Overview

At Motus Health and Performance, our physio team is experienced in screening, diagnosing and treating groin injuries in footballers, young and old. An accurate diagnosis is vital to guide management and return to training and play. This blog post will outline the anatomy of the groin, the types of groin injuries, and treatment options. If any of your questions aren’t answered here, please reach out to our team!

The ‘DOHA agreement’ is a global consensus statement that we use at Motus Health and Performance to guide our assessment and treatment of groin pain. This statement found groin pain to be present in 12.8% of males and 6.9% of women, with athletes involved in kicking sports such as football and AFL having a much higher incidence of groin pain. Specifically in footballers, groin pain accounted for 4–19% of all injuries for males and 2–14% in females.   

ANATOMY

The groin, also known as the inguinal region, is located at the junction of the abdomen and the inner thigh. It is defined by several anatomical structures, including muscles, tendons, ligaments, and nerves. Key structures in the groin include the inguinal ligament, which runs from the anterior superior iliac spine to the pubic tubercle, the hip flexor, the adductor muscle group and the pubic symphysis. 

 

WHAT ARE THE TYPES OF GROIN INJURY?

Adductor Related Groin Pain (Adductor Strains)

Adductor related groin pain is caused by a strain to the adductor muscles or an irritation to the adductor tendon (adductor tendinopathy). A muscle strain will present lower down on the inner thigh and commonly has an acute mechanism (e.g. overstretching), whereas a tendon irritation will present much higher up (near the attachment point) and is often caused by training overload.

 

Hip Flexor Related Groin Pain

Groin pain can also be caused be an aggravated hip flexor muscle. Whilst the hip flexor isn’t a part of the adductor muscle group itself, as it is in close proximity to the inner thigh, a strained or irritated hip flexor can commonly refer pain into the groin region.

 

Abdominal (inguinal) Related groin pain

Similar to the hip flexor, groin pain can be referred from the abdominal region. Causes for this include inguinal ligament injuries or inguinal hernias. Abdominal related groin pain is often brought on by coughing and sneezing or with loaded abdominal movements (e.g. a sit up).

 

Hip Joint Related Groin Pain

Hip joint related groin pain is caused by an irritation to the ball and socket capsule of the hip joint itself. This can be caused by a variety of factors including FAI and labral irritations and can commonly refer down into the groin region.

 

Pubic Symphysis Related Groin Pain

The pubic symphysis is a cartilaginous joint that connects the left and right pubic bones at the front of the pelvis. It can contribute to groin pain when subjected to excessive stress which is often experienced by athletes involved in sports requiring repetitive twisting or kicking motions such as football.

 

Pubic Aponeurosis

The pubic aponeurosis is a thin, fibrous structure that connects the pubic bones and is a junction that provides an attachment for muscles of the abdomen and groin regions. The pubic aponeurosis can be irritated due to overuse or trauma and has been shown in some studies to be the causal factor of 62.8% of groin pain in an athletic cohort.

 

Pubic Apophysitis

Apophysitis is a general term describing an inflammation or stress injury to the areas around growth plates in children and adolescents. Pubic apophysitis is an irritation to the growth plate at the front of the hip, with the most common location in footballers being the anterior inferior iliac spine. This condition is a common cause of groin pain in young athletes involved in kicking sports.

 

 

COMMON CAUSES OF GROIN INJURY 

Often the mechanisms of injury involve:

  • Overstretch / powerful contraction. An acute overstretching mechanism such as lunging for a ball with an outstretched leg, a powerful kicking movement or forcefully pushing laterally can cause a muscle strain. This is the most common cause of adductor related or hip flexor related groin pain. 
  • Overuse. When engaging in sports involving repetitive kicking and twisting, such as football, a sharp increase in training load and/or a lack of rest between training bouts can lead to the onset of groin pain. This will often be the cause of adductor tendinopathy, abdominal (inguinal) related groin pain, hip joint related groin pain, pubic symphysis related groin pain, pubic aponeurosis or pubic apophysitis.
  • Direct trauma. A direct and forceful impact to the abdomen can be a cause of abdominal related groin pain, however this is rare as abdominal irritations are more commonly caused from an excess in forceful twisting movements as outlined above. 

