Groin pain — when nobody can agree on what to call it

Written by Dr Steven Hewitt — Chiropractor · AHPRA: CHI0001115420 · Last reviewed: August 2026

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What Is Groin Pain?

The naming problem is not trivial, and it is not new. In 2015 a group of clinicians and researchers from multiple disciplines met in Doha specifically to sort it out, because terms like sports hernia, Gilmore's groin and incipient hernia were, in the words of one recent paper, causing confusion [1]. What came out of that meeting — usually called the Doha agreement — was a shift away from labels and towards simply naming the structure involved.

The result is four defined entities for groin pain in athletes, plus two broader categories:

• Adductor-related groin pain — the inner thigh muscles and their tendons. The most common by a distance [2]
• Iliopsoas-related groin pain — the deep hip flexor at the front of the hip
• Inguinal-related groin pain — the inguinal canal region and the abdominal wall structures around it
• Pubic-related groin pain — the pubic bone and the joint between its two halves
• Hip-related groin pain — the hip joint itself, including FAI syndrome and labral problems
• Other causes — including problems that are not musculoskeletal at all

So what is a "sports hernia"?

Usually it means inguinal-related groin pain: pain in the region of the inguinal canal, often with tenderness of the abdominal wall structures, in an athlete, without a true hernia being present. The trouble with the term is that it implies a hernia that needs repairing, when frequently there is no hernia to repair. Athletic pubalgia tends to be used for much the same territory, sometimes extending to the pubic bone and the adductor origin. Neither term tells you which tissue is painful, which is the thing that decides what to do next.

We use the Doha terms on this page. If you have been given one of the older labels, that is not a reason to distrust whoever gave it to you — they are still in common use — but it is worth establishing what was actually found.

Important note: Groin pain is not always musculoskeletal. Pain accompanied by fever, a visible or enlarging lump, testicular pain or swelling, blood in the urine, unexplained weight loss, or night pain unrelated to activity should be assessed medically before any musculoskeletal treatment. A true inguinal hernia is a surgical matter, not a rehabilitation one.

Who Typically Experiences This?

The kicking athlete

Football in all its codes, and any sport with repeated kicking, is where this presents most often. The kicking action loads the adductor origin at the pubis eccentrically and at speed, and it does so while the trunk is rotating in the opposite direction. Adductor injuries are the most common problem in athletes presenting with both acute and long-standing groin pain [2].

The change-of-direction athlete

Sports built on rapid deceleration and cutting — hockey, netball, basketball, tennis — load the same tissue differently. Here the adductors are working to decelerate hip abduction rather than to generate a kick, often repeatedly and often when fatigued late in a session.

The athlete returning from a break

A recognisable pattern: pre-season, or the first few weeks back after a lay-off, in someone whose training volume has climbed faster than their tissue capacity. Previous groin injury and reduced adductor strength are both recognised risk factors [2].

The person who is not an athlete at all

Groin pain outside sport is a different problem and needs a wider view. Hip joint pathology becomes more likely with age, and non-musculoskeletal causes need excluding. If you have groin pain without a clear loading history, the first job is establishing what it is not.

The Fascial Lens: Why We See This Differently

The pubis is not a set of separate attachments

The conventional way to describe this region is as a collection of individual structures that happen to attach near each other: adductor longus here, rectus abdominis there, the inguinal ligament nearby. Dissection studies over the last decade have made that picture look inadequate.

In 2017 Schilders and colleagues performed a layered dissection of the anterior symphyseal soft tissues in seven fresh-frozen cadavers, specifically to work out what connects to what [3]. Two findings stand out. The first is that the pyramidalis — a small triangular muscle most people have never heard of — is the only abdominal muscle lying in front of the pubic bone, and it was present on both sides in every specimen. It arises from the pubic crest and the anterior pubic ligament, and the proximal adductor longus tendon interlaces with the deep portion of that same ligament.

The second is a negative finding, and it corrects something widely believed: the rectus abdominis is not attached to the adductor longus. The connection everyone assumes runs through the "six-pack" muscle in fact runs through the pyramidalis and the ligament between them. Schilders named this the pyramidalis–anterior pubic ligament–adductor longus complex, or PLAC.

Why that changes how the region fails

A 2021 review of MRI findings in 145 athletes with adductor avulsions found that these injuries are almost never isolated [4]. The adductor longus was completely separated from the pyramidalis in 81 of them, partially separated in seven, and still in continuity in 55; 48 also had a partial pectineus avulsion, and six distinct patterns of PLAC injury were identified. Associated rectus abdominis injuries occurred in only five patients — 3.5% — which again is not where the common assumption points. The authors concluded that "PLAC injury" is the more appropriate term, because the complex tends to fail as a unit.

