Groin pain is not one diagnosis. Pain in the inner thigh or near the pubic bone can come from the adductor muscles and tendons, the iliopsoas, the pubic symphysis, inguinal structures, the hip joint or the rectus-abdominis/adductor aponeurosis.
Adductor-related groin pain is usually characterized by tenderness of the adductor region and pain when the adductors are loaded, but multiple pain sources frequently coexist. In one multidisciplinary series of athletes with groin pain, 44% had more than one clinical entity.
At Novo Soft Tissue in the Denver Tech Center, Dr. Scott King begins by determining which structure is actually producing the symptoms. The examination assesses pain location, adductor loading, hip motion, abdominal and inguinal findings, strength and whether MRI or ultrasound is needed. Treatment is then selected according to the diagnosis and may include progressive loading, manual soft-tissue treatment, shockwave therapy, imaging or referral.
Why “Groin Strain” Is Often Too Vague
Groin pain describes a location. The tissue diagnosis still has to be established. Structures that can produce pain in the same general region include:
- the adductor longus, adductor brevis and gracilis
- the rectus-abdominis/adductor aponeurosis at the front of the pubic bone
- the iliopsoas
- the pubic symphysis and adjacent bone
- inguinal structures
- the hip joint
- nerves, and bone stress injuries of the pelvis or femoral neck
Labels such as “groin strain,” “sports hernia” or even “adductor tendinopathy” should not be assigned simply because pain occurs in the groin. Wherever possible, Novo describes the actual anatomical structure involved.
How Groin Pain Is Classified
The 2015 Doha agreement, a consensus of 24 international experts, created a clinical classification for groin pain in athletes. It defines four clinical entities—adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain—and adds hip-related groin pain and other causes as separate categories.
Under the Doha consensus definition, adductor-related groin pain is identified when adductor tenderness is accompanied by pain during resisted adduction. The pain on testing should reproduce the athlete’s familiar pain in the adductors. This is a clinical pattern, not proof of a specific microscopic tendon lesion, and a positive squeeze test alone does not establish adductor tendinopathy.
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. That cohort was 98% male and 60% soccer players, so the exact percentages may differ in other athletes. How the categories are separated is explained in adductor groin pain vs. hip, iliopsoas and pubic pain.
The Adductor Origin and the Aponeurosis
The proximal adductor longus origin at the pubic bone is a common site of symptoms. Long-standing problems can involve the tendon and its enthesis, the myotendinous tissue, the adjacent aponeurotic plate shared with the rectus abdominis, or nearby pubic structures. Early MRI case series in competitive and recreational athletes documented visible adductor enthesopathy in some athletes with adductor-related groin pain. Those series also tested pubic cleft steroid injections, but they do not establish injection as a routine treatment.
Some cases labeled “adductor strain” actually involve the connective-tissue complex linking the rectus abdominis, pubic plate and adductor longus origin. That injury is explained in adductor longus and rectus-abdominis aponeurosis injuries.
Not All Groin Pain Is Adductor-Related
- Hip-related groin pain: femoroacetabular impingement, labral pathology, osteoarthritis where age-appropriate and other intra-articular problems. Clues include deep groin pain, reduced or painful hip flexion and rotation, and catching or clicking. Hip examination should be part of every persistent groin-pain assessment because intra-articular hip disorders may coexist with adductor-related symptoms. Lateral hip pain is covered on the lateral hip pain page.
- Iliopsoas-related groin pain: becomes more likely when tenderness over the iliopsoas is accompanied by pain with resisted hip flexion or hip-flexor stretching. See iliopsoas and hip flexor pain.
- Inguinal-related groin pain: pain and tenderness in the inguinal canal region without a palpable hernia, often provoked by abdominal resistance, coughing or Valsalva. A true inguinal hernia is a different diagnosis and is referred appropriately. Pain centered in the lower abdominal wall rather than the groin is covered on abdominal wall, oblique and rectus muscle pain.
- Pubic-related groin pain: primarily localized by tenderness around the pubic symphysis rather than by one definitive resistance test.
- Bone stress injury: femoral neck or pubic stress injury should be considered with high training loads, rest or night pain, progressive weight-bearing pain or bony tenderness, particularly in endurance athletes. These are imaged or referred promptly.
- Other causes: obturator, ilioinguinal or genitofemoral nerve symptoms, referral from the lumbar spine, and urologic, abdominal or gynecologic conditions. Not all groin pain is musculoskeletal. Atypical symptoms require appropriate medical evaluation.
Acute Adductor Injury vs. Long-Standing Groin Pain
Acute partial strains generally follow a different course from long-standing adductor-related groin pain. A systematic review reported return-to-play times ranging roughly from one to seven weeks after partial injuries, while complete tendon avulsions require individualized structural assessment. Recovery times are not guaranteed and depend on the injury and the sport.
Imaging or referral is considered promptly after an acute pop, visible bruising, a palpable defect, marked weakness, a forced-abduction injury, inability to continue playing or any suspicion of a complete proximal avulsion. An obvious acute avulsion is not treated as chronic tendinopathy.
