Athletic groin pain: correct diagnosis in hip-groin pain, the power of exercise, and the surgery decision

Short answer

"Athletic groin" is not a single disease but a regional pain — and correct treatment depends on correctly naming which structure the pain comes from. The international consensus (Doha agreement, 2015) classifies groin pain according to examination finding: adductor (inner-thigh muscle), iliopsoas (hip-flexor muscle), inguinal (groin canal), and pubic (pelvic bone junction)-related groin pain — plus, as a separate heading, hip joint-related pain (including femoroacetabular impingement). The most common type in footballers is the adductor-related one, and the basis of its treatment is not medication or an injection but gradual strengthening exercise.

Two strong pieces of evidence stand out: in long-standing adductor pain, an active exercise program was found clearly superior to passive physical therapy in a randomized trial; and in prevention, a Copenhagen adductor exercise of a few minutes a few times a week reduced groin problems in footballers by about 41%. In impingement syndrome arising from the hip joint, both arthroscopic surgery and structured physiotherapy work; although surgery gets a little ahead in randomized trials, the difference is not large and the number of patients who improve with physiotherapy is by no means small. This article provides general information; it does not replace an examination and an individualized diagnosis.

Why is the groin a confusing region?

In the groin, muscles, tendons, the groin canal, the pelvic bone junction (pubic symphysis), and the hip joint are nested within a few centimeters; moreover, more than one structure can be problematic at the same time. For years each school gave a different name to the same picture ("sportsman's hernia," "osteitis pubis," "pubalgia"...) and this confusion also muddled treatment. In 2014, 24 international experts meeting in Doha simplified the terminology (Doha agreement):

Doha class	Source of the pain	Typical finding
Adductor-related	The inner-thigh muscles and tendon attachment	Tenderness on the inner side + pain on resisted leg squeeze
Iliopsoas-related	The muscle that flexes the hip (iliopsoas)	Pain on resisted hip flexion and/or stretch
Inguinal-related	The groin canal region	Tenderness in the canal region; can increase with straining/coughing, no palpable hernia
Pubic-related	The pubic symphysis and adjacent bone	Direct tenderness over the pelvic junction
Hip-related	The hip joint itself (impingement, labrum, etc.)	Pain with joint tests; pain often deep in the groin

The most common in footballers is adductor-related groin pain. Groin injuries make up roughly 4–19% of all injuries in men's football; in teams followed over a season, in any given week more than 20% of players may report a groin complaint. Striking the ball, sudden direction changes, and sprinting are the main triggers.

When should you see a physician without delay? Most groin pains are muscle-tendon in origin and are not emergencies; however, the following findings suggest a more serious problem and require prompt evaluation: inability to bear weight on the leg or walking with a limp; steadily increasing pain that persists at rest and at night (especially in runners and athletes with disturbed eating/energy balance, with regard to a femoral neck stress fracture); groin pain together with fever; pain or swelling in the testicle; sudden severe pain with abdominal bloating-vomiting (a strangulated hernia); severe pain that settles in suddenly after trauma. These pictures are outside the scope of this article and require a direct physician evaluation.

The basis of treatment: adductor strengthening

This is the area where the evidence is most solid:

In treatment: In a randomized trial in athletes with long-standing (average 9–10 months) adductor pain (Hölmich, Lancet 1999), an 8–12-week active strength and coordination program directed at the hip-abdominal muscles was found markedly superior to passive physical-therapy methods (massage, stretching, electrotherapy); the good-outcome rate was clearly higher in the active exercise group.
In prevention: In a cluster-randomized trial covering 35 Norwegian football teams (652 players) (Harøy, 2019), a Copenhagen adductor exercise program applied three times a week pre-season and once a week in-season reduced the risk of groin problems by 41% (weekly complaint frequency 21.3% versus 13.5%).
The Copenhagen exercise is a simple movement, done in a side-plank-like position with the top leg supported on a partner or a bench, loading the inner-thigh muscles eccentrically (contraction while lengthening); it increases adductor strength measurably within a few weeks. It can cause marked muscle stiffness at first; for this reason the dose is increased gradually.

Corticosteroid (cortisone) injection and passive methods alone do not close the capacity gap at the root of the problem; they can temporarily silence the pain, but the evidence-based central treatment is gradual loading.

