Shockwave Therapy for Adductor Tendinopathy & Groin Pain: What Does the Evidence Show?

Current evidence supports shockwave as a plausible adjunct in selected chronic athletic groin presentations, particularly as part of a structured rehabilitation program. The strongest randomized evidence involves pubic overload rather than isolated adductor tendinopathy, while the newest focused-ESWT study involved broader groin pain syndrome. Direct adductor-specific comparative trials remain limited.

Novo therefore uses shockwave after the pain source has been localized rather than treating all groin pain with the same protocol.

Three different evidence questions

The shockwave research on groin pain is easy to misread because studies enrolled different diagnoses. They answer three separate questions:

1. Isolated adductor tendinopathy. Direct comparative ESWT trials in imaging-defined adductor tendinopathy are limited.
2. Groin pain syndrome. A 2026 prospective study combined focused ESWT with rehabilitation in soccer players with a broader groin pain diagnosis.
3. Pubic overload and osteitis pubis. A randomized study added shockwave to rehabilitation in amateur football players.

Broader tendinopathy research supports the biological plausibility of shockwave in tendon problems, but it does not provide an adductor-specific effect size. These populations should not be combined into one pooled "adductor shockwave" claim. A result in pubic overload does not automatically transfer to an adductor tendon problem, and a result in a mixed groin pain syndrome group does not tell us which structures responded. That is why the diagnosis is established before shockwave is considered.

The 2026 focused shockwave study

A 2026 prospective study followed 31 soccer players with clinically and MRI-confirmed groin pain syndrome through a program combining three focused shockwave sessions with 16 weeks of structured rehabilitation. Average HAGOS function improved from 47.2 to 90.0 and pain decreased from 6.8 to 1.9 by four months.

Because every athlete received both shockwave and rehabilitation and there was no control group, the study cannot determine how much of the improvement was caused by shockwave itself.

The details matter for anyone comparing protocols (Santilli, 2026):

• Participants: 31 consecutive adult soccer players, mean age 28.4 ± 5.8 years, 77.4% male
• Diagnosis: groin pain syndrome confirmed clinically and on MRI. The study did not limit enrollment to isolated adductor tendinopathy.
• Shockwave: three weekly focused sessions using a Duolith device, 2,400 pulses per session at 4 Hz and an energy flux density of 0.20 mJ/mm²
• Rehabilitation: a supervised 16-week program of progressive adductor strengthening, core stabilization and stretching
• HAGOS (groin-specific function): 47.23 ± 7.79 at baseline, 77.94 ± 16.18 at one month and 90.00 ± 14.26 at four months
• Pain (VAS): 6.81 ± 1.25, 3.68 ± 1.11 and 1.90 ± 1.45
• Roles and Maudsley score: 2.39, 1.52 and 1.26
• Statistics and safety: all changes over time had p < 0.001, and no adverse events were reported

The authors described their own findings as descriptive and hypothesis-generating. They stated that the changes cannot be attributed specifically to focused ESWT because the 16-week rehabilitation program likely contributed substantially, and they called for randomized trials comparing the combined treatment with rehabilitation alone.

Reading the 2026 numbers carefully

HAGOS, the Copenhagen Hip and Groin Outcome Score, is a patient-reported questionnaire covering pain, symptoms, daily function, sport and recreation, physical activity and quality of life, scored from 0 to 100. The authors reported that the changes exceeded established thresholds for a clinically important difference. Large improvements are expected, however, when athletes complete four months of supervised rehabilitation, and some recovery also reflects natural history and the tendency for symptoms to ease after people seek care at their worst. A rehabilitation-only comparison group is the only way to separate those effects from the contribution of shockwave. Until that trial is done, the 2026 data show that the combined program is feasible, well tolerated and associated with substantial improvement.

The pubic overload randomized study

In a randomized study of football players with pubic overload and osteitis pubis, adding shockwave to a structured rehabilitation program produced faster pain relief and an earlier return to football than rehabilitation alone.

This was pubic-overload research, not an isolated adductor-tendinopathy trial.

The study analyzed 143 amateur football players with groin pain and clinical and radiological signs of pubic overload over one year (Schöberl, 2017). Forty-four players were randomized into an intensive rehabilitation program with shockwave (26 players) or without shockwave (18 players). A separate control group of 51 players stopped sport without a standardized rehabilitation program.

• Players receiving shockwave had earlier pain relief on VAS (p < 0.001) and returned to football significantly earlier (p = 0.048).
• Forty-two of the 44 randomized players returned to football within four months and had no recurrent groin pain within one year.
• The 51 players in the rest-only control group returned after 240 days, and 26 of them (51%) had recurrent groin pain.
• Follow-up MRI did not show any effect of shockwave therapy.

Two points stand out. First, structured rehabilitation itself was strongly associated with better outcomes than rest alone. Second, the shockwave benefit was in pain relief and speed of return, not in imaging appearance. The study does not show that shockwave improved MRI healing.

Exercise remains the foundation

Active strengthening has the strongest historical randomized evidence for long-standing adductor-related groin pain. Shockwave and manual therapy should therefore be considered adjuncts to restoring adductor capacity rather than replacements for it.

