Where groin pain in athletes comes from
The groin is where several structures that transmit large forces meet: the thigh adductors, the iliopsoas, the abdominal muscles that attach to the pubic symphysis, and the hip joint itself. In football and hockey they are loaded by every kick, push-off and sharp change of direction. When the number of such stimuli grows faster than the muscles and tendons can adapt to them, pain appears – usually gradually, without a single clear injury.
For years many names were used that meant different things in different countries. The Doha agreement (Doha, 2014) brought order to this by dividing groin pain into four clinical categories: adductor-related, iliopsoas-related, inguinal-related and pubic-related. Pain coming from the hip joint, for example with femoroacetabular impingement (FAI), was described separately, as were other causes that need medical investigation.
How we tell the source of the pain apart
The most common is adductor-related pain: pressure on the attachment at the pubic bone hurts, as does squeezing the knees together against resistance. Iliopsoas-related pain gets worse with resisted hip flexion and stretching the front of the thigh. Inguinal-related pain is felt over the inguinal ligament, often when coughing or doing abdominal exercises, and pubic-related pain directly over the symphysis.
The adductor strength test is very useful: squeezing a ball or a measuring device between the knees. It shows both the pain and the strength deficit, and repeated every few weeks it measures progress. We also examine the hip joint – if the symptoms point to a problem inside the joint, you can read more on the hip pain page.
Treatment – adductor strength comes first
The best documented approach for adductor-related pain is an active, graded strength programme. We start with isometric exercises, move on to work against resistance and the Copenhagen exercise (Copenhagen adduction), and at the same time strengthen the abdominal muscles and the glutes. Manual therapy and soft tissue work can bring the pain down in the first weeks, but they will not replace training.
When the symptoms are recent, improvement usually comes within a few weeks. Pain that has lasted for many months needs longer work and patient grading of the load.
For iliopsoas-related and pubic-related pain the principle is similar, but the emphasis shifts: more work on the strength of the hip flexors and abdominal muscles, and more cautious dosing of sprints and kicks. If the source is the hip joint, we add pelvic control exercises and choose ranges of motion that do not provoke pain. In many players the categories overlap, which is why we set the programme individually rather than following a single template.
Return to play and when to come in
We return to play in stages: straight-line running, accelerations, changes of direction and, last of all, kicks with increasing power. Moving on is decided by the pain not building up and by the strength test result, not by the number of days alone. We run the whole process as part of sports physiotherapy, with an exercise plan that is worth keeping for good.
Prevention matters a lot here. Regular adductor strength training, for example the Copenhagen exercise done several times a week in pre-season and once a week during the season, reduces the risk of groin problems in footballers. It is also worth watching out for sudden jumps in load – especially at the start of pre-season and after a break.
If your groin pain comes back every season or does not go away despite a break from playing, book a visit via the Contact page.