In this blog, I teach you everything you need to know about groin pain rehab!
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Anatomy & Function
First, I’m going to review the anatomy and function of the hip region, which is important to know for determining the source of groin pain and how to treat it.
The hip is a ball and socket joint. The ball is the head of your thigh bone, or femur, and the socket, known as the acetabulum, is part of your pelvis. There is a lining of cartilage around the acetabulum called the labrum that helps with stability and load distribution through the joint.
The primary movements of the hip are flexion, extension, adduction, abduction, internal rotation, and external rotation.
Hip flexion is performed by several different muscles including the tensor fascia latae, sartorius, pectineus, and adductor longus and brevis, but for this blog I’ll focus on the iliacus, psoas, and rectus femoris.
Hip extension is primarily performed by the gluteus maximus, hamstrings, and adductor magnus.
Hip adduction, or moving your thigh toward the midline of your body, is performed by the adductors, as well as the pectineus and gracilis muscles. For this blog, I will primarily focus on the adductor longus muscle as it is the most commonly involved in groin pain.
Hip abduction, or bringing your thigh away from the midline of your body, is performed primarily by the gluteus medius, gluteus minimus, and the tensor fascia latae.
Although the hip abductors are not often a source of groin pain, they will be important in the exercises I share later in the blog. Many of the muscles I just mentioned are also involved in hip internal and external rotation, as well as stabilizing the pelvis.
Sources of Groin Pain
There are several potential musculoskeletal sources of groin pain: adductor-related, iliopsoas-related, inguinal-related, pubic-related, and hip-related.
Generally, pain or tenderness localized to one of these structures, in addition to a reproduction of pain through contracting or stretching that specific structure, can help determine the source of symptoms. Notably, the pain felt with resistance testing must be in the location of that structure being tested. This is why the anatomy is so important to know.
As a quick disclaimer before diving into each possible diagnosis, it’s always important to be evaluated by a healthcare professional since there are some causes of groin pain that require imaging and specific medical management, such as a fracture, avascular necrosis, and other conditions that aren’t the focus of the exercises and education in this blog.
With that out of the way, let’s get into it.
Key reference throughout: Thorborg et al 2018
Adductor-Related Groin Pain
Adductor-related groin pain is common in athletes who do sports that involve kicking and cutting. It is identified by the presence of pain or tenderness in the adductor area with palpation, as well as resistance testing that reproduces pain in the adductors. It is more likely the culprit of groin pain if symptoms are also present with stretching the adductors. As I mentioned earlier, the most commonly affected muscle is the adductor longus, and it is usually strained from kicking or changing direction.
Iliopsoas-Related Groin Pain
Iliopsoas-related groin pain refers to pain and tenderness at the front of the thigh, along the iliopsoas, that is reproduced with resisted hip flexion and/or stretching of the hip flexors. The rectus femoris, which also falls under this category, is most commonly strained during sprinting and kicking while the iliacus and psoas can become strained from change of direction movements.
Inguinal-Related Groin Pain
Inguinal-related groin pain is characterized by pain in the inguinal area which is between your lower abdominals, pubic bone, and the bone at the front of your hip called the anterior superior iliac spine, or ASIS. Symptoms may be reproduced with coughing, sneezing, and resisted trunk flexion.
Although it can initially be difficult to differentiate inguinal-related groin pain from adductor-related groin pain, adductor-related groin pain will typically improve with adductor-specific exercises, which I will cover a little later. Inguinal-related groin pain, however, will not improve and may in fact worsen with adductor-specific exercises or with increases in activity in general.
It’s important to note that an inguinal hernia does not fall under this category of groin pain. Therefore, a palpable bulge should not be present.
Pubic-Related Groin Pain
Pain at the pubic symphysis, which is where the left and right sides of your pelvis come together, and the bones next to it is the hallmark sign of pubic-related groin pain. There are no specific resistance tests for pubic-related groin pain, but it can be more likely if both resisted trunk flexion and resisted hip adduction reproduce symptoms in the pubic area.