The landmark randomized trial found that a structured active-strengthening program was substantially more effective than passive physiotherapy for long-standing adductor-related groin pain. Twenty-three athletes in the active-training group returned to their previous sport level without pain compared with four in the comparison group. The trial enrolled 68 athletes with a median symptom duration of 40 weeks, treated for 8 to 12 weeks, and reported an adjusted odds ratio of 12.7 (95% CI 3.4 to 47.2). The program targeted strength and coordination of the muscles acting on the pelvis, particularly the adductors (Hölmich, 1999). That trial established progressive strengthening as a foundational treatment rather than an optional add-on.

Long-term follow-up of the original trial showed that the benefits of active rehabilitation were durable for many athletes years later. Forty-seven of the 59 original participants were re-examined 8 to 12 years later, and a significant effect of active training remained, particularly among soccer players (Hölmich, 2011).

Later programs build on the same principle. A small later study using a modified Hölmich program reported return to sport in 13 of 15 athletes, but the uncontrolled design means those results should not be treated as an RCT-level success rate (Yousefzadeh, 2018). A 2024 randomized trial in 30 male soccer players with adductor-related groin pain found that adding the Copenhagen adduction exercise to an eight-week rehabilitation program produced greater gains in eccentric hip-adduction strength, larger pain reductions and better HAGOS scores than the same program without it (Alsirhani, 2024). Modern rehabilitation can include progressive eccentric adductor loading such as Copenhagen-style exercise when appropriate, but exercise selection and dose should match the patient's current capacity. The 1999 protocol is not the only effective program.

Where manual therapy fits

A randomized trial found that a multimodal program including manual therapy returned athletes to sport faster than the comparison exercise program—12.8 versus 17.3 weeks—although only about half of athletes in either group achieved full return. The multimodal program combined heat, Van den Akker manual therapy, stretching and a return-to-running program, while the comparison group did home exercise and a structured return to running (p = 0.043). There was no difference in the objective outcome score or pain during sport (Weir, 2011).

Manual treatment can therefore be a meaningful adjunct, but the trial does not show that it replaces progressive strengthening.

Radial or focused?

The 2026 groin pain syndrome study used focused shockwave, and its results should not be cited as radial-specific evidence. No study has compared radial and focused shockwave for adductor-related groin pain. The superficial adductor origin may be reached by either, while deeper or more localized targets may suit focused energy. Device choice depends on the structure involved and how it responds. Treatment is directed to the proximal adductor region and kept away from genital structures. General differences are covered in radial vs. focused shockwave.

When shockwave is not the right next step

Shockwave is not used for a suspected complete proximal adductor avulsion, a suspected hernia, a femoral neck or pubic stress injury, or groin pain from a non-musculoskeletal cause. These need imaging or referral first. Hip-related groin pain also needs its own assessment, because intra-articular hip problems can coexist with adductor-related symptoms. The clinical distinctions are covered in adductor groin pain vs. hip, iliopsoas and pubic pain, and aponeurotic injuries in adductor longus and rectus-abdominis aponeurosis injuries.

What better evidence would look like

The next useful studies would enroll athletes classified with the Doha system, separate adductor-related, pubic-related and aponeurotic presentations, compare rehabilitation alone with rehabilitation plus shockwave, use sham controls where possible, report device type and energy settings in reproducible detail, and track recurrence for at least a season.

Where shockwave fits

Shockwave is a reasonable adjunct in selected chronic groin presentations after the involved structure has been identified. The randomized evidence supports it in pubic overload, and the newest focused-ESWT data in groin pain syndrome are encouraging but uncontrolled. Neither should be described as a definitive isolated-adductor-tendinopathy trial. For most athletes, shockwave is considered when a well-structured strengthening program has been followed but symptoms are still limiting training or sport.

How Novo uses this evidence

We first classify the groin pain, examine the adductors, iliopsoas, pubic region, inguinal structures and hip, and decide whether imaging is needed. When adductor-related or pubic-related pain is confirmed and progress with loading has stalled, focused or radial shockwave may be added to progressive strengthening and, where appropriate, manual treatment. See how we approach adductor tendinopathy and groin pain.

References

• Santilli G, Santoboni F, Checchi E, et al. Integrating focused shockwave therapy into rehabilitation for groin pain syndrome: a prospective study in soccer players. Life. 2026;16(3):509. PMID 41901027. (link)
• Schöberl M, Prantl L, Loose O, et al. Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study. Knee Surgery, Sports Traumatology, Arthroscopy. 2017;25(6):1958-1966. PMID 28093636. (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)
• Hölmich P, Nyvold P, Larsen K. Continued significant effect of physical training as treatment for overuse injury: 8- to 12-year outcome of a randomized clinical trial. American Journal of Sports Medicine. 2011;39(11):2447-2451. PMID 21813441. (link)
• Yousefzadeh A, Shadmehr A, Olyaei GR, Naseri N, Khazaeipour Z. The effect of therapeutic exercise on long-standing adductor-related groin pain in athletes: modified Hölmich protocol. Rehabilitation Research and Practice. 2018;2018:8146819. PMID 29721339. (link)
• Alsirhani AA, Muaidi QI, Nuhmani S, Thorborg K, Husain MA, Al Attar WSA. The effectiveness of the Copenhagen adduction exercise on improving eccentric hip adduction strength among soccer players with groin injury: a randomized controlled trial. The Physician and Sportsmedicine. 2024;52(5):497-506. PMID 38376593. (link)
• Weir A, Jansen JA, van de Port IG, Van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Manual Therapy. 2011;16(2):148-154. PMID 20952244. (link)