Groin Pain in Athletes: Why Getting the Diagnosis Right Matters

Groin pain is one of those sporting injuries that can sound straightforward — until you actually have it.

An athlete might describe a “groin strain”, a tight adductor, pain at the front of the hip, or discomfort around the pubic region. Sometimes symptoms settle after a few days of rest, only to return as soon as running speed, kicking or change of direction increases again.

The reason is simple: not all groin pain is the same.

At Up N Adam, our physiotherapist Pat Nolan recently presented an in-service to our clinical team on the assessment and rehabilitation of groin pain in athletes, using the internationally recognised Doha Agreement as a framework.

The key message was an important one for athletes:

Successful treatment starts with working out what is actually contributing to your groin pain — rather than simply treating the area that hurts.

What actually causes groin pain?

The Doha Agreement was developed by an international group of experts to create a clearer way of describing and assessing groin pain in athletes.

Rather than using vague diagnoses such as “groin strain”, sporting groin pain can be considered in several major categories:

• Adductor-related groin pain – involving the muscles on the inside of the thigh and their attachment around the pelvis.

• Iliopsoas-related groin pain – involving the major hip-flexor complex.

• Inguinal-related groin pain – symptoms associated with the inguinal region, often aggravated by abdominal loading, coughing or straining.

• Pubic-related groin pain – symptoms localised around the pubic symphysis and adjacent bone.

• Hip-related groin pain – where the hip joint itself may be contributing, including conditions such as femoroacetabular impingement (FAI), labral pathology or osteoarthritis.

Importantly, an athlete can have more than one of these presentations at the same time.

There are also less common causes of groin pain that need to be considered. This is one reason a good assessment matters.

It isn't just about what shows up on a scan

One of the useful principles of the Doha approach is its emphasis on the athlete's history and physical examination.

Pat's assessment isn't simply about finding a painful spot.

We want to understand questions such as: When does it hurt? Is it painful sprinting, kicking or changing direction? What happens after training? Does squeezing the legs reproduce symptoms? Is there pain with resisted hip flexion? What movement does the hip have? Has training load recently increased? And can the athlete actually produce and tolerate the forces their sport demands?

The location of tenderness combined with specific tests that reproduce the athlete's familiar symptoms can help us determine which structures are most likely involved.

That distinction matters because the rehabilitation for hip-related pain may look quite different from rehabilitation for an adductor-related problem.

Strength testing can tell us more

This is an area where Pat's approach fits particularly well with what we do at Up N Adam.

Rather than relying solely on how something looks or feels, we can objectively assess an athlete's strength.

For groin injuries, this can include testing adductor and abductor strength, side-to-side differences and the athlete's capacity to generate force without provoking symptoms.

Importantly, asymmetry isn't automatically an injury.

Strength results need to be interpreted alongside the athlete's symptoms, sport, training history, hip movement and clinical examination.

The numbers help us make better decisions — they don't replace clinical reasoning.

Rest alone often isn't the answer

This is particularly important for athletes with recurring groin pain.

Reducing training may temporarily settle symptoms, but if the athlete returns to exactly the same sporting demands without rebuilding capacity, the problem can simply reappear.

Pat's rehabilitation approach progresses the athlete from settling symptoms and managing load, through to progressively restoring strength and ultimately returning to the high-speed movements required by their sport.

For an adductor-related problem, for example, rehabilitation might progress from relatively simple adductor isometrics through increasingly challenging strengthening such as Copenhagen adduction exercises, before adding faster and more dynamic loading.

Eventually, rehabilitation needs to resemble sport.

That means progressing towards running, acceleration, sprinting, deceleration, lateral movement, cutting and change of direction where appropriate.

For a footballer, simply being able to squeeze a ball between their knees isn't enough.

They need to be able to sprint, plant, cut and kick — repeatedly — and recover from those loads.

Sometimes the problem is the training week

Pat also highlighted something we see frequently in sporting injuries:

The athlete isn't necessarily weak — they may simply be overloaded.

Imagine a footballer who normally plays once per week but, because of postponed games, suddenly has matches midweek as well.

Their groin pain becomes progressively worse after each game and takes two or three days to settle.

Adding a huge strengthening program on top of that workload may not be the smartest first step.

Sometimes rehabilitation means reorganising the training week, reducing unnecessary load and creating enough recovery between high-intensity sessions while maintaining as much sport participation as possible.

Good sports physiotherapy isn't always about adding more exercises.

Sometimes it's about finding the right dose of everything the athlete is already doing.

When can I return to sport?

Return to play shouldn't simply be based on how many weeks have passed since the injury.

Before unrestricted return, we want an athlete to demonstrate things such as pain-free or acceptably low-symptom strength testing, appropriate adductor strength, good functional capacity and the ability to tolerate the movements their sport requires.

For field-sport athletes, that may include progressively exposing them to maximum-speed running, cutting, deceleration and change of direction before returning to unrestricted competition.

The aim isn't simply to make the groin feel better.

The aim is to prepare the athlete's groin for what they're going to ask it to do next.

Got groin pain that keeps coming back?

If you've been resting, stretching or treating a “tight groin” but the pain keeps returning when you run faster, kick, change direction or increase your training, it may be worth having it properly assessed.

Pat Nolan is now consulting at Up N Adam Performance Training & Physiotherapy in Hamilton North, Newcastle.

Pat has a particular interest in applying evidence-based assessment and progressive rehabilitation to sporting injuries. His approach is to identify the likely source of the athlete's symptoms, understand the loads that are driving them and build a rehabilitation plan that takes them all the way back to the demands of their sport.

Book an appointment with Pat at www.upnadamptphysio.com and let's work out what's driving your groin pain — and what needs to change to get you confidently back to sport.

Bookings also available on our website for the following services at Up N Adam Performance Training & Physiotherapy:

• CycleFit by Physiotherapist Dean Waterman - At Up N Adam, for all your bike fitting solutions www.cyclefitphysio.com

• Dietitian - Sweat testing, weight-loss or to optimise your training nutrition / fuelling www.nutrientnation.com.au

• VO2 Max testing - to discover more effective ways to train efficiently www.flowitri.com.au

• Strength & Conditioning Programs - contact us or book via the website or email us at upnadamptphysio@gmail.com

• Remedial Massage - to relieve accumulative muscle tension & keep you training well.