ATHLETIC GROIN PAIN (SPORTS HERNIA/ATHLETIC PUBALGIA)
Doha Classification | Adductor-Related Most Common | Multidisciplinary Management
DOHA CLASSIFICATION (4 ENTITIES)
Critical Must-Knows
- Doha classification distinguishes 4 entities: adductor, inguinal, pubic, hip-related
- Adductor squeeze test is key diagnostic maneuver for adductor-related pain
- Copenhagen adductor protocol is evidence-based rehab for adductor injuries
- Differential diagnosis includes FAI - always examine hip ROM and impingement
- Multidisciplinary approach essential: physio, sports medicine, surgery last resort
Examiner's Pearls
- "Athletic pubalgia = chronic groin pain in athletes without inguinal hernia
- "Soccer/football players most affected - kicking and change of direction
- "MRI shows pubic symphysis edema, secondary cleft sign, adductor pathology
- "Conservative management succeeds in 70-80% with proper rehabilitation
Clinical Imaging
Imaging Gallery
Critical Athletic Groin Pain Exam Points
Doha Classification Required
Four distinct entities must be identified: adductor-related (most common), inguinal-related (sports hernia), pubic-related (osteitis pubis), and hip-related (FAI). Examiners expect you to distinguish these clinically.
Adductor Squeeze Test
Diagnostic test for adductor-related pain. Patient supine, hip/knee flexed 45 degrees, squeeze against resistance. Positive = reproduces groin pain. Perform at 0, 45, and 90 degrees hip flexion.
Hip Pathology First
Always exclude hip pathology before diagnosing athletic pubalgia. FAI and labral tears present with groin pain. Perform FADIR, FABER tests and assess hip ROM. Hip MRI if suspicious.
Conservative First
12-week rehabilitation trial mandatory before considering surgery. Copenhagen adductor protocol is evidence-based. Surgery only after failed conservative management with multidisciplinary input.
Quick Decision Guide - Athletic Groin Pain
| Clinical Pattern | Doha Entity | Key Test | First-Line Treatment |
|---|---|---|---|
| Pain with kicking, adduction | Adductor-related | Adductor squeeze test positive | Copenhagen protocol 8-12 weeks |
| Deep groin ache, no hernia bulge | Inguinal-related (sports hernia) | Inguinal canal tenderness on exam | Core strengthening, consider repair if failed |
| Pubic symphysis point tenderness | Pubic-related (osteitis pubis) | MRI shows pubic edema, secondary cleft | Load management, gradual return to sport |
| Deep groin pain, C-sign, limited IR | Hip-related (FAI/labral) | FADIR positive, alpha angle over 55 degrees | Hip arthroscopy if conservative fails |
DOHADOHA - The Four Entities of Groin Pain
Memory Hook:DOHA consensus gives us 4 buckets - most athletes have Adductor pain, but check the Hip first!
SQUEEZESQUEEZE - Adductor Assessment
Memory Hook:SQUEEZE test at 3 angles (0, 45, 90 degrees) - the cornerstone of adductor diagnosis
COPENHAGENCOPENHAGEN - Rehab Protocol Elements
Memory Hook:COPENHAGEN protocol = Gold standard adductor rehab developed in Denmark - 8-12 weeks progressive loading
TEAMMULTIDISCIPLINARY - Team Approach
Memory Hook:TEAM approach is mandatory - surgery is the last resort, not first line
Overview and Epidemiology
Athletic groin pain (also termed athletic pubalgia or sports hernia) describes chronic groin pain in athletes that interferes with sport participation. The term "sports hernia" is a misnomer - most cases do not have a true hernia but rather musculotendinous injury or pubic symphysis pathology.
Key epidemiological features:
- Prevalence: 5-18% of soccer players report groin pain annually
- Gender: 80% male athletes
- Sports: Soccer/football, ice hockey, rugby, Australian Rules Football
- Mechanism: Kicking, rapid acceleration/deceleration, change of direction
- Chronicity: Often insidious onset, chronic by time of presentation
Why Athletes?
