- Groin pain, while complex, typically resolves effectively through a tailored conservative treatment program focusing on rehabilitation.
- Groin pain often arises from muscle imbalances that overload the pubic region during physical activity.
- Groin pain often involves multiple anatomical structures, requiring careful diagnosis for a personalized and effective treatment plan.
- A specific rehabilitation program is crucial for addressing the underlying causes and achieving full recovery.
Table of Contents
Groin pain (pubalgia)
Groin pain, often referred to as “pubalgia” in Italian, is a generic term indicating chronic pain in the pubic and groin region, at the convergence of the abdominal muscles and the adductor muscles of the thigh. It is a particularly common condition in athletes — especially footballers, rugby players, hockey players, and runners — but can also affect non-athletes, particularly women during pregnancy and postpartum.
The term “pubalgia” has long been a source of terminological confusion, grouping different conditions under a single label. The international scientific community has recently proposed the term “groin pain” with a classification based on the anatomical structures involved, to overcome the ambiguity of the old term.
Groin pain is a complex pathology that requires careful differential diagnosis and a specific rehabilitation program, but in the vast majority of cases, it resolves with conservative treatment.
Anatomy: The Pubic Region
The pubic region is an anatomical crossroads where opposing muscular forces converge:
- From top to bottom: the abdominal muscles (rectus abdominis, obliques) insert onto the pubic symphysis and the pubic crest
- From bottom to top: the adductor muscles of the thigh (adductor longus, gracilis, pectineus) insert onto the inferior pubic ramus
The pubic symphysis — the fibrocartilaginous joint that unites the two pubic bones — is the point of maximum convergence of these forces. During running, changes of direction, and kicking, the pubic symphysis undergoes enormous stresses, especially in torsion. When the imbalance between muscular forces exceeds the tissues’ capacity for adaptation, groin pain develops.
The iliopsoas — the large hip flexor muscle — is closely related to groin pain, as its contracture alters the biomechanics of the pelvis and overloads the pubic symphysis.
Classification of Groin Pain
The modern classification of groin pain (Doha agreement, 2015) distinguishes:
1. Adductor-related Groin Pain (the most common)
Pain in the adductor region (inner thigh), with tenderness on palpation of the adductor insertion on the pubis and pain during resisted adduction.
2. Rectus Abdominis-related Groin Pain (Sportsman’s Hernia)
Pain in the lower inguinal region and anterior abdominal wall, often with abdominal wall weakness. This is the most debated form and often confused with an inguinal hernia.
3. Iliopsoas-related Groin Pain
Pain in the anterior inguinal region, aggravated by resisted hip flexion. Related to iliopsoas contracture or tendinopathy.
4. Pubic Bone-related Groin Pain (Osteitis Pubis)
Chronic inflammation of the pubic symphysis, with pain on palpation of the symphysis and signs of bone edema on MRI.
5. Inguinal Hernia
A true inguinal hernia must always be excluded in the differential diagnosis of groin pain.
In many cases, multiple structures are involved simultaneously, making diagnosis and treatment particularly complex.
Causes and Risk Factors
Muscle Imbalance
The fundamental cause of groin pain is the imbalance between abdominal musculature and adductor/hip flexor musculature:
- Weak abdominals + strong adductors: typical of footballers, where the kicking motion strengthens the adductors but not the abdominals
- Contracted iliopsoas: iliopsoas contracture pulls the pelvis into anterior tilt, overloading the pubic symphysis
Sports Factors
- Football: the sport most at risk (changes of direction, kicks, sprints)
- Ice hockey: lateral gliding and braking movements
- Rugby and American football: tackles, collisions, changes of direction
- Running: overload from excessive volume or intensity
- Tennis: serve and lateral movements
Predisposing Factors
- Hip stiffness: limitation of internal rotation and abduction
- Core weakness: lumbopelvic instability
- Pelvic alterations: asymmetries, sacroiliac dysfunctions
- Previous muscle injuries: adductors, iliopsoas, rectus abdominis
- Sudden increase in training volume: programming errors
- Playing surface: hard or uneven ground
Groin Pain in Pregnancy and Postpartum
Groin pain in pregnancy is caused by the release of relaxin (a hormone that softens pelvic ligaments to prepare for childbirth), postural changes in the pelvis, and increased weight. The pubic symphysis becomes hypermobile and painful. The condition generally resolves in the months following childbirth.
