Every football and rugby player knows the script. A twinge in the groin, a diagnosis of “groin strain,” a few weeks of rest, and then the slow, frustrating realisation that the problem is not going away. Months pass. Performance drops. The same pain returns. The issue is not that the injury is untreatable, but that the label “groin strain” is too imprecise to guide effective management.
This article treats groin pain not as a single entity, but as a region with three distinct diagnostic categories: adductor-related pain, hip joint pain (including femoroacetabular impingement and labral pathology), and pubic or abdominal wall pain. These conditions present with overlapping symptoms but demand entirely different examinations, imaging decisions, and treatment pathways. We will examine how the Doha agreement and recent ESSKA guidance separate these pathways, what the evidence still cannot settle, and when specialist assessment is essential. At PSM, our professional-sport level assessment, diagnostics, treatment, and rehabilitation bring clarity to this diagnostic challenge, helping patients understand their problem and make informed decisions about their return to performance.
Why Groin Strain Is a Label, Not a Diagnosis
Hip and groin pain accounts for up to 10% of consultations in sports medicine and is most common in young and middle aged active people, a population that includes most footballers and rugby players at some stage of their playing life. That scale alone makes precision worthwhile. The difficulty is that precision has been slow to arrive. A systematic review conducted for the Doha agreement found 33 different terms used for groin pain diagnosis across 72 studies, with colloquial labels such as athletic pubalgia, sports hernia and core muscle injury sitting alongside more formal terms. These labels are not interchangeable. They imply different tissues, different mechanisms and, too often, different treatment plans.
The consensus process has improved things, and it is worth being clear about how far. The Doha agreement meeting, held in November 2014 and published in 2015, brought 24 experts from 14 countries together and established shared terminology and a clearer clinical framework. What they did not do was settle the underlying questions. Diagnostic work up remains challenging because of complex regional anatomy, multiple possible contributors and the high prevalence of imaging abnormalities in asymptomatic athletes. Terminology was harmonised. Diagnostic uncertainty was not eliminated.
Applied before a structured examination, the label groin strain pre-empts the differential rather than narrowing it, so the actual source of pain may sit in the hip joint, the adductor origin or the pubic and abdominal wall.
The 2024 ESSKA-EHPA-ESMA consensus carries real weight here. Its panel of 57 experts from 22 countries worked in steering, rating and reader groups and included hip surgeons, sports medicine doctors, hernia surgeons, radiologists and physiotherapists, with the resulting 13 statements graded through formal consensus. It is framed as a reference frame rather than a strict guideline, and it is worth reading alongside specialist musculoskeletal radiology input when imaging decisions arise.
One caution on language. Clinicians commonly describe unresolved groin pain as becoming a six month problem, but that is a pattern observed in practice, not a published statistic, and it is worth weighing as clinical experience rather than as evidence. The more defensible claim is that a label applied too early tends to delay the examination that would have separated these pathways in the first place.
How the Doha Categories Map Onto Three Clinical Pathways
That distinction matters because Doha is used clinically as four named groin entities plus hip-related pain: adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain, with hip-related pain alongside them (AMSSM Doha Agreement case listing). This article simplifies that list into three pathways: adductor, hip joint, and pubic and abdominal wall. It is a reader-facing simplification, not a replacement for the Doha terms. The grouping sorts categories by the clinical decisions they drive, not by anatomy alone, so examination sequence and initial loading follow the pathway rather than the site of pain.
Iliopsoas-related pain is not omitted. For routing purposes it is carried with the adductor pathway, because both are extra-articular and load-sensitive, but hip flexor and iliopsoas enthesopathy presentations shift the examination emphasis and the loading programme that follows. A hip flexor enthesopathy is not rehabilitated as an adductor origin problem merely because both produce groin pain.
Inguinal-related pain belongs inside the pubic and abdominal wall pathway. It involves the inguinal canal and posterior wall and overlaps heavily with pubic presentations, so the two are assessed and managed as one load problem rather than separate silos.
The categories are not exclusive. Adductor enthesopathy, pubic change and intra-articular hip pathology frequently co-exist. A category therefore describes the dominant pattern, not an either-or answer; management may need sequencing rather than a single label. A specialist assessment will usually record a mixed picture, such as adductor-related pain with pubic involvement, rather than forcing the patient into one box.
The Aspetar state-of-play review, published in October 2026, is explicit that it is not an updated consensus and that uncertainty persists about anatomy, diagnostic testing, imaging interpretation and management (Aspetar review). The exact structure generating pain can be difficult to pin down. That is a reason for careful sequencing, examination and reassessment over time, not for confident labelling. The sections that follow take each pathway in turn, beginning with the adductor.