Athletic groin pain represents chronic repetitive microtrauma in athletes performing high-intensity kicking and cutting movements. The pubic symphysis and adductor insertion are subjected to repeated eccentric loads during deceleration and change of direction. Unlike acute adductor strains, this is a chronic overuse syndrome.
The Doha Agreement (2014):
The Doha agreement on terminology and definitions in groin pain in athletes established a standardized classification system to replace the confusing historical terminology (Gilmore's groin, sportsman's hernia, hockey groin syndrome, etc.).
Pathophysiology and Mechanisms
Relevant anatomy:
The pubic symphysis is the fibrocartilaginous joint connecting the left and right pubic bones. It experiences significant shear and compression forces during athletic movements.
Key muscular insertions:
- Adductor longus - Primary pain generator (inserts on anterior pubic body)
- Gracilis - Medial aspect of groin
- Rectus abdominis - Superior pubic insertion
- External oblique - Forms anterior inguinal canal wall
- Transversalis fascia - Posterior inguinal canal wall
Adductor-Related Pathophysiology
Mechanism: Repeated eccentric loading of adductor longus at its enthesis (pubic insertion). Microtrauma leads to tendinopathy, partial tears, and chronic inflammation. Peak load occurs during kicking deceleration phase.
Inguinal-Related Pathophysiology
Mechanism: Weakness or disruption of the posterior inguinal wall (transversalis fascia, conjoint tendon). Creates a "dilated superficial inguinal ring" without frank hernia. Imbalance between strong hip flexors and weak abdominal wall.
Pubic-Related Pathophysiology
Mechanism: Pubic symphysis stress reaction or osteitis pubis. Repeated shear forces cause bone marrow edema, secondary cleft formation (parasymphyseal cyst), and eventual sclerosis. MRI shows characteristic edema pattern.
Hip-Related Pathophysiology
Mechanism: Femoroacetabular impingement (FAI) or labral tear presents as groin pain. Cam or pincer morphology causes anterior impingement. Often coexists with adductor pathology - the hip is the hidden driver.
The Hip Connection
Always evaluate the hip first. Up to 50% of athletes with "groin pain" have underlying hip pathology (FAI, labral tear). Hip pathology can cause secondary adductor overload as compensation. Treating the groin without addressing the hip leads to failure. Perform FADIR test, assess hip internal rotation, and obtain hip MRI if suspicious.
Biomechanics of kicking:
During the soccer kick:
- Wind-up phase: Hip extension, adductors eccentrically control abduction
- Acceleration phase: Rapid hip flexion, adductors co-contract
- Deceleration phase: Peak adductor load - eccentric lengthening to control leg
- Follow-through: Continued eccentric adductor demand
The deceleration phase generates the highest forces on the adductor longus enthesis.
Classification Systems
The Doha agreement (2014) established a clinical entity-based classification system for groin pain in athletes.
Adductor-related groin pain (most common - 68%)
Clinical features:
- Pain with adduction resistance (squeeze test positive)
- Pain on palpation of adductor tendons (especially longus)
- Pain with stretching adductors
- Pain with kicking or change of direction
Physical examination:
- Adductor squeeze test at 0, 45, 90 degrees hip flexion
- Palpation of adductor longus enthesis (tender)
- Strength testing (often weak compared to contralateral)
- Assess adductor:abductor strength ratio
Imaging:
- MRI: Adductor longus tendinopathy, partial tear, bone marrow edema at enthesis
- Ultrasound: Dynamic assessment of adductor tendon
Squeeze Test Angles
Perform the adductor squeeze test at three hip flexion angles: 0 degrees (extended), 45 degrees (semi-flexed), and 90 degrees (flexed). Different angles stress different portions of the adductor complex. Most sensitive at 45 degrees for adductor longus pathology.
Clinical Presentation and Assessment
History taking:
Pain Characteristics
- Location: Precise location (adductor, inguinal, pubic, deep hip)
- Onset: Acute vs insidious (usually insidious)
- Aggravating: Kicking, sprinting, change of direction
- Relieving: Rest (but returns with activity)
- Night pain: Suggests hip pathology if present
Functional Impact
- Sport-specific: Can they kick? Sprint? Cut?
