Clinical synthesis based on the 2015 Doha agreement (Weir BJSM, PMID 26031643), the pivotal RCT of Hölmich on active training (Lancet 1999, PMID 9989713), the evidence-based framework of Thorborg (JOSPT 2018, PMID 29510653) and the preventive cluster-RCT of Haroy on the Copenhagen Adduction Exercise (BJSM 2019, PMID 29891614).

Groin pain of the athlete (groin pain in athletes) covers a set of clinical presentations long conflated under the generic term "pubalgia". This terminological imprecision has held back research, disrupted communication between clinicians and led to poorly targeted treatments.¹ The 2015 Doha agreement, led by 24 international experts from 14 countries, redefined this nosology into five distinct clinical entities, based on the clinical examination: pain related to the adductors, the iliopsoas, the pubis, the inguinal region, and the hip.¹ Of these, groin pain related to the adductors (Adductor-Related Groin Pain, ARGP) is the most frequent presentation.²

How is this condition defined, who does it affect and what are the risk factors?

ARGP is defined by the simultaneous presence of three criteria on clinical examination: (1) pain on palpation of the insertion of the adductor longus tendon (adductor longus) on the pubic tubercle, (2) pain on resisted hip adduction, and (3) reproduction of the familiar pain during the hip compression test (squeeze test) in the supine position.¹,² This operational definition is now the standard for research and clinical practice.³

ARGP mainly affects a young, male athletic population, in disciplines combining rapid changes of direction, accelerations, decelerations and ball kicks. Male football is the most studied sport: hip and groin injuries account for 12–16 % of all injuries depending on the season, in the UEFA cohort of 23 professional clubs followed over seven seasons, with an incidence of 1.1 per 1,000 hours of exposure (3.5 in matches, 0.6 in training); adductor-related injuries are the most frequent (399 out of 628).⁴ Across all sports, a meta-analysis of 71 studies, mostly in football, puts hip and groin injuries at 11 % of injuries, with 0.71 per 1,000 exposure hours, matches and training combined, an incidence 6.5 times higher in matches than in training and 1.8 times higher in men.¹⁵

The risk factors have been robustly identified by the systematic reviews of Whittaker et al. (BJSM 2015, PMID 25833903), Ryan et al. (BJSM 2014, PMID 24795341) and Mosler et al. (BJSM 2015, PMID 26031646). Three factors stand out with a high level of evidence:⁵,⁶,⁷

• Previous groin injury : the most powerful risk factor, with odds ratios reported between 2 and 7 depending on the cohort. This underlines the importance of complete rehabilitation and of preventive programmes after a first injury.⁵
• Adductor weakness, in particular eccentric strength. Athletes with an eccentric strength below the median of their cohort have a risk about 4 times higher of groin injury.⁷
• Adductor/abductor strength imbalance. A ratio below 80 % is identified as a threshold increasing the risk. It is the most widely used strength criterion for guiding rehabilitation and assessing readiness to return.⁷

Other contributing factors include: higher competitive level, reduced range of internal rotation of the hip, inter-limb asymmetry, and cumulative exposure to load.⁵ An acute-to-chronic workload ratio (ACWR) above 1.5 was associated with injuries in team sports,⁸ but this indicator is contested and is validated neither as a prevention tool nor as a criterion for resuming sport.¹³,¹⁴

What happens in the tendon and how does ARGP evolve naturally?

The pathophysiology of ARGP fits within the tendon pathology continuum model of Cook and Purdam (BJSM 2009, PMID 18812414), which explicitly moves away from the idea of a purely inflammatory "tendinitis".⁹ This model describes three sequential but not strictly irreversible stages:⁹

1. Reactive tendinopathy : a non-inflammatory proliferative response to acute overload. The tendon thickens to increase its surface area and reduce stress per unit of area. A stage that is reversible with adequate load management.
2. Remodelled tendon (tendon disrepair): the overload persists, there is a disorganisation of the collagen fibres, an increase in proteoglycans and the beginning of neovascularisation. A stage that is partially reversible.
3. Degenerative tendinopathy : structural changes with areas of cell death, matrix loss and focal acellularity. A stage considered to be largely irreversible, but the tendon can nevertheless function if the residual healthy areas bear the loads.