Adductor-Related Groin Pain: What the Examination Actually Shows
Within that adductor category, the examination is more specific than the label suggests. Adductor-related pain is typically reported at the origin near the pubic attachment, after kicking, sprinting or repeated change of direction, and is provoked by squeezing the legs together. A 2026 IJSPT clinical commentary on adductor-related athletic groin pain (DOI 10.26603/001c.167118) highlights why this presentation is challenging to separate from neighbouring sources: complex regional anatomy and overlapping clinical features.
Adductor squeeze testing is the reference test for the adductor-related category in the Doha framework. It is performed at controlled loads and compared side to side, and the Copenhagen adduction test adds a higher-load adduction challenge. Palpation of the proximal origin and side-to-side adduction strength testing complete the picture. The history should track load progression, a principle equally visible in our calf tear return-to-race case.
Adductor-related groin pain remains a clinical diagnosis. Ultrasound or MRI is used to clarify atypical behaviour, exclude other sources or quantify tendinopathic change, and not to make the diagnosis alone. Imaging findings must be matched to the examination because tendon change can be present without pain.
What separates it from the other pathways is the behaviour: provocation by adduction load and relief with load modification, without true clicking, catching or deep joint pain, and usually without inguinal canal tenderness. If those features are present, the hip joint or pubic and abdominal wall pathways need testing before the adductor label is accepted.
Hip Joint Pain: When the Problem Is Inside the Joint
Where adductor-related pain is provoked by adduction load and eases with load modification, pain arising inside the joint behaves differently from the first step of the examination.
Presentation
Intra-articular pain is typically felt deep in the groin or anterior hip. Patients tend to point deep into the hip rather than to the adductor origin. Catching, clicking, giving way and stiffness are common, as is pain in a deep squat or after prolonged sitting. Provocation is not confined to adduction.
Examination
FADIR (flexion, adduction and internal rotation) is the standard provocative test for intra-articular hip pain, with FABER used in support. Internal rotation range is measured and compared side to side, because restriction points towards the joint rather than the tendon.
What sits inside the joint
Cam and pincer morphology, labral pathology, chondral damage and early osteoarthritis. Recent ESSKA guidance addresses FAI and osteoarthritis definitions directly, and FAI syndrome requires symptoms, clinical signs and imaging findings together rather than morphology alone, as Aspetar’s clinical approach to hip-related groin pain sets out. Where chondral change and early osteoarthritis dominate, management runs along a separate pathway, including how viscosupplementation works in selected cases.
Imaging decisions
Plain radiographs with appropriate hip views assess morphology first; MRI or MR arthrography then details labral and chondral status in more depth. The ESSKA-EHPA-ESMA consensus specifies which investigations to request in a young active adult and notes that imaging is neither fully sensitive nor specific. Asymptomatic cam morphology is common in athletes, so findings must be interpreted against the examination.
Routing matters. Hip preservation has grown into a subspecialty, with more procedures performed, mostly on young and active patients, as the 2024 consensus report records. Treated as an adductor strain, intra-articular pain is loaded through a programme that cannot resolve it.
Pubic and Abdominal Wall Pain: The Overlooked Third Pathway
If the hip joint is the overlooked intra-articular source, the pubic and abdominal wall pathway is the overlooked extra-articular one. Pain sits at the pubic symphysis or lower abdominal wall and is provoked by trunk loading, coughing, sprinting, kicking and sudden changes of direction. It may refer into the inguinal canal, which is one reason it is mistaken for a hernia.
A naming problem, not just an anatomical one. This pathway carries the worst terminology: athletic pubalgia, sports hernia, core muscle injury, inguinal-related groin pain and osteitis pubis, labels that the assessment sequence below sorts into one pathway. Different labels imply different structures and different specialists, yet they often describe the same load problem at the same attachment.
Examination depends on sequence. Resisted sit-up or trunk flexion, palpation of the pubic symphysis and inguinal canal, and the squeeze test all feature. The squeeze test overlaps with adductor testing, so a specialist assessment sequences the examination deliberately: if adduction is tested first, pubic and inguinal findings can be masked, and if trunk flexion is tested first, the same patient may be labelled differently. Ask how the tests were sequenced and why.
Imaging is supportive, not decisive. Dynamic ultrasound can assess the inguinal canal and posterior wall, while MRI can show pubic bone marrow oedema and symphysis change in more detail. Imaging findings have to be read against history, examination and functional behaviour together.
One load problem, not two. Pubic and adductor findings frequently co-exist at the same bony attachment. Rehabilitation should therefore be programmed around a shared load problem, not two separate injuries, which changes progression and return-to-running decisions.
How the Diagnosis Changes the Plan
That overlap is exactly why management is routed by category, not by symptom location. Two athletes with near-identical pain in the same spot can reasonably follow very different plans.