Recommended product
Essenziale per il rinforzo progressivo e controllato della muscolatura adduttoria e abduttoria dell’anca durante la riabilitazione del dolore inguinale.
Fascia elastica terapeutica resistenza media — View on Amazon
(paid link)
Symptoms
Pain
- Location: pubic, inguinal region and/or inner thigh (adductors)
- Radiation: can radiate to the perineum, lower abdomen, inner thigh
- Character: dull, deep pain, which worsens with activity and improves with rest
- Onset: gradual, progressive — starts as post-training discomfort and becomes increasingly present
Aggravating Factors
- Kicking a ball
- Changing direction while running
- Sneezing and coughing (increase abdominal pressure)
- Getting out of bed or a chair
- Resisted adduction (squeezing knees against resistance)
Typical Progression
- Pain only after intense sports activity
- Pain during and after activity
- Pain at the start of activity, which improves with warm-up, then returns afterwards
- Constant pain that prevents sports activity
- Pain even in daily activities (walking, climbing stairs)
Diagnosis
Clinical Examination
- Palpation: pain at the pubic symphysis, adductor insertion, rectus abdominis
- Adductor test: resisted adduction (squeezing knees against the examiner’s resistance) — reproduces pain
- Iliopsoas test: resisted hip flexion — inguinal pain
- Rectus abdominis test: resisted sit-up — pubic/inguinal pain
- Hip assessment: joint mobility (internal rotation often reduced)
- Exclusion of inguinal hernia: assessment of the inguinal canal
Imaging Diagnostics
- Ultrasound: evaluates the condition of the adductor tendons, iliopsoas, and abdominal wall
- Pelvic MRI: examination of choice — visualizes bone edema of the pubic symphysis, tendon lesions, occult inguinal hernias
- Pelvic X-ray: can show irregularities of the pubic symphysis (osteitis pubis)
Conservative Treatment
Conservative treatment is effective in 80-90% of cases. It requires patience: recovery times are generally long (8-16 weeks).
Phase 1 — Pain Reduction (Weeks 1-3)
- Sports rest: suspend the aggravating activity (NOT absolute rest)
- NSAIDs: for pain and inflammation control
- Ice: 15-20 minutes on the pubic area after activities
- Manual therapy: release of the iliopsoas, adductors, and lumbopelvic musculature
- Physical therapies: shockwave therapy (effective for adductor tendinopathy), laser therapy
Phase 2 — Muscle Rebalancing (Weeks 3-8)
The core of the treatment: strengthening the core and rebalancing abdominals/adductors.
- Strengthening of deep abdominal muscles (transversus abdominis)
- Strengthening of adductors (eccentric and isometric exercises)
- Stretching of the iliopsoas and adductors
- Lumbopelvic stabilization: exercises for the core and glutes
- Hip mobilization: recovery of internal rotation
Phase 3 — Return to Sport (Weeks 8-16)
- Sport-specific exercises: changes of direction, accelerations, decelerations
- Progressive running: gradual resumption of running
- Return to sport-specific movements: kicking (if a footballer), specific sport movements
Surgery
Surgery is reserved for resistant cases (10-20%) after at least 3-6 months of conservative treatment. Options include:
- Adductor tenotomy (partial section of the tendon)
- Abdominal wall repair (for sportsman’s hernia)
Exercises for Groin Pain
Your physical therapist will guide the progression of exercises. Fundamental rule: no exercise should increase pubic pain. If an exercise causes pain, reduce intensity or stop it.
Phase 1 — Isometrics and Stretching
Isometric adduction with ball
Iliopsoas stretch
Adductor stretch
Phase 2 — Progressive Strengthening
Copenhagen plank (adductors)
Dead bug (core stabilization)
Single-leg glute bridge
Phase 3 — Functional Exercises
Sumo squat
Lateral lunges
Recommended product
Mantiene il corretto allineamento pelvico durante la guida prolungata, riducendo la tensione sulla muscolatura inguinale e prevenendo le recidive.
Cuscino ergonomico per auto con supporto lombare — View on Amazon
(paid link)
Kicking with elastic resistance
Recovery Times
| Severity | Indicative Times |
|---|---|
| Mild (post-activity only) | 4-6 weeks |
| Moderate (pain during activity) | 8-12 weeks |
| Severe (daily pain) | 12-20 weeks |
| Post-surgical | 3-6 months |
Adhering to recovery times is crucial to prevent recurrences, which are frequent in groin pain if the return to sport is too early.
