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Groin Strain

Original Editor - Els Van Haveras part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Vidya Acharya, Astrid Lahousse, Geubels Kaat, Nele Kiekens, Mats Vandervelde, Prince Wilson, Kim Jackson, Admin, Laure Lievens, Muhammad Arslan, Wanda van Niekerk, Lucinda hampton, Kai A. Sigel, Joao Costa, Alexandra Stead, George Prudden, Uchechukwu Chukwuemeka, Leana Louw, 127.0.0.1, Naomi O'Reilly, Els Van Haver, Claire Knott and Rachael Lowe

Introduction

Overview of the muscles of the hip and thigh - anterior and posterior views
Overview of the muscles of the hip and thigh - anterior and posterior views

A groin strain is a musculoskeletal injury affecting the adductor muscle–tendon unit. It is typically characterised by localised tenderness over the adductor tendon or its attachment to the pubic bone, along with pain in the groin region reproduced during resisted hip adduction.[1][2] Groin muscle strain is prevalent in multidirectional sports including football (soccer), rugby, ice hockey, and Gaelic football, where the repeated sprinting, kicking, cutting, twisting and changing directions put high stress on the hip adductor muscles.[1][3][4] The most common type of groin injury in these sports is associated with the adductors.[5] The eccentric contraction produces a higher maximum force than the concentric contraction.[6] Eccentric loading at longer muscle length increases passive tension, and reduces contractile ability, increasing the mechanical load on the muscle–tendon unit.[7] Therefore, sports that involve the forceful eccentric contraction of the hip adductors are associated with a higher risk of adductor strain injuries.[8] The underlying injury most commonly involves the adductor muscle–tendon unit. Injury may occur within the muscle or at the proximal adductor tendon insertion on the pubic bone, with more proximal tenderness suggesting greater tendon involvement.[9]

Image: Overview of the muscles of the hip and thigh - anterior and posterior views.[10]

Clinically Relevant Anatomy

In human anatomy, the groin is the junctional area between the abdomen and the thigh on either side of the pubic bone. This is also known as the medial compartment of the thigh.[11][12]

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[13]

Anterior view pelvis, pubic bone in red
Anterior view pelvis , with the pubis bone highlighted in red.

The groin is a complex anatomical region comprising the lower abdominal, iliopsoas, and hip adductors, together with the pubic symphysis, inguinal structures, and adjacent neurovascular tissues.[2][14] Adductor strains predominantly involve the hip adductor musculature, particularly the adductor longus, which is the most frequently injured muscle in athletes.[1][15]

The adductor muscle group:

  • The adductors of the hip joint include 6 muscles: the adductor longus, magnus and brevis, gracilis, obturator externus, and pectineus.[16]
  • All these muscles are innervated by the obturator nerve except that of pectineus, which receives innervation from the femoral nerve.[17]
  • The adductors all originate on the pubic ramus as almost all insert on the linea aspera of the posterior femur.
  • The adductor longus has a proximal attachment at the pubis body and contributes to an anatomical structure across the anterior pubic symphysis that facilitates force transmission across the pelvis during lower-limb movements.[18][19]
  • This anatomical relationship is clinically relevant because the proximal adductor longus is a common site of injury in athletes.[20]
  • The posterior head of the adductor magnus has a proximal attachment on the ischial tuberosity anteroinferiorly and attaches distally on the medial distal femur at the adductor tubercle.
  • The gracilis insertion is on the medial border of the tuberosity of the tibia.[21]
  • The primary function of this muscle group is adduction of the thigh in open-chain motions and stabilisation of the lower extremity and pelvis in closed chain motion.[16]

Epidemiology

Overall Incidence

Groin injuries are common in team sports and represent a substantial burden for athletes.[22][23][24] A recently published systematic review and meta-analysis revealed an overall hip and groin injury incidence of 0.71 injuries per 1,000 exposure hours, representing 11% of all sports injuries, with the most common type being adductor (0.41 per 1,000 exposure hours).[25] There is an increased risk of injury for male athletes, and for injuries to occur during a match rather than during training, reflecting the high burden of groin injuries in sports.[26]

Sex Differences

A 2026 systematic review and meta-analysis involving 3,133 team-sport athletes found no significant sex-related differences in the overall prevalence of hip and groin injuries or in the prevalence of time-loss and non-time-loss injuries.[27] However, subgroup analysis in this study demonstrated that male football players had more than twice the odds of developing groin problems compared with female football players. These findings indicate that, although hip and groin injuries occur at comparable rates in male and female athletes overall, male football players constitute a higher-risk subgroup and may benefit from targeted screening and injury prevention programmes.[27]

Age-Related Risks

A biomechanical study determined that the incidence of groin injuries was higher during the adolescent period of a player's life due to the gradual increase of hip adductors muscle forces with age.[28] The study found greatest increase (49%) in adductor muscle force was observed between the under-12 and under-15 age groups. The study also proposed that tendons do not adapt as rapidly as muscle during growth, so they thought that this could lead to the increased stress on the adductor muscle–tendon unit and increase the risk of injuries in the groin area in adolescent football players.[28]

Professional Football

A prospective cohort study of 86 professional players from a United States Major League Soccer (MLS) team for seven seasons (2016-2022) identified adductor strains as the second most common type of soft-tissue, non-contact lower extremity injury after hamstring strains.[29] About 23% of players suffered at least one adductor injury, and 20% were actually injured again. The majority of injuries took place when they were training (70%) and the injury risk seemed to be higher during matches. Overuse injuries (30%), change of direction (26.7%), running (13.3%) and kicking (10%) were the most common injury mechanisms. Moreover, a history of injury to the adductor was one of the strongest predictors of re-injury: the risk of future adductor injury was 167-times greater among players who had already experienced an adductor injury. This study highlights the significant prevalence of adductor strains in professional football and the need for proactive and preventive measures to treat them.[29]

Reporting Considerations

The exact incidence of groin muscle strains in most sports is unknown because athletes often play through minor groin pain and the injury goes unreported with overlapping diagnoses can skew the incidence.[30]

Aetiology

Groin strain occurs from excessive stretching and/or overloading of the muscles and tendons of the groin area leading to the tearing of muscle fibres, either partially or completely.[31] The adductor muscle group, specifically the adductor longus, is most frequently involved but the gracilis, adductor brevis, adductor magnus, iliopsoas, rectus femoris, and lower abdominal muscles may be involved.[8] They can also occur as a result of repeated microtrauma (overuse) resulting from repeated loading of the groin muscles without proper rest, or, less frequently, as a result of a direct blow to the area of the groin.[32]

A groin strain usually happens during sporting activities involving rapid acceleration, deceleration, sprinting, kicking, jumping, twisting or quick changes of direction, as the adductor muscles are subject to excessive tensile stress.[9] They are most common in soccer and ice hockey, but also have been seen in rugby, Australian rules football, and American football, basketball, and tennis.[33][15][34][35] These sports have extremely high mechanical requirements of hip adductor muscles which are associated with the risk of acute strain and recurrent injuries.[9]

Risk Factors

Previous Injury

Several intrinsic and extrinsic factors have been associated with an increased risk of groin strain in athletes.[36][37] Previous groin or adductor injury appears to be the most consistent and strongest risk factor for a subsequent injury, perhaps due to ongoing neuromuscular impairments, incomplete healing or muscle weakness after return to sport.[38] Recurrent injuries do happen and it is important to reach full functional status before returning to athletics.[39]

