Athletic pubalgia and adductor tendinopathy: groin pain in the athlete 2026 update

Clinical synthesis based on the 2015 Doha agreement (Weir BJSM, PMID 26031643), the pivotal RCT by Hölmich on active training (Lancet 1999, PMID 9989714), the evidence-based framework of Thorborg (JOSPT 2018, PMID 29510653) and the preventive cluster-RCT by Haroy on the Copenhagen Adduction Exercise (BJSM 2019, PMID 29891614).

What are the fundamentals to know about groin pain and adductor tendinopathy?🔗 Copy

Groin pain in the athlete (groin pain in athletes) covers a set of clinical pictures long conflated under the generic term “pubalgia”. That terminological imprecision has held back research, disrupted communication between clinicians and led to poorly targeted treatment.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, a l'iliopsoas, the pubis, the inguinalregion, and the hip.¹ Adductor-related pain (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 longustendon on the pubic tubercle, (2) pain on resisted hip adduction, and (3) reproduction of the familiar pain on the hip compression (squeeze) test in supine.¹,² This operational definition is now the standard for research and for clinical practice.³

ARGP mainly affects a young, male sporting population, in disciplines that combine rapid changes of direction, accelerations, decelerations and kicking. Men's football is the most studied sport: groin injuries account for 4 à 19 % of all reported injuries in the UEFA Elite Club Injury Study cohorts.⁴ Adductor muscle injuries are the most frequent cause, with an incidence of about 1.2 injuries per 1000 hours of match play.⁴ Ice hockey, rugby, Australian rules football and sprinting also carry a high exposure.⁵

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 stand out with a high level of evidence:⁵,⁶,⁷

• A previous groin injury : the most powerful risk factor, with odds ratios reported between 2 and 7 depending on the cohort. That underlines the importance of complete rehabilitation and of preventive programmes after a first injury.⁵
• Adductor weakness, particularly eccentricstrength. Athletes whose eccentric strength is below the median for their cohort have roughly a fourfold higher risk of groin injury.⁷
• An adductor-to-abductor strength imbalance. A ratio below 80 % is identified as the threshold that raises the risk. It is the most widely used strength criterion for shaping rehabilitation and for judging readiness to return.⁷

Other contributing factors include: a higher competitive level, reduced hip internal rotation range, between-limb asymmetry, and cumulative exposure (an acute:chronic workload ratio above 1.5).⁵,⁸

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

The pathophysiology of ARGP sits within the continuum model of tendon pathology of Cook and Purdam (BJSM 2009, PMID 18812414), which explicitly moves away from the idea of a purely inflammatory “tendinitis”.¹³ The model describes three sequential but not strictly irreversible stages:¹³

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

The ICON 2019 consensus (Scott et al. 2020 BJSM, PMID 31399426) recommends the term tendinopathy rather than tendinitis or tendinosis, in the absence of reliable clinical markers that would distinguish these entities non-invasively.¹⁴

natural history of untreated ARGP is that of a persistent, limiting condition. The pain, initially after exertion, progresses to appear from the start of activity, then continuously during exertion, and finally during activities of daily living (getting out of a car, turning over in bed).¹⁵ Chronicity (pain > 2 months) is a strong marker of poor prognosis and can lead to giving up sport without structured active intervention.¹⁶ Early, targeted intervention significantly changes the trajectory of the condition.

How do you assess and diagnose adductor tendinopathy with certainty?🔗 Copy

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

The history is the cornerstone of the clinical diagnosis of ARGP.¹,² The clinician should characterise several dimensions precisely:

• Precise location : ask the patient to point to the painful area with a single finger. Typical ARGP pain projects onto the proximal insertion of adductor longus on the pubic tubercle, sometimes radiating down the inner thigh.³
• Mode of onset : sudden (during a sprint, a kick, a change of direction) or insidious (gradual onset with accumulating load). The 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, kicking, running up and down 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 injuries that could influence current biomechanics.⁵
• Recent training load : an abrupt increase in volume, intensity or frequency, or a change of surface. An ACWR (Acute:Chronic Workload Ratio) above 1.5 is an established risk factor.⁶
• Functional impact : use the HAGOS (Copenhagen Hip and Groin Outcome Score) as a standardised PROM: 37 items, 6 subscales (pain, symptoms, ADLs, sport/recreation, participation, quality of life). Validated in French.⁷

Which clinical tests should you perform, and which other conditions should you rule out?