Prevention
- Core and adductor strengthening: specific program in the training plan
- Regular stretching: iliopsoas, adductors, hamstrings
- Hip mobility: maintain good internal hip rotation
- Gradual load progression: avoid sudden increases in volume or intensity
- Adequate warm-up: before sports activity, include adductor and core activation exercises
- Appropriate surface: avoid hard and uneven ground
To learn more about the relationship between pelvis, posture, and pain, consult the article on pelvis and posture and the Complete Guide to Hip Pain.
Frequently Asked Questions (FAQ)
Yes, groin pain heals completely in 80-90% of cases with conservative treatment. The key is a comprehensive rehabilitation program that addresses muscle imbalance and a gradual return to sport. Recurrences are frequent if recovery is incomplete or return to sport is too early.
It depends on the severity. In mild forms, it is possible to modify training by avoiding aggravating movements (kicking, changes of direction) and maintaining low-impact activities (swimming, cycling). In moderate-to-severe forms, a period of rest from sports activity is necessary, replaced by the rehabilitation program. Your physical therapist will guide the modifications.
No, although it is much more common in athletes. Groin pain can also affect sedentary individuals with muscle imbalances, women during pregnancy and postpartum, and workers who perform activities with repetitive hip flexion and rotation movements.
An inguinal hernia is the protrusion of abdominal contents (fat or intestine) through the inguinal canal. Groin pain (sportsman’s hernia) is a weakness of the abdominal wall without protrusion of contents. An inguinal hernia presents a palpable bulge, while groin pain does not. The distinction is fundamental because an inguinal hernia always requires surgical intervention. Your doctor will perform the differential diagnosis.
Shockwave therapy is particularly effective for adductor-related groin pain (insertional tendinopathy). It stimulates tendon repair and reduces pain. Generally, 3-5 sessions are performed one week apart. They should always be combined with an exercise program and not used as isolated therapy.
Groin pain can radiate to the perineal region and, in men, to the ipsilateral testicle. However, testicular pain always requires medical evaluation to rule out urological causes (torsion, epididymitis, varicocele, inguinal hernia). Consult your doctor for an appropriate diagnosis.
Frequently Asked Questions
Does groin pain heal completely?
Groin pain typically resolves effectively with a tailored conservative treatment program focused on rehabilitation. A specific rehabilitation program is crucial for addressing the underlying causes and achieving full recovery, allowing for complete resolution in most cases.
Can I continue training with groin pain?
Continuing training with groin pain is generally not recommended without professional guidance, as it can exacerbate the condition and delay recovery. A physical therapist can assess the specific injury and recommend appropriate modifications or a temporary cessation of activity to facilitate healing.
Does groin pain only affect athletes?
While groin pain is particularly common among athletes, especially those involved in sports requiring rapid changes of direction or repetitive kicking, it can also affect non-athletes. Various factors, including muscle imbalances and certain activities, can contribute to its development in the general population.
What is the difference between groin pain and an inguinal hernia?
Groin pain is a general term for discomfort in the pubic and groin region, which can stem from various causes, including muscle imbalances or inflammation. An inguinal hernia, however, is a specific condition where tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles, often presenting as a bulge and causing pain in the groin area. While an inguinal hernia can cause groin pain, not all groin pain is indicative of an inguinal hernia.
For a broader overview of related conditions, see our complete guide to hip pain.
Sources and Scientific References
- Mitrousias V et al. (2023). Anatomy and terminology of groin pain: Current concepts. J ISAKOS. 8:381-386. DOI | PubMed
- Zuckerbraun BS et al. (2020). Groin Pain Syndrome Known as Sports Hernia: A Review. JAMA Surg. 155:340-348. DOI | PubMed
- Forlizzi JM et al. (2023). Core Muscle Injury: Evaluation and Treatment in the Athlete. Am J Sports Med. 51:1087-1095. DOI | PubMed
- Serafim TT et al. (2022). Return to sport after conservative versus surgical treatment for pubalgia in athletes: a systematic review. J Orthop Surg Res. 17:484. DOI | PubMed
- Puig PL et al. (2004). [Pubalgia: from diagnosis to return to the sports field]. Ann Readapt Med Phys. 47:356-64. DOI | PubMed