Femoroacetabular impingement: the concept and an important caveat

Femoroacetabular impingement — abbreviated FAI (the early contact during movement of the thigh-bone head-neck with the edge of the hip socket) — is a leading cause of hip-related groin pain. According to the international consensus (Warwick agreement, 2016), the diagnosis rests on a triple condition: appropriate complaint (groin/hip pain increasing with activity or prolonged sitting) + examination finding (pain on impingement tests) + appropriate bone shape on imaging (cam and/or pincer morphology). If all three are not present together, it is not called "FAI syndrome."

The reason for this distinction is striking: cam/pincer bone shape is also very common in people with no complaints at all. In a systematic review screening asymptomatic volunteers, cam morphology was found in an average of 37% (even higher in athletes). That is, having an "impingement appearance" on MRI or X-ray does not mean disease on its own; the image gains meaning only if it coincides with a complaint and examination finding. A surgery decision is not made just because "it showed on the scan."

Surgery or physiotherapy in FAI? Randomized trials speak both ways

This question has been tested by more than one randomized controlled trial; the honest summary is this:

UK FASHIoN (Lancet 2018; 348 patients): Arthroscopic surgery was compared with a physiotherapist-led personalized conservative program. Both groups improved markedly; at 12 months the hip quality-of-life score (iHOT-33) was, on average, 6.8 points better in favor of surgery — statistically significant and above the "smallest important difference" threshold, but a modest difference. This is the published primary outcome (12 months); whether the difference is maintained in the longer term and its cost-effectiveness are not yet settled.
FAIT (BMJ 2019; 222 patients): Similarly, both groups improved; at 8 months a small-to-moderate difference was found in favor of surgery.
Mansell et al. (2018; 80 patients, military population): At two years no significant difference was found between surgery and physiotherapy; however, the study was small and the crossover rate between groups was high.

Interpretation: Starting with physiotherapy is a reasonable and defensible strategy; a significant portion of patients reach their goals without surgery. On the other hand, in a correctly selected patient the measurable added contribution of arthroscopy is also real; saying "surgery has no place at all" is exaggerating the evidence in one direction. The decision should be made in a shared way, weighing together age, complaint duration, cartilage status, the quality of the conservative treatment tried, and the patient's goals. In a hip with marked arthritis, the benefit of arthroscopy is limited. And it is not yet proven that surgery prevents arthritis in the long term.

Is "sportsman's hernia" a real hernia? Why does the distinction matter?

In the picture popularly called "sportsman's hernia," there is often no palpable real hernia. This condition, whose current name is inguinal-related groin pain (in the surgical literature "inguinal disruption"), is associated with weakness/tension in the back wall of the groin canal; in a real inguinal hernia, by contrast, a bulge that classically becomes prominent on straining is palpable, and its treatment is planned separately. But an important caveat: the absence of a palpable bulge does not definitively rule out a real hernia — small or hidden (occult) inguinal/femoral hernias may not give a bulge on examination; if suspicion persists, it is evaluated with ultrasound/MRI. The distinction is made by examination and, if needed, ultrasound/MRI. In inguinal-related pain too, the first step is usually structured exercise and load regulation; in resistant, well-selected cases there are randomized data showing that surgical repair can be superior to conservative treatment (Paajanen, 2011). A limitation of that study is that it was done before the current Doha terminology (2015), with an older definition and patient selection; for this reason it is not correct to generalize its result as "surgery is superior in all inguinal-related pain" — the finding belongs to selected chronic cases. So here too the picture is not black-and-white: neither "hernia surgery" for every groin pain, nor categorically rejecting surgery in resistant inguinal pain, is correct.

Return to sport: not the calendar, steps

In groin pain, return to sport is planned not by a date but by criteria:

The pain being under control in daily life and examination tests (including the leg-squeeze test),
Rebuilding adductor strength with gradual exercise (compared with the healthy side),
Gradual loading in the order straight running → direction change → striking the ball → partial participation in training → full training → match,
Monitoring the pain response at each step: mild pain that settles quickly is tolerated in most programs; pain that increases or carries into the next day indicates the step is premature.

A step skipped in haste is the most common cause of recurrence; a significant portion of groin problems begins insidiously anyway and tends to become chronic.

