Athletic Groin Pain

Lower Limb

Overview

Athletic groin pain is a common condition in sports involving kicking, sprinting, and rapid directional changes, characterized by pain in the groin region due to muscle strain, tendinopathy, or pubic bone-related pathology. The condition often involves the adductor muscles, rectus abdominis, iliopsoas, or pubic symphysis and can significantly impair athletic performance. Early diagnosis and management are essential to prevent chronic pain and allow safe return to sport.

Pathophysiology

Athletic groin pain results from cumulative microtrauma or acute injury to structures around the groin, commonly affecting the adductor longus, brevis, and magnus muscles due to eccentric loading during hip abduction and external rotation movements. The rectus abdominis and its attachment to the pubic bone can be strained through repetitive flexion and rotation. Chronic overuse leads to tendinopathy, inflammation at muscle-tendon junctions, and potential pubic symphysis dysfunction. Poor core stability, weak hip abductors, and muscle imbalances increase injury risk.

Patient Education

Groin pain in athletes requires graduated return to sport based on pain-free strength and range of motion rather than time alone; continuing aggravating activities often delays recovery and increases chronicity risk.

Typical Presentation

Site

Lower medial aspect of the groin, adductor region, or lower abdomen near pubic bone; may radiate along medial thigh

Quality

Sharp, burning, or dull aching pain; may feel like muscle tightness or strain

Intensity

Mild to moderate (3-7/10) that worsens with activity; often improves with rest

Aggravating

Kicking, sprinting, rapid deceleration, hip adduction against resistance, trunk rotation, sit-ups, side-stepping, pivoting movements

Relieving

Rest, ice application, gentle stretching, hip adduction exercises, anti-inflammatory modalities

Associated

Hip stiffness, reduced hip range of motion, weak hip abductors and external rotators, core instability, altered gait pattern, groin tenderness on palpation, positive adductor squeeze test

Orthopaedic Tests

Adductor Squeeze Test

Procedure

Patient supine with hip flexed to 45° and knee flexed to 90°. Examiner places a pressure biofeedback unit or ball between the knees and asks patient to squeeze maximally for 5 seconds. Repeat at 0°, 45°, and 90° hip flexion.

Positive Finding

Pain reproduction in the adductor region or groin, or weakness compared to contralateral side; typically most sensitive at 45° hip flexion.

Sensitivity / Specificity

72–86% / 52–81%

Delporte et al., 2017, British Journal of Sports Medicine; Thorborg et al., 2011, Journal of Athletic Training

Interpretation

Suggests adductor longus pathology or adductor-related groin pain. Lower specificity means positive result should be correlated with clinical presentation and imaging findings.

Long Adductor Stretch Test

Procedure

Patient supine at 45° hip abduction and external rotation (frog-leg position). Examiner applies gentle overpressure through the knee or inner thigh into further abduction/external rotation, holding 30 seconds.

Positive Finding

Reproduction of groin pain on the affected side; patient may report increased symptoms with prolonged stretch.

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Assesses flexibility and provocation of adductor muscles; high prevalence in athletes with adductor-related groin pain. Often used in conjunction with squeeze testing.

Hip Flexor Strength Test (Thomas Test Position)

Procedure

Patient supine with affected hip extended off the end of the table and contralateral knee flexed to stabilize. Examiner applies resistance as patient attempts to lift the extended leg upward against gravity and manual resistance.

Positive Finding

Pain in the anterior groin or hip flexor region; weakness or inability to maintain resistance compared to contralateral side.

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Assesses iliopsoas dysfunction; hip flexor weakness or pain is common in athletic groin pain, particularly in sports requiring repetitive kicking or sprinting.

Copenhagen Adductor Test (Sidelying Adduction)

Procedure

Patient sidelying on affected side, hip and knee flexed to 45°. Examiner applies manual resistance against adduction of the top leg, or patient attempts resisted adduction of bottom leg with top leg supporting.

Positive Finding

Pain in the adductor region of the groin; inability to maintain contraction or weakness on affected side; difficulty sustaining the position.

Sensitivity / Specificity

68–82% / 65–76%

Thorborg et al., 2011, Journal of Athletic Training; Delporte et al., 2017, British Journal of Sports Medicine

Interpretation

Evaluates adductor strength and endurance in a functional position. Weakness suggests adductor deficiency; pain indicates adductor-related groin pain. Often progressed in rehabilitation.

Single-Leg Stance Hip Adduction Test

Procedure

Patient standing on affected leg with contralateral hip flexed to 90°. Examiner observes pelvic stability and applies gentle resistance to abduction of the flexed hip. Patient maintains position for 30 seconds.

Positive Finding

Pain in the medial groin; pelvic drop or ipsilateral hip hiking on the stance side; inability to maintain control.

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Assesses dynamic stability and adductor function in standing. Positive findings suggest weakness, poor motor control, or pain with functional adduction—common in athletic populations with groin pain.

Resisted Hip Adduction (Supine, Neutral Hip)

Procedure

Patient supine with hip in 0° flexion/extension and 0° abduction/adduction. Examiner places hand on medial thigh and applies resistance as patient adducts the hip against manual resistance.

Positive Finding

Pain in the medial groin, pubic region, or along the adductor muscles; weakness or inability to generate force.