The ICON 2019 consensus (Scott et al. 2020 BJSM, PMID 31399426) recommends using the term tendinopathy rather than tendinitis or tendinosis, in the absence of reliable clinical markers to distinguish these entities non-invasively.¹⁰

The natural history of untreated ARGP is that of a persistent and limiting condition. The pain, initially post-exertion, progresses to appear from the start of the activity, then continuously during exertion, and finally during activities of daily living (getting out of a car, turning over in bed). Chronicity (pain > 2 months) is a strong marker of poor prognosis and can lead to cessation of sport without structured active intervention. Early, targeted intervention significantly alters the trajectory of the condition.

Which questions should you ask to understand the patient and their history?

History-taking is the cornerstone of the clinical diagnosis of ARGP.¹,² The clinician must characterise several dimensions precisely:

• Precise location : ask the patient to point to the painful area with a single finger. The pain of typical ARGP is projected onto the proximal insertion of adductor longus on the pubic tubercle, sometimes radiating to the inner thigh.³
• Mode of onset : sudden (during a sprint, kick, change of direction) or insidious (gradual onset with accumulating load). Insidious forms, more frequent in chronic tendinopathy, are the most likely to respond to progressive active treatment.³
• Triggering and aggravating activities : sprints, changes of direction, ball kicks, climbing and descending hills, getting out of a car, turning over in bed. Identifying the provocative movements guides the load modification.⁴
• Injury history : previous groin, knee, back or hip problems that could influence the current biomechanics.⁵
• Recent training load : sudden increase in volume, intensity, frequency or change of surface. An acute-to-chronic workload ratio (ACWR) above 1.5, associated with injuries in team sports,⁶ is contested and is not an established risk factor.¹⁴,¹⁵
• Functional impact : use the HAGOS (Copenhagen Hip and Groin Outcome Score) as a standardised PROM: 37 items, 6 subscales (pain, symptoms, ADL, sport/recreation, participation, quality of life). Validated in French.⁷

Which clinical tests should be performed and which other conditions must be ruled out?

The clinical diagnosis of ARGP rests on an objective triad recommended by the Doha agreement and the evidence-based framework of Thorborg et al. (JOSPT 2018, PMID 29510653):¹,²

1. Palpation reproducing the familiar pain : deep, progressive palpation of the insertion of the adductor longus tendon on the pubic tubercle. It is the most consistent and most localising sign.¹ Excellent sensitivity, more limited specificity (pubic pain also possible in osteitis pubis).
2. Pain on resisted hip adduction : test in the supine position at different angles of hip flexion (0°, 45°, 90°) to load different portions of the adductor group. The Hölmich test at 0° with manual resistance above the medial malleoli is the most widely used.⁷
3. Squeeze test (hip compression test) : supine, hips at 45° or 90° of flexion, ask the patient to squeeze the examiner's fist between their knees. Reproduction of the familiar pain = positive test.⁸ Inter-examiner reliability was high in the study by Hölmich (2004);⁸ a more recent study finds it variable depending on the adductor resistance test (κ 0.22 to 0.74).¹⁷

Imaging is not required first-line if the clinical picture is clear.² It becomes essential to rule out other diagnoses in cases of doubt, severe trauma, red flags, or failure of conservative treatment.⁹,¹⁰ Caution: MRI detects abnormalities (pubic bone oedema, adductor longus abnormalities) in a high proportion of athletes who are asymptomatic, up to 71 % in some cohorts (Branci 2015 BJSM, PMID 25512059). A positive image therefore does not necessarily mean a symptomatic cause: imaging must be precisely correlated with the clinical examination.¹¹

Should patients be classified according to the Doha entities?

Yes, systematically. The Doha classification is considered a fundamental element of effective management and clear communication between clinicians and researchers.¹ It replaces the vague, catch-all term "pubalgia" with a precise diagnosis based on the anatomical and clinical entity responsible for the symptoms.¹²

The 2015 Doha system defines five clinical entities for groin pain:¹

1. Adductor-related : painful palpation of adductor longus + familiar pain on resisted adduction.
2. Iliopsoas-related : iliopsoas palpation (anterior groin region, laterally) + pain on resisted hip flexion + pain on stretching (modified Thomas).
3. Pubic-related : direct painful palpation of the pubic symphysis or the adjacent pubic ramus, in the absence of criteria for adductor or iliopsoas.
4. Inguinal-related : pain reproduced on palpation of the inguinal canal, aggravated by Valsalva or coughing. No palpable hernia.
5. Hip-related : groin pain of suspected intra-articular origin, with positive FADIR or FABER tests.

