Groin Pain: Into the Bermuda Triangle Part 1

This blog is part of a series on groin pain by Jim Scanlan, Physiotherapist.  Keep an eye out for monthly releases in this series!

Diagnosing, managing & rehabilitating injuries in the Bermuda triangle

Keywords: Groin Pain; Adductor; Rehabilitation


Sports involving rapid acceleration, deceleration or sudden changes in direction commonly result in groin injuries (1).  This includes football (soccer) (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), (12) & (13); rugby league (14); Australian rules football (15); ice hockey (16); Gaelic football and cricket (16) & (17).  Athletes with a previous groin injury are at a greater risk than those with no previous history (up to 2.4 times greater over consecutive seasons within football) (11).  The diagnosis of groin injuries is complex with a multifactorial aetiology (18).  This blog is the first in a series discussing some of these complexities, along with management and rehabilitation strategies. Beginning with adductor related groin pain (ARGP).

Adductor Related Groin Pain (ARGP):

ARGP is defined as adductor tenderness and pain on resisted adduction testing (see Figure 1) (18).  ARGP has an incidence of between 3 and 23% (19), (20) & (21) more commonly affecting young to middle-aged athletic males compared to females.  Certain sports, such as football, have a yearly incidence of 10-18% (21) with approximately 53% of ARGP within football being from overuse (22).

Figure 1: Groin Pain (Weir A, Brukner P, Delahunt E, et al, 2015) (18)

The Copenhagen ‘Hip and Groin Outcome Score’ (HAGOS) (23) is a patient reported outcome measure with six separate subscales, assessing pain; symptoms; physical function in daily living; physical function in sport and recreation; participating in physical activities and hip and / or groin quality of life.  It has substantial test-retest reliability with adequate measurement qualities for use with physically active, young to middle-aged patients with long-standing hip and / or groin pain.

As defined by Weir et al. (2015) (18) ARGP was found to be the most common clinical entity (61% of athletes) (24) , with the vast majority of these athletes being male (98%) football (60%) players.  There were multiple causes for the ARGP. Unfortunately study quality on groin injury management has been historically low (25). This could be because there is a close and complex relationship between ARGP and Pubic Related Groin Pain, along with other aspects of groin pain such as iliopsoas and inguinal.  

The most efficacious treatment for long-standing ARGP is exercise therapy.  There is insufficient  evidence within the literature to recommend a specific exercise protocol or modality (19).  However the exercises described in the modules from Hölmich et al (1999) (26) and iteration (27) appear to be beneficial, regarding reduction in pain and return to sport without groin pain at 16 week follow up in comparison to passive treatments (exercise stretching, electrotherapy and transverse friction massage).  Emphasis should be paid to adductor eccentric strength in particular (27).  Use of The ‘Copenhagen Adduction’ (CA) exercise (see Figure 2) reduced the prevalence and risk of groin problems in male footballers by 41% (28).

Figure 2: The Copenhagen Adduction Exercise (A) starting / ending position and (B) mid positions, for the different levels of the adductor strengthening programme (Haroy J, Clarsen B, Wiger EG, et al, 2019) (28)

Rehabilitation focused on inter-segmental control has been associated with improved HAGOS (23) scores and good rates of pain-free return to sport across (29) a variety of groin pain diagnoses (18).

SSC Sports Medicine Groin Lab – 180 Cut Series – YouTube (29)

For those patients wanting to return to sport the ‘Strategic Assessment of Risk and Risk Tolerance’ (StARRT) Framework, established in 2016 (30), is a good starting point for making return to play decisions post ARGP (see Figure 3).

Figure 3 Strategic Assessment of Risk and Risk Tolerance Framework (Ardern CL, Glasgow P, Schneiders A, et al. 2016) (30)


  • Groin pain has clearly defined clinical entities.  Groin injuries are complex with a multifactorial aetiology.
  • HAGOS is a valid tool to monitor long-standing groin pain rehabilitation.
  • The most efficacious treatment for long-standing ARGP is exercise therapy.

Acknowledgements: Thank you to the Association Chartered Physiotherapists in Sports and Exercise Medicine @physiosinsport for their support in publishing this Blog.

Competing Interests: None

Jim Scanlan NHS Fife Advanced Practitioner Physiotherapist in General Practice

MSc; BSc (Hons); Pg Dip Orho Med; Pg Dip Injection Therapy; IRMER Certified; 

HCPC; MCSP; ACPSEM: Silver Accreditation. Twitter: @jim_physio


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