Hip-Related Groin Pain
Hip-related groin pain may be associated with clicking, locking, catching, or giving way, in addition to hip and groin pain. Potential sources of hip-related groin pain could be any part of the hip joint including the labrum, acetabulum, or femoral head. Femoroacetabular Impingement Syndrome, better known as FAI, is a hip joint pathology defined by a triad of symptoms, clinical signs, and specific findings on imaging. Usually hip range of motion, especially internal rotation, is limited in people who have FAI.
Imaging
What about imaging, such as x-rays and MRIs?
It is potentially important for diagnosing or ruling out one of the more serious pathologies I mentioned earlier.
Imaging may also be helpful in diagnosing hip-related groin pain since it is one of the diagnostic criteria of FAI. However, according to Thorborg et al, imaging is no better than the diagnostic criteria I just discussed for helping to determine the source of groin pain. It also does not provide further information on how to rehab the issue or how long it will take to get better.
These authors also explain that there is no high-level evidence that supports the superiority of surgery or medical management over rehabilitation for hip-related groin pain, so imaging may be of limited value in the actual management of symptoms.
Therefore, imaging is not always necessary and musculoskeletal sources of groin pain, such as the ones in this blog, often respond just as well, if not better, to non-operative management.
So what can you do for these different types of groin pain?
Load Management & Activity Modifications
First, it’s important to understand that it might take anywhere from a couple months to a year or more for symptoms to resolve. There may be certain activities that you need to modify or limit in the short-term while also gradually building up the capacity of the structures contributing to your groin pain.
For example, if you have adductor-related groin pain that gets worse during and immediately after your pickup soccer game, or, for the rest of the world, football game, it might be smart to temporarily stop playing or limit the amount of time you play for. Simultaneously, you should be performing specific exercises that target the adductors to increase their capacity to tolerate load.
A common occurrence is that someone will experience groin pain, stop all activity, and then once their pain subsides, they go right back to the same level of activity they were doing before. At this point, though, their capacity to tolerate that activity has decreased. So when they go back to it, they are less able to tolerate that same amount of load and the pain returns, sometimes worse.
This is why it’s so important to continue to increase your body’s capacity even while you limit or modify your activities in the short-term.
Monitoring Pain
It’s also helpful to understand that the rehabilitation process is not a linear path. You may experience symptoms that fluctuate on a day to day or week to week basis. It is therefore important to track your function alongside your pain.
Going back to the soccer example, you might experience a 3/10 pain after playing for 20 minutes. A few weeks later, you might experience a 3/10 pain after playing for 40 minutes. Although you are still experiencing the same symptoms, you are able to play soccer for twice as long before the onset of symptoms. This is a huge win.
Tracking your pain alongside your function can help guide the amount of activity you do and make sure you don’t do more than your current capacity.
Local Tissue Exercise Options & Progressions
With that information in mind, the most important aspect of rehab is building the capacity of the local tissues involved in your symptoms. Going back to what I said earlier about the different potential sources of groin pain, if you have tenderness in your adductors, your symptoms are present with resisted adduction testing, and you notice weakness in your adductor muscles, that will be the area you want to target most.
For any athlete with groin pain, it is recommended to monitor and address hip adductor, abductor, and abdominal muscle strength.
Let’s start with adductor-focused exercises.
Adductor Exercise Progression
You can begin loading the adductors even while you’re experiencing symptoms by simply scaling the exercise to your current tolerance. This exercise progression begins with light loads that can be done very early after an acute injury and gradually increases the amount of loading. Either begin with the first exercise or find which level you can perform comfortably and progress from there.
Level 1: Supine Adductor Squeeze – Lie on your back with your knees bent and squeeze an object like a ball or a foam roller between your knees. Aim for 3-5 sets of 20-60 second holds.
Another option is lying with your legs flat and squeezing a ball or other object between your ankles.
Level 2: Isometric Short Lever Copenhagen Plank – Put your top knee on a bench with your forearm on the ground and lift your hips, forming a straight line from your knee to your shoulder, and hold this position. Work your way up to 3-5 sets of 20-60 second holds.
Level 3: Isometric Long Lever Copenhagen Plank – To progress, simply move away from the bench and put your ankle on top of it instead of your knee. Try to perform 3-5 sets of 20-60 second holds.
Level 4: Copenhagen Plank Thrusters – After mastering the isometric hold, see if you can lift your hips up and down.