Agreement between examiners on these entities varies: in 48 male athletes, κ 0.40 for the adductors, 0.57 for the iliopsoas, 0.12 for the pubis and 0.62 for the hip; ranking the entities by order of clinical importance improves it for the adductor, inguinal and iliopsoas entities (κ 0.52 to 0.65).¹⁶ The insertion of adductor longus remains the main site of pain on palpation; palpations of the adductors that do not target adductor longus are poorly reproducible.¹⁷

Clinical presentations of mixed type are frequent (a patient may present simultaneously with pain related to the adductors AND to the pubis).¹,¹³ The optimal therapeutic strategy for these cases remains less clearly defined than for pure entities, but the generally recommended approach consists of treating the dominant entity while taking the other components into account.¹²

Where to start? What is the hierarchy of interventions?

Conservative management is universally recognised as the first-line treatment for ARGP.¹ The hierarchy places the active approach at the top of the therapeutic pyramid. The starting point is not complete rest (which delays resumption and promotes deconditioning) but a targeted modification of load to reduce the provocative stresses on the tendon junction of the adductors.²

The initial intervention combines:

1. Patient education : explain the nature of the injury (overload tendinopathy, non-inflammatory), the continuum model, the meaning of pain in the tendon context (a sign of irritability and not of active structural damage), and the treatment plan step by step.³
2. Load management : identify aggravating activities (sprints, changes of direction, kicks) and modify or temporarily remove them. Maintain a pain-free general physical activity (cycling, swimming, pool running).²
3. Early introduction of therapeutic exercises : start with isometric contractions at low to moderate intensity (analgesic effect), then progress to concentric/eccentric strengthening.⁴

What is the place of progressive exercise and the Copenhagen Adduction?

Therapeutic exercise is the cornerstone of ARGP treatment, with a high level of evidence supporting its effectiveness.¹,⁵ The historical reference programme is the Hölmich protocol, whose pivotal RCT, published in the Lancet in 1999 (PMID 9989713), remains the pillar of the literature:⁶

The Hölmich protocol is structured in two progressive modules (8-12 weeks):⁶

• Module 1 (weeks 1-2) : adductor isometrics (ball between the knees), static abdominals, balance, gentle stretching.
• Module 2 (weeks 3-8+) : addition of concentric and eccentric strengthening under load (slide-board skiing, pulley adduction, dynamic balance exercises), with progression of functional difficulty.

Modern approaches integrate the same principles by personalising the progression to the patient and their sport. The general four-phase scheme currently recommends:

1. Phase 1: Isometrics (weeks 0-2): static contractions of the adductors at different hip angles for an analgesic effect and early muscle activation. Loads 60-70 % MVC, 5 sets of 30-45 s, 3 times/week.⁷
2. Phase 2: Progressive isotonic strengthening (weeks 2-6): concentric and eccentric exercises with progressive load. Copenhagen Adduction Exercise, side-lying hip adduction with a band or weights, lumbopelvic stability exercises. Added to the rehabilitation of 30 footballers with adductor-related pain, the Copenhagen Adduction improved eccentric strength, pain and HAGOS;¹² in 57 young footballers, at equal volume, a pragmatic trial finds no significant difference in strength compared with an isometric squeeze, but more muscle soreness with the Copenhagen;¹³ the squeeze remains an alternative depending on tolerance.
3. Phase 3: Plyometrics and functional work (weeks 6-10): lateral lunges, cutting drills, single-leg hops, controlled rotation exercises that simulate sport-specific demands.
4. Phase 4: Sport-specific reintroduction (weeks 8-12+): gradual return to running, progressive changes of direction, accelerations / decelerations, kicks for the sports concerned.

Manual therapies, shockwave therapy, injections: how effective are they really?

Although exercise is central, some adjunct therapies can have a place in a multimodal plan, mainly to modulate symptoms in the short term and facilitate participation in the active programme.

🛡️ Manual therapies : soft-tissue massage, hip joint mobilisations, myofascial releases and techniques on the lumbopelvic chain can reduce pain in the short term and improve range of motion. However, the evidence for long-term efficacy as a stand-alone treatment is limited.⁸ Recommended position: temporary adjunct to create a window of opportunity allowing the exercises to be better tolerated, never the main treatment.