Sensitivity / Specificity

70–78% / 60–72%

Delporte et al., 2017, British Journal of Sports Medicine

Interpretation

Directly loads the adductors in neutral. Positive result is consistent with adductor strain or adductor-related groin pain. Should be assessed bilaterally for comparison.

⚠ Red Flags

  • •Severe sharp pain or inability to bear weight suggesting acute muscle rupture
  • •Signs of inguinal hernia (palpable bulge, sudden onset with valsalva maneuver)
  • •Testicular pain or swelling requiring urgent urological assessment
  • •Fever, lymphadenopathy, or systemic symptoms suggesting infection
  • •Progressive neurological symptoms suggesting nerve compression
  • •History of cancer or unexplained weight loss suggesting metastatic disease
  • •Severe trauma with suspected avulsion fracture of pubic bone

⚡ Yellow Flags

  • •Excessive training volume without adequate recovery periods
  • •Fear-avoidance behaviors limiting normal movement and activity
  • •Perfectionist or highly competitive personality increasing injury risk
  • •Poor adherence to rehabilitation protocols
  • •Psychological distress or depression affecting recovery trajectory
  • •Belief that pain means serious structural damage despite reassurance
  • •Overly aggressive return to sport without strength restoration

Osteopathic Techniques

Region

Adductor muscles (longus, brevis, magnus)

Technique

Soft Tissue

Rationale

Direct soft tissue mobilization reduces muscle tension, improves circulation, breaks down adhesions, and promotes tissue healing in chronically tight adductors; facilitates neuromuscular relaxation prior to stretching and strengthening

Region

Hip and pelvis

Technique

MET

Rationale

Muscle energy techniques normalize hip range of motion, particularly adduction and external rotation; improve neuromuscular control and restore proper hip mechanics while reducing strain on pubic symphysis

Region

Rectus abdominis and lower abdomen

Technique

Soft Tissue

Rationale

Reduces tension in rectus abdominis and its pubic attachments; releases fascial restrictions that contribute to pubic pain and restores normal anterior chain mechanics

Region

Lumbar spine and pelvis

Technique

Articulation

Rationale

Restores lumbar-pelvic mobility and core stability; addresses underlying lumbar restrictions that force compensatory loads through the groin structures

Region

Iliopsoas

Technique

Soft Tissue

Rationale

Releases tension in iliopsoas which, when tight, increases hip flexor dominance and compensatory adductor activation; improves hip flexion mechanics during running and kicking

Region

Pubic symphysis and lower abdomen

Technique

Functional

Rationale

Functional release of pubic symphysis dysfunction improves force distribution across the pelvis; normalizes patterns of muscle activation and reduces localized inflammation and pain

Add-On Approaches

Chinese Medicine

Acupuncture to Spleen meridian points (SP6, SP9, SP10) and local ashi points in the groin; moxibustion for cold-type pain; herbal formulas such as Du Huo Ji Sheng Tang to promote circulation and reduce chronic inflammation

Chiropractic

Hip joint manipulation to improve hip mobility; sacroiliac joint adjustment to optimize pelvis mechanics; soft tissue techniques to adductors and iliopsoas

Physiotherapy

Progressive strengthening of hip abductors (gluteus medius and maximus), external rotators, and core stabilizers; neuromotor training for dynamic hip control; running technique analysis and modification; agility drills with pain monitoring

Remedial Massage

Deep tissue massage to adductors and rectus femoris; trigger point release in iliopsoas and lower abdominal muscles; fascial techniques to release abdominal-pelvic restrictions; sports massage for recovery between training sessions

Rehabilitation Exercises

Supine Figure-4 Hip Stretch (Piriformis and Deep Hip Rotators)

StretchingBeginner

Adductor Lunge Stretch

StretchingBeginner

Butterfly Stretch (Hip Flexor and Adductor)

StretchingBeginner

Clamshells (Gluteus Medius Activation)

StrengtheningBeginner

Side-Lying Hip Abduction

StrengtheningBeginner

Supine Hip Bridge with Gluteal Squeeze

StrengtheningIntermediate

Standing Single-Leg Romanian Deadlift

StrengtheningIntermediate

Copenhagen Adductor Squeeze (Supine or Side-Lying)

StrengtheningIntermediate

Dead Bug Core Stability

PosturalBeginner

Quadruped Core with Hip Extension (Bird Dog)

PosturalIntermediate

Single-Leg Stance with Upper Body Rotation

BalanceIntermediate

Stationary Cycling (Pain-Free Speed and Duration)

CardiovascularBeginner

Referral Criteria

  • •Persistent symptoms beyond 4-6 weeks despite conservative management
  • •Suspected muscle rupture or complete tendon tear (sudden weakness, inability to bear weight)
  • •Suspected inguinal hernia requiring surgical evaluation
  • •Progressive neurological symptoms (numbness, weakness in lower limb)
  • •Signs of systemic infection or fever accompanying groin pain
  • •Failure to progress in strength and range of motion after 8-12 weeks of rehabilitation
  • •Testicular or urological symptoms requiring urologist assessment
  • •Imaging findings (MRI, ultrasound) suggesting significant structural damage
  • •Need for advanced diagnostic imaging (MRI) to clarify diagnosis
  • •Recurrent injuries preventing safe return to sport despite rehabilitation