Start with your knee on the bench for a short lever Copenhagen and eventually progress to putting your ankle on the bench for a long lever variation. Aim for 3-5 sets of 6-15 repetitions.
Abductor Exercise Options
Although the hip abductors are not a common source of groin pain, many people who have hip and groin pain have decreased hip abduction strength. There are many ways to target your hip abductors.
Here are several variations you can try:
Option 1: Side Lying Hip Abduction – Lie on your side and lift your top leg up and down slowly and with control.
Try to keep your heel in line with your tailbone and point your toes straight ahead or slightly down toward the floor.
You can make this harder by adding a band at your knees or ankles, or by wearing a weight cuff around your ankle. Work up to 3-5 sets of 12-15 reps.
Option 2: Banded Crab Walks – Place a band just above your knees and stand in a semi-squat position with your feet facing straight ahead of you. Take short sideways steps, keeping tension through the band the whole time by pushing against it with your knees. Work up to 10-20 steps each direction and repeat for 3-5 sets. If this is too easy, you can make it more challenging by either increasing the resistance of the band or by putting the band down by your ankles instead.
Option 3: Cable Column Hip Abduction – With the strap around your ankle, kick straight out to the side, away from your body. You can make this more challenging by increasing the amount of weight and by progressing the volume of reps and sets. Try to work up to 3-5 sets of 10-15 reps on each side.
Option 4: Side Plank – Lie on your side with your legs stacked on top of each other and your forearm on the floor. Lift your hips up and hold. If this is too difficult, you can do a short side plank by bending your knees and lifting from there instead of from your feet. You can make it harder by lifting your top leg at the top position of the plank. Work up to 3-5 sets of 20-60 second holds on each side.
Hip Flexor & Abdominal Exercise Options
The iliacus, psoas, and rectus femoris all share a common function of flexing the hip, and are also a potential source of groin pain. It is also common to find abdominal or trunk muscle weakness in people with groin pain.
Here are a few exercise variations to target the hip and trunk flexors:
Option 1: Dead Bug Progression – Start on your back with your hips and knees bent up to 90 degrees each. Slowly extend one leg straight out to hover above the floor and then return to the starting position. Repeat on the other side and continue to alternate. Work up to 3-5 sets of 10-15 reps on each side.
You can make this more challenging by putting a band around your feet or by progressing to a straight leg dead bug.
To perform the straight leg dead bug, lie on your back with your legs straight up in the air. Slowly lower one leg down to hover right above the ground and then return to the starting position and repeat on the other side, alternating for the prescribed amount of reps on each side. Try not to let your back arch while you perform the movement.
To make it harder on your trunk, lift both arms up in the air and lower the opposite arm along with your leg. Once again, work up to 3-5 sets of 10-15 reps on each side.
Option 2: Forearm Plank – Start in a plank position on your forearms, forming a straight line from the back of your head to your tailbone. If this is too difficult, drop down to your knees. If it’s too easy, you can try performing alternating hip extension in a slow and controlled manner to increase the challenge on the down leg. Work up to 3-5 sets of 20-60 seconds.
Option 3: Standing Hip Flexion – Place a band around your feet and march one knee up toward your chest then place it back in its starting position and repeat on the other side. Continue alternating for the desired amount of reps.
To make this easier, take the band away or lean forward slightly and place your hands on a wall directly in front of you. To make it more challenging, lift your foot to the top of a high box to increase range of motion or increase the resistance of the band. Work up to 3-5 sets of 10-15 reps on each side.
Exercise Considerations
If you’re someone who is just looking to get back to the gym or your normal daily activities, identifying the area contributing to your symptoms and using the local exercises to build the capacity of those tissues might be enough.
If you have multiple areas of symptoms or weakness, you can incorporate multiple categories. Similarly, if you’re someone who participates in activities like soccer, hockey, or other sports where groin pain is prevalent, you might want to add all of these options into your program to build the capacity of the structures around the hip in general and help reduce the risk of injury.
Keep in mind that you might only do 1 exercise per category, 2-3 times per week. More isn’t necessarily better, especially in the short-term.
You may also want to consider adding in more global exercises in which these hip muscles work together with the rest of the trunk and legs. Generally, you should try to add in a squat and a hinge exercise to your lower body training program.