Adductor-related pain is managed primarily through progressive, active exercise-led rehabilitation: loading the adductor origin through range and strength, then rebuilding tolerance to kicking and change of direction. Shockwave or a targeted injection is considered only in selected cases where pain is blocking the loading needed to progress, and never as a substitute for that loading.
Hip joint pain takes a different route. In selected patients an intra-articular injection may be used for diagnostic clarification or short term relief, and referral for hip arthroscopy is appropriate in some cases. Rehabilitation stays central either way. Knowing when that referral is worth considering is part of what a sports orthopaedic specialist assesses.
Pubic and abdominal wall pain normally begins with a structured trunk, pelvic control and loading programme. Posterior wall repair or laparoscopic hernia surgery is reserved for carefully selected cases, which is one reason hernia surgeons were included in the 2024 consensus expert groups.
Misrouting carries a real cost. Loading a hip joint problem as though it were an adductor strain, or resting a pubic load problem as though it were intra-articular, delays the correct programme and can turn a manageable presentation into a long one.
Progression within any of these pathways should be criterion-based rather than calendar-based, in the same way that hamstring rehabilitation advances by function rather than by weeks. The category sets the direction; the criteria set the pace.
What the Evidence Still Cannot Settle
Even with the routing logic above, the evidence base does not offer a tidy, settled answer. The evidence base leaves several areas genuinely unsettled: which structure is generating pain, how diagnostic testing should be interpreted, what imaging findings mean, and how to sequence management.
Terminology has proved stubbornly resistant to consensus. Experts asked to label identical clinical cases still chose very different descriptors depending on their professional background and country of training. It is therefore unsurprising that patients commonly arrive with a different name for the same presentation depending on which clinician they saw first.
The 2024 ESSKA-EHPA-ESMA consensus itself is best read as a reference frame rather than a strict guideline. It targets young active adults with hip or groin pain and explicitly excludes children and adolescents, so it is not a universal protocol for every age group or presentation. It gives structure to the diagnostic chain, not a definitive algorithm.
Imaging is where the ambiguity is most acute. Abnormal findings are common in asymptomatic athletes, and the consensus is clear that imaging is neither fully sensitive nor fully specific and must be interpreted alongside history and examination. Not every abnormal finding converts into a diagnosis, which means scans support clinical reasoning rather than replacing it.
The practical conclusion is that diagnosing groin pain is a process, not an event: history, structured examination, targeted imaging and reassessment over time. A single test or a single scan rarely settles the question, which is why specialist, multidisciplinary assessment matters when the picture stays unclear.
When to Seek Specialist Assessment
Given that even consensus bodies disagree on aspects of groin pain, the practical question becomes when to stop self-managing and seek specialist assessment. Specialist assessment is worth considering when pain persists or worsens despite a reasonable loading programme, when it recurs every time sport resumes, when deep joint pain comes with clicking or catching, or when the working diagnosis does not explain how the symptoms behave.
Some presentations need urgent medical review rather than a routine sports medicine appointment. Red flags include severe night pain, unexplained weight loss, fever, significant trauma, inability to weight bear and new neurological symptoms.
A good assessment begins with structured history: onset, aggravating and relieving factors, previous imaging and previous labels. That is followed by systematic examination of the adductor, hip joint and pubic and abdominal wall regions. Imaging decisions are made afterwards, not first, because the examination determines which structures need imaging and how any finding should be interpreted. If you are unsure who to see for an injury, that decision is part of the assessment process.
At Pro Sports Medicine in Cardiff, sports medicine doctors, consultant musculoskeletal radiology, diagnostic ultrasound and MRI sit within one clinic, which is the setup intended to resolve exactly this kind of diagnostic ambiguity for active people across South Wales and the West of England.
Prepare for the appointment by bringing the pain timeline, what makes it worse, what you were told previously and any existing imaging. The history often decides which pathway is tested first.
Conclusion: What to Do With This Differential
Groin pain is a region with three pathways, not a single diagnosis. “Groin strain” should be the start of a differential, not the end of one. If an assessment ends without a named pathway and a named test result, ask for both.
Three examinations should be expected and questioned. Adductor squeeze tests the adductor pathway. FADIR (flexion, adduction and internal rotation) tests the hip joint. Resisted sit-up or trunk flexion tests the pubic and abdominal wall pathway. Ask what each result showed, not simply whether it reproduced pain.
Two rules are worth applying to any ongoing plan. First, if a consistent loading programme has not changed pain or function after several weeks, ask for the diagnosis to be reassessed rather than repeating the same programme. Second, ask how any imaging finding is linked to the examination, and whether that same finding is common in athletes without pain. A scan abnormality without a matching clinical picture is not a diagnosis.
Identifying the correct pathway is what makes rehabilitation specific, progress measurable and return to football or rugby structured rather than trial and error. The labels matter less than the route they send you down, and the reassessment points that keep that route honest.