The clinical diagnosis of ARGP rests on an objective triad recommended by the Doha agreement and by 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. This is the most consistent and most localising sign.¹ Excellent sensitivity, more limited specificity (pubic pain also occurs in osteitis pubis).
2. Pain on resisted hip adduction : test in supine 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, asking the patient to squeeze the examiner's fist between their knees. Reproduction of the familiar pain = a positive test.⁸ Good intra- and inter-examiner reliability when standardised.⁷

Imaging is not required first line if the clinical picture is clear.² It becomes indispensable for ruling out other diagnoses in cases of doubt, severe trauma, red flags, or failure of conservative treatment.⁹,¹⁰ Caution: MRI detects abnormalities (pubic bone marrow oedema, adductor longus changes) in a high proportion of asymptomaticathletes, 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 by the Doha agreement entities?

Yes, systematically. The Doha classification is considered a fundamental element of effective management and of 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 Doha 2015 system defines five clinical entities for groin pain:¹

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

In practice, mixed clinical presentations are frequent (a patient can have adductor-related AND pubic-related pain at once).¹,¹³ The optimal treatment strategy for these cases remains less clearly defined than for the pure entities, but the generally recommended approach is to treat the dominant entity while taking the other components into account.¹²

Which treatment strategies are the most effective for adductor tendinopathy?🔗 Copy

Where do you 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 treatment pyramid. The starting point is not complete rest (which delays the return and encourages deconditioning) but a targeted modification of load to reduce the provocative stresses on the adductor tendon junction.²

The initial intervention combines:

1. Patient education : explaining the nature of the injury (an overload, non-inflammatory tendinopathy), the continuum model, the meaning of pain in a tendon context (a sign of irritability rather than of active structural damage), and the step-by-step treatment plan.³
2. Load management : identifying the aggravating activities (sprints, changes of direction, kicking) and modifying or temporarily removing them. Maintaining general pain-free physical activity (cycling, swimming, pool running).²
3. Early introduction of therapeutic exercise : starting with low to moderate intensity isometric contractions (an analgesic effect), then progressing to concentric and eccentric strengthening.⁴

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

Therapeutic exercise is the cornerstone of ARGP treatment, with a high level of evidence supporting its efficacy.¹,⁵ The historic reference programme is the Hölmich protocol, whose pivotal RCT published in the Lancet in 1999 (PMID 9989714) 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 (a ball between the knees), static abdominal work, balance, gentle stretching.
• Module 2 (weeks 3-8+) : adding concentric and eccentric loaded strengthening (ski slide-board, cable adduction, dynamic balance exercises), with progression of functional difficulty.

Modern approaches apply the same principles while personalising the progression to the patient and their sport. The general four-phase scheme recommended today is:

1. Phase 1: Isometrics (weeks 0-2): static adductor contractions at different hip angles, for analgesia and early muscle activation. Loads 60-70 % MVC, 5 sets of 30-45 s, 3 times a week.⁷
2. Phase 2: Progressive isotonic strengthening (weeks 2-6): concentric and eccentric exercise with progressive load. Copenhagen Adduction Exercise +++, side-lying hip adduction with a band or weight, lumbopelvic stability exercises.
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+): a gradual return to running, progressive changes of direction, accelerations and decelerations, and kicking for the sports concerned.

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

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

🛡️ Manual therapies : soft-tissue massage, hip joint mobilisations, myofascial release 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 The recommended position: a temporary adjunct to create a window of opportunity allowing better tolerance of the exercises, never the main treatment.

⚡ Extracorporeal shockwave therapy (ESWT) : systematic reviews show a moderate positive effect in chronic cases that do not respond to rehabilitation alone (the data are mainly on insertional overload tendinopathy in general).⁹ It must be built into a progressive exercise programme.

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

Beyond the physical: how do you educate the patient and address psychological factors?

