Groin Injuries

  • Per HölmichEmail author
  • Lasse Ishøi
  • Andreas Serner
  • Kristian Thorborg


Groin injuries, both long-standing and acute, constitute a major proportion of sport injuries. The diagnosis is based on a clinical entity approach and relies on a comprehensive examination using standardized clinical tests. Treatment of both long-standing and acute groin injuries is focused on structured exercise therapy and load management. An exercise program consisting of active adductor exercises has shown promising potential to reduce the risk of groin problems in athletes.


  1. 1.
    Bharam S, Feghhi DP, Porter DA, Bhagat PV. Proximal adductor avulsion injuries: outcomes of surgical reattachment in athletes. Orthop J Sports Med. 2018;6:2325967118784898.CrossRefGoogle Scholar
  2. 2.
    Bleakley CM, Glasgow P, MaCauley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 2012;46:220–1.CrossRefGoogle Scholar
  3. 3.
    Charnock BL, Lewis CL, Garrett WE Jr, Queen RM. Adductor longus mechanics during the maximal effort soccer kick. Sports Biomech. 2009;8:223–34.CrossRefGoogle Scholar
  4. 4.
    Dimitrakopoulou A, Schilders E. Current concepts of inguinal-related and adductor-related groin pain. Hip Int. 2016;26(Suppl 1):2–7.CrossRefGoogle Scholar
  5. 5.
    Ekstrand J, Hagglund M, Walden M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011;39:1226–32.CrossRefGoogle Scholar
  6. 6.
    Esteve E, Rathleff MS, Bagur-Calafat C, Urrutia G, Thorborg K. Prevention of groin injuries in sports: a systematic review with meta-analysis of randomised controlled trials. Br J Sports Med. 2015;49:785–91.CrossRefGoogle Scholar
  7. 7.
    Esteve E, Rathleff MS, Vicens-Bordas J, Clausen MB, Holmich P, Sala L, Thorborg K. Preseason adductor squeeze strength in 303 Spanish male soccer athletes: a cross-sectional study. Orthop J Sports Med. 2018;6:2325967117747275.CrossRefGoogle Scholar
  8. 8.
    Griffin DR, Dickenson EJ, O’Donnell J, Agricola R, Awan T, Beck M, Clohisy JC, Dijkstra HP, Falvey E, Gimpel M, Hinman RS, Holmich P, Kassarjian A, Martin HD, Martin R, Mather RC, Philippon MJ, Reiman MP, Takla A, Thorborg K, Walker S, Weir A, Bennell KL. The Warwick agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. 2016;50:1169–76.CrossRefGoogle Scholar
  9. 9.
    Haroy J, Clarsen B, Thorborg K, Holmich P, Bahr R, Andersen TE. Groin problems in male soccer players are more common than previously reported. Am J Sports Med. 2017;45:1304–8.CrossRefGoogle Scholar
  10. 10.
    Haroy J, Clarsen B, Wiger EG, Oyen MG, Serner A, Thorborg K, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med. 2018. Scholar
  11. 11.
    Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247–52; discussion 252.CrossRefGoogle Scholar
  12. 12.
    Holmich P, Holmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med. 2004;38:446–51.CrossRefGoogle Scholar
  13. 13.
    Holmich P, Larsen K, Krogsgaard K, Gluud C. Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports. 2010;20:814–21.CrossRefGoogle Scholar
  14. 14.
    Holmich P, Thorborg K, Dehlendorff C, Krogsgaard K, Gluud C. Incidence and clinical presentation of groin injuries in sub-elite male soccer. Br J Sports Med. 2014;48:1245–50.CrossRefGoogle Scholar
  15. 15.
    Holmich P, Thorborg K, Nyvold P, Klit J, Nielsen MB, Troelsen A. Does bony hip morphology affect the outcome of treatment for patients with adductor-related groin pain? Outcome 10 years after baseline assessment. Br J Sports Med. 2014;48:1240–4.CrossRefGoogle Scholar
  16. 16.
    Holmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, Krogsgaard K. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353:439–43.CrossRefGoogle Scholar