Eccentric Hip Adductor Weakness

A modifiable risk factor in relation to groin strain is weakness of the eccentric hip adductor muscles.[40][41] The athletes with eccentric weakness have a limited ability to absorb these high tensile stress forces generated when they run, kick, cut and change direction quickly.[15] Therefore, eccentric strengthening programmes are now an important element of rehabilitation and injury prevention.[42]

Reduced Hip Range of Motion

The lack of range of motion at the hip has also been linked to the risk of groin strain, especially a loss of internal and external rotation.[43] Limited hip mobility can shift lumbopelvic biomechanics and may be associated with a greater mechanical loading of the adductor musculotendinous unit, particularly if there is a loss of muscle strength or neuromuscular control.[38]

Training Load and Physical Conditioning

Poor training loads in the preseason and during the season can be considered as extrinsic risk factors.[38] Decreased strength, endurance, and sport-specific conditioning in athletes puts them at risk of developing muscle overload and therefore may be more prone to injury.[9] In addition to this, a sudden increase in training intensity or volume without proper progression poses an increased risk for injury.[44]

Sport-Specific Demands

There are also a number of sports activities that place a significant strain on the groin that can lead to groin strains.[9] The hip adductors are subjected to high mechanical loading during sports that involve repetitive kicking, sprinting, acceleration and deceleration, cutting, jumping and sudden changes in direction, such as soccer, ice hockey, rugby, basketball and other sports, leading to an increased risk of acute and recurrent muscle injury.[8][15]

Early Symptom Recognition

Persistent groin pain, stiffness or loss of function and no time off sport should not be ignored, and may lead to a clinically significant adductor strain.[45] Symptom monitoring and early intervention can therefore help minimise progression to a more serious chronic injury.[38]

Other Contributing Factors

Other factors that can impact injury risk are sport-specific playing positions and personal biomechanical factors.[46] Although playing position is not an independent causal factor, changes in the demands of the movements and cumulative load may affect the occurrence and recovery of injury.[47] In summary, groin strain is acknowledged as a multi-factorial injury that occurs when a combination of previous injury, muscle weakness, limited mobility, inadequate conditioning, training load and sport-specific biomechanical demands interact.

Mechanism of Injury

Non-contact (Eccentric) Mechanism

The majority of groin strains occur from non-contact mechanisms in high intensity sporting activities including sprinting, acceleration, deceleration, cutting, kicking, jumping, reaching, and rapid changes of direction.[48] These movements stretch out the muscles of the adductors under high mechanical loads and stretch them at the same time (eccentric effect).[9] The most frequently cited cause of most adductor strains is rapid eccentric loading especially with the hip in external rotation, abduction and extension or during a rapid change in hip movement from extension to flexion.[49]

Closed and Open Kinetic Chain Mechanisms

Adductor injuries may happen when relating to both closed kinetic chain (CKC) and open kinetic chain (OKC) movements. A common occurrence that causes CKC injuries is when the foot stays on the ground and the hip and trunk move away from it, e.g. when cutting, trying to get the ball, or by taking a turn.[49] On the other hand, OKC injuries are due to free movement of the injured limb during activities, like kicking, jumping, landing, or reaching with the injured leg. The patterns of motion are different, but both put the adductor musculotendinous unit under a high degree of loading at the end ranges of hip motion, resulting in high tensile stress and potential muscle or tendon injury.[50]

Muscle-Specific Injury Mechanisms

The mechanism of injury can vary depending on the particular adductor muscle affected. An adductor longus injury often happens with hip extension, abduction and external rotation.[49] Adductor magnus, on the other hand, are more likely to occur when the hip is bent, and the thigh bone is twisted inwards and the knee straight or slightly bent.[51] The difference is due to the special anatomical and functional function of the posterior (ischiocondylar) part of the adductor magnus, which is a hip extensor when the hip is flexed to a large degree.[29][52]

Contact Injury Mechanism

Acute contact injuries are less frequently and result from direct trauma to the groin or medial thigh.[9] Muscle contusion, intramuscular bleeding, haematoma formation are more likely to occur after direct trauma when compared to non-contact strains, leading to greater structural damage. Therefore, contact injuries tend to have longer rehabilitation and return to play times.[47]

Chronic (Overuse) Mechanism

Chronic or overuse groin strains are caused by repetitive loading over time, rather than a sudden and traumatic incident.[9] The ability of muscle to withstand load gradually diminishes with repeated high intensity training, with biomechanical abnormalities becoming persistent over time, muscle fatigue, strength deficiencies and inadequate recovery, and eventually pain, loss of function and adductor strain.[53]

Clinical Presentation

The primary symptom of groin strain is intense pain in the groin area often extending to anteromedial area of thigh.[48][54] Muscle strain injuries often arise from excessive stretching or stretching when the muscle is being activated.[55] When there is a strain in the muscle, the damage is often localised near the muscle-tendon junction.[56] Acute adductor longus injuries may also involve tendinous rupture or avulsion, primarily at the proximal insertions. [57]

Clinically for an adductor strain, the patient presents with pain in the inner thigh and tenderness along the muscle belly, tendon or insertion. The pain is exacerbated by adduction.[58] Tears frequently occur at the myotendinous junction, which is the weakest part of the muscle-tendon unit but is also commonly seen in the muscle belly.[59] There is a well-established clinical grading system for muscle tears, which has 3 components:[60]

  • Grade 1: no loss of function or strength. Muscle tears can show normal appearances or a small area of focal disruption (<5% of the muscle volume), with hematoma and perifascial fluid relatively common on imaging with US and MRI.
  • Grade 2: severe, with some weakness. Injury corresponds to a partial tear, with muscle fibre disruption seen (>5% of the muscle volume) but not affecting the whole muscle belly. In acute grade 1 or 2 strains of the adductor muscle, there is intense pain in the groin area, like a sudden stab with a knife, if the athlete attempts to continue the activity. Locally a haemorrhage and swelling can be seen a few days after the injury. A typical trauma history, localised tenderness and difficulties to contract the hip abductors.
  • Grade 3: complete muscle tear and complete functional loss. Injuries are complete muscle tears with frayed margins and bunching and/or retraction of the torn muscle fibres. Complete muscle tears or grade 3 strains are most often found in the distal musculotendinous junction located toward the insertion on the femur.

Differential Diagnosis

The differential diagnosis of groin pain is wide and is most frequently due to musculoskeletal causes in athletes.[61] The most common presentation is adductor-related pain and is usually caused by overloading of the adductor muscle–tendon unit during sports.[62] Additional musculoskeletal causes include pubic, inguinal, and iliopsoas related groin pain, and non-musculoskeletal conditions such as hernias and genitourinary disorders should also be taken into account when evaluating a patient with groin pain. A systematic clinical examination is a key component to differentiate these and lead to appropriate management.[46]

Traditionally, groin pain has been thought to be complex with various definitions and terminologies without any diagnostic criteria.[63] In a systematic review on the treatment of groin pain in athletes, more than 30 different diagnostic terminologies were used to describe groin pain which adds up to the complexity of groin injuries in athletes.[64]

Differentiating groin tendinopathy and strain

The difference between groin tendinopathy and strain are:

  • Adductor strains are acute injuries that result from a sudden overload of the muscle–tendon unit, whereas adductor tendinopathy is a chronic overuse condition that develops gradually because of repetitive mechanical loading.[65][9]
  • Acute adductor strains most commonly occur at the myotendinous junction, whereas chronic adductor tendinopathy primarily affects the proximal tendon insertion at the pubic bone due to repetitive mechanical loading and tendon degeneration.[4][48]

See page for adductor tendinitis.

