Athletic Groin Pain (Sports Hernia/Athletic Pubalgia)

Athletic groin pain (also termed athletic pubalgia or sports hernia) is 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.

Burden. In prospective surveillance, hip/groin injuries are 12-16% of all time-loss injuries in men's professional football, with a consistent incidence over time (UEFA injury studies: Werner 2009, PMID 19945984; Werner 2018, PMID 29691289). Adductor-related injury is the commonest entity, about 63% of hip/groin injuries in elite football (Werner 2018, PMID 29691289). Onset is often insidious and the problem is chronic by the time of presentation; mean absence is about 15 days per injury, with about 15% re-injury in elite football (Werner 2009, PMID 19945984).

Who and how. Soccer/football, ice hockey, rugby codes, Australian Rules Football and other change-of-direction sports. The mechanism is kicking, rapid acceleration and deceleration, and change of direction: chronic repetitive microtrauma, with the pubic symphysis and adductor insertion subjected to repeated eccentric loads during deceleration and change of direction. Unlike an acute adductor strain, this is a chronic overuse syndrome.

Terminology follows the Doha agreement (2014), set out under Classification Systems.

The pubic symphysis is the fibrocartilaginous joint connecting the left and right pubic bones, and it experiences significant shear and compression forces during athletic movements. The structures inserting around it:

• Adductor longus - the primary pain generator, inserting on the anterior pubic body
• Gracilis - medial aspect of the groin
• Rectus abdominis - superior pubic insertion
• External oblique - forms the anterior inguinal canal wall
• Transversalis fascia - posterior inguinal canal wall

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Adductor-related. Repeated eccentric loading of adductor longus at its enthesis, the pubic insertion. Microtrauma leads to tendinopathy, partial tears and chronic inflammation.

Inguinal-related. Weakness or disruption of the posterior inguinal wall (transversalis fascia, conjoint tendon), which creates a "dilated superficial inguinal ring" without a frank hernia sac. The underlying imbalance is between strong hip flexors and adductors and a weak abdominal wall.

Pubic-related. Pubic symphysis stress reaction, or osteitis pubis. Repeated shear forces cause bone marrow oedema, secondary cleft formation (a parasymphyseal cyst) and eventual sclerosis, and MRI shows a characteristic oedema pattern.

Hip-related. Femoroacetabular impingement (FAI) or a labral tear presenting as groin pain. Cam or pincer morphology causes anterior impingement. It often coexists with adductor pathology: the hip is the hidden driver.

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Biomechanics of kicking. During the soccer kick:

1. Wind-up phase: hip extension, adductors eccentrically control abduction
2. Acceleration phase: rapid hip flexion, adductors co-contract
3. Deceleration phase: peak adductor load, eccentric lengthening to control the leg
4. Follow-through: continued eccentric adductor demand

The deceleration phase generates the highest forces on the adductor longus enthesis.

The Doha agreement (2014) established a clinical entity-based classification for groin pain in athletes, diagnosed by history and examination, in three categories: the defined clinical entities (adductor-, iliopsoas-, inguinal- and pubic-related groin pain), hip-related groin pain, and other causes. It replaced the confusing historical terminology (Gilmore's groin, sportsman's hernia, hockey groin syndrome and the like) because those eponymous and pathoanatomical labels assert a pathology that is often unproven, so quote the Doha term and give the old name ("sports hernia", "osteitis pubis") only as a gloss. The entities coexist, so finding one does not exclude the others. Two are developed further in adductor-related groin strain and pubic-related groin pain.

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Adductor-RelatedIliopsoas-RelatedInguinal-RelatedPubic-RelatedHip-Related

Adductor-related groin pain is the most common entity. It presents as pain with resisted adduction (a positive squeeze test), on palpation of the adductor tendons (especially longus), on stretching the adductors, and with kicking or change of direction.

Examination. The adductor squeeze test is performed at three hip flexion angles, 0, 45 and 90 degrees, because different angles stress different portions of the adductor complex; it is most sensitive at 45 degrees for adductor longus pathology. Palpate the adductor longus enthesis, which is tender; test strength, which is often weak compared with the contralateral side; and record the adductor:abductor strength ratio.

Iliopsoas-related groin pain is the entity most often omitted, yet in the seven-season UEFA surveillance it was the second most common specific diagnosis after adductor-related injury (Werner 2009, PMID 19945984). It changes the examination and is a common reason a "treated" adductor or pubic case fails to settle.

What it is. Pain arising from the iliopsoas musculotendinous unit at the anterior hip: tendinopathy, a strain of the muscle-tendon junction, or iliopsoas bursopathy. It frequently coexists with adductor-related pain, because the two anterior pelvic force couples are loaded together in kicking and sprinting, which is one reason long-standing groin pain is so often multi-entity rather than a single diagnosis.

How it presents.