- Training load: Recent increase in volume/intensity
- Previous injury: Prior adductor or groin issues
- Bilateral: Often affects contralateral side eventually
- Duration: Weeks to months by presentation
Physical examination sequence:
Systematic Groin Examination
- Gait assessment (antalgic, waddling)
- Posture and pelvic alignment
- Muscle atrophy (adductors, core)
- Scars from previous surgery
- Adductor longus at pubic insertion
- Pubic symphysis midline tenderness
- Inguinal canal along its course
- Anterior hip joint line
- Hip flexion, extension (compare sides)
- Hip internal rotation (limited in FAI)
- Hip external rotation (painful in labral tear)
- Straight leg raise (adductor stretch)
- Adductor squeeze test (0, 45, 90 degrees)
- FADIR test (hip impingement)
- FABER test (hip/SI joint)
- Resisted sit-up (rectus/core)
- Single leg stance (pubic stress)
- Adductor strength (manual or dynamometer)
- Abductor strength (Trendelenburg)
- Core strength (plank hold time)
- Adductor:abductor ratio (target greater than 80%)
Key Physical Examination Tests
| Test | Technique | Positive Finding | Significance |
|---|---|---|---|
| Adductor squeeze test | Supine, 45deg hip flexion, squeeze fist between knees | Reproduces groin pain | Adductor-related groin pain |
| FADIR test | Supine, flex hip 90deg, adduct and internally rotate | Anterior groin pain | Hip impingement (FAI) |
| FABER test | Supine, flex-abduct-externally rotate hip (figure-4) | Anterior or lateral hip pain | Labral tear or SI joint |
| Resisted sit-up | Supine crunch with legs extended | Inguinal canal or rectus pain | Inguinal-related (core deficiency) |
| Single leg stance | Stand on affected leg for 30 seconds | Pubic symphysis pain | Pubic-related (osteitis pubis) |
Differential Diagnosis - Red Flags
Exclude serious pathology:
- Stress fracture: Femoral neck, pubic ramus (night pain, unable to weight-bear)
- Avascular necrosis: Hip AVN (risk factors, limited ROM)
- Infection: Septic arthritis, osteomyelitis (fever, elevated inflammatory markers)
- Malignancy: Bone tumor (rare, but consider if atypical presentation)
- Referred pain: Lumbar radiculopathy, intra-abdominal pathology
When to image urgently:
- Inability to weight-bear
- Night pain awakening from sleep
- Constitutional symptoms (fever, weight loss)
- Progressive neurological symptoms
Investigations
Imaging Protocol
AP pelvis standing (assess pubic symphysis, exclude fracture)
- Look for pubic sclerosis, irregularity (osteitis pubis)
- Measure pubic symphysis width (normal less than 10mm)
- Assess hip joint space (arthritis)
Frog-leg lateral hip (assess for FAI)
- Alpha angle measurement (cam lesion if greater than 55 degrees)
- Best view for anterior femoral head-neck junction
Gold standard for athletic groin pain
Protocol: Coronal and axial T1, T2, STIR sequences
Adductor-related findings:
- Adductor longus tendinopathy (increased signal)
- Partial thickness tear
- Bone marrow edema at pubic insertion
Pubic-related findings:
- Pubic bone marrow edema (bilateral often)
- Secondary cleft sign (parasymphyseal cyst) - pathognomonic
- Pubic symphysis fluid/irregularity
Inguinal-related findings:
- Posterior inguinal wall signal changes
- Conjoint tendon injury
- Rectus abdominis strain
Hip-related findings:
- Labral tear (needs intra-articular contrast for best sensitivity)
- Cam or pincer morphology
- Cartilage damage
MRI Hip vs Pelvis
Order "MRI pelvis and hips" rather than separate studies. Pelvis protocol captures pubic symphysis and adductors. Dedicated hip sequences assess labrum and cartilage. Intra-articular gadolinium contrast (MR arthrogram) improves labral tear detection if hip pathology suspected.