Groin Pain classification

In the attempt to address the different terminologies and definitions used, a consensus meeting was held in Doha, Qatar during the first World Conference of Grain Pain in Athletes , in November 2014. A group of 24 experts from 14 different countries was invited to agree on a standard terminology, along with accompanying definitions. [1]

A classification system of groin pain was described in three main subheading during the Doha agreement meeting;

The Doha agreement diagnostic classification [1]
Defined Entities Other musculoskeletal causes Red flag conditions
  • Adductor-related groin pain
  • Iliopsoas-related groin pain
  • Inguinal-related groin pain
  • Pubic-related groin pain
  • Hip-related groin pain
  1. Inguinal or femoral hernia
  2. Posthernioplasty pain
  3. Nerve entrapment
    • Obturator
    • Ilioinguinal
    • Genitofemoral
    • Iliohypogastric
  4. referred pain
    • Lumbar spine
    • Sacroiliac joint
  5. Apophysitis or avulsion fracture
    • Anterior superior iliac spine
    • Anterior inferior iliac spine
    • Pubic bone
  6. Referred pain

Stress fracture

  • Neck of femur
  • Pubic ramus
  • Acetabulum

Hip joint

  • Arthritis of the hip joint (reactive or infectious)

Inguinal lymphadenopathy Intra-abdominal abnormality

  • Prostatitis
  • Urinary tract infections
  • Kidney stone

Gynaecological conditions Spondyloarthropathies

  • Testicular tumours
  • Bone tumours
  • Prostate cancer
  • Urinary tract cancer ▸ Digestive tract cancer ▸ Soft tissue tumours

Diagnostic Procedures

The assessment starts with a detailed history of the patient, followed by detailed physical examination to determine the onset, mechanism, location and type of symptoms.[66] Patients with an groin strain will usually present with pain on palpation of the affected adductor muscle or tendon, localised swelling to the adductor area, weakness with hip adduction, and pain with resisted adduction. A clinical diagnosis, based on the classification system in the Doha Agreement, is typically sufficient to make the diagnosis and imaging is not routinely needed in most cases. [1][67]

However, imaging may be indicated when the diagnosis is uncertain, symptoms persist, or alternative diagnoses need to be excluded. Magnetic resonance imaging (MRI) is the preferred imaging modality for evaluating muscle injuries, while ultrasound may also be useful in the acute setting.[68] A standardised MRI assessment protocol for acute groin injuries has been developed, and it has shown good intra-rater reliability and interrater reliability, therefore it can be used to consistently evaluate and classify acute groin injuries.[69] Radiological findings around the pubic symphysis, such as bone marrow oedema, are common in athletes with adductor- and pubic-related groin pain but may also be present in asymptomatic athletes. Therefore, imaging findings should always be interpreted in conjunction with the patient's history and clinical examination, as radiological abnormalities do not necessarily indicate the source of symptoms. [70]

Outcome Measures

The Copenhagen hip and groin outcome score (HAGOS)

The Copenhagen Hip and Groin Outcome Score (HAGOS) is a valid and self-administered patient-reported outcome measure designed specifically for physically active people with hip and groin disorders.[71] It is a six-subscale scale that measures pain, symptoms, physical function in activities of daily living, physical function in sport/recreation, participation in physical activities and hip/groin-related quality of life.[72] HAGOS can be used to measure disability prior to treatment, track treatment care and recovery after treatment. HAGOS is a valid and reliable patient-reported outcome measure that can be used to assess baseline disability, monitor treatment outcomes and evaluate rehabilitation progress in physically active individuals with hip and groin. [73]

Assessment

Observation

Observe the patient in standing and walking for:[74]

  • Antalgic gait
  • Medial thigh swelling or bruising
  • Asymmetry or muscle deformity (in severe injuries)
  • Difficulty with weight-bearing or single-leg stance

ROM testing

Assessment of the following with the patient seated:[74]

  • Hip internal rotation
  • Hip external rotation
  • Symmetry of hip range of motion between limbs
  • Seated straight leg raise (if lumbar radiculopathy is suspected)
  • Hamstring flexibility
  • Patellar and Achilles tendon reflexes, when neurological involvement is suspected

Assess the following with the patient supine:[74]

  • Active and passive hip flexion
  • Hip extension
  • Hip abduction
  • Hip adduction
  • Hip internal and external rotation
  • Palpation of the adductor muscle belly, myotendinous junction, and proximal tendon insertion
  • Palpation of the pubic symphysis and surrounding bony landmarks
  • Localised tenderness
  • Swelling or palpable muscle defect
  • Pain during passive hip abduction (adductor stretch)

Assess the following with the patient in side lying:[74]

Palpation

The adductor muscle group should be palpated from the proximal attachment at the pubic bone, to the musculotendinous junction and to the muscle belly.[79] The clinical findings may include:[15]

  • Localised tenderness
  • Swelling
  • Muscle spasms
  • A palpable defect in complete muscle tears

Strength Assessment

Evaluate hip adductor strength using:

  • Manual muscle testing[80]
  • Hand-held dynamometry (where available)[81]

Patients with an adductor strain typically demonstrate:[8]

  • Pain during resisted hip adduction
  • Reduced adductor muscle strength
  • Pain during resisted muscle testing to identify musculotendinous involvement

Special Tests

Bilateral evaluation of adductor muscle and strength: palpation at the adductor insertion at the pubic bone, adduction against resistance (squeeze tests in 0° and 45°), and passive stretching of the adductor muscles.[58]

Squeeze Test

[82]

  1. If adductor longus muscle is injured pain will be elucidated to the injured area by resisting leg adduction and in passive stretching at full abduction of the hip. Tenderness on palpation is localised to the injury site at the origin of the adductor longus tendon or at the musculotendinous junction.[1]
  2. Evaluation of iliopsoas muscle-related pain, strength and flexibility: palpation above the inguinal ligament, isometric strength test in hip flexion and a modified Thomas test.[83]
  3. Abdominal muscle-related pain and strength: palpation of the abdominal muscle insertion at the pubic bone and a functional sit-up test and symphysis joint tenderness at palpation.[83]
  4. The location of the injury was based on a minimum of 1 positive finding on palpation, stretching, or muscle resistance testing.[4]

Medical Management

The initial approach to an acute groin strain is generally a conservative management, with a relative rest period, followed by ice, compression, pain medication and early physiotherapy.[84] Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics may be prescribed to help relieve pain where clinically appropriate.[85] Injection at the adductor longus enthesis is helpful for refractory patients to conservative management.[86]

Surgical intervention should generally be considered only after an adequate trial of conservative management has failed to improve symptoms and function in patients with longstanding adductor-related groin pain.[87] Current evidence suggests that adductor tenotomy can facilitate a return to sport and improve patient-reported outcomes in carefully selected individuals; however, surgical techniques vary, and the available evidence is largely based on case series and observational studies..[88][89][90]

In a recent systematic review that compared surgical intervention to conservative intervention, there was a quicker return to return to play (RTP) time in athletes who had surgical intervention. However, the varied nature of surgical interventions and lack of quality randomised control trial (RCT) in the meta-analysis makes it impractical to recommend the surgical intervention.[91]

