Assessment of Athletes with Groin Pain

Original Editor - Prince Wilson Top Contributors - Prince Wilson

Introduction[edit | edit source]

Groin pain including groin strains are common among athletes who participate in sports with repetitive and forceful hip movement.[1] Ice hockey and various football codes have been identified as sports with high prevalence of groin injuries due to the high intensity nature.[2] Groin injuries accounts for 14 - 19% of all injuries in male football clubs and 2 - 14% in women. [3]

Groin pain is typically thought of as difficult to diagnose and manage.[4] In a systematic review on the treatment of groin pain, 33 different diagnostic terms were used to describe groin pain.[5] The poor understanding of underlying pathology and structural attachment has created confusion regarding diagnosis and terminologies.[6] The current understanding of hip joint pathologies which causes groin pain adds up to the complexities surrounding the diagnosis of groin pain.[6]

However, in November 2014, an agreement meeting was held in Doha, Qatar involving experts in sports medicine. The Doha agreement meeting on terminology and definitions of Groin pain in athletes was held to address the problem. [7]

Assessment[edit | edit source]

The Doha agreement agreed on three (3) subheadings for classifying groin pain of athletes. [7]

  1. Defined clinical entities for groin pain:
    1. Adductor-related
    2. Iliopsoas-related
    3. Inguinal-related
    4. Pubic-related groin pain
  2. Hip-related groin pain
  3. Other causes of groin pain in athletes

Thorborg et al. (2018) provided a clinical framework for examination of athletes with Groin pain. The framework provides a comprehensive examination guideline of the entire groin and hip joint region of an athlete with groin pain that clinicians can utilise in their assessment. When serious pathology and other differential diagnosis have been rule out, the diagnosis can be made with focal findings on examination using the guidelines from the Doha agreement to classify the injury into 1 of the 4 clinical entities.[8]

Subjective Assessment[edit | edit source]

  • Location of pain: The location of pain is essential in identifying the structures involved and should be enquired from the patient. Groin pain felt more anteriorly is the thigh region indicative of the iliopsoas related groin pain. Pain located more to the proximal inner thigh is indicative of adductor related groin pain.
  • Injury mechanism: change of direction, kicking, reaching and jumping are the common actions associated with groin injuries. [9]
  • Acute or gradual onset: Groin pain can either be of an acute onset or gradual onset and knowing how the pain developed is important in both examination and management.
  • Systemic symptoms: unexplained weight loss, fatigue, fever, painful urination and night pain should be treated with urgency and referred for further investigations.[10]

Objective Assessment[edit | edit source]

A groin examination classification system adapted from the Doha meeting can be use as a guide in the examination of athletes that present with groin pain. [7]

Groin classification Pain Location Assessment

groin pain

Proximal inner thigh( adductor region) Adductor tenderness on palpation and pain on resisted adduction testing or adductor stretching

groin pain

inguinal canal region Tenderness on inguinal canal on palpation and resistance testing of the abdominal muscles or during coughing/sneezing
Iliopsoas-related groin pain Anterior thigh Tenderness on iliopsoas palpation and resisted hip flexion or pain on stretching the hip flexors.
Pubic-related groin pain Pubis Tenderness of the pubic symphysis and adjacent bone

The hip joint should be considered as a cause of groin pain and should be assessed in athletes with groin pain. Objective examination which includes passive range of motion and hip special tests (Flexion-abduction-external rotation (FABER) and Flexion-adduction-internal rotation (FADIR) test) should be performed in all athletes who present with groin pain. Clinical tests used for the hip joint have good sensitivity but lacks specificity and can be used to rule out hip related groin pain. [11][7]

Adductor related groin pain[edit | edit source]

Palpation of the adductor muscle group in particular the Adductor Longus:


Adductor groin squeeze testing :


iliopsoas related groin pain[edit | edit source]

Palpation of the iliopsoas muscle:


Resisted hip flexion test:


Inguinal related groin pain[edit | edit source]

Palpation of the inguinal ligament:


Abdominal resisted testing:


Pubic related groin pain[edit | edit source]

No resisted testing is described for pubis related pain and maybe be reproduced on adductor abdominal testing, how ever there may be local tenderness on the pubis symphysis and surrounding bones.


References[edit | edit source]

  1. Serner A, Mosler AB, Tol JL, Bahr R, Weir A. Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis. British journal of sports medicine. 2019 Feb 1;53(3):158-64.
  2. Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of hip flexor and hip adductor strains in National Collegiate Athletic Association athletes, 2009/2010-2014/2015. The American journal of sports medicine. 2017 Oct;45(12):2713-22.
  3. Waldén M, Hägglund M, Ekstrand J. The epidemiology of groin injury in senior football: a systematic review of prospective studies. British journal of sports medicine. 2015 Jun 1;49(12):792-7.
  4. Hölmich P. Groin injuries in athletes–new stepping stones. Sports Orthopaedics and Traumatology. 2017 Jun 1;33(2):106-12.
  5. Serner A, van Eijck CH, Beumer BR, Hölmich P, Weir A, de Vos RJ. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. British journal of sports medicine. 2015 Jun 1;49(12):813-.
  6. 6.0 6.1 Thorborg K, Hölmich P. Advancing hip and groin injury management: from eminence to evidence. 2013
  7. 7.0 7.1 7.2 7.3 Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, Lovell G, Meyers WC, Muschaweck U, Orchard J, Paajanen H. Doha agreement meeting on terminology and definitions in groin pain in athletes. British journal of sports medicine. 2015 Jun 1;49(12):768-74.
  8. 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 Apr;48(4):239-49.
  9. Serner A, Mosler AB, Tol JL, Bahr R, Weir A. Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis. British journal of sports medicine. 2019 Feb 1;53(3):158-64.
  10. Gabbe BJ, Bailey M, Cook JL, Makdissi M, Scase E, Ames N, Wood T, McNeil JJ, Orchard JW. The association between hip and groin injuries in the elite junior football years and injuries sustained during elite senior competition. British journal of sports medicine. 2010 Sep 1;44(11):799-802.
  11. Mosler AB, Weir A, Hölmich P, Crossley KM. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis. British journal of sports medicine. 2015 Jun 1;49(12):810-.
  12. Brian Abelson. Anatomy & Palpation of the Adductor Muscles of the thigh covers the: Adductor Longus, Adductor Brevis, Pectineus, Adductor Magnus, and Gracilis. Available from
  13. WichitaPT. Groin squeeze test demonstration. Accessed from
  14. David G. Simons Academy - DGSA. how to palpate the iliopsoas muscle distal to the inguinal ligament. Accessed from
  15. prohealthsys. Resisted hip flexion testing. Accessed from
  16. Blackriver & Bootsma Education. Comprehensive pelvic ligament palpation including the inguinal ligament. Accessed from on 18/11/2021
  17. Physio Plus Fitness. Abdominal resisted muscle testing. Accessed from
  18. Pubic symphysis palpation. Accessed from on 18/11/2021