Dynamic assessment of adductor tendons and inguinal canal
- Operator-dependent but useful adjunct
- Can assess adductor during contraction
- Evaluate inguinal canal during Valsalva
- Less sensitive than MRI for bone edema
Local anesthetic injection for diagnostic confirmation
- Adductor enthesis injection (if adductor-related suspected)
- Hip intra-articular injection (if hip-related suspected)
- Positive = symptom relief during injection supports diagnosis
- Can guide surgical decision-making
Management Algorithm
Conservative First - Always
All athletes should undergo 8-12 week trial of conservative management before considering surgery. Success rates are 70-80% with proper rehabilitation. Surgery is reserved for failed conservative treatment with clear structural pathology.
Adductor-Related Groin Pain Treatment
Goal: Restore adductor strength and endurance, normalize adductor:abductor ratio
Conservative Protocol
- Relative rest (avoid aggravating activities)
- Ice after activity
- NSAIDs for symptom control
- Load management (reduce training volume 50%)
- Maintain cardiovascular fitness (cycling, swimming)
- Copenhagen adductor protocol (evidence-based)
- Progressive eccentric adductor exercises
- Core strengthening (planks, obliques)
- Adductor plank variations
- Sport-specific drills (gradual introduction)
- Target adductor:abductor ratio greater than 80%
- Graded return to training
- Monitor training load (acute:chronic workload ratio)
- Continue maintenance adductor strengthening
- Biomechanical assessment (kicking technique)
- Prevention program ongoing
Copenhagen Adductor Protocol (detailed):
Progressive exercises performed 3 times per week:
- Isometric adductor squeeze (various angles)
- Copenhagen adductor plank (side plank with leg support)
- Eccentric adductor slide (standing slide-board)
- Single-leg adductor stability
- Sport-specific movements (kicking progressions)
Copenhagen Protocol Evidence
The Copenhagen adductor strengthening protocol is the only evidence-based rehabilitation program specific for adductor injuries. Developed in Denmark, it focuses on progressive eccentric loading and has been shown to reduce adductor injury rates by 41% in soccer players. Core exercise of the protocol is the Copenhagen plank.
Surgery if conservative fails:
If conservative management fails after 12 weeks, adductor tenotomy (release of adductor longus) can be considered. Reserved for chronic recalcitrant cases. Results are variable with 60-85% return to sport rates.
Surgical Techniques (When Conservative Fails)
Minimal Repair Technique (Muschaweck)
Indications:
- Failed 12+ week conservative management
- Inguinal-related groin pain
- Posterior wall deficiency on imaging
- No true hernia present
Surgical Steps
- Supine position
- Oblique inguinal incision (as for hernia repair)
- Incise external oblique aponeurosis
- Protect ilioinguinal nerve
- Assess posterior inguinal wall
- Identify transversalis fascia deficiency
- Evaluate conjoint tendon
- Look for true hernia (often absent)
- Reinforce transversalis fascia with sutures
- Conjoint tendon to inguinal ligament (modified Bassini)
- Avoid mesh if possible (stiffness, decreased ROM)
- Some surgeons use mesh in selected cases
- Close external oblique aponeurosis
- Subcutaneous and skin closure
- No drain typically required
Outcomes:
Return to sport typically 8-12 weeks. Success rate 85-95% with proper patient selection. Complications include infection, hematoma, and chronic pain (less than 5%).