Physiotherapy Management

The treatment of musculotendinous groin strains are generally conservative. Surgical treatment in acute groin injuries is rarely indicated.[86]

Physical therapy aims to restore normal function as soon as possible through progressive rehabilitation, and in the acute phase, immobilisation is only allowed for the shortest period of time required to make a correct diagnosis and to minimise the adverse effects of prolonged immobilisation such as loss of function and muscle atrophy.[92]

  • The primary goal of the treatment program is to minimise the effects of immobilisation, regain full range of motion, and restore full muscle strength, endurance and coordination. Therefore, crutches, local cold application, and anti-inflammatory medication are recommended in the initial phase. Muscle exercises can usually be started early, but training should be performed within the limits of pain with careful isometric contractions against resistance.[93]
  • Following the acute phase, progressive therapeutic exercise should be initiated within a pain-free range of motion, with exercise intensity increased gradually according to symptom tolerance, ensuring that activities do not provoke pain during or after rehabilitation.[94][95]
  • As rehabilitation progresses, mild pain can be allowed during exercise, but it should subside immediately after the cessation of training.[96]
  • When full range of motion is accomplished, the injured muscle and tendon tolerate higher loads and the goal of rehabilitation should shift towards specific strength training exercises aiming for muscular recovery, increased endurance and a full range of motion.[97]
  • The final step is the gradual return to sports activity, which may in some cases take as long as 3 to 6 months.[98]

Adductor-related groin strain injury program

Rehabilitation programmes targeting intersegmental control have been shown to improve functional performance and expedite return to sport in athletes with groin pain across various diagnostic entities, highlighting the importance of addressing movement control during rehabilitation.[99]

The intervention consists of three (3) levels, addressing intersegmental control and strength, linear running mechanics and increasing linear running load tolerance and multidirectional mechanics and the transition back to high intensity sprinting.[99]

Level 1: Intersegmental control and strength

Streams Progressions
Hip Flexor Supine Standing Supported Free Standing.
Lateral Hip Control Supported Hip Hitched Free Standing Hip Hitch Step Up
Abdominal Crook Lying Leg Lift Crook lying Alternate Leg Drop Pallof Kneeling Split Lunge
Double leg Squat High Goblet Squat Low Goblet Squat Front Squat
Lateral Hip Strength Abduction/External rotation in mini squat Abduction/External rotation in a mini squat at wall Banded Squat
Deadlift Hip Hinge 1/2 Rack Deadlift Floor Deadlift
Lunge Split Lunge Overhead Split Lunge Weighted Split Lunge
Plyometric On Spot Hopping Line Hopping Cone Hopping

Level 2: Linear running mechanics

Linear Instructions
Marching and skipping March skip on the spot with arms overhead, maintaining lumbopelvic and neutral and with aggressive ground contact
Barbell/Overhead Running Run with dowel overhead or barbell across shoulders focusing on tall running posture and keeping stick still
Leg change drill In single leg stand, focus on rapid leg change to drive alternating leg extension and swing leg recovery.
Complete 5-6reps of 3-4sets. Focus entirely on the quality of execution


Level 3: Multidirectional mechanics and transitions

Linear Instructions
Lateral shuffle Side shuffle between 2 cones 8 meters apart arms locked overhead focusing on getting away from cones as quickly as possible. Progress to race to instruction or shadow opponent while shuffling
Zig-Zag cutting 5 cones in zig zag formation, 5 meters apart from each other. Run and cut as quickly as possible around the cones. Add holding a med ball for increased resistance and higher centre of mass. (CoM)
180-degree cone cutting. 5 cones in a semi-circle, start in the middle and run at any cone and cut back straight to the starting point. Add holding a med ball for increased resistance and CoM.
Complete 3-4sets of 5-6reps. Focus entirely on the quality of execution

The patient progresses to level 2 once they have a negative crossover sign and from level 2 to level 3 when they have a symmetrical internal hip rotation at 90 degrees, pain-free groin squeeze test at 45 degrees and no symptoms during the Linear running programme. Progression from level 3 when they complete the multidirectional drills at maximum intensity pain-free. [99]

Modified Hölmich Protocol

The recently published study suggests that modified Hölmich protocol may be safer and more effective than the Hölmich protocol in athletes with longstanding adductor groin pain in promoting their return to sports activity.[100] Hölmich et al. (1999) showed that therapeutic exercise (concentrated on hip and abdominal muscle strengthening) compared with physiotherapy including passive agents (stretching, TENS, transverse friction massage, and laser therapy) leads to better results in terms of reducing pain and returning to sports activity.[101] The modified Hölmich ten-week protocol that benefits from strengthening the muscles affecting the pelvis, core stabilisation, hip adductor stretching and high-intensity eccentric exercise of the hip adductors may have a considerable effect on primary measured outcomes including pain, hip adductor and abductor muscle strength, hip ROM, functional ability, and returning to the sport.[100]

Stretching Exercises

[102]

Strengthening Exercises

Hip Adductors

Side-lying hip-adduction and ball-squeeze exercises display the highest overall activation of adductor longus muscle.[103]

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[104]
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[105]
Resisted training

Resisted work typically involves with weights or elastic bands.

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[106]

Eccentric exercises

Eccentric exercises[107] often include a simple adduction strengthening programme based on Copenhagen Adduction Exercise reduced the risk of a groin problem in footballer players according to the study published in the British Journal of Sports Medicine.[108]

Other exercises

Squats can help in strengthening hip and knee muscles including the adductors. Greater stance width in the squat and deadlift, and squeezing a medicine ball between the legs in the leg press may increase adductor longus muscle activity. The research shows that squats performed at 30° of hip external rotation and at least 90° of knee flexion significantly increased the activity of hip adductors.[109]  

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[110]

Hip Abductors

Strengthening the hip abductors along with hip adductors is important as decreased strength in the hip abductors (gluteus medius) has been found in athletes who sustained a groin injury due to reduced activity.[108] Ensuring that hip abductor strength training is included in the rehabilitation programme is another key factor in groin injury prevention.[111][112] The most evidence-based treatment for both acute and chronic adductor-related issues is progressive strength training combined individualised sport[9] specific loading.

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[113]

Prevention

Recurrence of groin strains after return to sport is a risk, so there needs to be both primary and secondary prevention strategies implemented to reduce the risk of injury.[114] To identify the athlete at risk and possibly correct the predisposing factor(s), the intrinsic and extrinsic risk factors for the injury type must be known.[115]

Previous groin injuries, reduced hip adduction strength, higher level of play and lower levels of sports-specific training are associated with increased risk of new groin injuries.[116] A progressive, resistant hip adduction and abduction exercise programme, balance training, abdominal and core strengthening exercises, coordination exercises for the pelvic musculature, eccentric strengthening exercises and sport specific skating movement on a slide board has been found to be effective in the treatment of chronic groin strains and may also be effective in injury prevention for these strains.[117]

Adductor strain injury prevention programme

Below is a suggested adductor strain injury prevention programme.[30]