⚡ Extracorporeal shockwave therapy (ESWT) : systematic reviews show a moderate positive effect for chronic cases not responding to rehabilitation alone (data mainly on overload insertional tendinopathy in general).⁹ Must be integrated into a progressive exercise programme.

💊 Injections : the corticosteroids can provide short-term relief but are controversial because of the risk of tendon weakening and loss of effect in the medium to long term. The PRP (Platelet-Rich Plasma) has mixed results in recent meta-analyses, with no consistent superiority over placebo for tendinopathies in general.¹⁰ Injections should remain a last-resort conservative option, before discussing surgery for selected cases.

Beyond the physical: how to educate and address psychological factors?

A purely biomedical approach is often insufficient for chronic pain. Therapeutic education and consideration of psychosocial factors are essential components of successful management.³

🧠 Therapeutic education : explain to the patient that the pain of a tendinopathy does not necessarily signify ongoing tissue damage, but rather a sensitivity to load. This reduces fear of movement (kinesiophobia) and encourages adherence to the programme. It is essential to set realistic expectations : average time to return to sport after a groin injury ~12-16 weeks, with great individual variability.¹¹

🧘‍♂️ Psychological factors : actively screen for kinesiophobia (TSK-11), pain catastrophising (PCS) and anxiety about returning to sport. Reassuring communication, progressive goals and highlighting intermediate successes strengthen self-efficacy. Gradual exposure to "feared" movements is an effective strategy for overcoming kinesiophobia.

How do you make the patient an active participant in their recovery through self-management?

Active involvement of the patient is a determining factor for long-term success. The aim is to give the patient the tools needed to understand their condition, interpret their symptoms and modulate their activities autonomously.¹

🎯 The pillar of self-management rests on monitoring and management of pain and load. The patient learns to use the VAS (Visual Analogue Scale) to guide their progression according to the 24 h rule :²

• Acceptable pain during exercise: ≤ 4/10 VAS.
• No aggravation the next day (the following morning).
• No prolonged joint stiffness.
• Ability to repeat the exercise at the next session with stable or decreasing pain.

This method avoids the "overload -> reaction -> rest" cycle that prolongs rehabilitation. It allows the patient to adjust their volume and intensity day to day, favouring progressive tissue adaptation rather than recurrent irritation.²

When and how should a safe return to sport be planned?

Return to sport (Return To Sport, RTS) is not decided on the time elapsed since the injury but on the attainment of objective functional criteria: in a cohort of 81 athletes with an acute adductor injury, rehabilitated against pain-free criteria, those who had become clinically pain-free had fewer reinjuries within the year (5 % versus 21 %), and 5 of the 6 reinjuries occurred within 2 months of the return.⁴ The 2016 Bern consensus describes return to sport as a continuum, run in parallel with rehabilitation, rather than a decision taken at the end.³

Planning is structured in several stages, each stage having to be validated before the next:

1. Pain control and restoration of the basics : the patient must be asymptomatic in ADL and in basic exercises. Painless squeeze test. Symmetrical strength on manual isometric tests.⁶
2. Restoration of strength and neuromuscular control : specific strength criteria, usually an adductor/abductor strength ratio above 80 % and adductor strength of at least 90 % of the uninjured side; adductor weakness, absolute or relative to the abductors, is a risk factor for groin injury (see the fundamentals), and lower, painful strength on the squeeze test is one of the signs that best distinguish athletes with groin pain.⁵
3. Progressive sport-specific introduction : linear runs → curves → changes of direction → accelerations / decelerations → kicks / tackles. Each step validated by absence of pain (≤ 4/10 VAS during and after).²
4. Psychological preparation : the return is accompanied by a psychological response (emotions, confidence in performance, risk appraisal) measured by validated scales, such as the I-PRRS (Injury-Psychological Readiness to Return to Sport) or, after ACL reconstruction, the ACL-RSI, whose scores are lower in those who give up sport.⁸

The long-term prevention of recurrences relies on the integration of specific programmes into the athlete's routine. The Adductor Strengthening Programme (ASP) of Haroy et al. (BJSM 2019, PMID 29891614), based on the Copenhagen Adduction Exercise at three levels of progression, 3 times a week during the 6 to 8 weeks of pre-season then once a week during the 28 weeks of the season, reduced by 41 % the risk of reporting a groin problem (OR 0.59; 95 % CI 0.40 to 0.86) in a cluster-RCT of 652 semi-professional Norwegian footballers, the mean prevalence falling from 21.3 % to 13.5 %.⁹ This outcome, measured weekly by questionnaire (OSTRC), is not an injury with time lost from sport. The preventive effect rests on this single trial: a later cluster-RCT in amateur footballers of both sexes (14 to 46 years), comparing an adductor programme with an extended neuromuscular warm-up, finds no difference in the incidence of groin injuries between the groups,¹⁰ and an observational cohort of 162 rink hockey players does not link the number of Copenhagen Adduction sessions to groin problems.¹¹ Inexpensive (one partner is enough to stabilise the ankles), this programme keeps its place in prevention, without being a demonstrated standard.