Complications
Complications of Athletic Groin Pain Management
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Chronic recalcitrant pain | 20-30% if undertreated | Proper diagnosis, adequate conservative trial, multidisciplinary approach |
| Premature return to sport | Common in professional athletes | Structured return to sport protocol, objective criteria (strength, pain-free) |
| Surgical site infection | Less than 5% post-surgery | Sterile technique, prophylactic antibiotics, wound care |
| Chronic postoperative pain | 5-10% after sports hernia repair | Proper patient selection, nerve protection during surgery |
| Weakness after tenotomy | Variable (10-40%) | Partial vs complete release, progressive rehabilitation |
| Hip arthritis progression | If FAI untreated | Early recognition and treatment of hip pathology |
Recurrent groin pain:
The most common "complication" is recurrent or persistent groin pain. Causes include:
- Inadequate rehabilitation (did not complete Copenhagen protocol)
- Premature return to sport (return before strength normalized)
- Missed hip pathology (FAI driving adductor overload)
- Wrong diagnosis (another cause of groin pain)
- Chronic pubic pathology (osteitis pubis takes months to resolve)
Prevention strategies:
- Structured return to sport criteria
- Ongoing maintenance strengthening
- Training load monitoring (acute:chronic ratio less than 1.5)
- Biomechanical assessment and correction
- Early recognition and treatment of recurrent symptoms
Postoperative Care and Rehabilitation
Postoperative management varies by surgical procedure performed.
Postoperative Protocol After Sports Hernia Repair
Rehabilitation Timeline
- Protected mobilization, gentle walking
- No straining or Valsalva maneuvers
- Ice and elevation for swelling
- Pain management with NSAIDs
- Avoid hip flexion resistance
- Progressive core activation (gentle transversus abdominis)
- Hip ROM exercises (pain-free)
- Light cardiovascular work (stationary bike)
- No kicking or cutting movements
- Monitor wound healing
- Progressive core strengthening program
- Begin straight-line jogging (week 6)
- Sport-specific drills (non-contact)
- Gradual increase in training volume
- Maintain core strengthening
- Full training participation (week 8-10)
- Contact drills as tolerated
- Match simulation
- Gradual return to competition
- Maintenance program ongoing
Return to sport criteria:
Pain-free with all movements, core strength normalized, passed functional testing, and medical clearance obtained before full return to competition.
General rehabilitation principles across all procedures:
Load Management
Progressive increase in training load. Monitor acute:chronic workload ratio (keep less than 1.5). Avoid rapid spikes in volume or intensity.
Functional Testing
Objective criteria before return: strength tests, hop tests, sport-specific movements. Not just time-based progression.
Prevention Focus
Ongoing maintenance programs (Copenhagen protocol for adductor, core strengthening for all). Prevention of recurrence critical.
Multidisciplinary
Surgeon, physiotherapist, exercise physiologist, sports medicine physician. Team approach to return to sport decisions.
Prevention and Return to Sport
Primary prevention in athletes:
Preseason Screening
- Adductor strength assessment
- Adductor:abductor ratio (target greater than 80%)
- Hip ROM assessment (screen for FAI)
- Core stability testing
- Identify at-risk athletes
Prevention Programs
- Copenhagen adductor protocol (3x weekly)
- Core strengthening program
- Hip mobility and strengthening
- Proper warm-up and cool-down
- Progressive training load management
Load Monitoring
- Acute:chronic workload ratio (keep less than 1.5)
- Avoid rapid spikes in training volume
- Monitor GPS data in field sports
- Periodization of training
- Adequate recovery between sessions
Early Intervention
- Address symptoms early (don't ignore groin tightness)
- Modify training load at first sign
- Sports medicine physician assessment
- Prevent acute becoming chronic
Return to sport criteria:
Objective criteria before full return:
- Pain-free with all sport-specific movements
- Adductor strength greater than 90% of contralateral
- Adductor:abductor ratio greater than 80%
- Functional tests passed (sprint, cut, kick)
- Graded training progression completed without symptoms
Return to Sport Protocol
- Straight-line jogging
- Progress to running
- No cutting or kicking
- Pain-free requirement
- Add lateral movements
- Progressive cutting drills
- Figure-8 running