  17. 17.
    Ishoi L, Sorensen CN, Kaae NM, Jorgensen LB, Holmich P, Serner A. Large eccentric strength increase using the Copenhagen adduction exercise in football: a randomized controlled trial. Scand J Med Sci Sports. 2016;26:1334–42.CrossRefGoogle Scholar
  18. 18.
    Jacobsen JS, Hölmich P, Thorborg K, Bolvig L, Jakobsen SS, Søballe K, Mechlenburg I. Muscle-tendon-related pain in 100 patients with hip dysplasia: prevalence and associations with self-reported hip disability and muscle strength. J Hip Preserv Surg. 2017;5:39–46.CrossRefGoogle Scholar
  19. 19.
    Jensen J, Holmich P, Bandholm T, Zebis MK, Andersen LL, Thorborg K. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. Br J Sports Med. 2014;48:332–8.CrossRefGoogle Scholar
  20. 20.
    Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10:207–18.CrossRefGoogle Scholar
  21. 21.
    Light N, Thorborg K. The precision and torque production of common hip adductor squeeze tests used in elite football. J Sci Med Sport. 2016;19:888–92.CrossRefGoogle Scholar
  22. 22.
    Mosler AB, Agricola R, Weir A, Holmich P, Crossley KM. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis. Br J Sports Med. 2015;49:810.CrossRefGoogle Scholar
  23. 23.
    Mosler AB, Weir A, Eirale C, Farooq A, Thorborg K, Whiteley RJ, Hlmich P, Crossley KM. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. Br J Sports Med. 2018;52:292–7.CrossRefGoogle Scholar
  24. 24.
    Neumann DA. Kinesiology of the hip: a focus on muscular actions. J Orthop Sports Phys Ther. 2010;40:82–94.CrossRefGoogle Scholar
  25. 25.
    Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011;150:99–107.CrossRefGoogle Scholar
  26. 26.
    Reiman MP, Thorborg K. Clinical examination and physical assessment of hip joint-related pain in athletes. Int J Sports Phys Ther. 2014;9:737–55.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Sailly M, Whiteley R, Read JW, Giuffre B, Johnson A, Holmich P. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br J Sports Med. 2015;49:828–34.CrossRefGoogle Scholar
  28. 28.
    Schlegel TF, Bushnell BD, Godfrey J, Boublik M. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med. 2009;37:1394–9.CrossRefGoogle Scholar
  29. 29.
    Serner A, Tol JL, Jomaah N, Weir A, Whiteley R, Thorborg K, Robinson M, Holmich P. Diagnosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med. 2015;43:1857–64.CrossRefGoogle Scholar
  30. 30.
    Serner A, Van Eijck CH, Beumer BR, Holmich P, Weir A, de Vos RJ. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med. 2015;49:813.CrossRefGoogle Scholar
  31. 31.
    Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, Holmich P. Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings? Br J Sports Med. 2016;50:1541–7.CrossRefGoogle Scholar
  32. 32.
    Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, Yamashiro E, Holmich P. Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes. Scand J Med Sci Sports. 2018;28:667–76.CrossRefGoogle Scholar
  33. 33.
    Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, Yamashiro E, Holmich P. Characteristics of acute groin injuries in the hip flexor muscles—a detailed MRI study in athletes. Scand J Med Sci Sports. 2018;28:677–85.CrossRefGoogle Scholar
  34. 34.
    Tansey RJ, Benjamin-Laing H, Jassim S, Liekens K, Shankar A, Haddad FS. Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion. Bone Joint J. 2015;97-B:1488–92.CrossRefGoogle Scholar
  35. 35.
    Taylor R, Vuckovic Z, Mosler A, Agricola R, Otten R, Jacobsen P, Holmich P, Weir A. Multidisciplinary assessment of 100 athletes with groin pain using the Doha agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clin J Sport Med. 2018;28:364–9.CrossRefGoogle Scholar