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

🧠 Therapeutic education : explain to the patient that pain in a tendinopathy does not necessarily mean continuing tissue damage, but rather a sensitivity to load. That reduces fear of movement (kinesiophobia) and encourages adherence to the programme. It is essential to set realistic expectations : the mean time to return to sport after a groin injury is about 12-16 weeks, with wide individual variation.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 all strengthen self-efficacy. Graded exposure to the “feared” movements is an effective strategy for overcoming kinesiophobia.¹²

How do you secure lasting recovery and prevent recurrence?🔗 Copy

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

Actively involving the patient is a decisive factor in long-term success. The aim is to give the patient the tools they need to understand their condition, interpret their symptoms and modulate their activities independently.¹

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

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

This method avoids the “overload -> reaction -> rest” cycle that prolongs rehabilitation. It lets the patient adjust volume and intensity day by day, favouring progressive tissue adaptation rather than recurrent irritation.³

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

The return to sport (Return To Sport, RTS) must never be dictated by the time elapsed since the injury but by meeting a series of objective functional criteria.⁴ A successful return is defined not only by resuming competition but by sustaining it over time (at least 2 months) with no significant recurrence.⁵

Planning proceeds in several stages, each of which must be cleared before the next:

1. Pain control and restoring the basics : the patient must be symptom-free in ADLs and in the basic exercises. A pain-free squeeze test. Symmetrical strength on manual isometric testing.⁷
2. Restoring strength and neuromuscular control : specific strength criteria. An adductor-to-abductor strength ratio > 80 % is a key indicator drawn from the risk-factor literature.⁸ Adductor strength should be ≥ 90 % of the healthy side.⁵
3. Progressive sport-specific reintroduction : linear running → curves → changes of direction → accelerations and decelerations → kicking and tackling. Each step is cleared by the absence of pain (≤ 4/10 on the VAS during and after).²
4. Psychological readiness : assess with a validated scale such as the I-PRRS (Injury-Psychological Readiness to Return to Sport). Fear of recurrence can impair performance and increase the risk of a new injury.⁹

In practice, preventing long-term recurrence means building specific programmes into the athlete's routine. The Adductor Strengthening Programme (ASP) of Haroy et al. (BJSM 2019, PMID 29891614), built on 3 progressive sets of the Copenhagen Adduction Exercise once a week in pre-season then once a week in season, demonstrated a 41 % reduction in the risk of groin injury in a cluster-RCT of 652 Norwegian amateur footballers.¹⁰ This simple programme, quick to run (5 minutes) and cheap (a partner is enough to stabilise the ankles), is now the recommended preventive standard for men's football and other at-risk sports.

What do real clinical cases teach us about groin pain?🔗 Copy

Analysis of a “classic” case in an amateur footballer.

The “classic” ARGP case is a male footballer or ice hockey player with gradual-onset pain at the adductor insertion on the pubis, worsened by accelerations, changes of direction and kicking.

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

• Patient education : explaining the condition, load management, and the importance of adhering to the programme.
• Manual therapy : used in the short term to modulate pain and improve hip and pelvic mobility.
• A modified Hölmich progressive exercise programme : the pillar of treatment, starting with pain-free isometrics then progressing to concentric and eccentric work, including functional exercises.

The results showed a significant improvement in pain (VAS down 2.5 points on average), in adductor strength and in HAGOS scores after 8 weeks of the programme, with most participants returning to football pain-free.¹ That timescale (8-12 weeks) is consistent with the literature for well-conducted active management in the amateur footballer.²

📍 Key lessons :

• Do not confuse “long-standing” with “incurable”: even after more than 2 months, a properly conducted active approach gives good results.
• The programme should be progressive and tolerable (the 24 h rule) rather than maximal from the outset.
• Education and adherence matter as much as the technical content of the exercises.

The diagnostic challenge: when ARGP mimics or accompanies other conditions.

🕵️‍♂️ The groin is an anatomically complex 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 cups their hip between thumb and index finger). The FADIR and FABER tests are key. The prospective cohort study of Falvey et al. (2016 BJSM, PMID 26644112) in 382 athletes showed that 17 % of those presenting with groin pain in fact had intra-articular hip pathology.³
• Iliopsoas-related pain : anterior or medial groin pain, reproduced by resisted hip flexion at 90° and by the modified Thomas test. Often confused with ARGP.
• Osteitis pubis : a band of pubic pain, exquisitely tender on direct palpation of the symphysis, often seen in footballers. It can coexist with ARGP.
• Sportsman's hernia (“sportsman's groin”): pain worsened by coughing and Valsalva, sometimes with an inguinal bulge. Diagnosis is difficult, often confirmed by dynamic ultrasound and a surgical opinion.
• Pubic stress fracture : above all in long-distance runners, in a context of REDs (Relative Energy Deficiency in Sport). Bone pain at night, bone marrow oedema on MRI.