- Continue to be pain-free
- Kicking progressions (if soccer/football)
- Sport-specific drills
- Non-contact training
- Increase intensity progressively
- Full team training
- Contact drills
- Match simulation
- Medical clearance required
- Gradual return to competition
- May start as substitute
- Progress to full match play
- Continue maintenance strengthening
Outcomes and Prognosis
Conservative management outcomes:
| Entity | Conservative Success | Timeframe |
|---|---|---|
| Adductor-related | 70-80% return to sport | 8-12 weeks |
| Inguinal-related | 50-60% (many need surgery) | 12 weeks trial |
| Pubic-related | 80-90% (patience required) | 3-6 months |
| Hip-related | 50-70% (many need arthroscopy) | 12 weeks trial |
Surgical outcomes:
| Surgery | Return to Sport | Timeframe | Success Rate |
|---|---|---|---|
| Sports hernia repair | 85-95% | 8-12 weeks | High with proper selection |
| Adductor tenotomy | 60-85% | 12-16 weeks | Variable, controversial |
| Hip arthroscopy | 85-90% | 4-6 months | Excellent in athletes |
Prognostic factors (good outcome):
- Early recognition and treatment
- Proper diagnosis (Doha classification)
- Adequate conservative trial (8-12 weeks minimum)
- Good rehabilitation compliance
- Appropriate surgical selection (if indicated)
- Multidisciplinary team approach
Prognostic factors (poor outcome):
- Chronic duration (greater than 6 months) before presentation
- Premature return to sport
- Inadequate rehabilitation
- Missed hip pathology
- Multiple previous failed treatments
- Bilateral involvement
Copenhagen Protocol Evidence
Studies show the Copenhagen adductor strengthening protocol reduces adductor injury rates by 41% in soccer players when used as prevention program. When used as treatment for adductor-related groin pain, it has 70-80% success rate for return to sport within 8-12 weeks.
Evidence Base and Key Studies
Doha Agreement on Groin Pain Terminology
- Consensus statement establishing standardized terminology for groin pain in athletes
- Defined 4 clinical entities: adductor-related, inguinal-related, pubic-related, hip-related
- Replaced confusing historical terms (Gilmore groin, sportsman hernia, etc.)
- Provided clinical examination standards for each entity
- Foundation for consistent research and clinical practice
Copenhagen Adductor Strengthening Program
- RCT of 35 football teams (greater than 1000 players) over 1 season
- Progressive adductor strengthening program (Copenhagen protocol) vs control
- Copenhagen protocol reduced groin injury rate by 41%
- Compliance was key - teams with high compliance had best results
- Program focused on eccentric loading and progressive overload
MRI Findings in Athletic Pubalgia
- MRI findings in 100 athletes with groin pain
- Secondary cleft sign (parasymphyseal cyst) highly specific for pubic-related pain
- Adductor pathology present in 68% (most common finding)
- Posterior inguinal wall changes in 35% (sports hernia)
- Hip pathology (labral tear, FAI) in 25% - often missed cause
Surgical Outcomes for Sports Hernia
- Surgical series of 8000 athletes with inguinal-related groin pain
- Minimal repair technique (transversalis reinforcement without mesh)
- Return to sport 90% at mean 10 weeks postoperative
- Success rate 95% with proper patient selection
- Complications low (infection less than 2%, chronic pain less than 5%)
Hip Arthroscopy Outcomes in Athletes
- Systematic review of hip arthroscopy for FAI in athletes
- Return to sport rate 85-90% at same or higher level
- Mean return to sport time 5.6 months
- Predictors of good outcome: younger age, minimal arthritis, isolated cam lesion
- Many athletes with 'groin pain' have underlying hip pathology
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Soccer Player with Groin Pain (2-3 min)
"A 24-year-old professional soccer player presents with 3 months of left groin pain. Pain is worst with kicking and change of direction. He has continued playing but performance is declining. Examination shows tenderness over the adductor longus insertion and positive adductor squeeze test at 45 degrees. What is your assessment and management?"
Scenario 2: 'Sports Hernia' Decision Making (3-4 min)
"A 28-year-old rugby player has inguinal-related groin pain for 6 months. He has completed 16 weeks of physiotherapy including core strengthening with only 30% improvement. MRI shows posterior inguinal wall signal changes consistent with sports hernia but no frank hernia. He wants to know about surgery. Walk me through your assessment and surgical decision-making."