Warm-up Bike
Adductor stretching
Sumo squats
Side lunges
Kneeling pelvic tilts
Strengthening program Ball squeezes (legs bent to legs straight)
Different ball sizes
Concentric adduction with weight against gravity
Adduction in standing on a cable column or elastic resistance
Seated adduction machine
Standing with involved foot on sliding board moving in the sagittal plane
Bilateral adduction on sliding board moving in the frontal plane (ie, simultaneous bilateral adduction)
Unilateral lunges with reciprocal arm movements
Sports-specific training On ice kneeling adductor pull together
Standing resisted stride lengths on cable column to simulate skating
Slide skating
Cable column crossover pulls
Clinical goal Adduction strength at least 80% of the abduction strength


Copenhagen Adductor Exercise

In a cluster-randomised controlled trial involving 35 semi-professional Norwegian football teams, using a simple adductor strengthening exercise (Copenhagen Adductor Exercise) with three progression levels, three times per week during the preseason (6-8 weeks), and once per week during the competitive season (28 weeks). There was a significant reduction in the risk of groin problems compared to the controlled group who trained as normal during the season. The intervention group was made up of 18 teams, 339 players and the controlled group 17 teams, 313 players. The prevalence of groin problems was measured weekly in both groups during the competitive season using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire. [108]

Return to Play Criteria

Return to play (RTP) after a groin strain should involve a criteria-based, multi-disciplinary assessment and not be solely based on time.[97] Rehabilitation should be tailored to symptom resolution and strength and function restoration, and ensure successful completion of the sport-specific performance tasks, to reduce risk of re-injury and maximise performance upon return to competition.[118]

Clinical Criteria

The athlete needs to meet the following criteria before being allowed to continue to play the sport in an unrestricted manner:[118]

  • Pain-free palpation of the injured hip adductors muscle.
  • Abduction with no pain at hip maximum isometric position at outer range of hip abduction.
  • Maximal passive stretch of adductor without pain.
  • Adductors to be flexible as in the uninjured side.
  • When indicated, appropriate tissue healing on magnetic resonance imaging (MRI) to support clinical decision making and exclude significant structural complications. MRI should be used to support, not supplant clinical evaluation.
  • Athlete-reported readiness, such as confidence to return to sport, no fear of reinjury, and functional recovery.

Functional Criteria

The athlete should show good strength, neuromuscular control, and movement quality such as:[118]

  • Exercise of hip adductors performed with elastic resistance at 10-Repitation Maximum without pain.
  • Isomeric and eccentric strength of adductors with minimal asymmetrical development to side-to-side.
  • Normal performance of the adductor squeeze test (no pain and sufficient adductor strength).
  • Functional movements performed without compensatory movement patterns and in a pain-free manner.
  • The Copenhagen adduction exercise is routinely performed to increase the strength of the adductors and is considered by experts as part of the rehabilitation process but has not been recommended as a stand-alone criterion for return to play.

Sport-Specific Performance Criteria

The athlete should be able to engage in sport-specific activities at high intensities without pain and/or apprehension prior to returning to unrestricted competition, including:[118]

  • Ability to run at maximum perceived effort without pain in a straight line.
  • Sport-specific movements that are associated with the mechanism of the injury such as kicking, acceleration, deceleration, and planned or reactive change of direction movements.
  • The ability to pass the simulated match drill and high demand (“worst case scenario”).
  • Re-establishment of pre-injury external training loads (where monitoring technology is available) such as GPS-derived running metrics.
  • Successful completion of progressive team training, high intensity practice before clearance for competitive match play.

Return-to-Play Continuum

Return to play should be considered as a progressive process with three progressive steps:[97]

  • Clinically pain-free – all clinical pain provocation tests are negative.
  • Controlled sport-specific training – completion of supervised, progressive sport-specific training activities.
  • Return to full team training – to allow for full team training before competitive match play.

The final decision to return to competition should incorporate clinical findings and the athlete's functional capacity, readiness reported by the athlete, and sport-specific performance, and also take into account contextual factors such as coaching decisions, competition requirements, and risk tolerance.[97] Athletes who reach the clinically pain-free stage prior to the next step in the RTP continuum seem to be less likely to reinjure themselves than those who return before that stage is reached.[118]

Conclusion

Groin strains are common in sports, especially adductor muscle strain. Diagnosis should use the clinical diagnostic entities provided by the Doha agreement meeting. There is support for an association of precious injury and greater abductor to adductor strength ratios as well as sport specificity of training and pre-season sport-specific training as individual risk factors for groin strain injury in athletes.[116] Most athletes will return to sports with no pain and normal function with appropriate rehabilitation and rarely will there be a need for surgery. Active training rehabilitation was found to be very effective in managing groin strains. [4]

Resources

This 17 minute video is a good overview of the muscles of the hip and thigh.