  36. 36.
    Thorborg K, Bandholm T, Holmich P. Hip- and knee-strength assessments using a hand-held dynamometer with external belt-fixation are inter-tester reliable. Knee Surg Sports Traumatol Arthrosc. 2013;21:550–5.CrossRefGoogle Scholar
  37. 37.
    Thorborg K, Bandholm T, Zebis M, Andersen LL, Jensen J, Holmich P. Large strengthening effect of a hip-flexor training programme: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016;24:2346–52.CrossRefGoogle Scholar
  38. 38.
    Thorborg K, Branci S, Nielsen MP, Langelund MT, Holmich P. Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function. Br J Sports Med. 2017;51:594–9.CrossRefGoogle Scholar
  39. 39.
    Thorborg K, Branci S, Nielsen MP, Tang L, Nielsen MB, Holmich P. Eccentric and isometric hip adduction strength in male soccer players with and without adductor-related groin pain: an assessor-blinded comparison. Orthop J Sports Med. 2014;2:2325967114521778.CrossRefGoogle Scholar
  40. 40.
    Thorborg K, Holmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med. 2011;45:478–91.CrossRefGoogle Scholar
  41. 41.
    Thorborg K, Petersen J, Magnusson SP, Holmich P. Clinical assessment of hip strength using a hand-held dynamometer is reliable. Scand J Med Sci Sports. 2010;20:493–501.CrossRefGoogle Scholar
  42. 42.
    Thorborg K, Rathleff MS, Petersen P, Branci S, Holmich P. Prevalence and severity of hip and groin pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J Med Sci Sports. 2017;27:107–14.CrossRefGoogle Scholar
  43. 43.
    Tsukada S, Niga S, Imamura S, Saito M, Hatanaka J. Iliopsoas disorder in athletes with groin pain: prevalence in 638 consecutive patients assessed with MRI and clinical results in 134 patients with signal intensity changes in the Iliopsoas. JB JS Open Access. 2018;3:e0049.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Ueblacker P, English B, Mueller-Wohlfahrt HW. Nonoperative treatment and return to play after complete proximal adductor avulsion in high-performance athletes. Knee Surg Sports Traumatol Arthrosc. 2016;24:3927–33.CrossRefGoogle Scholar
  45. 45.
    Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007;35:467–74.CrossRefGoogle Scholar
  46. 46.
    Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, Lovell G, Meyers WC, Muschaweck U, Orchard J, Paajanen H, Philippon M, Reboul G, Robinson P, Schache AG, Schilders E, Serner A, Silvers H, Thorborg K, Tyler T, Verrall G, de Vos RJ, Vuckovic Z, Holmich P. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49:768–74.CrossRefGoogle Scholar
  47. 47.
    Weir A, Jansen JA, Van de Port IG, Van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Man Ther. 2011;16:148–54.CrossRefGoogle Scholar
  48. 48.
    Werner J, Hagglund M, Ekstrand J, Walden M. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men’s professional football: the 15-year prospective UEFA Elite Club Injury Study. Br J Sports Med. 2018. Scholar
  49. 49.
    Werner J, Hagglund M, Walden M, Ekstrand J. UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med. 2009;43:1036–40.CrossRefGoogle Scholar

Copyright information

© ISAKOS 2019

Authors and Affiliations

  • Per Hölmich
    • 1
    Email author
  • Lasse Ishøi
    • 1
  • Andreas Serner
    • 2
  • Kristian Thorborg
    • 1
  1. 1.Sports Orthopedic Research Center—Copenhagen (SORC-C), Department of Orthopedic SurgeryCopenhagen University HospitalAmager-HvidovreDenmark
  2. 2.Department Sports Groin Pain CenterAspetar Orthopaedic and Sports Medicine HospitalDohaQatar

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