Adductor-related groin pain is usually associated with adductor tenderness and pain during resisted adduction. Iliopsoas-related pain is more likely with iliopsoas tenderness and painful resisted hip flexion or stretching. Pubic-related pain centers on the pubic symphysis, while inguinal-related symptoms occur in the inguinal canal region. Hip-related pain requires separate assessment because hip joint pathology can produce very similar groin symptoms.
Groin pain describes a location. The tissue diagnosis still has to be established, and more than one structure is often involved.
The Doha framework
In 2014, 24 international experts met in Doha, Qatar, to agree on terminology for groin pain in athletes. The resulting classification, published in 2015, has three main headings (Weir, 2015):
- Defined clinical entities: adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain.
- Hip-related groin pain.
- Other causes of groin pain in athletes.
The entities are defined by history and physical examination rather than imaging. The consensus also stressed that pain reproduced during a test should be felt in the structure being tested. For example, pain in the inguinal region during resisted adduction would not count as adductor-related groin pain. An athlete can be given more than one entity at the same time.
| Clinical entity | Typical pain location | Most useful examination findings | Important caveat |
|---|---|---|---|
| Adductor-related | Upper inner thigh near the adductor origin | Adductor tenderness and pain on resisted adduction | A clinical pattern, not proof of a specific tendon lesion |
| Iliopsoas-related | Front of the hip and upper thigh | Iliopsoas tenderness; more likely with painful resisted hip flexion or hip-flexor stretching | Overlaps with hip joint pain |
| Inguinal-related | Inguinal canal region | Inguinal canal tenderness, no palpable hernia; more likely if worse with abdominal resistance, cough or Valsalva | Not the same as a true inguinal hernia |
| Pubic-related | Pubic symphysis and adjacent bone | Local tenderness of the symphysis and immediately adjacent bone | No specific resistance test identifies it |
| Hip-related | Deep groin or front of the hip | Restricted or painful hip motion; catching, locking or clicking | Single clinical tests have weak diagnostic accuracy |
| Other causes | Variable | Nerve, bone stress, referred, abdominal, urologic or gynecologic features | Atypical symptoms need medical evaluation |
The table summarizes how clinicians categorize groin pain. It is not a self-diagnosis tool, because the same location can be shared by several structures.
Adductor-related groin pain
Under the Doha consensus definition, adductor-related groin pain is identified when adductor tenderness is accompanied by pain during resisted adduction. The pain usually sits near the adductor longus origin at the pubic bone and is often aggravated by kicking, cutting, side-to-side movement and sprinting.
This is a clinical entity definition. It identifies an adductor-related pain pattern but does not prove a particular microscopic change in the tendon. Long-standing symptoms can involve the tendon and enthesis, the myotendinous tissue, the aponeurosis shared with the rectus abdominis, or nearby pubic structures. That last possibility is covered in adductor longus and rectus-abdominis aponeurosis injuries.
What the adductor squeeze test shows
The adductor squeeze test asks the patient to squeeze a cuff or the examiner's fist between the knees. A study of 18 uninjured Gaelic games athletes compared the test at 0, 45 and 90 degrees of hip flexion. The 45-degree position produced the highest adductor muscle activity and the highest pressure values, averaging about 237 mmHg compared with about 203 mmHg at 0 degrees and 186 mmHg at 90 degrees (Delahunt, 2011).
That study measured muscle activation in healthy athletes. It did not test diagnostic accuracy. The adductor squeeze test is useful for reproducing symptoms and measuring adductor capacity, but a painful squeeze test does not uniquely identify which groin structure is injured. Squeezing also loads the abdominal wall and the pubic region, so pain during the test still has to be localized.
Iliopsoas-related groin pain
Iliopsoas-related groin pain becomes more likely when tenderness over the iliopsoas is accompanied by pain with resisted hip flexion or hip-flexor stretching. The pain is usually felt at the front of the hip and upper thigh rather than along the inner thigh. Because the iliopsoas crosses directly in front of the hip joint, this entity and hip-related groin pain can be difficult to separate. That comparison is covered in iliopsoas pain vs. hip joint pain.
Inguinal-related groin pain
Inguinal-related groin pain is distinct from a palpable inguinal hernia and may be provoked by abdominal resistance, coughing or Valsalva. Under the Doha definition, it requires pain in the inguinal canal region and tenderness of the inguinal canal without a palpable hernia.
This is one reason the term "sports hernia" causes confusion. It has been applied to inguinal-related pain, to injuries of the rectus-abdominis/adductor aponeurosis and to other conditions. It should not be treated as if it were the same thing as a true inguinal hernia. When a hernia or other significant abdominal problem is suspected, the appropriate pathway is medical or surgical referral.
Pubic-related groin pain
Pubic-related groin pain is primarily localized by tenderness around the pubic symphysis rather than by one definitive resistance test. The Doha group did not identify a resistance test that specifically provokes pubic-related pain. Terms such as pubic overload and osteitis pubis are used for related presentations in the literature.
Hip-related groin pain
Hip examination should be part of every persistent groin-pain assessment because intra-articular hip disorders may coexist with adductor-related symptoms. The Doha agreement stated that the hip joint should always be considered as a possible cause of groin pain and noted that hip-related pain can be hard to distinguish from other causes and may coexist with them (Weir, 2015).
