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]. That meeting produced the Doha agreement: a shift away from labels and towards simply naming the structure involved.

If you live in Victoria, there is a fair chance you already know one of those older terms. Osteitis pubis became a familiar diagnosis in the AFL through the 2000s, to the point that it was often applied to chronic groin pain generally — and that is precisely the confusion the Doha agreement was written to resolve, by naming the structure involved rather than the region.

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.

The usual explanation is that the abdominal wall and the groin muscles are joined by a thick sheet of tissue across the front of the pubic bone, and that a groin strain tears one end of it. Careful dissection work over the last decade has taken that picture apart. The sheet is not thick — about a millimetre and a half — and the muscle almost everyone assumes is involved, the rectus abdominis or “six-pack”, does not attach to the adductor at all [6].

What does the connecting is a small triangular muscle sitting in front of the pubic bone called the pyramidalis, together with the ligament crossing the joint and the adductor tendon woven into it [3]. Schilders and colleagues named that arrangement the PLAC. The name matters less than what follows from it: on MRI in 145 athletes with adductor injuries, the damage was almost never confined to the adductor — the complex tends to fail as a unit [4]. That is the most practically useful finding on this page, because it is why treating the sore adductor and nothing else so often disappoints.

What crosses the midline is genuinely unsettled. One group reports adductor tendon fibres connecting into the tendon on the opposite side, and offers it as the reason groin symptoms are so often bilateral [6]. A 2024 dissection study describes the layers differently and states plainly that its findings oppose that [5]. Every recent study agrees that something joins the two halves at the pubis; which structures do it is still being argued. For assessment the implication is the same either way — examining only the painful side can miss what is happening on the other.

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.

Australian clinicians describe it as a load problem, not a mystery

When researchers interviewed the medical and fitness staff at all sixteen AFL clubs, every respondent described osteitis pubis as an overuse problem — an imbalance between the load applied to the pelvis and the capacity of the pelvic structures to tolerate it [7]. Several went further, describing it as the end point of a continuum, with adductor tendinopathy appearing as an early warning sign along the way. That fits what imaging had already shown: among 52 athletes with groin pain and tenderness over the pubic bones, 77% had bone marrow oedema visible on MRI [8]. Both are observational rather than causal, but they point the same way — and the same staff noted that simply reducing load is not the answer either, since the load is what the sport requires.

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 tell you when.

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 single-leg and carrying work. Which hand the weight is in is not a detail — it changes which muscles do the work.

In a single-leg Romanian deadlift, holding the weight on the same side as the working leg produced significantly more adductor longus activity; holding it on the opposite side shifted the demand towards gluteus medius instead [9]. That opposite-side effect is consistent elsewhere: during loaded walking, hip abductor activity rose on the side away from the weight and did not change on the side carrying it [10], and the same pattern appears in the walking lunge [11].

It is worth knowing that this is movement-specific rather than a general rule — in a static split squat, the two load positions did not differ [11]. So we choose the exercise and the load position together, according to which side of the pelvis needs the work.

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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