A separate 2024 study using dissection, histology and micro-CT on ten pelvic halves described two conjoined aponeuroses at the pubis [5]. The external oblique aponeurosis extends into the adductor longus aponeurosis, forming one continuous plate attaching just distal to the pubic crest. The rectus abdominis and pyramidalis aponeuroses attach at the pubic crest and intermingle with the gracilis and adductor brevis aponeuroses, forming a second. Both attach to bone through fibrocartilage — and micro-CT found matching bone morphology at each site, a small impression under one and an elongated ridge under the other. The tissue arrangement has left a mark in the skeleton.

The connection to the anterior oblique sling

That first finding — external oblique aponeurosis continuous with adductor longus aponeurosis — is the lower crossing of the anterior oblique sling, demonstrated anatomically. The sling runs from the adductors on one side, through the abdominal wall, across the midline, and up to the opposite shoulder girdle. The pubis is where it anchors.

This is why we do not treat groin pain as a local problem. If a diagonal chain from thigh to opposite shoulder is transferring load poorly, the pubis is one of the places that shows it — and treating only the painful end tends to leave the reason for the loading untouched. It is also why groin pain and lower abdominal pain so often occur together: at the pubis they are not separate tissues.

What Does the Research Say?

Progressive loading has the strongest evidence, for both new and long-standing problems

A 2023 clinical concepts review states that progressive strength training and sport-specific loading is the treatment with the highest level of evidence for both acute and long-standing adductor-related problems [2]. Passive approaches do not carry the same support.

The trunk is part of the treatment, not an optional extra

The same review describes addressing hip adductor, gluteal and trunk strength, along with balance, coordination and plyometrics, as mandatory across prevention and rehabilitation [2]. That conclusion was reached from sports medicine research rather than from any fascial model — which makes it a useful independent check on the anatomy described above.

No single examination test settles the diagnosis

A 2023 reliability study of clinical tests for inguinal-related groin pain found agreement between examiners ranging from slight to substantial depending on the test, and concluded plainly that "there is no single perfect clinical examination test" [1]. This is a presentation where the pattern across several findings matters more than any one result.

Imaging should look at the whole complex

Where imaging is indicated after an adductor avulsion, the recommendation is to assess every component of the PLAC rather than the adductor tendon alone [3][4] — because an intact-looking tendon can sit alongside a separation from the pubic bone.

How We Approach Groin Pain

First, establishing what it is

Assessment sorts the presentation into one of the Doha categories, or identifies that it belongs elsewhere. That means examining the adductors, the abdominal wall, the pubic region and the hip joint, and taking a careful history of how the pain began and what loads it. Where the picture points to a hernia, a hip joint problem needing imaging, or a complete tendon avulsion, our job is referral rather than treatment, and we will say so.

Then, fascial balance across the anterior oblique sling — before we add load

This is where our approach differs most. Before loading the groin we address how tension is distributed across the anterior oblique sling using Fascial Manipulation, working at the relevant centres of coordination rather than only at the painful site. The reasoning is straightforward: loading a poorly organised pattern tends to reinforce that pattern. Restoring the balance first means the strength work that follows is building on something worth building on.

Then progressive loading

Once the pattern is organised, load is added deliberately. Exercises we commonly use include the Copenhagen adduction exercise and its regressions, the half Turkish get-up, and side-lying knee-to-knee work. The half get-up earns its place because it loads the trunk and the hip together in a way that isolated adductor work does not.

Then integration into whole-body movement

From there we progress into loaded split-stance work — typically kettlebell carries and presses with the load on the same side as the lead leg when the goal is adductor and anterior chain loading. Switching the load to the opposite side changes the demand to the external rotators and abductors, which is a different training goal for a different presentation.

Then dynamic and sport-specific loading

The final stage is plyometric and change-of-direction work, reintroducing the speed and the deceleration demands that the tissue has to tolerate to return to sport. This stage is not optional for an athlete: returning to a kicking sport without having rehearsed the loads of kicking is how recurrences happen.

Please note: The information on this page describes our general clinical approach and is intended for educational purposes only. Individual presentations vary, and your assessment and management will be tailored specifically to you. Nothing on this page constitutes clinical advice for your individual situation. Please consult a registered health practitioner for advice about your specific condition.

What Can You Do Right Now?

Stop guessing at the label. If you have been told you have a sports hernia or athletic pubalgia, ask which structures were actually tender and what the examination found. The name matters far less than the location.

Do not simply rest and wait. Complete rest reduces symptoms in the short term and reduces tissue capacity at the same time. The evidence points towards graded loading rather than avoidance [2]. That does not mean training through significant pain — it means finding the level the tissue tolerates and building from there.

Be careful with aggressive stretching. Stretching a painful adductor origin is a common instinct and is rarely the answer. Strength work has the evidence; stretching does not carry the same support in this presentation.

Note what provokes it. Kicking, sprinting, cutting, sit-ups, coughing, getting out of the car. The pattern of what hurts is genuinely diagnostic information, and writing it down for a week before your assessment makes that assessment considerably more useful.

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