Possible hip sources include femoroacetabular impingement (FAI), labral pathology, osteoarthritis where age-appropriate and other intra-articular problems. Clues include:
- pain that feels deep in the joint rather than along the adductors
- reduced hip range of motion, especially rotation
- pain with hip flexion and rotation
- catching, locking, clicking or giving way
- symptoms that are not reproduced by adductor loading alone
No single clinical test, including the FADIR test, proves FAI or a labral tear. The consensus paper noted that most clinical hip tests have weak diagnostic properties when studied in isolation, which is why hip findings are interpreted together and imaging is used when the clinical picture warrants it. Pain on the outside of the hip is a different problem, covered on the lateral hip pain page.
More than one source is common
In a multidisciplinary assessment of 100 athletes, adductor-related pain was the most common clinical entity, occurring in 61%, but 44% had more than one source of groin pain. Pubic-related groin pain was the least common entity, at 4% (Taylor, 2018).
That cohort came from a specialist sports groin clinic and was 98% male, with 60% soccer players. Kicking and change-of-direction sports place particular demands on the adductors, so the exact proportions may differ in runners, golfers, hikers or female athletes. The broader point still holds: finding adductor pain does not rule out hip, iliopsoas, pubic or inguinal involvement. In practice, a second source that goes unrecognized is a common reason an otherwise sensible adductor program stalls, so a persistent case is re-examined rather than simply given more of the same treatment.
Why imaging does not settle it alone
Imaging is useful, but reactive and structural changes around the pubic symphysis and adductor origin are common in athletes, including some without symptoms. Imaging therefore has to be interpreted alongside the history and examination. A 2019 imaging review emphasized that an accurate diagnosis is reached only when clinical assessment and imaging are combined, because several studies in asymptomatic athletes show reactive changes are common (Madani, 2019). A 2017 imaging review described MRI as particularly helpful when groin pain is poorly localized, because it can evaluate the rectus-adductor aponeurosis, pubic bone and hip in one study (Lee, 2017).
Other causes to keep in mind
- Bone stress injury: femoral neck or pubic stress injury, especially with high training loads, rest or night pain, progressive pain with weight-bearing or bony tenderness. These need prompt imaging or referral.
- Nerve symptoms: obturator, ilioinguinal or genitofemoral nerve involvement, or referral from the lumbar spine, particularly with burning, numbness or tingling.
- Non-musculoskeletal causes: urologic, abdominal or gynecologic conditions.
Not all groin pain is musculoskeletal. Atypical symptoms require appropriate medical evaluation.
Acute injury or long-standing pain?
The Doha categories are most often applied to long-standing groin pain, but timing matters too. Acute partial strains generally follow a different course from long-standing adductor-related groin pain. A systematic review of acute adductor injuries in 594 male athletes reported return-to-play times of about one to seven weeks after partial injuries treated with physical therapy, while complete adductor longus tears were managed either nonoperatively or surgically (Farrell, 2023). An acute pop, bruising, a palpable defect, marked weakness or inability to continue playing should prompt imaging or referral rather than a routine tendinopathy approach.
What a thorough groin examination includes
- the exact location of pain and where it spreads
- palpation of the adductor origin, iliopsoas, inguinal canal and pubic symphysis
- resisted adduction, including the squeeze test
- resisted hip flexion and hip-flexor stretching
- abdominal resistance and the response to coughing or Valsalva
- passive hip range of motion and hip provocation tests
- adductor strength compared with the other side and with hip abduction strength
- running, cutting and kicking tolerance when it is safe to test
Findings are interpreted together. One positive test rarely settles the diagnosis.
How the categories guide treatment
Classifying the pain changes what happens next. Adductor-related groin pain has the strongest exercise evidence: in a landmark randomized trial, an active strengthening program returned far more athletes to their previous sport without pain than passive physiotherapy (Hölmich, 1999). Hip-related pain may need hip-specific assessment or imaging. Inguinal-related pain and suspected hernias may need surgical evaluation. Pubic-related pain and aponeurotic injuries change how loading is progressed and when MRI is useful.
How Novo approaches groin pain
We examine the adductors, iliopsoas, abdominal wall, inguinal region, pubic symphysis and hip in every persistent case, measure adductor strength and load tolerance, and decide whether imaging is needed. When adductor-related pain is confirmed, treatment is built around progressive strengthening, with manual treatment or shockwave therapy considered as adjuncts. See how we approach adductor tendinopathy and groin pain.
References
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine. 2015;49(12):768-774. PMID 26031643. (link)
- Taylor R, Vuckovic Z, Mosler A, et al. Multidisciplinary assessment of 100 athletes with groin pain using the Doha agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clinical Journal of Sport Medicine. 2018;28(4):364-369. PMID 28654441. (link)
- Delahunt E, Kennelly C, McEntee BL, Coughlan GF, Green BS. The thigh adductor squeeze test: 45° of hip flexion as the optimal test position for eliciting adductor muscle activity and maximum pressure values. Manual Therapy. 2011;16(5):476-480. PMID 21429785. (link)
- Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. The Lancet. 1999;353(9151):439-443. PMID 9989713. (link)
- Madani H, Robinson P. Top-ten tips for imaging groin injury in athletes. Seminars in Musculoskeletal Radiology. 2019;23(4):361-375. PMID 31509865. (link)
- Farrell SG, Hatem M, Bharam S. Acute adductor muscle injury: a systematic review on diagnostic imaging, treatment, and prevention. American Journal of Sports Medicine. 2023;51(13):3591-3603. PMID 36661128. (link)
- Lee SC, Endo Y, Potter HG. Imaging of groin pain: magnetic resonance and ultrasound imaging features. Sports Health. 2017;9(5):428-435. PMID 28850315. (link)