What We Examine
- Exact pain location: adductor origin, pubic bone, inguinal canal, iliopsoas or deep hip
- Adductor tenderness and pain during resisted adduction
- Adductor squeeze strength and side-to-side differences
- Eccentric adductor capacity and the balance between hip adduction and abduction strength
- Hip range of motion and hip joint provocation
- Iliopsoas testing, abdominal resistance and inguinal findings
- Running, change-of-direction and kicking tolerance where relevant
- Features suggesting bone stress, nerve involvement or a non-musculoskeletal cause
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. The goal is not simply to make palpation less tender. The adductors must regain enough force and load tolerance for the patient’s actual activity.
When Is Imaging Needed?
Straightforward adductor-related groin pain often does not need imaging at first. MRI is most useful for prolonged unexplained groin pain, a suspected adductor origin tear, rectus-adductor aponeurosis injury, pubic bone stress response, hip pathology, complex symptoms involving several structures, failure of appropriate conservative care or a significant acute injury.
Ultrasound can assess superficial adductor tendon and muscle and dynamic inguinal structures. For the deeper common rectus-adductor aponeurosis, MRI may provide substantially more information: in one study of professional soccer players, ultrasound was 44.4% sensitive for these lesions. 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.
How Treatment Is Selected
Progressive Adductor Loading
Active strengthening has the strongest historical randomized evidence for long-standing adductor-related groin pain and is the foundation of treatment. A typical progression moves from isometric adduction to short-lever and then long-lever adductor loading, eccentric adductor work such as Copenhagen-style progressions, trunk and pelvic control, and then running, lateral movement, cutting, kicking, sprinting and return to sport. Exercise selection and dose are matched to the patient’s current capacity rather than a fixed program.
Manual Soft-Tissue Treatment
Manual treatment may be useful when clinically relevant soft-tissue restriction or mechanical sensitivity limits adductor loading. It should be integrated with progressive strength restoration rather than used as a substitute for rebuilding capacity. When the exam finds restricted proximal adductor tissue, Manual Adhesion Release may be part of that plan. Chronic injury can involve connective-tissue remodeling, as discussed in muscle fibrosis after a strain, but not every case of adductor pain is a fibrosis or adhesion problem.
Focused or Radial Shockwave
Focused or radial shockwave may be considered for selected chronic presentations once the pain source has been localized. Randomized evidence supports adding shockwave to rehabilitation for pubic overload, and a 2026 prospective study combined focused shockwave with rehabilitation in broader groin pain syndrome. Direct isolated-adductor-tendinopathy comparative trials remain limited. See the shockwave evidence review.
Hip and Pelvic Rehabilitation
Hip strength, hip mobility and trunk control are addressed when deficits contribute to the presentation.
Imaging
MRI or ultrasound is used selectively to answer a specific diagnostic question.
Referral
Referral is appropriate for a complete tendon avulsion, a significant aponeurotic injury, a suspected hernia, significant hip pathology, concern for a stress fracture, refractory symptoms or other non-soft-tissue causes.
You do not need to decide which treatment you need before your visit. All four tools are compared on the services page, and shockwave at Novo is explained on shockwave therapy in Denver.
What Research Says
- Classification: the Doha agreement defines adductor-, iliopsoas-, inguinal- and pubic-related groin pain clinically, with hip-related pain and other causes as separate categories (Weir, 2015).
- Multiple diagnoses are common: among 100 athletes, 61% had adductor-related pain and 44% had more than one clinical entity, in a mostly male soccer population (Taylor, 2018).
- Active training: in a randomized trial of 68 athletes with long-standing adductor-related groin pain, 23 in the active-training group and 4 in the comparison group returned to their previous sport without groin pain (Hölmich, 1999).
- Manual therapy as part of a program: a randomized trial found a multimodal program that included manual therapy returned athletes to sport in 12.8 versus 17.3 weeks, although only about half of athletes in either group made a full return (Weir, 2011).
- Shockwave: randomized evidence supports adding shockwave to rehabilitation for pubic overload (Schöberl, 2017), and an uncontrolled 2026 study combined focused shockwave with rehabilitation in groin pain syndrome (Santilli, 2026).
- Imaging: reactive changes are common in asymptomatic athletes, so imaging is combined with clinical assessment (Madani, 2019).
This is why Novo localizes the pain generator before treating persistent groin pain as an adductor problem.
Adductor vs. hip, iliopsoas and pubic pain → · Rectus-adductor aponeurosis injuries → · Shockwave evidence review →
Sources: Weir et al., Br J Sports Med 2015 · Taylor et al., Clin J Sport Med 2018 · Hölmich et al., Lancet 1999 · Weir et al., Man Ther 2011 · Delahunt et al., Man Ther 2011 · Schilders et al., J Bone Joint Surg Am 2007 · Schilders et al., J Bone Joint Surg Am 2009 · Farrell et al., Am J Sports Med 2023 · Todeschini et al., Rev Bras Ortop 2019 · Madani & Robinson, Semin Musculoskelet Radiol 2019 · Schöberl et al., Knee Surg Sports Traumatol Arthrosc 2017 · Santilli et al., Life 2026
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