Scenario 3: Osteitis Pubis Management (2-3 min)
"An elite Australian Rules footballer has bilateral pubic-related groin pain for 4 months. MRI shows extensive pubic bone marrow edema bilaterally and a secondary cleft sign. He has tried 4 weeks of rest and NSAIDs with minimal improvement. He is frustrated and wants to return to playing. How do you manage this situation?"
Scenario 4: Hip Drives the Groin (3-4 min)
"A 26-year-old soccer player was treated for 'adductor-related groin pain' with 12 weeks of Copenhagen protocol. He improved initially but symptoms recurred when he returned to full training. On re-examination, you notice his hip internal rotation is 15 degrees (normal 45 degrees) and FADIR test reproduces his groin pain. What now?"
MCQ Practice Points
Doha Classification Question
Q: What are the four clinical entities in the Doha classification of groin pain in athletes? A: (1) Adductor-related (most common, 68%), (2) Inguinal-related (sports hernia), (3) Pubic-related (osteitis pubis), (4) Hip-related (FAI/labral). This classification replaced confusing historical terms and provides clinical examination standards for each entity.
Adductor Squeeze Test Question
Q: How is the adductor squeeze test performed and what does it assess? A: Patient supine, hip and knee flexed to 45 degrees, examiner places fist between knees, patient squeezes knees together against resistance. Positive test = reproduces groin pain, indicates adductor-related groin pain. Most sensitive at 45 degrees hip flexion for adductor longus pathology. Should also test at 0 and 90 degrees.
Copenhagen Protocol Question
Q: What is the Copenhagen adductor strengthening protocol and what is its evidence base? A: Evidence-based progressive eccentric adductor strengthening program performed 3 times weekly for 8-12 weeks. Core exercise is the Copenhagen plank (side plank with adduction component). RCT showed 41% reduction in groin injury rates in soccer players. First-line treatment for adductor-related groin pain with 70-80% success rate.
Secondary Cleft Sign Question
Q: What is the secondary cleft sign and what does it indicate? A: Parasymphyseal cyst (fluid-filled cavity) adjacent to pubic symphysis seen on MRI. Pathognomonic for chronic pubic-related groin pain (osteitis pubis). Represents extension of symphyseal pathology into adjacent pubic bone. Indicates established chronic pathology requiring prolonged conservative management (3-6 months).
Hip Pathology Question
Q: Why is it critical to assess hip pathology in athletes with groin pain? A: Up to 50% of athletes with "groin pain" have underlying hip pathology (FAI, labral tear) that can cause secondary adductor overload. Hip pathology presents as groin pain. Limited hip internal rotation and positive FADIR test indicate hip impingement. Treating the adductor without addressing the hip leads to recurrence. Always perform FADIR test and assess hip ROM.
Sports Hernia Question
Q: What is a 'sports hernia' and how does it differ from a true inguinal hernia? A: Sports hernia (inguinal-related groin pain) is weakness or disruption of posterior inguinal wall (transversalis fascia, conjoint tendon) WITHOUT a peritoneal hernia sac. No palpable bulge on examination (unlike true hernia). MRI shows posterior wall signal changes. Treated with core strengthening; surgical repair if conservative fails (85-95% success). Term "hernia" is a misnomer.