Squats, Lunges, Step-Ups, & Split Squats
Squats include variations such as lunges, step-ups, and split squats. You can increase the amount of load going through your hips by increasing the range of motion, the amount of weight you are lifting, or the volume, referring to how many total sets and reps you perform. Here are several different options:
Option 1: Bodyweight Squat – Start by performing bodyweight squats. You can make these easier by reducing your range of motion by going to a box, or you can make them harder by holding a dumbbell or kettlebell for a goblet squat.
Option 2: Barbell Back Squat – Start with a higher box for decreased hip flexion range of motion.
As you start to feel better, gradually increase the depth by using a smaller box or taking the box away. If you use a box, try to just tap it and stand back up as opposed to sitting down all the way.
Option 3: Reverse Lunges – You can make these easier by decreasing the range of motion and touching your back knee down to a pad or step. You can make them harder by increasing the load with dumbbells, kettlebells, or a barbell.
You can also gradually increase the range of motion by performing deficit reverse lunges and having your front foot on a step or weight plate.
Option 4: Step-Ups – Start with a low box and gradually increase the height. You can also add load with dumbbells, kettlebells, or a barbell.
Option 5: Split Squats – Start with an isometric split squat, aiming for 3-5 sets of 30-60 seconds on each side.
If this is too difficult, you can hold for less time or support your body weight with a band, barbell, or TRX straps.
Once those become easier, you can perform for reps or you can try to load your hips even more with rear foot elevated split squats.
Adding a deficit will make you go through an even larger range of motion through your hips which loads them even more. You can also add weight for a further challenge.
For any of these options, gradually work up to 3-5 sets of 6-15 reps.
Deadlifts & Hip Thrusts
Hinging focuses primarily on hip flexion and extension and is a great way to load the hip extensors like the glutes and hamstrings. The two options I’m going to present are deadlifts and hip thrusts.
There are a wide variety of deadlift variations you can try.
Option 1: Romanian Deadlift (RDL) – Start with an RDL, which starts from the standing position, and keep the range of motion tolerable by limiting the amount of hip flexion. You can perform RDLs with a barbell, dumbbells, or kettlebell. Eventually, try to increase your range of motion to increase loading through your hips.
Option 2: Single Leg RDL – You can also try single leg RDLs which will increase the demand through your hip abductors. You can make these easier by holding on for balance or by decreasing the depth of your movement. You can make them harder by holding weight, such as a dumbbell or kettlebell.
Option 3: Conventional Deadlift – Pulling from the floor for a conventional deadlift will increase the amount of hip flexion. You can make these easier and reduce the amount of hip flexion by placing the bar on blocks. You can make them harder by increasing the amount of weight and/or the amount of reps and sets you perform.
Option 4: Sumo Deadlift – A sumo deadlift will load the adductors more than the other deadlift variations. Keep the load and range of motion tolerable. You can make these easier by pulling from blocks and make them harder by pulling from the floor to increase the range of motion or by adding load or volume.
Hip thrusts are another great hinging exercise. You can start by doing a double leg hip thrust isometric and eventually progress to a single leg hip thrust isometric. Aim for 3-5 sets of 30-60 seconds.
You can also perform them for repetitions through a tolerable range of motion. You can make these easier by limiting the range of hip flexion and extension you go through. You can progress them by adding weight like a weight plate, dumbbells, or a barbell. You can also try increasing the range of motion you go through or the amount of reps and sets you perform.
In general, all of these variations can be made easier by limiting the amount of hip flexion you move into. They can be made more challenging by increasing the range of motion, the load, and/or the volume.
Gradually work up to 3-5 sets of 6-15 reps.
For any of these options, gradually work up to 3-5 sets of 6-15 reps.
Sport-Specific Exercise Progressions
If you are trying to get back to sport activities, you should also incorporate more sport-specific loading to best prepare your body for those demands. Specifically, sprinting, cutting and changing direction, and kicking will load the structures that commonly contribute to groin pain and should be progressed before returning to sport activities.
- Running – The most important aspect here is to monitor your training load. Doing too much too soon could end up bringing on your symptoms and setting you back in your rehab. In general, the higher the volume and/or intensity, the more you are loading the structures that can contribute to groin pain. Start with a walk-jog progression and gradually build up to your goal.
