Question 1

What is the Doha classification and why does it matter for my groin pain?

Accepted Answer

The Doha classification (2014 consensus from sports medicine experts) categorizes groin pain into 33 different entities across 4 main categories: (1) Adductor-related (60-70% of cases) - adductor longus tendinopathy or tear. (2) Iliopsoas-related (10-20%) - hip flexor tendinopathy. (3) Inguinal-related (5-15%) - sportsman's hernia/athletic pubalgia. (4) Pubic-related (5-10%) - pubic bone stress or osteitis pubis. Why it matters: Groin pain is NOT one condition - it's a symptom with many causes. Accurate diagnosis using Doha classification determines correct treatment. For example, adductor-related groin pain responds to Copenhagen protocol (strengthening), while sportsman's hernia requires surgery. Treating the wrong diagnosis explains why 30-40% of groin pain becomes chronic - misdiagnosis is common. Your sports medicine doctor or orthopaedic surgeon should use Doha classification to identify your specific cause(s) - many athletes have multiple overlapping pathologies.

Question 2

Is athletic groin pain the same as a sports hernia? Do I actually have a hernia?

Accepted Answer

NO - 'sports hernia' is a MISLEADING term (not a true hernia in most cases). True inguinal hernia (bowel protruding through abdominal wall) is RARE in athletes (<5% of groin pain). 'Sports hernia' (better term: athletic pubalgia or inguinal-related groin pain) refers to: Torn or weakened lower abdominal muscles (external oblique, internal oblique, conjoint tendon). Tear in posterior inguinal wall (transversalis fascia). Torn or stretched inguinal ligament. These create weakness in the groin region causing pain with kicking, twisting, sit-ups. Different from true hernia: (1) No visible/palpable lump (true hernia has lump). (2) Does NOT require emergency surgery (true hernia can strangulate). (3) Surgical repair uses sutures WITHOUT mesh (true hernia uses mesh). However, some athletes DO have occult (hidden) inguinal hernia only visible on dynamic ultrasound or MRI - appears during Valsalva (straining). This IS a true hernia requiring different surgical technique (mesh repair or laparoscopic hernia repair). BOTTOM LINE: 'Sports hernia' usually means torn abdominal wall muscles, NOT bowel hernia. Your surgeon should clarify exact diagnosis before surgery.

Question 3

I've had groin pain for 6 months and physiotherapy hasn't helped. Does this mean I need surgery?

Accepted Answer

MAYBE - but need to determine WHY physiotherapy failed first. Common reasons physiotherapy fails: (1) WRONG DIAGNOSIS (most common) - treating adductor tendinopathy when the actual problem is FAI (hip impingement) or pubic stress. Solution: Repeat assessment by sports medicine specialist, consider MRI if not done. (2) INADEQUATE PHYSIOTHERAPY - did you complete home exercise program 5-6 days per week? Did you do Copenhagen protocol correctly? Many athletes attend sessions but don't do home exercises - this fails 60-70% of time. Solution: Strict compliance with strengthening program for minimum 8-12 weeks. (3) CONTINUING AGGRAVATING ACTIVITIES - continuing to play through pain prevents healing. Solution: Relative rest (maintain fitness without kicking/cutting) for 4-8 weeks. (4) UNADDRESSED BIOMECHANICAL FACTORS - tight hips, weak core, poor running technique. Solution: Comprehensive assessment and correction. (5) STRUCTURAL PROBLEM REQUIRING SURGERY - sportsman's hernia (torn abdominal wall), severe adductor tear (>50% tendon), FAI with labral tear. Solution: Surgical repair. If you've had 3-6 months of PROPER physiotherapy (compliance, correct diagnosis, adequate rest) without improvement, surgery consultation is reasonable. Success rates: Sportsman's hernia repair 85-90%, adductor tenotomy 70-85%, hip arthroscopy for FAI 80-90%. But surgery without post-operative physiotherapy also fails - both are needed.

Question 4

Can I play through groin pain or will I make it worse?

Accepted Answer

SHORT ANSWER: Playing through significant groin pain (>4/10 severity) usually makes it worse and increases chronic pain risk from 20% to 50-60%. LONG ANSWER: Depends on pain severity and diagnosis: (1) MILD PAIN (1-3/10) during warm-up that DISAPPEARS completely during activity and does NOT worsen next day - acceptable to continue playing with modified training (reduce kicking volume, avoid maximal sprints). Continue Copenhagen protocol and monitoring. (2) MODERATE PAIN (4-6/10) during activity, worse after activity, affects performance - SHOULD NOT play. This indicates ongoing tissue damage. Playing through this level converts acute injury (8-12 weeks recovery) to chronic injury (6-12 months recovery). 50% of athletes who 'push through' develop chronic groin pain requiring surgery. (3) SEVERE PAIN (7-10/10) or sudden onset during single event - STOP IMMEDIATELY. Could indicate acute adductor tear or avulsion fracture requiring urgent assessment. EXCEPTION - End of season: If finals/important match and pain is moderate (4-6/10), some athletes choose to play with understanding they're prolonging recovery and accepting higher surgery risk (60% vs 30%). Should have corticosteroid or PRP injection beforehand (temporary pain relief) and plan definitive treatment in off-season. BOTTOM LINE: Early appropriate rest and rehabilitation (8-16 weeks) prevents chronic pain. Playing through pain often leads to 6-12 month recovery or surgery. Your team/surgeon can help weigh competition importance against long-term risk.

Question 5

What is the Copenhagen adduction protocol and why is it so important?

Accepted Answer

The Copenhagen adduction protocol is an EVIDENCE-BASED exercise program for preventing and treating groin injuries in athletes. Developed by Danish researchers (Harøy 2017), it's the ONLY exercise proven to reduce groin injury risk. WHAT IT IS: Side-lying hip adduction exercise - lie on side on bench/partner's leg, lift bottom leg upward against partner's resistance or resistance band. Progressions: (1) Bent knee (both legs bent) - easiest. (2) Bottom knee straight, top knee bent - intermediate. (3) Both knees straight - hardest. Perform 3 sets of 6-10 reps, 2-3 times per week. WHY IT WORKS: Strengthens adductor longus eccentrically (muscle lengthening under load) - this is how adductors work during kicking and cutting. Creates muscle hypertrophy (size increase) 15-20%. Improves adductor strength 30-40% at 8-12 weeks. EVIDENCE: Reduces groin injury incidence by 41% (Harøy 2019 RCT, 661 male footballers). Athletes with previous groin injury who don't do Copenhagen protocol have 2.4x higher re-injury risk. CLINICAL USE: Used as PREVENTION (pre-season and in-season) and TREATMENT (rehabilitation after injury). Most important single exercise for athletic groin pain. Many physiotherapists now consider Copenhagen protocol NON-NEGOTIABLE for return to sport clearance after groin injury. If you don't complete this program, your surgeon/physio should not clear you to return to kicking sports. TECHNIQUE CRITICAL: Must be done correctly (controlled movement, full range, progressive difficulty). Incorrect technique (momentum, partial range) provides no benefit. Your physiotherapist should supervise initial sessions to ensure proper form.

Medical Disclaimer

Athletic Groin Pain (Sports Hernia/Athletic Pubalgia)

📖What is Athletic Groin Pain (Sports Hernia/Athletic Pubalgia)?

🔬What Causes It?

⚠️Risk Factors

You may be at higher risk if:

🛡️Prevention