Athletic groin pain is one of the least understood, poorly defined, and under-researched conditions in sports
—Updated on 4/15/2017—
Athletic groin pain is another one of those medical garbage bag terms describing pain in the lower abdominal and groin region. There are many names to describe it. In fact, there are 33 different terminologies found in literature to describe groin pain in athletes. These names include Sports Hernia, Athletic Pubalgia, Gilmore’s Sign, and Hockey Groin.
Due to the proximity of numerous anatomical structures, diagnosing can be a real challenge. Dr. Chris Larson, a renowned Hip Orthopedic Surgeon and Team Physician for the Minnesota Vikings has broken down this type of pain into 4 categories:
- Adductor related – Muscle strains / tears
- Osteitis Pubis – Inflammation of the pubic bone at the muscle insertion(s)
- Hip Joint related – This includes diagnoses such as femoral acetabular impingement (FAI) and labral tears
- Sports Hernia (Core Muscle Injury) – A weakening/tear of the posterior inguinal wall of the lower abdomen that is NOT a true hernia.
Athletic groin pain occurs more often in males in sports that involve cutting, pivoting, and kicking. It is most common in soccer, ice hockey, and football athletes.
The majority of athletic groin pain occurs gradually without a known injury. The pain presents with exertion (sprinting, cutting, sitting up, and sometimes coughing), but is mostly painless at rest. The pain is vague and can radiate to the inner thigh, abdomen, and scrotum in males.
Per interviews with sports hernia sufferers, they report the pain almost always begins as groin pain that gradually progresses into abdominal pain.
There is a laundry list of potential sources for the pain. Research has shown that the rectus abdominis in combination with an adductor tear is the most common soft tissue injury in athletic groin pain. Differential diagnoses can be sub-divided:
|• Osteitis Pubis
• Labral Tear
• Stress Fracture
|• Core Muscle Injury
• Rectus Femoris
• Adductor Group
• Rectus Abdominis
|• True Hernia
• Nerve Entrapment
• Other Orthopedic Conditions
Tenderness to palpation to the lower abdominals and proximal adductors, and symphyseal pain is common. The adductor resisted squeeze test has been shown to be discriminative between soccer players with and without groin pain with good reliability. But, it does not help identify specific structures that are involved.
Imaging is useful to both exclude other pathologies and assist in diagnosis. The two main imaging modalities are MRI and ultrasound. It should be noted, however, that Sports Hernia (36%) and hip pathologies (64%) are quite common on MRI in asymptomatic collegiate and professional hockey players.
Causes and Risk Factors
As with most soft tissue injuries, a sudden increase in training volume or a drastic change in exercise selection increases the risk of injury. Of note, previous groin injury has been shown to be very predictive of future injury. It has been found that the recurrence rate of groin strains in Australian Rules football was 32%.
Range of Motion
Multiple studies have found strong associations with reduced hip range of motion (ROM) and future injury. In a 2007 study in the Journal of Orthopedic Surgery, the researchers looked at the association between hip ROM and future groin injuries. They found that mean preseason hip ROM (IR+ER) in the injured group was 44.7° and the mean hip ROM in the uninjured group was 53.7° (measured in supine with hip/knee flexed at 90°).
Recently, researchers are finding a strong association between ROM limiting hip disorders (FAI for example) and athletic groin pain. A 2013 article found that radiographic FAI was seen in 86% of athletes undergoing a hernia repair.
Tim Tyler’s et al. 2001 article in AJSM examined 81 professional hockey players and found that players were 17 times more likely to sustain an adductor strain if their adductor strength was less than 80% of their abductor strength. Therefore, a reasonable goal is to achieve a 1:1 ratio of adductor:abductor strength in your athletes (measured using a hand-held dynamometer in sidelying).
In regards to core strength, one study found that the Bent Knee Fallout Test (BKFO) was failed by 87% of subjects with a diagnosis of muscle core injury. Here is a good link on how to perform the BKFO Test.
In Stuart McGill’s Ultimate Back Fitness book, he writes that anecdotally some pro hockey coaches feel that athletes with the ability to hold a side bridge for >70 seconds is protective for sports hernias.
