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

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Adductor Squeeze Test

Procedure

Patient supine with the legs straight (hips at 0°). Place your forearm or fist between the ankles and ask the patient to squeeze as hard as they can. Repeat with the hips bent to 45° and knees to 90°, squeezing a fist or ball between the knees. A pressure cuff can be used to measure strength.

Positive Finding

The patient's own groin pain is reproduced, in the adductor region.

Sensitivity / Specificity

80% (46 athletes with an adductor injury)/74% (35 injured athletes without one)

Reference: Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, et al. Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings?. Br J Sports Med. 2016;50(24):1541-1547.

Interpretation

Supports adductor-related groin pain. Only count the athlete's own pain as positive. Squeeze strength and pain are useful to track progress and return to sport. Groin pain in athletes can come from the adductors, iliopsoas, inguinal region, pubic bone or hip joint, and more than one area can be involved. From one study of 81 male athletes seen within 7 days of an acute groin injury, with MRI as the reference (Serner 2016). 46 had an adductor injury on MRI; the comparison group was the 35 athletes with another groin injury or a normal MRI, so specificity was measured against other injured athletes, not healthy people. A test counted as positive only if it reproduced the athlete's own injury pain. Figures apply to acute injuries, not long-standing groin pain. Figures are for the squeeze with the legs straight (hips at 0°). With hips at 45° and knees at 90° the same study found 67% / 63%.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Hip Flexor Strength Test (Thomas Test Position)

Procedure

Patient in the modified Thomas position: sitting on the end of the plinth, then lying back hugging the other knee, with the tested leg hanging down. Ask the patient to lift the thigh up against your resistance.

Positive Finding

Reproduction of the patient's own pain in the front of the hip or groin, or weakness.

Sensitivity / Specificity

72% (18 athletes with a hip flexor injury)/67% (63 injured athletes without one)

Reference: Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, et al. Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings?. Br J Sports Med. 2016;50(24):1541-1547.

Interpretation

Loads the hip flexors (iliopsoas, rectus femoris) in a lengthened position and points to iliopsoas-related groin pain when positive. In acute injuries, hip flexor tests were poor at showing which muscle was injured; MRI helps when the exact location matters. From one study of 81 male athletes seen within 7 days of an acute groin injury, with MRI as the reference (Serner 2016). 18 had a hip flexor injury on MRI (rectus femoris, iliopsoas or sartorius); the comparison group was the 63 athletes with another groin injury or a normal MRI. The authors found hip flexor tests poor at predicting which muscle was injured, and suggested MRI when the exact location matters. Figures apply to acute injuries only.

Sources

No accuracy study

Copenhagen Adductor Test (Sidelying Adduction)

Procedure

Patient lies on the affected side. Support the top leg at the knee or ankle at hip height, and ask the patient to lift the body up into a side plank, holding with the top leg (the Copenhagen adduction exercise), or to push the top leg down into your hand.

Positive Finding

Groin pain during the hold, or unable to hold as long as on the other side.

Interpretation

Mainly an exercise and a way to measure adductor strength and load tolerance. Useful to track rehabilitation; not an established diagnostic test. A literature search (Europe PMC, September 2026) found no study reporting the diagnostic accuracy of this test, so no figure is shown.

No accuracy study

Resisted Hip Adduction (Supine, Neutral Hip)

Procedure

Patient supine with the legs straight and together. Place your hand on the inside of the knee and ask the patient to push the leg inwards against your resistance, compared with the other side.

Positive Finding

Reproduction of the patient's own adductor pain, or weakness.

Interpretation

Supports adductor involvement. Resisting adduction from an abducted (outer range) position loads the adductors more and was the better-studied version. Pain in the lower abdomen or near the inguinal canal with resisted sit-ups instead points to inguinal-related groin pain. No study of this exact version was found, so no figure is shown. Resisted adduction from an outer-range (abducted) position was studied in acute groin injuries; see the adductor strain page.

Sources

No accuracy study

Passive Adductor Stretch (Frog Position)

Procedure

Patient supine with the hips and knees bent, soles together, knees falling out to the sides. Apply gentle overpressure on the inside of the knees, comparing sides.