Analysis of a "classic" case in an amateur footballer.

The "classic" case of ARGP concerns a male footballer or hockey player with gradual-onset pain at the insertion of the adductors on the pubis, aggravated by accelerations, changes of direction and kicks.

🎯 The verified case report of Yousefzadeh et al. (2018, PMC IJSPT, PMID 29721339) illustrates multimodal management in 37 athletes (amateur footballers) suffering from long-standing ARGP (duration > 2 months). The intervention combined:¹

• Patient education : explanation of the condition, load management, importance of adherence to the programme.
• Manual therapy : used in the short term to modulate pain and improve hip and pelvis mobility.
• Modified Hölmich progressive exercise programme : cornerstone of the treatment, starting with pain-free isometrics then progressing to concentrics and eccentrics, including functional exercises.

The results showed a significant improvement in pain (VAS -2.5 points on average), adductor strength and HAGOS scores after 8 weeks of the programme, with a return to football without pain in the majority of participants.¹ This timeframe (8-12 weeks) is consistent with the literature for active, well-conducted management in the amateur footballer.²

📍 Key lessons :

• Do not confuse "long-standing" with "incurable": even after > 2 months, a correct active approach gives good results.
• The programme must be progressive and tolerable (24 h rule) rather than maximal from the outset.
• Education and adherence are as important as the technical content of the exercises.

The diagnostic challenge: when ARGP mimics or coexists with other conditions.

🕵️‍♂️ The inguinal region is a complex anatomical crossroads. Pain can arise from multiple structures and diagnostic confusion is frequent.

Several common mimics or comorbidities are documented:

• Hip pathology (FAI, labral involvement) : femoroacetabular impingement can cause pain referred to the groin, often with a typical C-sign (the patient encircles their hip with the hand between thumb and index finger). FADIR and FABER tests are key. The prospective cohort study by Falvey et al. (2016 BJSM, PMID 26626272) of 382 athletes showed that 17 % of those consulting for groin pain actually had an intra-articular hip pathology.³
• Iliopsoas-related pathology : anterior / medial groin pain, reproduced by resisted hip flexion at 90° and the modified Thomas test. Often confused with ARGP.
• Osteitis pubis : band-like pubic pain, exquisite on direct palpation of the symphysis, often associated in footballers. May coexist with ARGP.
• Sportsman's hernia ("sportsman's groin"): pain aggravated by coughing, by Valsalva, sometimes an inguinal bulge. Difficult diagnosis, often confirmed by dynamic ultrasound and surgical opinion. This inguinal entity, which the Manchester consensus calls inguinal disruption because no true hernia is present in it, is the subject of a dedicated article: athletic pubalgia (sports hernia).
• Pubic stress fracture : mainly in long-distance runners, in the context of REDs (Relative Energy Deficiency in Sport). Nocturnal bone pain, MRI bone oedema.

The mini-review with clinical case by Bisciotti et al. (2015 Muscles Ligaments Tendons J, PMID 26605198) reminds us that several pathologies can coexist behind the same groin pain, including bone, muscle, tendon and inguinal canal, and for this reason recommends a standardised clinical evaluation backed by an imaging protocol.

Complex case studies: FAI and sports hernia associations, multidisciplinary involvement.

🧩 In the high-level athlete, groin pain frequently results from several associated pathologies :

1. ARGP + FAI : the clinical association is frequent, but none of the data cited here concerns a combined surgical procedure involving the hip and adductors. The only surgical series available is that of Schilders et al. (Am J Sports Med 2013, PMID 23408590), which reports, in 43 professional athletes (39 footballers and 4 rugby players) who underwent a selective partial release of adductor longus after failure of conservative treatment, a return to the previous level for 42 of them in 9.2 weeks on average, with a mean VAS falling from 5.8 to 0.2 (mean follow-up of 40 months, case series, level of evidence 4).⁵ Neither femoroacetabular impingement nor hip arthroscopy features in this series. The idea that FAI is an underlying mechanical factor creating excessive stress on the adductors therefore remains a hypothesis, and the indication for a combined surgery cannot be deduced from it.