For clinicians

The Doha classification consists of clinical entities based on standardized examination, not diagnostic tests; more than one entity is often present together, and inter-class reliability is not perfect. In adductor-related pain, the resisted adduction (squeeze) test and palpation of the attachment site are fundamental; deep groin pain after prolonged sitting + FADIR positivity suggests the hip joint. FADIR is sensitive but its specificity is low; an imaging finding (cam: alpha angle, pincer: lateral CE angle/retroversion) permits a diagnosis of FAI syndrome only when combined with the clinical picture — asymptomatic cam prevalence ~37%, higher in the athletic population. In FASHIoN and FAIT the conservative arm was not "ordinary physical therapy" but protocolled and supervised programs; in daily practice one should not attach the label "failed conservative treatment" before conservative treatment reaches this quality. In the differential, a real inguinal/femoral hernia, stress fracture (femoral neck!), avulsion (adolescent), hip OA, urological-gynecological causes, and lumbar origin should be kept in mind; night pain, weight loss, and sudden non-traumatic pain are red flags. In a chronic case, planning progressive loading over the kinetic chain (adductor-abdominal co-contraction, pubic symphysis load-sharing) improves outcomes more than seeking an isolated single structure.

Frequently asked questions

I have groin pain; is this a "sportsman's hernia"?

Often no. The most common cause of groin pain is problems related to the inner-thigh muscles (adductors); in a real hernia, by contrast, there is a palpable bulge that classically becomes prominent on straining — but the absence of a palpable bulge does not fully rule out a real hernia, as small/hidden hernias can be silent on examination. In the picture called "sportsman's hernia" there is usually no real hernia; the correct name is inguinal-related groin pain. Examination and, if needed, ultrasound/MRI make the distinction; the treatment plan also changes completely accordingly.

An "impingement" (FAI) appearance showed on my hip MRI; do I need surgery?

An image alone is not a reason for surgery. The same bone shape is also present in about a third of people with no complaints at all. A diagnosis of femoroacetabular impingement syndrome is made by the coincidence of all three: complaint + examination finding + imaging. Even if the diagnosis is correct, the first option is often structured physiotherapy; surgery comes up in selected patients.

Is surgery or physiotherapy better in FAI?

In randomized trials, both paths improved patients markedly. In the largest study (UK FASHIoN), the surgery group reached scores an average of 6.8 points better (out of 100) at 12 months — a significant but modest difference; in a small study, no difference was found. Practical translation: starting with physiotherapy is safe and reasonable; in a correctly selected patient who does not improve despite adequate-duration quality conservative treatment, arthroscopy is an evidence-based option.

What is the Copenhagen adductor exercise, and does it really work?

It is a simple exercise done in a side-plank-like position with the top leg supported, loading the inner-thigh muscles while lengthening. In a randomized trial covering 652 footballers, a short program based on this exercise reduced groin problems by about 41%. It is cost-free and can be added to a warm-up; but in a painful period the dose should be adjusted gradually under the supervision of a professional.

Will a cortisone injection be the solution for my groin pain?

Not as a permanent solution. An injection can temporarily reduce pain but does not close the strength and load-capacity gap at the root of the problem; the treatment with the strongest evidence is a gradual strengthening program. Injections should be considered only in selected situations, to accompany an exercise program.

When can I return to the field?

Not by the calendar, but by steps: control of pain → rebuilding of strength → straight running → direction change and striking the ball → gradual training → match. The pain response is monitored at each step; pain that increases or carries into the next day requires going back a step. In long-standing groin pain this process can take weeks-months; early return is the most common cause of recurrence.

Scientific references

Weir A ve ark. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015;49:768-74.
Griffin DR ve ark. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 2016;50:1169-76.
Griffin DR ve ark. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018;391:2225-35.
Palmer AJR ve ark. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial (FAIT). BMJ 2019;364:l185.
Mansell NS ve ark. Arthroscopic surgery or physical therapy for patients with femoroacetabular impingement syndrome: a randomized controlled trial with 2-year follow-up. Am J Sports Med 2018;46:1306-14.
Harøy J ve ark. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med 2019;53:150-7.
Hölmich P ve ark. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353:439-43.
Frank JM ve ark. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy 2015;31:1199-204.
Werner J ve ark. UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 2009;43:1036-40.
Werner J ve ark. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men's professional football: the 15-year prospective UEFA Elite Club Injury Study. Br J Sports Med 2019;53:539-46.
Waldén M ve ark. The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med 2015;49:792-7.
Sheen AJ ve ark. 'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014;48:1079-87.
Paajanen H ve ark. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with 1-year follow-up. Surgery 2011;150:99-107.
Ishøi L ve ark. Large eccentric strength increase using the Copenhagen Adduction exercise in football: a randomized controlled trial. Scand J Med Sci Sports 2016;26:1334-42.
Griffin DR ve ark. Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT (full study report). Health Technol Assess 2022;26(16):1-236.

This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.