Positive Finding

Reproduction of the patient's own groin pain, or less range than on the other side.

Interpretation

Supports adductor involvement. Pain deep in the groin rather than along the adductors may point to the hip joint; check hip rotation and the FADIR test.

Not a diagnostic test

Single-Leg Functional Tests (Stance, Squat, Hop)

Procedure

Ask the patient to stand on the affected leg, then do a single-leg squat and, if pain-free, hop. Watch pelvic control and ask about groin pain.

Positive Finding

Groin pain with loading, or poor pelvic or knee control.

Interpretation

Shows load tolerance and movement control, which guide rehabilitation and return to sport. Not a diagnostic test.

⚠ 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

Active exercise for the muscles around the pelvis, especially the adductors, has the best evidence: in a trial of athletes with long-standing adductor-related groin pain, far more returned to sport pain-free after active training than after passive physiotherapy. A package that included manual therapy sped return to sport in another trial, but did not ease pain more than exercise.

Region

Adductors (longus, brevis, magnus) and iliopsoas

Technique

Soft tissue, hip and thigh
Contested
Evidence is conflicting across studies
A manual therapy package sped return to sport in one trial, with no extra pain relief. Active training beat passive physiotherapy, and a review favoured exercise alone.

Rationale

Hands-on work to the hip and thigh muscles to ease tension and pain, given alongside exercise.

How it's done & evidence

How it's done

Hands-on kneading, stretching and sustained pressure to the muscles around the hip and thigh: the hip flexors, adductors and hamstrings, and tensor fasciae latae with the iliotibial band.

Evidence in Athletic Groin Pain

Weir 2011 (RCT, long-standing adductor-related groin pain): heat, Van den Akker manual therapy and stretching returned athletes to sport faster than exercise therapy (12.8 vs 17.3 weeks), with no difference in pain or objective outcome; only about half in each group fully returned. Hölmich 1999 (RCT, n=68): active training far beat physiotherapy without active training (23 vs 4 back to sport without groin pain). Lahuerta-Martín 2023 (5 studies, 3 pooled): exercise alone eased pain more than passive therapy plus exercise in the short term (very low certainty).

Region

Adductors

Technique

Muscle energy, hip and thigh musclesNo trials found

Rationale

Low-force, patient-powered stretch for tight hip and thigh muscles.

How it's done, cautions & evidence

How it's done

The muscle (for example the hamstrings, adductors or rectus femoris) is taken to its barrier. The patient pushes gently, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Athletic Groin Pain

Searched 24 Oct 2026: no trials of adductor MET in athletic groin pain.

Region

Pubic symphysis

Technique

Muscle energy, pelvis (innominate and pubis)No trials found

Rationale

Gentle patient-powered contractions to restore pelvic (innominate or pubic) movement.

How it's done, cautions & evidence

How it's done

The innominate (or pubis) is taken to its restricted barrier. The patient makes a short, gentle contraction against equal resistance (a few seconds), relaxes, and the new barrier is taken up. Repeat, then re-check pelvic landmarks. Check for pubic dysfunction first, with consent.

Cautions

Do not use if the contraction causes severe pain, with a fracture or unstable joint in the area, or after recent surgery.

Evidence in Athletic Groin Pain

Searched 24 Oct 2026: no trials of pubic or pelvic MET in athletic groin pain.

Sources

Region

Lumbar spine and pelvis

Technique

Articulation, lumbarNo trials found

Rationale

Gentle, rhythmic mobilisation of the lower back and pelvis to ease stiffness.

How it's done, cautions & evidence

How it's done

Rhythmic, low-velocity movement of restricted lumbar segments within their passive range, with no thrust, usually side-lying or prone. The amplitude can vary.

Cautions

Side effects reported in trials were mild and short-lived: soreness, tiredness or a flare of existing symptoms.

Evidence in Athletic Groin Pain

Searched 24 Oct 2026: no trials of lumbar or pelvic mobilisation in athletic groin pain.

Sources

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