• Deep anterior groin pain, felt below the inguinal ligament rather than over the pubis or the adductor origin
• Pain reproduced by resisted hip flexion (especially with the hip flexed beyond 90 degrees) and by passive hip extension or stretch of the psoas
• Tenderness deep in the femoral triangle, lateral to the femoral vessels
• May report a deep, non-painful or painful clunk on moving from a flexed-abducted-externally-rotated position into extension

Examination. Resisted hip flexion, seated or supine, localises the pain to the iliopsoas, and the modified Thomas test shows pain or tightness on the symptomatic side as the hip is extended. Deliberately re-test the adductor squeeze and pubic palpation, because mixed adductor/iliopsoas/pubic patterns are the rule, not the exception.

The snap is not the pain. An audible or palpable internal snapping hip (the iliopsoas tendon flicking over the iliopectineal eminence or femoral head) is a related but distinct problem; its mechanics, dynamic ultrasound assessment and surgical release are covered in the dedicated snapping-hip topic. A snapping hip can be entirely asymptomatic, and iliopsoas-related groin pain can occur without any snap.

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Inguinal-related groin pain ("sports hernia") presents as a deep groin ache, worse with exertion, with no palpable hernia bulge. The inguinal canal is tender on examination and there may be a "dilated superficial inguinal ring".

Examination. Palpate the inguinal canal, which is tender; assess for a cough impulse; perform a resisted sit-up, which is painful with rectus contraction; and check for a true inguinal hernia, which is usually absent.

True hernia versus sports hernia. A true inguinal hernia is a peritoneal sac protruding through the internal ring: a palpable, reducible bulge. A sports hernia is posterior wall weakness without a peritoneal sac: no palpable hernia, but inguinal canal tenderness. Most athletes with "sports hernia" do not have a true hernia.

Pubic-related groin pain ("osteitis pubis") presents as localised pubic symphysis pain with running and kicking, with point tenderness over the symphysis. It is bilateral in 50% of cases.

Examination. The pubic symphysis is tender to palpation, single-leg stance and resisted hip adduction are painful, and the athlete may have a waddling gait.

Hip-related groin pain (FAI/labral) presents as deep anterior groin pain with the C-sign (the patient cups the anterior hip with a hand), pain with hip flexion and internal rotation, and a catching or clicking sensation.

Examination.

• FADIR test (flexion-adduction-internal rotation) - impingement
• FABER test (flexion-abduction-external rotation) - labral
• Hip internal rotation limited (compare with the contralateral side)
• Anterior hip tenderness

Cam or pincer morphology and the labrum are characterised on radiographs and MR arthrogram, set out under Investigations.

History. Ask for the precise location of the pain (adductor, inguinal, pubic, deep hip), its onset (acute or insidious, usually insidious), what aggravates it (kicking, sprinting, change of direction) and what relieves it (rest, but it returns with activity). Night pain, if present, suggests hip pathology.

Function and load. Can they kick, sprint, cut? Has training volume or intensity recently increased? Is there a previous adductor or groin problem? The contralateral side is often affected eventually, and the duration is weeks to months by presentation.

Examination sequence.

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The wider differential. The Doha categories sit within a wider differential. Beyond the Doha entities, the surgeon must actively exclude non-musculoskeletal and serious causes: many a "groin strain" has turned out to be a femoral neck stress fracture, a hernia or intra-abdominal pathology.

Radiographs first. A standing AP pelvis assesses the pubic symphysis and excludes fracture: look for pubic sclerosis and irregular pubic margins (osteitis pubis, a late finding), measure the symphysis width (normal under 10mm) and assess the hip joint space for arthritis. On the same film read the alpha angle (cam lesion), the lateral centre-edge angle (pincer) and the crossover sign. A frog-leg lateral of the hip is the best view of the anterior femoral head-neck junction and the best view for measuring the alpha angle: normal is under 55 degrees, and over 55 degrees is cam morphology; radial MRI cuts are the alternative. A bone scan shows increased uptake in pubic-related pain but is non-specific.

MRI pelvis and hips is the gold standard. Order "MRI pelvis and hips" rather than separate studies: the pelvis protocol captures the pubic symphysis and adductors, and dedicated hip sequences assess the labrum and cartilage. The protocol is coronal and axial T1, T2 and STIR sequences; intra-articular gadolinium (MR arthrogram) improves labral tear detection when hip pathology is suspected. What it shows, by entity:

• Adductor-related: adductor longus tendinopathy (increased signal), partial-thickness tear, bone marrow oedema at the pubic insertion
• Pubic-related: pubic bone marrow oedema (often bilateral), the secondary cleft sign, symphyseal fluid or irregularity, and adductor insertional changes
• Inguinal-related: posterior inguinal wall signal changes, conjoint tendon injury, rectus abdominis strain
• Hip-related: labral tear (needs intra-articular contrast for best sensitivity), cam or pincer morphology, cartilage damage

The secondary cleft sign. A fluid-filled cyst adjacent to the pubic symphysis, the parasymphyseal cyst. It is highly specific for chronic pubic stress, described as pathognomonic, and represents extension of symphyseal pathology into the adjacent bone.