[119]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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.
  2. ↑ 2.0 2.1 Mitrousias V, Chytas D, Banios K, Fyllos A, Raoulis V, Chalatsis G, Baxevanidou K, Zibis A. Anatomy and terminology of groin pain: current concepts. J ISAKOS. 2023 Oct;8(5):381-386. PMID: 37308079.
  3. ↑ 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-.
  4. ↑ 4.0 4.1 4.2 4.3 Serner A, Tol JL, Jomaah N, Weir A, Whiteley R, Thorborg K, Robinson M, Hölmich P. Diagnosis of acute groin injuries: a prospective study of 110 athletes. The American journal of sports medicine. 2015 Aug;43(8):1857-64.
  5. ↑ Quintana-Cepedal M, Maniar N, del Valle Soto M, Crespo I, Olmedillas H. Epidemiology of hip and groin injuries in sport: a systematic review with meta-analysis and meta-regression of 5914 injuries from over 9 million exposure hours. British Journal of Sports Medicine. 2026 Jan 21.
  6. ↑ Douglas J, Pearson S, Ross A, McGuigan M. Chronic adaptations to eccentric training: a systematic review. Sports medicine. 2017 May;47(5):917-41.
  7. ↑ Franchi MV, Reeves ND, Narici MV. Skeletal muscle remodeling in response to eccentric vs. concentric loading: morphological, molecular, and metabolic adaptations. Frontiers in physiology. 2017 Jul 4;8:447.
  8. ↑ 8.0 8.1 8.2 8.3 McHugh MP, Nicholas SJ, Tyler TF. Adductor strains in athletes. International journal of sports physical therapy. 2023 Apr 1;18(2):288.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 Thorborg K. Current clinical concepts: exercise and load management of adductor strains, adductor ruptures, and long-standing adductor-related groin pain. Journal of athletic training. 2023 Jul 1;58(7-8):589-601.
  10. ↑ Overview of the muscles of the hip and thigh - anterior and posterior views image - © Kenhub https://www.kenhub.com/en/library/anatomy/hip-and-thigh-muscles
  11. ↑ Lourié D. Clinical anatomy of the groin. In: Novitsky YW, editor. Hernia surgery. Cham: Springer; 2025. p. 17-30.
  12. ↑ Granger A, Kollias T, Loukas M. Anatomy of the groin. In: Loukas M, Tubbs RS, editors. Malignancies of the Groin: Surgical and Anatomic Considerations. Cham: Springer International Publishing; 2017. p. 17-38.
  13. ↑ AnatomyZone Muscles of the Thigh Part 2 - Medial Compartment - Anatomy Tutorial Available from https://www.youtube.com/watch?time_continue=10&v=MjPAPTJdxa8
  14. ↑ Koulouris G. Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. American Journal of Roentgenology. 2008 Oct;191(4):962-72.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Farrell SG, Hatem M, Bharam S. Acute adductor muscle injury: a systematic review on diagnostic imaging, treatment, and prevention. Am J Sports Med. 2023;51(13):3591-3603.
  16. ↑ 16.0 16.1 Thorp LE. Hip anatomy. In: Nho SJ, Bedi A, Salata MJ, Mather RC III, Kelly BT, editors. Hip arthroscopy and hip joint preservation surgery. Cham: Springer; 2022.
  17. ↑ Ko HY. Functional anatomy of the lower extremity: musculature and nerve supply. In: Practical functional anatomy for spinal cord injury rehabilitation. Singapore: Springer; 2026.
  18. ↑ Norton‐old KJ, Schache AG, Barker PJ, Clark RA, Harrison SM, Briggs CA. Anatomical and mechanical relationship between the proximal attachment of adductor longus and the distal rectus sheath. Clinical Anatomy. 2013 May;26(4):522-30.
  19. ↑ Schilders E, Mitchell AW, Johnson R, Dimitrakopoulou A, Kartsonaki C, Lee JC. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Aug;29(8):2424-36.
  20. ↑ Kato, T., Taniguchi, K., Kodesho, T., Nakao, G., Yokoyama, Y., Saito, Y., & Katayose, M. (2022). Adductor longus: An anatomical study to better understand groin pain. Clinical Anatomy, 35(7), 867–872. https://doi.org/10.1002/ca.23881
  21. ↑ Öhlin A, Lindman I, Karlsson L, Sansone M. Hip anatomy and biomechanics. In Sports injuries: Prevention, Diagnosis, treatment and rehabilitation 2025 May 3 (pp. 1573-1580). Cham: Springer Nature Switzerland.
  22. ↑ 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.
  23. ↑ Mercurio M, Corona K, Galasso O, Cerciello S, Morris BJ, Guerra G, Gasparini G. Soccer players show the highest seasonal groin pain prevalence and the longest time loss from sport among 500 athletes from major team sports. Knee Surgery, Sports Traumatology, Arthroscopy. 2022 Jun;30(6):2149-57.
  24. ↑ Mosler AB, Weir A, Eirale C, Farooq A, Thorborg K, Whiteley RJ, Hӧlmich P, Crossley KM. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. British journal of sports medicine. 2018 Mar 1;52(5):292-7.
  25. ↑ Quintana-Cepedal M, Maniar N, Del Valle Soto M, Crespo I, Olmedillas H. Epidemiology of hip and groin injuries in sport: a systematic review with meta-analysis and meta-regression of 5914 injuries from over 9 million exposure hours. Br J Sports Med. 2026;60(7):543-551.
  26. ↑ Orchard JW. Men at higher risk of groin injuries in elite team sports: a systematic review. British journal of sports medicine. 2015 Jun 1;49(12):798-802.
  27. ↑ 27.0 27.1 Bailén-García T, Quintana-Cepedal M, de la Calle O, Medina-Sánchez M, Crespo I, Olmedillas H. Sex differences in hip and groin injury prevalence: a systematic review and meta-analysis of 3133 team-sport athletes. Biology of Sport. 2026 Jan 23;43(1):753-67.
  28. ↑ 28.0 28.1 Dupré T, Lysdal FG, Funken J, Mortensen KRL, Müller R, Mayer J, Krahl H, Potthast W. Groin injuries in soccer: investigating the effect of age on adductor muscle forces. Med Sci Sports Exerc. 2020;52(6):1330-7.
  29. ↑ 29.0 29.1 29.2 Davis R, Poor A, Swanik CB, Hall M, Brewer B, Higginson J. Adductor strain in a US Major League Soccer team: a prospective cohort study. Biomechanics. 2025;5(1):17.
  30. ↑ 30.0 30.1 Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin injuries in sports medicine. Sports health 2010;2(3):231-6.
  31. ↑ Mullen S, Hadley M, Vopat B, Wolf M. Core muscle injury producing groin pain in the athlete: diagnosis and treatment. J Am Acad Orthop Surg. 2023;31(11):549-556.
  32. ↑ Thorborg K, Sheen AJ. Inguinal-related groin pain and/or disruption in athletes: current understanding, assessment and management strategies. Open Access J Sports Med. 2026;16:510774.
  33. ↑ Candela V, De Carli A, Longo UG, Sturm S, Bruni G, Salvatore G, Denaro V. Hip and groin pain in soccer players. Joints. 2019 Dec;7(04):182-7.
  34. ↑ Mosenthal W, Kim M, Holzshu R, Hanypsiak B, Athiviraham A. Common ice hockey injuries and treatment: a current concepts review. Curr Sports Med Rep. 2017;16(5):357-362.
  35. ↑ Félix I, Draovitch P, Ellenbecker TS, Dines J. Tennis injuries of the hip and thigh. In Tennis Medicine: A Complete Guide to Evaluation, Treatment, and Rehabilitation 2019 Jan 9 (pp. 381-399). Cham: Springer International Publishing.
  36. ↑ Suárez-Arrones L. Identification of injury risk factors for lower extremity muscle injury and preventive training guidelines. In Physiological and Functional Assessment of Professional Football Players 2025 May 9 (pp. 207-218). Routledge.
  37. ↑ Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. The American journal of sports medicine. 2010 Oct;38(10):2051-7.
  38. ↑ 38.0 38.1 38.2 38.3 Martins TB, Martins TB, Migliorini F, Maffulli N, Okubo R. Risk Factors Associated with Groin Pain in Athletes: A Systematic Review. Life. 2025 Oct 30;15(11):1688.