The case report of Bisciotti et al. (2015 Muscles Ligaments Tendons J, PMID 26261782) describes a professional footballer with persistent groin pain initially read as simple ARGP, in whom imaging finally revealed osteitis pubis requiring a different treatment approach (prolonged offloading plus isometric work before resuming).⁴

Complex case studies: associations with FAI, sports hernia, multidisciplinary care.

🧩 In the elite athlete, groin pain frequently stems from several associated conditions :

1. ARGP + FAI : the study of Schilders et al. (KSSTA 2017, PMID 27475186) showed in a cohort of 41 patients that combined surgical treatment of the FAI (hip arthroscopy) and of the adductor tendinopathy (selective tenotomy) gave favourable results in chronic cases resistant to conservative treatment.⁵ That suggests FAI can be an underlying mechanical factor creating excessive stress on the adductors, and that ignoring the hip pathology can lead to failure when the tendinopathy is treated in isolation.

2. ARGP + sportsman's hernia : a classic but difficult association to manage. Rehabilitation alone can be insufficient. Paajanen et al. (Br J Sports Med 2011, PMID 20542963) published a case series showing that combined surgical repair of the inguinal wall plus treatment of the adductor tendon allows a satisfactory return to play.⁶

3. ARGP resistant to rehabilitation : may be considered for percutaneous adductor tenotomy. Older case studies (Akermark & Johansson, AJSM 1992 PMID 1416982) reported good results with this procedure in elite athletes at a therapeutic impasse.⁷ The surgical option nonetheless remains a last resort after a well-conducted active programme has failed over at least 3-6 months.

How do you apply these recommendations concretely in your practice?🔗 Copy

When and to which other professionals should you refer?

One of the physiotherapist's fundamental skills in direct access is recognising the situations that go beyond their scope and call for referral. That process, known as triage, rests on identifying clinical flags.¹

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

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

A 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 to:

• A sports physician or orthopaedic surgeon : suspected FAI, a sportsman's hernia with a bulge, failure of an active programme at 3-6 months, doubt about a surgical indication (tenotomy, inguinal wall repair).
• A radiologist : for targeted imaging (MRI with pubic sequences, dynamic ultrasound for hernia).
• A psychologist or pain therapist : high kinesiophobia (TSK-11 > 37), catastrophising (PCS > 30), associated depression, anxiety about returning to sport.⁶
• A dietitian : suspected REDs in the endurance athlete, pubic bone abnormalities, associated stress fractures.
• An occupational physician or ergonomist : where obstacles to returning to work predominate in the non-sporting patient.

How do you measure outcomes and overcome barriers to implementation?

🎯 To make sure the interventions are effective and to make progress objective, using PROMs (Patient-Reported Outcome Measures) is the standard of patient-centred practice.⁷ For ARGP, the reference tool is the HAGOS (Copenhagen Hip and Groin Outcome Score, Thorborg 2011 BJSM, PMID 21478502), a questionnaire validated in French with 6 subscales:⁸

• Pain, Symptoms, Activities of Daily Living, Sport and Recreation, Participation in physical activity, Hip/groin-related quality of life.
• A score from 0 (extreme) to 100 (no problem) on each subscale.
• MCID (Minimal Clinically Important Difference): it 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 the 24 h monitoring.
• Isometric strength tests at 0/45/90° of hip flexion with a handheld dynamometer. Calculating the adductor-to-abductor ratio and side-to-side symmetry.
• A graded squeeze test (force measured with a sphygmomanometer or dynamometer): it allows objective measurement and follow-up.
• Functional tests : single-leg hop, agility T-test, COD speed test, according to the sport.
• Psychological scales : TSK-11 (kinesiophobia), PCS (catastrophising), I-PRRS (readiness).

🚧 Barriers to implementation : systematic reviews identify the main ones:¹⁰

1. Lack of time : the most frequent obstacle. Strategies: automate pre-filling of PROMs (online forms before the consultation), a targeted rather than exhaustive test battery.
2. Limited access to resources : databases, journal subscriptions. Strategies: use PubMed (open access), French-language resources (HAS), professional networks.
3. The inertia of habit : “I have always done it this way”. Strategies: targeted continuing education, communities of practice, mentoring.
4. Resistance from the patient or the sporting staff : pressure for a fast return, unrealistic expectations. Strategies: shared education, transparent communication about the criteria.