2. ARGP + sports hernia : a classic association but difficult to manage. Rehabilitation alone may be insufficient. Paajanen et al. (Surgery 2011, PMID 21549403) published a randomised trial showing that surgical repair of the inguinal wall allows a markedly more frequent return to sport than conservative treatment (90 % versus 27 % at 3 months).⁶

3. ARGP refractory to rehabilitation : may be treated with a percutaneous tenotomy of the adductor. Older case studies (Akermark & Johansson, AJSM 1992 PMID 1456357) reported good results with this procedure in elite athletes at a therapeutic dead end.⁷ The surgical option nevertheless remains a last resort after failure of a well-conducted active programme lasting at least 3-6 months.

When and to which other professionals should you refer?

One of the fundamental skills of the physiotherapist in direct access is to recognise situations that fall outside their scope and require referral. This process, called triage, rests on the identification of clinical flags.¹

🚩 Red flags : taken in isolation, their diagnostic accuracy is low (high sensitivity, limited specificity).² Their strength lies in the combination and overall clinical reasoning. The presence of a suspicious cluster or an atypical course should prompt rapid referral to a general practitioner or specialist for further work-up.³

🟨 Yellow, blue and black flags : psychosocial factors, work / sport-related perceptions, systemic obstacles. Crucial for identifying patients at risk of chronic pain or prolonged disability.⁴

The significant presence of these factors should encourage interprofessional collaboration (IPC). Research shows that IPC in primary care improves patient outcomes, professional satisfaction and system efficiency.⁵ Referral can be made to:

• Sports physician or orthopaedic surgeon : suspected FAI, sports hernia with bulge, failure at 3-6 months of an active programme, doubt about the surgical indication (tenotomy, inguinal wall repair).
• Radiologist : for targeted imaging (MRI with adapted pubic sequences, dynamic ultrasound for hernia).
• Psychologist / pain-specialist therapist : high kinesiophobia or catastrophising, associated depression, anxiety about returning to sport.⁴
• Dietitian-nutritionist : suspected REDs in the endurance athlete, pubic bone abnormalities, associated stress fractures.
• Occupational physician / ergonomist : if barriers to return to work predominate in the non-athlete patient.

How do you measure outcomes and overcome barriers to implementation?

🎯 To ensure that interventions are effective and to objectify progress, the use of PROMs (Patient-Reported Outcome Measures) is part of patient-centred practice.⁶ For ARGP, the reference tool is the HAGOS (Copenhagen Hip and Groin Outcome Score, Thorborg 2011 BJSM, PMID 21478502), a validated questionnaire comprising 6 subscales:⁷

• Pain, Symptoms, Activities of Daily Living, Sport and Recreation, Participation in physical activities, Hip/groin-related quality of life.
• Score from 0 (extreme) to 100 (no problems) per subscale.
• MCID (Minimal Clinically Important Difference): varies by subscale, but an improvement of 10-15 points is generally considered clinically significant.

Other complementary measures:

• NPRS (Numerical Pain Rating Scale) 0-10 at each session and for 24 h monitoring.
• Isometric strength tests at 0/45/90° of hip flexion with a handheld dynamometer. Calculation of the adductor/abductor ratio and of side-to-side symmetry.
• Graded squeeze test (force with a sphygmomanometer or dynamometer): allows objective measurement and follow-up.
• Functional tests : single-leg hop, agility T-test, COD speed test depending on the sport.
• Psychological scales : TSK-11 (kinesiophobia), PCS (catastrophising), I-PRRS (readiness).

🚧 Barriers to implementation : some frequent barriers and ways to overcome them:

1. Lack of time : the most frequent barrier. Strategies: automate the pre-filling of PROMs (online forms before the consultation), a targeted rather than exhaustive battery of tests.
2. Limited access to resources : databases, journal subscriptions. Strategies: use PubMed (free access), French-language resources (HAS), professional networks.
3. Inertia of habits : "I've always done it this way". Strategies: targeted continuing education, communities of practice, mentoring.
4. Resistance from the patient or the sports staff : pressure for a quick return, unrealistic expectations. Strategies: shared education, transparent communication about the criteria.