Australian Context and Practical Considerations
Australian sport prevalence:
High-Risk Sports in Australia
- Australian Rules Football (AFL) - highest prevalence
- Soccer (A-League, NPL)
- Rugby League (NRL)
- Rugby Union (Super Rugby)
- Hockey (field and ice)
Sports Medicine Framework
- Sports Medicine Australia (SMA) guidelines
- State sporting institutes (AIS, VIS, NSWIS)
- Professional club medical departments
- Multidisciplinary team standard in elite sport
Australian guidelines and resources:
- Sports Medicine Australia: Practice standards for groin pain assessment
- AFL Medical Officers Association: Groin pain protocols
- Australian Institute of Sport: Return to sport frameworks
- Physiotherapy Board of Australia: Standards for sports physiotherapy
Medicolegal considerations:
Documentation and Consent
Critical documentation:
- Comprehensive history and examination (including hip assessment)
- Imaging reports (MRI findings documented)
- Conservative management trial (duration, compliance, response)
- Multidisciplinary discussion notes (if surgery considered)
- Return to sport criteria and clearance
Informed consent for surgery:
- Success rates (85-95% for sports hernia repair)
- Return to sport timeframe (8-12 weeks typical)
- Risks: Chronic pain (5-10%), infection, recurrence, incomplete relief
- Alternative: Continue conservative management
- Impact on career if professional athlete
Access to care:
- Public system: Referral to sports medicine physician, waiting times for MRI (weeks to months)
- Private system: Faster access to imaging and specialists
- Professional athletes: Club medical staff, immediate access
- Amateur athletes: Variable access, cost barriers for private MRI
Rehabilitation access:
- Physiotherapy: Often not covered by Medicare, private health insurance varies
- Exercise physiology: Medicare items available with chronic disease management plan
- Return to sport programs: Usually provided through sporting clubs
Research and Australian contributions:
Australian researchers have contributed significantly to groin pain literature:
- Adam Weir (Australian, lead author Doha agreement)
- Peter Brukner (Australian team physician, groin pain expert)
- FSHAA (Fellow of Sports and Hip Arthroscopy Australia)
AFL Medical Context
In Australian Rules Football, groin pain affects 10-15% of players each season. AFL medical officers follow structured return to sport protocols. Career-threatening if managed poorly (chronic osteitis pubis). Early recognition, proper diagnosis using Doha classification, and adequate conservative management are critical. Pressure to return early is a major risk factor for chronicity.
ATHLETIC GROIN PAIN (SPORTS HERNIA/ATHLETIC PUBALGIA)
High-Yield Exam Summary
Doha Classification (Know All 4)
- •Adductor-related = Most common (68%), squeeze test positive, adductor tenderness
- •Inguinal-related = Sports hernia, posterior wall deficiency, NO true hernia sac
- •Pubic-related = Osteitis pubis, MRI shows bone edema + secondary cleft sign
- •Hip-related = FAI/labral, positive FADIR, limited hip internal rotation
Physical Examination Must-Do Tests
- •Adductor squeeze test = 0, 45, 90 degrees hip flexion (most sensitive 45deg)
- •FADIR test = Hip flexion-adduction-internal rotation (impingement)
- •Hip internal rotation = Normal 45deg, limited if FAI (assess always)
- •Resisted sit-up = Rectus/inguinal canal pain (inguinal-related)
- •Pubic palpation = Point tenderness (pubic-related)
Imaging Protocol
- •First-line = AP pelvis + frog-leg lateral (screen FAI, pubic pathology)
- •Gold standard = MRI pelvis and hips (assess all entities)
- •Secondary cleft sign = Parasymphyseal cyst, pathognomonic for chronic pubic stress
- •Alpha angle = Frog-leg lateral, greater than 55deg = cam FAI
- •MR arthrogram = If hip suspected, best for labral tears
Treatment Algorithm (Conservative First)
- •Adductor-related = Copenhagen protocol 8-12wk, 70-80% success
- •Inguinal-related = Core strengthening 12wk, surgery if fails (85-95% RTS)
- •Pubic-related = Load management 3-6mo, patience critical, surgery rarely indicated
- •Hip-related = Hip physio 12wk, arthroscopy if fails (85-90% RTS)
- •All entities = Multidisciplinary approach, 12-week trial before surgery
Copenhagen Protocol Details
- •Evidence-based = RCT showed 41% reduction in groin injuries
- •Frequency = 3 times per week for 8-12 weeks
- •Focus = Progressive eccentric adductor loading
- •Core exercise = Copenhagen plank (side plank with adduction)
- •Outcome = 70-80% return to sport with proper compliance
Key Exam Pearls
- •Hip first always = 50% of 'groin pain' has hip pathology driving it
- •Secondary cleft sign = Chronic osteitis pubis, requires months to heal
- •Sports hernia misnomer = NO true hernia sac, posterior wall weakness
- •Surgery last resort = 12-week conservative trial mandatory
- •Premature RTS = Main cause of chronicity, objective criteria required