Introduction to Athletic Groin Pain
Athletic Groin Pain (AGP) is a term which refers to general groin pain around the crease of the leg and pelvis and the lower abdominal region. AGP has an incidence of up to 23% across all sports, is predominant in movements such as cutting and kicking, and is more prevalent in males than females. Although the name denotes to its high prevalence in athletic populations, Athletic Groin Pain is still an evident injury in both the weekend warrior and general populations alike.
What is Athletic Groin Pain?
Simply put, the terminology and understanding of AGP was confusing for a long time – right up until 2015 in fact – when the terminology and definitions of AGP were clearly laid out at the Doha Agreement Meeting on Groin Pain. Specifically relating to athletes in this case, three major subheadings of groin pain were outlined:
- Defined clinical entities for groin pain
- Hip-related groin pain
- Other causes of groin pain in athletes.
#1 – Defined clinical entities for groin pain
This denotes to the particular sites of pain and their relations to the development of Athletic Groin Pain. Clinical entities include:
- Adductor-related groin pain
- Iliopsoas-related groin pain
- Inguinal-related groin pain
- Pubic-related groin pain.
Adductor-related groin pain: adductor tenderness (near corner/crease of leg and crotch) and pain on resistance testing (e.g. adductor squeeze tests). Adductor palpation will likely produce positive tenderness results.
Iliopsoas-related groin pain: iliopsoas tenderness (high hip flexor region just above waist line), pain on resisted hip flexion and/or pain on stretching hip flexors.
Inguinal-related groin pain: canal pain and canal tenderness, but no palpable hernia. A resisted sit-up test (e.g. pushing against partner’s resistance) may produce inguinal-related pain.
Pubic-related groin pain: local tenderness of the pubic symphysis and adjacent bone. Palpation of the symphysis joint will likely produce positive tenderness results.
#2 – Hip-related groin pain
It would be wise to always consider the hip when assessing for Athletic Groin Pain. Furthermore, a detailed history of hip-related issues or injuries, along with a thorough hip examination will provide practitioners with relevant information regarding AGP. It must be noted that a decrease in hip internal rotation ability may be present in up to 85% of AGP cases, with hip stiffness relating to poor hip internal rotation seen as a risk factor for AGP.
FADIR (flexion, adduction and internal rotation) and FABER (flexion abduction and external rotation) tests may prove a useful tool during hip examination for a couple of reasons: firstly, negative results are useful in the exclusion of the hip’s relationship to the groin pain; and secondly, positive FADIR (flexion, adduction and internal rotation) and FABER (flexion abduction and external rotation) test results may link the groin pain to the hip. This provides us then with two scenarios:
- Femoral acetabular impingement (FAI). This presents as hip pain felt in the groin and is linked to up to 20% of AGP
- Stiff painless hip, which may contribute to groin pathology. Findings highlight a decrease in hip internal rotation in up to 85% of AGP cases, it is therefore considered a risk factor.
Additional to these potential outcomes, Cam or Pincer morphology at the hip joint could also play a role in AGP. Fair to say that the hip should not be excluded when assessing for Athletic Groin Pain.
How can we treat this? Rehabilitation targeting intersegmental control
Research by King et al (2018) on 205 AGP males with various clinical entities, anatomic diagnoses and movement clusters focused on a phased rehabilitation protocol. The rehab targeted the following (in order):
- Level 1: Intersegmental control and strength
- Level 2: Linear running mechanics and load tolerance
- Level 3: Multidirectional mechanics and sprinting.
Level 1 requires subjects to complete a number of exercises, focusing on stabilising and strengthening both specific areas of the body, and also the full body moving as a unit. By increasing neuromuscular control, patients will be able to link the various segments of the body together to create a foundation of strength and stability, which is essential to bulletproof the body long-term. Each exercise has progressions and regressions, so it allows for anyone to come in at various levels of base strength. Level 1 exercises should be included throughout the duration of the rehabilitation program, provided the individual is fully competent to maintain with one session per week.
Level 2 begins with linear running drills, focusing on lumbo-pelvic control and posture, leg swing recovery and increased rate of force development. In lay terms, there is a large emphasis on quality of movement during running. This is to ensure that a high technical standard is achieved and maintained for the future, further minimising risk of re-injury. The goal here, from a loading perspective, is to build a base of running volume and to increase tolerance to running. Level 2 starts with low volume and low intensity, both of which increase at different times throughout the program.
Note: subjects must be able to tolerate each level before progressing. If any subject has an increase in symptoms the morning after the run, then they must repeat the same running session when scheduled until they can tolerate (i.e. no increase in symptoms the morning after).
In level 3, linear running speed intensity increases. A reduction in volume occurs to coincide with the intensity increase. Level 3 also introduces multidirectional running drills, with a clear focus on segmental control, lateral rate of force development and improvements in agility. It’s essential that the body develops these capacities before returning to sports-specific movements. These exercises are instructed to be executed at as high an intensity as possible without reproduction of symptoms.
Frequency: 4x per week (two days on, 1 day off)
Sets/reps: 3-4 sets of 6-8 reps
Frequency: 3x per week (at least one day off between sessions). Can be done on the same day or another day as Level 1 session.
Sets/reps (linear drills): 3-4 sets of 5-6 reps.
Frequency: 3x per week (at least one day off between sessions).
Sets/reps: 3-4 sets of 5-6 reps.
It goes without saying that prevention is always better than management when it comes to injuries by bullet-proofing the body. Regular resistance training, in conjunction with linear and multidirectional running drills that are challenging in nature, will provide both athletes and general populations with a solid foundation for long-term health and performance.
At Absolute Health & Performance, each and every one of our exceptional Performance Coaches, Physiotherapists and Osteopath have experience working with both athletes and general populations through injury and performance alike. If you are sick and tired of groin pain affecting your performance or preventing you from participation altogether, then book in for an assessment consult with one of our highly-regarded Sports Physicians before beginning your rehabilitation program with our expert multidisciplinary team.
Written by Performance Coach Jonathan Stahl
- King, E., Franklyn-Miller, A., Richter, C., O’Reilly, E., Doolan, M., Moran, K., Strike, S. & Falvey, E. (2018). Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. British Journal of Sports Medicine, 0, 1-9. doi:10.1136/bjsports-2016-097089
- Braun, P. (2019, April 3). Assessment of Athletic Groin Pain [lecture slides].