 

WHAT ARE THE GRADES OF ADDUCTOR MUSCLE STRAIN AND THE ASSOCIATED SYMPTOMS?

If a muscle strain is present, a physiotherapy assessment can help to indicate the grade of the strain. The grade of injury and return to activity goals of the individual will dictate the appropriate treatment, so this is an important step. 

The grade is based on the amount of damage to the muscle fibres.
The following explains the classification system and typical signs and symptoms we see with each. 

GRADE 1

  • No loss of strength or function 
  • Sharp sensation brought on by an acute mechanism (e.g. kicking)
  • Mild pain in the groin region during adductor squeeze testing 
  • Groin squeeze testing with the force dynamometer brings on pain but there is no significant loss in strength when comparing to the uninjured side

GRADE 2

  • Loss in strength and function 
  • Severe sharp sensation brought on by an acute mechanism (e.g. kicking)
  • Moderate to severe pain in the groin region that worsens significantly with adductor squeeze testing 
  • Decreased adductor strength shown on force dynamometer testing when compared to uninjured side
  • Muscle fibre disruption may be seen and felt 
  • Bruising may be present 

GRADE 3 

  • Full thickness muscle tear 
  • Complete loss in strength and function 
  • Severe pain and inability to continue activity brought on by an acute mechanism (e.g. kicking)
  • Unable to complete dynamometer strength testing 
  • Significant muscle fibre disruption present 
  • Significant bruising may be present 
  • Full thickness tears often occur at the muscle weak point, which are the musculotendinous junctions near the attachments of the adductor at the hip and knee

 

HOW SHOULD YOU MANAGE GROIN PAIN OR INJURY? 

Management for groin pain will differ significantly depending on which type and cause of pain is present. Most conditions will require some relative rest from activity (pending on severity), followed by a specific graded rehabilitation program. A key component of most groin rehabilitation, especially for footballers, is rehabilitation running. Groin pain has been shown to have a high correlation with movement patterns and ensuring athletes correct any biomechanical factors which can predispose them to a higher risk of groin injuries. 

At Motus Health and Performance, we run a unique, 6 level return to running program, on field with our clients recovering from injury or surgery so we can coach correct technique, and so you’re not toughing it out alone, but with other clients with the same objectives as you. These progressive levels of our running program involve a structured exposure to the situations and environments that will challenge the groin the most. Often these positions and movements are where the injury initially took place. All accelerating, decelerating, change of direction, skills, and fitness elements of your sport and activity will be gradually re-introduced here. This ensures your physical performance is inline with your confidence, which helps to lower the chance of re-injury and ensure return to performance at the same level as before.


The final step of management is ensuring you’re across a thorough warm up, and injury prevention program to continue with after physiotherapy treatment which helps to prevent recurring groin injuries.

WHEN SHOULD WE SCAN? 

Physiotherapists can gain a lot of information to clinically diagnose your injury with a thorough assessment and often with groin injuries, there is no need for imaging. However, there may be instances where further investigation through imaging is required. This will depend on the suspected cause and severity of your pain. 

IS THERE A ROLE FOR TAPING MY GROIN INJURY? 

There are varying opinions when it comes to this topic, however we feel it depends on the prognosis, severity and type of the injury. Taping is not particularly common for groin injuries when compared to other lower limb complaints, but there may be instances when it can be used with returning to play! We offer taping only sessions in our clinic if this is something you need help with. Whether you’ve got a match coming up, or just need a bit of support for everyday activities, we’ve got you!

WHY YOU SHOULD SEE A PHYSIO FOR ANY GROIN RELATED PAIN OR INJURY

Most of the causes of groin pain outlined above require accurate treatment in the acute phase following injury, because, if treated poorly, groin injuries have a decreased chance of successful return to sport, and a high likelihood of re-injury. 

Seeing a Physio soon after the injury will enable pain relieving treatment, and the appropriate level of exercise focused rehabilitation to be prescribed. We use a variety of treatment modalities to manage pain, swelling and stiffness, allowing you to continue with school / work and other activities. From here, we lead and support you through a graded exercise rehabilitation program all the way through to returning to run, and ultimately sport – because we know what’s needed to get you back doing what you love!