- Cutting/Change of Direction – Sudden changes of direction are one of the more common causes of adductor strains. A gradual progression of reintegrating cutting and change of direction back into your training should start with lower speeds and greater angles. As you progress in your rehab, start to increase your speed as well as the sharpness of the angle you are cutting at. Before returning to sport activities, make sure you add a reactive component like a game of tag or a partner chase drill.
- Kicking – Different kicking techniques may place more or less load on the structures that can contribute to groin pain. Kicking with the laces, like shooting a soccer ball or kicking a field goal, will place more load on the hip flexors and will also load the adductors. Kicking with the inside of the foot, like passing a soccer ball, will mostly load the adductors with some load on the hip flexors. This is another reason why it’s important to know where your groin pain is coming from. If you have adductor-related groin pain, it’s likely that you’ll be able to kick with your laces comfortably before you’re able to kick with your instep, or inside of the foot, comfortably. When you begin kicking again, start with short distances and gradually increase your kicking distance. You can also start kicking with a balloon, kickball, or smaller sized soccer ball and gradually progress to a standard sized ball.
How To Individualize Your Program
As I said before, if you’re simply looking to get back to your regular gym sessions, running, cycling, hiking or other activities that don’t involve sprinting, kicking, or changing direction, then simply determining your source of groin pain and associated weaknesses and choosing those specific local exercises might be enough for you. If this applies to you, here is a sample program that might be helpful:
- Day 1: Local rehab exercises
- Day 2: Modified activity (running, cycling, hiking, etc)
- Day 3: Rest
- Day 4: Local rehab exercises
- Day 5: Modified activity (running, cycling, hiking, etc)
- Days 6 & 7: Rest
If you participate in sports with high prevalence of groin pain such as soccer or hockey, you may want to consider performing all of the categories of the local exercises as part of an injury prevention program. You could perform these exercises at the end of your normal training sessions, aiming for at least 2-3 sessions per week.
If you want to include the global exercises as well, here’s a blueprint for a program combining both global and local hip exercises:
- Squat Variation
- Hinge Variation
- Hip Adduction Exercise
- Hip Abductor Exercise
- Hip Flexor Exercise
You can simply repeat the same exercises 2-3 times per week, progressing as tolerated, or you can vary them slightly. For example, on Day 1 you might do:
- Barbell Back Squat
- Single Leg RDL
- Long Lever Copenhagen Isometric
- Cable Column Hip Abduction
- Forearm Plank
And on Day 2 you might do:
- Rear Foot Elevated Split Squat
- Hip Thrusts
- Short Lever Copenhagen Plank Thrusters
- Forearm Side Plank
- Standing Hip Flexion
Adjunct Therapies
I did not mention anything about stretching, mobilizations, shockwave, injections, or any other passive modalities or adjunct therapies. This is because the primary pillars of rehab for groin pain are modifying training load and increasing tissue capacity. Now, if performing some banded hip mobilizations feels good for you, then by all means go ahead and do them. But do not let them or any other treatments take precedence or priority over monitoring your training load and performing your rehab exercises to improve your capacity for load.
As far as shockwave, injections, needling, or any other passive modalities are concerned, there is simply not enough high quality evidence to warrant their use and therefore they cannot be recommended at this time. Again, I cannot stress enough that the two most important aspects of managing groin pain are load management and building tissue capacity, and passive modalities simply do not help you achieve those goals.
Summary
In summary, there are 5 different potential causes of groin pain: adductor-related, iliopsoas-related, inguinal-related, pubic-related, and hip-related groin pain. Having a healthcare professional perform a full medical history and assessing those specific structures with palpation and resistance testing is just as good as or better than imaging for diagnosing groin pain.
Most groin pain is managed well with rehab that focuses on load management and increasing tissue capacity. The most important thing is to identify symptoms and functional limitations, and address those with local rehab exercises targeting tissue capacity.
Looking for rehab or performance programs? Check out our store here!
Want to learn more? Check out some of our other similar blogs:
How To Improve Your Hip Range Of Motion, How To Perform Copenhagen Planks, Femoroacetabular Impingement (FAI)
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