  39. ↑ Patel BH, Okoroha KR, Jildeh TR, Lu Y, Baker JD, Nwachukwu BU, Foster MG, Allen AA, Forsythe B. Adductor injuries in the National Basketball Association: an analysis of return to play and player performance from 2010 to 2019. The Physician and sportsmedicine. 2020 Oct 1;48(4):450-7.
  40. ↑ Wang J, Zhai Y, Liu N, Zhang G, Wang D. Adductor strengthening programme improves groin injury risk factors in youth football players. Research in Sports Medicine. 2026 Jul 4;34(4):409-22.
  41. ↑ Alsirhani AA, Muaidi QI, Thorborg K, Husain MA, Al Attar WS. Enhancing eccentric hip adduction strength in soccer players: A systematic review and meta-analysis of randomized controlled trials. Isokinetics and Exercise Science. 2025 May;33(2):89-96.
  42. ↑ Harøy J, Thorborg K, Serner A, Bjørkheim A, Rolstad LE, Hölmich P, et al. Including the Copenhagen Adduction Exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players. Am J Sports Med. 2017;45(13):3052-9.
  43. ↑ Kelly M, Secomb J. Associations between hip pathology, hip and groin pain, and injuries in hockey athletes: a clinical commentary. International journal of sports physical therapy. 2024 May 2;19(5):625.
  44. ↑ Gabbett TJ. How much? How fast? How soon? Three simple concepts for progressing training loads to minimize injury risk and enhance performance. Journal of orthopaedic & sports physical therapy. 2020 Oct;50(10):570-3.
  45. ↑ Cotellessa F, Puce L, Formica M, May M, Trompetto C, Perrone M, et al. Effectiveness of a preventative program for groin pain syndrome in elite youth soccer players: a prospective, randomized, controlled, single-blind study. Healthcare (Basel). 2023;11(17):2367.
  46. ↑ 46.0 46.1 Maloy W, Merrigan B, Hulsopple CD. Groin pain and injuries: evaluation and management. American Family Physician. 2025 Apr;111(4):337-43.
  47. ↑ 47.0 47.1 Forsythe B, Hand C, Bohn C, et al. Adductor Injuries in Major League Soccer: A 10-Year Analysis of Injury Rate and Return to Play, and Performance Metrics by Player Position. Orthopaedic Journal of Sports Medicine. 2025;13(8).
  48. ↑ 48.0 48.1 48.2 Colberg RE. Hip adductor strain. In: Frontera WR, Silver JK, Rizzo TD Jr, editors. Essentials of Physical Medicine and Rehabilitation. 4th ed. Philadelphia (PA): Elsevier; 2020. p. 297–302. doi:10.1016/B978-0-323-54947-9.00053-5.
  49. ↑ 49.0 49.1 49.2 Serner A, Mosler AB, Tol JL, Bahr R, Weir A, Hölmich P, et al. Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis. Br J Sports Med. 2019;53(3):158-64.
  50. ↑ Jokela A, Pasta G, Della Villa F, et al. Mechanisms of severe adductor longus injuries in professional soccer players: a systematic visual video analysis. Orthop J Sports Med. 2025;13(2):23259671241309647.
  51. ↑ Mechó S, Balius R, Bossy M, et al. Isolated adductor magnus injuries in athletes: a case series. Orthop J Sports Med. 2023;11(1):23259671221138806.
  52. ↑ Corcoran D, McNamara T, Feehan J, Tripodi N. Adductor magnus: extending the knowledge–a short review of structure and function. International Journal of Osteopathic Medicine. 2023 Sep 1;49:100671.
  53. ↑ Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin injuries in sports medicine. Sports Health. 2010;2(3):231-6.
  54. ↑ Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports health. 2016 Jul;8(4):313-23.
  55. ↑ Finnern LS, Wilke J, Willwacher S, Pasanen K, Hollander K, Dalos D, Welsch GH, Krosshaug T, Edouard P, Gronwald T, Hoenig T. Qualitative and quantitative situational characteristics of muscle strains in sports: a systematic review and meta-analysis. British Journal of Sports Medicine. 2026 Jan 20.
  56. ↑ Tong S, Sun Y, Kuang B, Wang M, Chen Z, Zhang W, Chen J. A comprehensive review of muscle–tendon junction: Structure, function, injury and repair. Biomedicines. 2024 Feb 12;12(2):423.
  57. ↑ Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, Yamashiro E, Hölmich P. Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes. Scandinavian journal of medicine & science in sports. 2018 Feb;28(2):667-76.
  58. ↑ 58.0 58.1 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.
  59. ↑ Billone LM, Allred SJ, Flores DV. US of acute tendon tears. RadioGraphics. 2024 Nov 29;44(12):e240060.
  60. ↑ Davies AG, Clarke AW, Gilmore J, Wotherspoon M, Connell DA. imaging of groin pain in the athlete. Skeletal radiology. 2010 Jul;39(7):629-44.
  61. ↑ McKeever H. Differential diagnosis—Is it the pelvic floor, the hip, or the groin?. In Sports Medicine and the Pelvic Floor 2026 Jan 1 (pp. 221-240). Academic Press.
  62. ↑ Dinis J, Oliveira JR, Choupina B, Marques PS, Sá D, Sarmento A, Seabra P. Athletes with adductor-related groin pain: a narrative review. Cureus. 2024 Sep 4;16(9).
  63. ↑ Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. British journal of sports medicine. 2007 Apr 1;41(4):247-52.
  64. ↑ 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-.
  65. ↑ Bisciotti GN, Chamari K, Cena E, Garcia GR, Vuckovic Z, Bisciotti A, Bisciotti A, Zini R, Corsini A, Volpi P. The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review. Biology of sport. 2021 Mar;38(1):45-63.
  66. ↑ Nogueira Carrer HC, Zanca GG, Haik MN. Clinical Assessment of Chronic Musculoskeletal Pain—A Framework Proposal Based on a Narrative Review of the Literature. Diagnostics. 2022 Dec 26;13(1):62.
  67. ↑ Branci S, Thorborg K, Nielsen MB, Hölmich P. Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature. British journal of sports medicine. 2013 Jul 1;47(10):611-9.
  68. ↑ White LM, Naraghi AM, Mohankumar R, Bleakney RR. Imaging findings of sports-related acute core muscle injuries. Skeletal Radiology. 2026 May 9:1-6.
  69. ↑ Serner A, Roemer FW, Hölmich P, Thorborg K, Niu J, Weir A, Tol JL, Guermazi A. Reliability of MRI assessment of acute musculotendinous groin injuries in athletes. European radiology. 2017 Apr;27(4):1486-95.
  70. ↑ Branci S, Thorborg K, Bech BH, Boesen M, Nielsen MB, Hölmich P. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. British journal of sports medicine. 2015 May
  71. ↑ Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. British journal of sports medicine. 2011 May 1;45(6):478-91.
  72. ↑ Thorborg K, Branci S, Stensbirk F, Jensen J, Hölmich P. Copenhagen hip and groin outcome score (HAGOS) in male soccer: reference values for hip and groin injury-free players. Br J Sports Med. 2014;48(7):557-559.
  73. ↑ Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. British journal of sports medicine. 2011 May 1;45(6):478-91.
  74. ↑ 74.0 74.1 74.2 74.3 Suarez JC, Ely EE, Mutnal AB, Figueroa NM, Klika AK, Patel PD, Barsoum WK. Comprehensive approach to the evaluation of groin pain. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2013 Sep 1;21(9):558-70.
  75. ↑ McCarney L, Andrews A, Henry P, Fazalbhoy A, Selva Raj I, Lythgo N, Kendall JC. Determining Trendelenburg test validity and reliability using 3-dimensional motion analysis and muscle dynamometry. Chiropractic & Manual Therapies. 2020 Oct 19;28(1):53.
  76. ↑ Varadarajan B, Mohd Noor S, Manickaraj N. Passive hip adduction flexibility impairment measured with the modified Ober test predicts chronicity of iliotibial band syndrome: a cross-sectional pilot study. Physiotherapy Theory and Practice. 2025 Dec 31:1-8.
  77. ↑ Wang TG, Jan MH, Lin KH, Wang HK. Assessment of stretching of the iliotibial tract with Ober and modified Ober tests: an ultrasonographic study. Archives of physical medicine and rehabilitation. 2006 Oct 1;87(10):1407-11.
