Groin Pain Rehab

The purpose of this blog is to discuss groin pain, explain the different categories of groin pain, review exercises that you can use to help improve your groin function and assist in returning to play.

Looking to improve the strength, range of motion, and control of your hips to enhance your function and performance?  Check out our Hip Resilience program!

Types of Groin Pain

Groin pain can be classified into five categories:

  • Adductor related
  • Iliopsoas related
  • Inguinal related
  • Pubic related
  • And Hip & other

Adductor related can be assessed by testing if resisted hip adduction provokes pain and palpating the adductors for tenderness.

Iliopsoas-related can be assessed by testing if resisted hip flexion and stretching the hip flexors provoke pain. You can attempt to palpate the iliopsoas for tenderness, however, research has found this to be unreliable.

Inguinal-related can be assessed by palpating for pain in the inguinal canal region, confirming there isn’t a hernia present, and you may have pain with an abdominal contraction or when coughing or sneezing.

Pubic-related can be assessed by palpating for pain at the pubic symphysis and the pubic bone.

Hip and other could be various conditions ranging between FAI, hip osteoarthritis, nerve entrapment, spine referral, an avulsion or stress fracture, or some kind of medical issue.

https://bjsm.bmj.com/content/49/12/768

This blog will be focusing on managing groin pain associated with the first four categories. To assist in ruling out the hip and others category, you can use these four main tests.

A FADIR test where your hip is flexed to 90 degrees, then adducted over the midline, and then internally rotated, assessing for pain provocation at your hip joint assessing for FAI and OA.

A FABER test where your leg is abducted and externally rotated, placing your foot onto the opposite leg, and then your knee is pushed down, assessing for pain provocation at your hip joint assessing for FAI and OA.

A fulcrum test where you sit on the edge of a table and a clinician places one of their arms under your thigh and then uses their other arm to apply downward pressure on your knee, assessing for pain provocation in your thigh for a fracture.

A hop test where you jump up and down repeatedly on one leg at a time, assessing for pain provocation at the thigh, hip, or pelvis and inability to jump due to a fracture.

Groin Pain

Groin Pain Presentations

When struggling with groin pain, you may notice that you have a limitation in different ranges of motion and a reduction in strength. Typically you’ll see a loss in the range of motion for hip abduction, hip internal and external rotation, and possibly hip flexion and extension. You may also experience a decrease in hip adduction strength, hip flexion strength, and possibly hip abduction. In addition, you’ll likely notice that doing activities such as running, cutting, and kicking can be particularly bothersome.

Groin Pain Rehab Overview

There are two primary goals that your rehabilitation will focus on following an injury:

  1. Addressing your deficits in range of motion and strength associated with the injury
  2. A progressive return to your activities

To achieve these goals I recommend three key components for your rehab:

  1. Load management and activity modification to help in allowing recovery and maintenance of participation in your activities
  2. Exercises to isolate and reduce your deficits
  3. Progressive programs that target returning to limited activities such as running and kicking.
Groin Pain

Load Management & Activity Modification

The first step in rehabbing your groin injury is load management. Being able to balance the demands on this region with your ability to recover is important for long-term improvements. At first, you’ll need to reduce activities, limiting the challenge to the region. After a few days, you can begin to progress loading the region, slowly increasing the volume, intensity, and frequency of your activities as you find tolerable. It’s important to not rush this process and have excessive spikes in loading as this may predispose you to setbacks.

You can also modify activities that cause discomfort, such as squatting, running, or kicking. For instance, with squatting you can reduce the depth at first and then gradually increase it over time. Similar approaches can be done with running or kicking, which dedicated progressions will be provided.

Exercises for Groin Pain

Performing targeted exercises at reducing your deficits in range of motion and strength will be very beneficial for your rehab. As well, research from papers such as Markovic 2020 and Moreno-Pereze 2019 have identified that when your groin musculature is stronger, you are less likely to experience an injury to it.

Adduction

Level 1: Supine Squeeze – Lay on your back with your legs extended and a ball between your legs. Squeeze your ankles together, trying to crush the ball.

Level 2: Short Copenhagen Side Plank – On your side with your forearm down, place your top knee on a bench with your legs bent. Raise your hips and lower leg to be in line with your shoulder and hold.

Level 3: Calf on bench Copenhagen Side Plank – Set up the same, but with your legs straight and further out so your calf is on the bench.

Level 4: Copenhagen Side Plank – Move further out and have just your foot resting on the bench.

Level 5: Foot elevated Copenhagen Side Plank – Elevate your foot higher so that it is above your shoulder and hold.

Level 6: Copenhagen Adduction – Set up the same, but now begin raising and lowering down for repetitions.

Aim for 2 to 3 sets of 30-45 seconds and progress to the next variation as you can tolerate. Research suggests working towards being able to handle more and more repetitions of the Copenhagen adduction, reaching over 90 repetitions in a given week for best results.

Groin Pain

Hip Flexion

Level 1: Supine Isometric Hip Flexion – Lay on your back, flex your hip so your thigh is vertical, then put your hands on your knee. Push your knee into your hands and resist

Level 2: Standing Resisted Hip Flexion – Stand with your hands supported and a band or cable attached to your ankle. Raising your knee to parallel and return down for reps.

