory inguinal-related pain.

Acute adductor strain:

• •Early (0-2 weeks): relative rest, maintain cardiovascular fitness, isometric adductor activation
• •Loading (2-6 weeks): progressive adductor strengthening (isometric to isotonic to eccentric). Copenhagen adductor exercise progressed from short lever (knee on bench) to long lever (ankle on bench). Functional exercises
• •Return to sport: sport-specific running, cutting, kicking. Criteria-based - pain-free, adductor strength symmetry over 90% of the contralateral side, and adductor-to-abductor ratio over 0.8

Chronic adductor tendinopathy: progressive loading over a minimum of 8-12 weeks. Address biomechanical contributors. Load management. Pain during rehabilitation is acceptable (up to approximately 5/10) provided it settles within 24 hours.

Prevention: the Copenhagen adductor exercise is well-supported in football prevention programmes. Pre-season adductor strengthening, maintained hip range, graduated load progression, and the FIFA 11+ warm-up. Previous groin injury is the strongest risk factor - prevention programmes should continue long-term.

• •Doha Agreement on terminology and definitions in groin pain in athletes (Weir et al., BJSM 2015): the international consensus framework defining four clinical entities and recommending against the legacy terms sportsman hernia, Gilmore groin, and athletic pubalgia.
• •Warwick Agreement on FAI Syndrome (Griffin et al., BJSM 2016): companion consensus classifying hip-related groin pain separately but with frequent overlap with the Doha entities.
• •Haroy et al. Copenhagen adductor RCT (BJSM 2019): Copenhagen adductor exercise reduced groin problems in male footballers by around 41% compared with usual practice; established the exercise as a preventive standard.
• •BAMIC (British Athletics Muscle Injury Classification): UK system for classifying acute muscle injury severity and guiding return-to-play.
• •Holmich et al. exercise therapy for adductor-related groin pain (Lancet 1999): foundational trial showing active training-based rehabilitation outperformed passive treatment for chronic adductor-related groin pain.
• •FIFA 11+ warm-up programme: validated injury-prevention protocol with adductor strengthening components.

• •Doha Agreement (2015) terminology: adductor-related (commonest), iliopsoas-related, inguinal-related, pubic-related. Hip-related is Warwick Agreement (2016). Multiple entities commonly coexist. Sportsman hernia, Gilmore groin, and athletic pubalgia are outdated.
• •The squeeze test (adductor) and FADIR (hip) are the two highest-yield clinical tests. Perform FADIR on every groin-pain patient because FAI commonly coexists.
• •The ARC is the shared aponeurotic plate (rectus abdominis - adductor longus) at the anterior pubis that explains why adductor and pubic / inguinal symptoms overlap. The secondary cleft sign on MRI indicates an ARC tear.
• •MRI pubic bone marrow oedema is common in asymptomatic elite athletes - treat the patient, not the scan.
• •Copenhagen adductor exercise is well-supported for rehabilitation and prevention (Haroy 2019, around 41% reduction). Know it by name.
• •Previous groin injury is the strongest risk factor for future groin injury. In adolescents consider avulsion fracture, pubic apophysitis, or SUFE. Screen for RED-S in any female athlete with bone stress injury.