Shirley Sahrmann and Mike Boyle have discussed in the past about the theory of relative overuse from the adductors and weakness of the hip flexors leading to groin injuries. Since two of our adductor muscles are weak hip flexors (pectineus and adductor brevis), sports that require constant hip flexion/adduction recovery (i.e. hockey, soccer) are then potentially overworked.
Mike Reinold has discussed a quick way to assess hip flexor strength and control. In this test, you passively raise the hip into flexion and then let go while trying to keep the hip in the same position. He considers a no drop to be perfect, the ability to still maintain >90 degrees a mild deficit, and a drop below 90 degrees to be a problem.
Finally, I personally believe too much of our strength and conditioning of our athletes is spent in the sagittal plane with very little (if any) training in the frontal and transverse planes.
Regardless of the origin of symptoms, the general return to sport timeline is 6-18 weeks for athletic groin pain. No strong research has been conducted to determine the best treatment approach. Here we will propose a phased treatment progression that can serve as a guideline.
As a quick reference, Delmore et al. published a study looking at adductor longus activation during common hip exercises.
(Emphasis on sagittal plane, isometrics, and higher repetitions)
- Modalities, soft tissue work, and mobilizations of choice to manage pain/swelling and to begin to restore range of motion.
- Many professionals immediately encourage their athletes to begin stretching early after injury. Use caution as it may aggravate the condition and impede progress if stretching is anything more than gentle.
- Bridge and Plank progressions as tolerated.
- Sub-maximal isometrics of the adductor groups beginning with knees bent –> knees straight progressing to maximal isometrics.
- Double kneeling or half-kneeling static holds –> progress by adding Pallof Presses and Chops/Lifts.
(Emphasis on frontal plane, concentrics, and moderate volume)
- Anti-extension trunk training (i.e. Swiss Ball and TRX Rollouts)
- Goblet Squat isometric holds progressing to Front Squats and Sumo Squats (limit to pain free range of motion)
- Single-leg RDLs
- Open-kinetic chain adduction with cable column
- Low level plyometrics (i.e. box jumps)
- Low-intensity ladder drills to introduce velocity training
- Lateral sled pulls
(Emphasis on transverse plane, eccentrics, and velocity development)
- Progress to power development training with compound lifts
- Progress to multi-directional plyometrics and ladder drills
- Single-leg squats
- Lunge matrix
- Lean-Fall-Run speed progressions
- Slide board conditioning
- Adductor eccentrics
A 2015 systematic review looked at surgical vs. conservative rehab return to play time and broke down the comparisons into anatomic sub-groups:
Pubic Group (Symphysis and adjacent bone)
- Rehab group averaged 10.5 weeks before return to play compared to 23.1 weeks in the surgical group
Adductor Group (Adductor tendons)
- Both groups showed little difference in return to play time (18.3 weeks vs. 16.9 weeks)
Abdominal Group (Posterior abdominal wall, rectus abdominis, oblique and transverse muscles)
- No significant difference between groups (7.2 weeks vs. 7.9 weeks)
Return to Sport Benchmarks
Range of Motion
- Pain free Pubic Stress Test
- Essentially a Thomas Test with end-range overpressure into extension
- Symmetrical hip ROM and total hip ROM (IR+ER) ideally >50°, but use clinical judgement as each athlete will have anatomical variance.
- Adductor strength at least 80% of abduction strength
- Pain free Squeeze Test
- Single-leg vertical jump symmetry
- Single-leg hop testing (single-hop, triple-hop, cross-over hop)
Single-Leg Reactive Strength
- Compare the athlete’s single-leg vertical jump, ground contact time, and reactive strength index (RSI) to the uninvolved limb. Looking for symmetry.
- Repeated sprints
- Multi-directional drills (5-10-5, T-Test, etc.)
Athletic groin pain is one of the most frustrating conditions to manage in sports medicine due the heterogeneity of symptom presentation, the lack of valid special tests, and the almost non-existent agreement in the literature on best treatment. Because symptoms are velocity dependent, most medical professionals will get a false sense of readiness with their athletes when they are pain free with activities of daily living and jogging.
Ensure your athletes develop resiliency for game speed and metabolic specific demands by building a multi-planar strength foundation, satisfying clear benchmarks, and gradually building back up velocity in their training.