Level 3: Supine On Bench Hip Flexion – Lay on a bench with your hips at the bottom and knees hugged into your chest. Lower one leg to the ground at a time. Add external resistance as desired.

Aim for 2 to 3 sets of 30-45 seconds on the isometric and 8-15 reps on the others, progressing as you can.

Option 2 – One arm row. Set up the same way, however now you’ll perform this with just one arm at a time. This will increase the demand on resisting rotation. You can perform this with a DB, a landmine, or a band.

Groin Pain

Abdominals

Level 1: Deadbug Iso Hold – Lay on your back with your thighs and arms raised perpendicular to the floor. Hold this position.

Level 2: Deadbugs – In the same position, begin lowering your opposite arm and leg to the floor and then returning in. Alternate sides.

Level 3: Upper Extremity Resisted Deadbug – Set up the same, but this time holding onto a band or cable pulling from behind you. Maintain tension and alternate lowering your legs out.

Aim for 2 to 3 sets of 30-45 seconds on the isometric and 8-15 reps on the others, progressing as you can.

Abduction

Option 1: Side Lying Hip Abduction – laying on your side with a band around your knees and legs straight, raising your top leg up and lower down. Progress by moving the band to your ankles and then to your toes, or using a stronger band.

Option 2: Lateral Band Walk – standing in a partial squat with a band around your knees, step to the side, driving your knees apart while keeping your toes forward. Progress by moving the band to your ankles and then to your toes, or using a stronger band.

Option 3: Side Plank – On your side with your elbow down, lift your hips so there is a straight line from your ankle to your shoulders.If this is too hard, start with knees bent. If it’s too easy,  progress by raising your top leg.

Option 4: Standing cable abduction – Standing with an ankle cuff on your outside leg, attached to a cable stack. Keeping your leg straight and toes pointing forward, raise your leg out to the side and return in. Progress by increasing the cable resistance.

Aim for 2 to 3 sets of 30-45 seconds on the isometric and 8-15 reps on the others, progressing as you can.

Compound Movements for Groin Pain

Training larger compound movements is a great way to continue developing strength and range of motion for the groin, along with improving your overall functional ability. I’m going to present four categories of exercises with two options each.

Squats

Bilateral Squat

Goblet Squat: Standing with your feet hip width apart and a weight held to your chest, begin squatting down as low as you are comfortable, then stand up.

Back Squat: Set up and execute the same but with a bar across your shoulders.

Aim for 2 to 3 sets of 6 – 15 reps, progressing your depth and weight as you tolerate.

Unilateral Squat 

Split Squat: Standing in a split stance with one foot forward and the other back. Lower down until your back knee hovers just off the ground and then stand up.

RFESS: Set up in a split stance, but with your rear foot elevated on a bench. Execute the same, lowering until your back knee is just off the ground and then stand up.

Aim for 2 to 3 sets of 6 – 15 reps, progressing your depth and weight as you tolerate.

Hinges

Bilateral Hinge

DB RDL:  Set up standing with a dumbbell in your hand. Have a slight bend in your knees and begin lowering the DBs down your legs. Go as low as you’re comfortable and return up.

Conventional Deadlift: Start by grabbing the bar, get your chest up, and stand up. Lower down under control.

Aim for 2 to 3 sets of 6 – 15 reps, progressing your depth and weight as you tolerate.

Unilateral Hinge 

DB Single Leg RDL: Stand on one foot with dumbbells in your hands, begin lowering towards the floor while raising your other leg up towards the roof, then stand back up.

Barbell Single Leg RDL: Set up the same but hold a barbell in your hands. Lower as far down as you are comfortable.

Aim for 2 to 3 sets of 6 – 15 reps, progressing your depth and weight as you tolerate.

Return to Play Progression

The final component of your rehab is a progressive plan for returning to your most challenging  activities. For groin injuries, this is often going to be running, cutting, and kicking. 

Running

I’m going to outline a three stage running progression from a 2022 paper by Hickey et al. This was originally designed for hamstring injuries, however, its progression works very well for groin injuries as well. Once you can walk with a pain rating of four out of ten or less, you can start stage 1.

Stage 1 – begin jogging slowly over 20 meters, then increase your speed up to 50% of your maximum velocity for 60 meters, and then return to a slow jog for another 20 meters. If you can complete three repetitions at 50% of your maximal speed with four out of ten pain or less, you can progress to stage 2.

Stage 2 – build up speed over 30 meters and then maintain your speed over the next 50 meters, and then slow down over the remaining 20 meters. If you can complete three repetitions at 80% of your maximal speed with no pain, you can progress to stage 3.

Stage 3 –  accelerate over 40 meters, maintain your speed for 40 meters, and then slow down over 20 meters. You will gradually increase your top running speed in 5% increments until you are able to complete sprints at 100% running speed without any pain.

Cutting

I’m going to outline a four stage cutting progression. Start this progression once you are able to walk pain free.