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Ultrasound. Dynamic assessment of the adductor tendons and inguinal canal: operator-dependent, but a useful adjunct. It can assess the adductor during contraction and the inguinal canal during Valsalva, where it may show bulging, and it is less sensitive than MRI for bone oedema.

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Diagnostic injection, if indicated. Image-guided local anaesthetic at the suspected source (the adductor enthesis, the hip joint) supports the diagnosis when the pain is relieved during the injection and can guide surgical decision-making. The targets and their interpretation follow.

Recurrent groin pain is the most common "complication": recurrent or persistent groin pain. Its causes include:

• Inadequate rehabilitation (the Copenhagen protocol was not completed)
• Premature return to sport (return before strength normalised)
• Missed hip pathology (FAI driving adductor overload)
• Wrong diagnosis (another cause of groin pain)
• Chronic pubic pathology (osteitis pubis takes months to resolve)

Preventing it.

• Structured return-to-sport criteria
• Ongoing maintenance strengthening
• Training-load monitoring (the acute:chronic workload ratio, under Prevention and Return to Sport)
• Biomechanical assessment and correction
• Early recognition and treatment of recurrent symptoms

Postoperative management varies by the procedure performed.

Across all procedures. Training load rises progressively, without rapid spikes in volume or intensity, and the acute:chronic workload ratio is monitored. Return is decided on objective criteria (strength tests, hop tests, sport-specific movements), not on time alone. Maintenance programmes continue, the Copenhagen protocol for the adductor and core strengthening for all, and the return-to-sport decision is made by the team: surgeon, physiotherapist, exercise physiologist and sports medicine physician.

Conservative management outcomes, by entity:

Surgical outcomes by procedure:

A good outcome goes with:

• Early recognition and treatment
• Proper diagnosis (Doha classification)
• An adequate conservative trial (8-12 weeks minimum)
• Good rehabilitation compliance
• Appropriate surgical selection (if indicated)
• A multidisciplinary team approach

A poor outcome goes with:

• Chronic duration (greater than 6 months) before presentation
• Premature return to sport
• Inadequate rehabilitation
• Missed hip pathology
• Multiple previous failed treatments
• Bilateral involvement

Preseason screening. Adductor strength, the adductor:abductor ratio, hip range of motion (screening for FAI) and core stability identify the at-risk athlete.

Prevention programmes. The Copenhagen adductor protocol, a core strengthening programme, hip mobility and strengthening, proper warm-up and cool-down, and progressive management of training load.

Load monitoring. Keep the acute:chronic workload ratio under 1.5 and avoid rapid spikes in training volume; monitor GPS data in field sports, periodise training and allow adequate recovery between sessions.

Early intervention. Address symptoms early rather than ignoring groin tightness, modify training load at the first sign, and involve a sports medicine physician, so that an acute problem does not become chronic.

Return to sport criteria. Objective criteria before full return:

1. Pain-free with all sport-specific movements
2. Adductor strength greater than 90% of the contralateral side
3. Adductor:abductor ratio greater than 80%
4. Functional tests passed (sprint, cut, kick)
5. Graded training progression completed without symptoms

Athletic groin pain is a global problem of multidirectional field and court sports. The strongest epidemiological data come from prospective football (soccer) surveillance, but the principles apply to ice hockey, rugby codes, Australian Rules Football, Gaelic games and other change-of-direction sports.

Global epidemiology (PMID-backed):

Across these datasets the message is consistent: hip and groin complaints account for roughly one in eight time-loss injuries in men's professional football, adductor-related pain is by far the most common single diagnosis, and the burden has not fallen despite a modest decline in incidence — making prevention and accurate sub-classification a priority worldwide.

Where guidance converges and diverges:

There is broad international agreement on the core pathway: unified terminology (Doha), active exercise rehabilitation first, imaging to characterise rather than screen, and surgery only after a failed adequate conservative trial. Genuine practice variation centres on: (1) the threshold and technique for surgical repair of inguinal-related (so-called sports hernia) pain — open minimal repair, modified open repair, or laparoscopic/endoscopic repair, with no high-level head-to-head RCT establishing superiority; and (2) the role of adductor tenotomy, which remains controversial with variable reported outcomes.

Registry note: unlike arthroplasty, athletic groin pain has no implant joint registry. The closest registry-grade evidence is prospective injury surveillance (UEFA Elite Club Injury Study and similar national datasets), which functions as the field's outcome registry and is the source of the epidemiology above.

Global practice variation and resource setting: