Five Flavors of Groin Pain. Yours Is One of Them.
The SparkNotes
Groin pain in athletes is not one diagnosis. International agreement defines five separate clinical entities, plus FAI syndrome, and an athlete can have more than one at the same time.
The physical examination decides which one it is. Imaging is there to rule out something serious, not to name the problem.
Pubic bones look abnormal on scans in plenty of athletes who have no pain at all. The term “osteitis pubis” is no longer recommended.
Reduced hip strength, adduction especially, is a consistent finding. A difference of 15% to 20% can be measured reliably.
For adductor-related groin pain there is level 1 evidence that active rehabilitation beats passive treatment.
The Whole Story
If you have had groin pain for any length of time, you have probably collected names for it.
Sports hernia. Osteitis pubis. A groin strain that never quite went away. Hip impingement. Somewhere in there, a scan that found something, or a scan that found nothing and left you with neither an explanation nor a plan.
That is not bad luck and it does not mean you are a complicated case. For a long time the field itself could not agree on what to call these problems. Different clinicians used different words for the same thing, and the same word for different things, which made it almost impossible to compare one person's treatment to another's.
That changed. Two international agreements, one from Doha and one from Warwick, set out what the categories are and what has to be true to use each name.
The part that actually wears people down
In my experience the hardest part is not the confusion about what is going on. It is the length of time it takes to get an answer.
A lot of groin pain is chronic, and chronic groin pain is usually multifactorial rather than one single problem. Unless it is an acute injury, there is often no clean single answer waiting to be found.
That is especially true of FAI and labral tears. People go months, and sometimes years, before they have a final diagnosis, seeing several orthopaedic physicians and several physical therapists along the way.
I have had patients who were told it was a simple muscle strain. I have had patients who were told they were faking it.
By the time somebody has been through that, there is a significant psychological load sitting on top of the physical impairments. It is part of the problem, not a side effect of it, and it has to be treated that way.
Five names, agreed on purpose
ADDUCTOR-RELATED. Pain where the adductor tendon meets the pubic bone, sometimes running down the inside of the thigh. It is tender to press there, and it hurts when you squeeze your legs together against resistance.
ILIOPSOAS-RELATED. Pain at the front of the thigh, higher up and further out to the side than adductor pain. It is reproduced by resisted hip flexion, by stretching the hip flexor, or both.
INGUINAL-RELATED. Pain in the groin crease that gets worse with activity. When it is bad, it hurts to cough, to sneeze, or to sit up in bed. There is no hernia you can actually feel.
PUBIC-RELATED. Pain right at the pubic symphysis and the bone immediately next to it, tender to press. No single resistance test defines this one, which is part of why it gets confused with the others.
HIP-RELATED. Where the joint itself is the suspect, usually because of mechanical symptoms: catching, locking, clicking, or the hip giving way.
Alongside those sits FAI SYNDROME, and its definition is stricter than most people realize. It requires three things together — symptoms, clinical signs, and imaging findings. Cam or pincer morphology has to be present on the scan. A shape on an image, on its own, is not the diagnosis.
And there is a sixth category called simply “other”, which is an honest admission that some presentations do not fit.
The examination decides, not the scan
This is the part that surprises people, and it is stated plainly in the paper.
For athletes whose symptoms and clinical findings place them into one or more of the defined entities, there is currently no evidence that imaging improves either the diagnosis or the prediction of how they will do.
The authors go further than that. Excessive imaging is described as actively problematic, because shape does not equal damage. Their concern is that a scan showing normal age-related tissue changes leaves an athlete focused on those changes, more fearful of movement and exercise, and harder to treat than before they had it.
So the scan does have a job. It rules out the serious things. It does not tell you which of the five you have.
What the scans actually show
Abnormal findings around the pubic symphysis are common in athletes with adductor-related and pubic-related pain. They are also common in athletes with no symptoms whatsoever.
When footballers with and without groin pain were compared, only the higher grades of pubic bone marrow edema and a protrusion of the symphyseal disc were associated with pain. The low-grade findings showed up in both groups.
Bone marrow edema itself is better described as a bone stress reaction. Biopsies show no sign of inflammation in it. That is the reason the paper states that the diagnostic term “osteitis pubis” is not recommended on current evidence, and if you have been given that label, this is why you may hear it less often now.
The same caution applies in the inguinal region. Bulging on ultrasound has not been shown to be associated with groin pain, and asymptomatic athletes bulge too, so the false-positive rate is high.
What examination is good at, and what it is not
For acute adductor injuries, clinical examination is accurate at locating the problem, generally above 90% across the various adductor tests. More useful still, the ABSENCE of pain on palpation has the highest predictive value for ruling an injury out, again above 90%.
For acute hip flexor injuries it is a different story. Telling iliopsoas from proximal rectus femoris on clinical findings alone is genuinely hard, and the paper says the accuracy of the different hip flexor tests is not much better than flipping a coin.
That sentence is worth repeating because it is the kind of thing that usually gets left out of an explanation. A good assessment tells you what it is confident about and what it is not.
What does not get missed
Before any of the above applies, serious causes have to be ruled out, and groin pain has a real list.
Avascular necrosis, femoral neck fracture and femoral shaft stress fracture all present here. So do abdominal and pelvic organ problems that have nothing to do with muscle or tendon at all.
The history matters as much as the examination. A history of cancer is a genuine red flag in this region, because prostate cancer in men, breast cancer in women, and cancers of the reproductive organs can spread to the hip and pelvis. So are trauma, fever, unexplained weight loss, painful urination, night pain, and prolonged corticosteroid use.
Screening for those signs is part of what a doctor of physical therapy is trained to do. The evaluation includes checking for them and recommending further diagnostic testing or referral when it is warranted.
Strength is the part you can measure
Reduced hip muscle strength is a consistent finding in athletes with groin pain, and reduced hip adduction strength in particular. Athletes with adductor-related and pubic-related pain have also shown reduced hip abduction and abdominal strength.
Deficits greater than 20% in the adductors and abdominals have been documented repeatedly in this group. And differences of 15% to 20% can be measured reliably across all directions of hip movement, provided the same person does the testing each time.
That last detail is what makes strength useful rather than decorative. It means the number can be tracked, and a change in it means something.
It also matters because of how long people wait. Most athletes with groin pain keep training for several months before the pain finally stops them. Continuing to play through it produces movement compensations, and those cost function and performance on their own.
What actually works
For adductor-related groin pain there is level 1 evidence that a supervised active approach, built on exercise, produces a higher rate of successful return to play than passive physical therapy modalities.
Roughly 50% to 75% of athletes with adductor-related groin pain return to their previous pain-free level of activity with a general exercise approach.
Adjuncts such as manual adductor manipulation or shockwave therapy, added to exercise, appear to speed return to play. They do not improve overall treatment success compared with supervised active training alone. That is a meaningful distinction: faster is not the same as better.
Surgery is not the first line. For the adductors, tenotomy carries a risk of leaving the muscle weak and should be avoided where possible. For the iliopsoas, arthroscopic release causes atrophy with substantial volume loss and reduced hip flexion strength, so it is not recommended as first-line treatment.
Inguinal-related pain is the one place where surgery has beaten non-surgical care in a randomised trial. Even there, half of the participants treated without surgery had fully recovered at one year, and the authors still advise trying the non-operative route first given the risks that come with an operation.
The honest limits
This is a clinical commentary. It synthesises expert consensus and the reliable evidence that exists, and it is not itself a trial.
Some of the numbers people quote from this area need their context kept attached. Acetabular dysplasia and cam morphology have been associated with a substantially increased risk of developing hip osteoarthritis, but those findings come from middle-aged groups already presenting with hip pain, and whether they apply to athletes under 40 is described as currently unknown.
And functional or performance deficits have not been consistently found in athletes with groin pain unless there is clear hip pathology or a history of hip surgery.
What to do with it
If you have been handed three different names for the same pain, that is the history of the field rather than the state of your hip.
Ask which of the entities your examination actually points at, and which resisted test reproduced your pain.
If a scan is being ordered, ask what decision it is going to change. That is a fair question and it has a real answer.
Ask for your hip adduction strength to be measured and compared side to side, and ask for the number.
And expect the plan to be an active one, because that is what the strongest evidence in this area supports.
Follow along as Resurgo comes together.
SOURCE, verified from the PDF John supplied: Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, Hölmich P. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. Journal of Orthopaedic & Sports Physical Therapy. 2018;48(4):239–249. Epub 6 March 2018. doi:10.2519/jospt.2018.7850
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