Stage 1 – Lateral Shuffle – Standing in a quarter squat with a hip width stance, step to the side with your lead leg and push with your rear leg, repeating for 20 meters in each direction. If you can complete three repetitions with a pain rating of four out of ten or less, you can progress to stage 2.

Stage 2 – Zig Zag Shuffle – Set up 6 cones staggered 3 meters apart at 45 degree angles from one another. Start at the first cone, face forwards and shuffle to the next cone, then pivot and cut to the next cone. Repeat through all of the cones and then reverse back through. Once you can complete three repetitions without pain, you can progress to stage 3.

Stage 3 – 90 Degree Cuts – Set up three cones in the shape of an L, 10 meters apart from each other. Start at the first cone, run towards the middle cone, then cut to the side towards the third cone. Repeat in the opposite direction. Once you can complete three repetitions without pain, you can progress to stage 4.

Stage 4 – 180 Degree Cuts – Set up three cones in a line, 10 meters from the first to the second, and then 5 meters from the second to the third. Start at the first cone, sprint past the second and then plant and cut 180 degrees back to the second. Reset and perform the drill planting and cutting with the other leg.

Kicking

I’m going to outline a four stage kicking progression which will follow a similar progression as cutting and running.

Stage 1 – Short Distance Catch & Kick – Kick a stationary ball 3 to 5 meters. When receiving a kick in this stage, catch it with your non-involved foot. Once you can kick a ball 10 times in a row with a pain rating of four out or ten or less, move to the next stage.

Stage 2 – Short Distance Kicking – Receiving the ball from 3 to 5 meters away with your involved foot and return the ball. Once you can kick a ball 10 times in a row without pain, move to the next stage.

Stage 3 – Mid Distance Kicking – Perform the same drill as before, but now move further out so you are 10 to 15 meters away. Once you can kick a ball 10 times in a row without pain, move to the next stage.

Stage 4 – Long Distance Kicking – Continue with the same drill, but now move further out so you are kicking more than 15 meters.

Programming

To maximize your rehab, you want to ideally perform the groin specific exercises two to three times a week, with a day between repeating categories. If you have time available, performing the non-specific groin movements will also be beneficial. I’m going to lay out two examples of how you could program these, along with the return to activities progressions.

Example 1: Full Training Program

On this routine you will perform your return to running and cutting progression on Monday and Thursdays, with a Return to Kicking program on Wednesdays. On Tuesday you will perform bilateral squats and unilateral hinges, followed up with the specific groin movements at your ability level. On Friday you will perform bilateral hinges and unilateral squats, followed up again with your specific groin movements.

Example 2: Bare Bones Program

With this routine you will perform your return to running progression Monday, followed by your hip adduction and hip flexion exercises. On Tuesday you will perform your return to cutting and kicking progression, followed by your abdominals and hip abduction exercises. Then you’ll repeat Monday on Thursday and Tuesday on Friday.

These are just two examples of how you could lay everything out. You should adjust these based upon your time availability and needs.

Groin Pain

Monitoring Symptoms

During the rehab process, you may experience pain with exercise. This isn’t necessarily a problem or a sign that you need to pull back from what you’re doing. However, it is good to ask yourself a few questions to help in monitoring symptoms:

  • Is your pain during exercise tolerable? This is unique to each person, but generally somewhere around three to four out of ten is tolerable. 
  • Do your symptoms get worse with exercise? 
  • Is your pain worse the next day? 

Ideally when you’re exercising, you should be able to stay within a tolerable range for symptoms and then see your symptoms maintain or reduce going into the next day. Consider adjusting your exercise intensity, volume, or frequency to allow your symptoms to be within a tolerable range.

Return To Sport

For those participating in sports, an important question is: when is it safe to return? Serner 2020 found that using a criterion based return to sport protocol reduced groin reinjury risk. Here is a set of criteria modified from the Serner paper that can be used to progress to controlled sports practice and competition.

To return to controlled practices with reduced intensity and volume, you should have:

  • Pain free palpation of your groin region
  • Pain free maximum isometric for adduction, hip flexion, and hip abduction
  • Pain free full stretch into hip abduction and hip extension
  • Completion of stage 3 of running progression
  • Completion of stage 4 of cutting progression

If you have achieved all of these, then you can return to practice. You should work with your coach to reduce the intensity and volume of practice at first. If you have no increase in symptoms with practice, gradually increase the intensity and volume until you are back to full practice. Once you can return to full practice without symptoms, then you can return to competition.

Groin Pain Summary

Groin injuries can vary from lasting a few days to a few months. Commonly you’ll have deficits in range of motion and strength following a groin injury. Reducing these deficits through training and doing a gradual return to activities will be beneficial and possibly reduce your risk of reinjury.

Looking to improve the strength, range of motion, and control of your hips to enhance your function and performance?  Check out our Hip Resilience program!

Want to learn more? Check out our some of our other similar blogs:

Quadriceps Strain RehabAdductor StrainFAI

Thanks for reading. Check out the video and please leave any questions or comments below.

Leave a Reply

Your email address will not be published.

Fill out this field
Fill out this field
Please enter a valid email address.
You need to agree with the terms to proceed

Menu