  78. ↑ Shanmugaraj A, Shell JR, Horner NS, Duong A, Simunovic N, Uchida S, Ayeni OR. How useful is the flexion–adduction–internal rotation test for diagnosing femoroacetabular impingement: a systematic review. Clinical Journal of Sport Medicine. 2020 Jan 1;30(1):76-82.
  79. ↑ Bauer R, Wolfram S. Palpation of the Musculature. In Atlas of Palpation 2024 Oct 29 (pp. 101-193). Berlin, Heidelberg: Springer Berlin Heidelberg.
  80. ↑ Oliva-Lozano JM, Dominguez S, Paul D, Cost R, Gómez-Carmona C. Hip adductor strength tests used in the context of sports: practical considerations. International Journal of Sports Medicine. 2025 Mar 16.
  81. ↑ Thorborg K, Petersen J, Magnusson SP, Hölmich P. Clinical assessment of hip strength using a hand-held dynamometer is reliable. Scand J Med Sci Sports. 2010;20(3):493-501.
  82. ↑ Wichita, groin squeeze test. Access from https://www.youtube.com/watch?v=GwxrgZ_XgOU
  83. ↑ 83.0 83.1 Hölmich P. Groin injuries in athletes—development of clinical entities, treatment, and prevention. Dan Med J. 2015 Dec 1;62(12):B5184.
  84. ↑ Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports health. 2016 Jul;8(4):313-23.
  85. ↑ Masuku P, Schellack N, Mogale K, Mokwele N, Skosana P. Hands on management of muscle pain and injuries. South African Family Practice. 2018 Sep 1;60(5):26-36.
  86. ↑ 86.0 86.1 Kiel J, Kaiser K. Adductor Strain. 2018
  87. ↑ Bisciotti GN, Chamari K, Cena E, Garcia GR, Vuckovic Z, Bisciotti A, et al. The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review. Biol Sport. 2021;38(1):45-63.
  88. ↑ Bisciotti GN, Chamari K, Zini R, Corsini A, Auci A, Bisciotti AL, Bisciotti AN, Cena E, Rodriguez Garcia G, Volpi P, Vuckovic Z. Adductor longus tenotomy in the treatment of groin pain syndrome in athletes: a systematic review. Joints. 2023;1:e602.
  89. ↑ Atkinson HD, Johal P, Falworth MS, Ranawat VS, Dala-Ali B, Martin DK. Adductor tenotomy: its role in the management of sports-related chronic groin pain. Archives of orthopaedic and trauma surgery. 2010 Aug;130(8):965-70.
  90. ↑ Queiroz RD, Carvalho RT, Queiroz Szeles PR, Janovsky C, Cohen M. Return to sport after surgical treatment for pubalgia among professional soccer players. Revista brasileira de ortopedia. 2014 May;49:233-9.
  91. ↑ Bastia P, Ghirarduzzi P, Schiavi P, Donelli D, Pedrazzini A, Leigheb M, Ceccarelli F, Pogliacomi F. Surgical or conservative treatment in ARGP syndrome? A systematic review. Acta Bio Medica: Atenei Parmensis. 2019;90(Suppl 12):14.
  92. ↑ Dubois B, Esculier JF. Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine. 2020 Jan 1;54(2):72-3.
  93. ↑ Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries: biology and treatment. The American journal of sports medicine. 2005 May;33(5):745-64.
  94. ↑ Tedeschi R, Giorgi F, Platano D, Berti L, Donati D. Optimizing conservative management of groin pain in athletes: insights from a narrative review. Life. 2025 Mar 6;15(3):411.
  95. ↑ Almeida MO, Silva BN, Andriolo RB, Atallah ÁN, Peccin MS. Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain. Cochrane database of systematic reviews. 2013(6).
  96. ↑ Smith BE, Hendrick P, Bateman M, Holden S, Littlewood C, Smith TO, Logan P. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British journal of sports medicine. 2019 Jul 1;53(14):907-12.
  97. ↑ 97.0 97.1 97.2 97.3 Serner A, Weir A, Tol JL, et al. Return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes: a prospective cohort study. Orthop J Sports Med. 2020;8(1):2325967119897247.
  98. ↑ McSweeney SE, Naraghi A, Salonen D, Theodoropoulos J, White LM. Hip and groin pain in the professional athlete. Canadian Association of Radiologists Journal 2012;63(2):87-99.
  99. ↑ 99.0 99.1 99.2 King E, Franklyn-Miller A, Richter C, O’Reilly E, Doolan M, Moran K, Strike S, Falvey É. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. British journal of sports medicine. 2018 Aug 1;52(16):1054-62.
  100. ↑ 100.0 100.1 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;1-10.
  101. ↑ Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, Krogsgaard K. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. The Lancet. 1999 Feb 6;353(9151):439-43.
  102. ↑ The Prehab Guys. 3 Exercises to Prehab your Adductor Strain / Groin Pain. Available from https://www.youtube.com/watch?v=f2e_oi2FbPM
  103. ↑ Delmore RJ, Laudner KG, Torry MR. Adductor longus activation during common hip exercises. Journal of sport rehabilitation 2014;23(2):79-87.
  104. ↑ Natalie Wetzel.Adductor isometric exercise. Available from https://www.youtube.com/watch?time_continue=6&v=bmjGd7z7fHc
  105. ↑ Jason Craig Hip Adductor Strengthening in Side Lying. Available from https://www.youtube.com/watch?v=bP9W4-vgSgA
  106. ↑ Upright Health An exercise to safely strengthen your adductors.Available from https://www.youtube.com/watch?time_continue=4&v=jn22rqsaeV8
  107. ↑ Jensen J, Hölmich P, Bandholm T, Zebis MK, Andersen LL, Thorborg K. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. British Journal of Sports Medicine 2014;48(4):332-8.
  108. ↑ 108.0 108.1 108.2 Harøy J, Clarsen B, Wiger EG, Øyen MG, Serner A, Thorborg K, Hölmich P, Andersen TE, Bahr R. The adductor strengthening programme prevents groin problems among male football players: a cluster-randomised controlled trial. British journal of sports medicine 2019;53(3):150-7.
  109. ↑ Pereira GR, Leporace G, das Virgens Chagas D, Furtado LF, Praxedes J, Batista LA. Influence of hip external rotation on hip adductor and rectus femoris myoelectric activity during a dynamic parallel squat. The Journal of Strength & Conditioning Research 2010;24(10):2749-54.
  110. ↑ 2Fitathome.com Sumo Squats: Works your inner thighs, quads and glutes! Multiple Fitness Level Tutorial. Available from https://www.youtube.com/watch?v=MSC4X5k1QC4
  111. ↑ Krommes K, Bandholm T, Jakobsen MD, Andersen LL, Serner A, Hölmich P, Thorborg K. Dynamic hip adduction, abduction and abdominal exercises from the Holmich groin-injury prevention program are intense enough to be considered strengthening exercises–a cross-sectional study. International journal of sports physical therapy 2017;12(3):371.
  112. ↑ Kloskowska P, Morrissey D, Small C, Malliaras P, Barton C. Movement patterns and muscular function before and after onset of sports-related groin pain: a systematic review with meta-analysis. Sports Medicine 2016;46(12):1847-67.
  113. ↑ eHowFitness How to Do Thigh Abduction & Adduction Exercises With Bands : Stretching & Exercise. Available from https://www.youtube.com/watch?time_continue=6&v=HE-8qeIZo3o
  114. ↑ 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.
  115. ↑ Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. The American journal of sports medicine. 2010 Oct;38(10):2051-7.
  116. ↑ 116.0 116.1 Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. British journal of sports medicine. 2015 Jun 1;49(12):803-9.
  117. ↑ Hölmich P, Larsen K, Krogsgaard K, Gluud C. Exercise program for prevention of groin pain in football players: a cluster‐randomized trial. Scandinavian journal of medicine & science in sports. 2010 Dec;20(6):814-21.
  118. ↑ 118.0 118.1 118.2 118.3 118.4 Estévez Rodríguez JL, Rivilla García J, Jiménez-Sáiz SL, Jiménez-Rubio S. Consensus of return-to-play criteria after adductor longus injury in professional soccer. Sports (Basel). 2025;13(5):134.
  119. ↑ Muscles of the hip and thigh video - © Kenhub https://www.kenhub.com/en/library/anatomy/hip-and-thigh-muscles
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