Understanding Athletic Groin Pain: A Clinical Perspective on Diagnosis and Evidence-Based Rehabilitation

Athletic groin pain remains one of the most diagnostically challenging musculoskeletal conditions encountered in sports medicine. Unlike acute muscle strains, groin pain often represents a complex interaction between multiple anatomical structures, including the adductor musculature, pubic symphysis, iliopsoas complex, inguinal region, and intra-articular hip joint.

The Doha Agreement fundamentally changed the clinical approach to groin pain by emphasizing a classification system based on the primary pain-generating tissue rather than relying on vague terms such as "sports hernia" or "groin pull." This framework has significantly improved diagnostic consistency among sports medicine physicians and physical therapists.

Because symptoms frequently overlap, successful management begins with an accurate differential diagnosis supported by a comprehensive clinical examination, objective strength assessment, and evidence-informed clinical reasoning.

Why Is Athletic Groin Pain Difficult to Diagnose?

Athletes rarely present with isolated pathology. Instead, they frequently demonstrate impairments involving multiple structures simultaneously.

Research has demonstrated that hip-related pathology, adductor dysfunction, reduced force production, altered movement mechanics, and impaired lumbopelvic control commonly coexist, making reliance on a single orthopedic test clinically inappropriate.

This complexity explains why imaging findings alone rarely correlate with symptoms.

For example, systematic reviews evaluating magnetic resonance imaging (MRI) have demonstrated that 54% to 67% of completely asymptomatic individuals exhibit acetabular labral abnormalities, while many continue participating in high-level athletics without limitations.

These findings reinforce one of the most important principles in orthopedic physical therapy:

Treat the patient—not the MRI.

Pain is a multidimensional clinical presentation requiring integration of history, objective examination, functional capacity, and patient-reported symptoms.

Clinical Presentation of Femoroacetabular Impingement Syndrome (FAIS)

Among athletes presenting with chronic groin pain, Femoroacetabular Impingement Syndrome (FAIS) represents one of the most frequently encountered intra-articular pathologies.

Clohisy and colleagues reported characteristic symptom patterns among patients diagnosed with symptomatic FAIS:

• 73% described sharp pain.

• 73% also reported an aching sensation.

• 71% experienced pain during physical activity.

• 69% reported pain while running.

• 65% experienced pain during prolonged sitting.

• 63% experienced pain with pivoting movements.

• Approximately 46% reported mechanical symptoms such as popping or clicking.

The gradual onset of symptoms is particularly noteworthy. Approximately 65% of patients developed symptoms insidiously, whereas only 21% reported traumatic onset, highlighting the cumulative effect of repetitive hip loading during sport.

Physical Examination Should Extend Beyond Pain Provocation

Modern sports rehabilitation emphasizes identifying physical impairments rather than simply reproducing pain.

A systematic review involving 22 studies and 819 patients demonstrated that individuals with symptomatic FAIS consistently exhibited significant deficits in hip muscle strength across multiple planes of motion, whereas limitations in hip range of motion were less consistent.

These findings support the growing emphasis on objective strength assessment using handheld dynamometry, particularly during evaluation of:

• Hip adduction

• Hip abduction

• Hip internal rotation

• Hip external rotation

• Functional movement capacity

The International Hip-related Pain Research Network (IHiPRN) further recommends standardized measurement of physical capacity and strength as part of the routine clinical examination to improve treatment planning and monitor rehabilitation outcomes.

Diagnostic Accuracy of the FADIR Test

The Flexion-Adduction-Internal Rotation (FADIR) test remains one of the most frequently performed orthopedic examinations for suspected FAIS.

Meta-analysis demonstrates:

Diagnostic Measure	Value
Sensitivity	91–99%
Specificity	5–9%
Positive Likelihood Ratio	1.02–1.04
Negative Likelihood Ratio	0.14–0.45

From a clinical standpoint, these statistics indicate that the FADIR test possesses excellent sensitivity but poor specificity.

A negative FADIR test substantially decreases the probability of FAIS, making it valuable as a screening examination. Conversely, a positive test should never be interpreted in isolation because numerous other hip pathologies can reproduce symptoms.

Clinical diagnosis therefore requires synthesis of patient history, objective examination findings, imaging when indicated, and clinical reasoning.

Imaging Findings Should Always Be Interpreted in Context

One of the most common misconceptions among patients is that abnormal MRI findings automatically explain pain. Current evidence suggests otherwise.

Meta-analyses have shown that more than half of asymptomatic athletes demonstrate acetabular labral abnormalities despite reporting no pain or functional limitation. 

Conversely, cartilage defects demonstrate a much stronger association with symptomatic hip pathology, occurring in approximately 64% of symptomatic individuals compared with only 9.6% of asymptomatic populations. 

These findings highlight the importance of correlating imaging results with clinical presentation rather than treating radiographic abnormalities alone.

References:

Ayeni, O. R., Chu, R., Hetaimish, B., et al. (2013). A painful squat test provides limited diagnostic utility in CAM-type femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy, 22(4), 806–811. https://doi.org/10.1007/s00167-013-2668-8

Clohisy, J. C., Knaus, E. R., Hunt, D. M., Lesher, J. M., Harris-Hayes, M., & Prather, H. (2009). Clinical presentation of patients with symptomatic anterior hip impingement. Clinical Orthopaedics and Related Research, 467(3), 638–644. https://doi.org/10.1007/s11999-008-0680-y

Freke, M. D., Kemp, J., Svege, I., Risberg, M. A., Semciw, A., & Crossley, K. M. (2016). Physical impairments in symptomatic femoroacetabular impingement: A systematic review of the evidence. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-096152

Grace, T., Samaan, M. A., Souza, R. B., Link, T. M., Majumdar, S., & Zhang, A. L. (2018). Correlation of patient symptoms with labral and articular cartilage damage in femoroacetabular impingement. Orthopaedic Journal of Sports Medicine, 6(6). https://doi.org/10.1177/2325967118778785

Heerey, J. J., Kemp, J. L., Mosler, A. B., et al. (2019). What is the prevalence of hip intra-articular pathologies and osteoarthritis in active athletes with hip and groin pain compared with those without? A systematic review and meta-analysis. Sports Medicine, 49(6), 951–972. https://doi.org/10.1007/s40279-019-01092-y

Ishøi, L., Thorborg, K., Kraemer, O., Lund, B., Mygind-Klavsen, B., & Hölmich, P. (2019). Demographic and radiographic factors associated with intra-articular hip cartilage injury: A cross-sectional study of 1,511 hip arthroscopy procedures. American Journal of Sports Medicine. https://doi.org/10.1177/0363546519861088

Kapron, A. L., Aoki, S. K., Peters, C. L., & Anderson, A. E. (2015). In-vivo hip arthrokinematics during supine clinical exams: Application to the study of femoroacetabular impingement. Journal of Biomechanics, 48(11), 2879–2886. https://doi.org/10.1016/j.jbiomech.2015.04.022

Kemp, J. L., & Beasley, I. (2016). 2016 International Consensus on Femoroacetabular Impingement Syndrome: The Warwick Agreement—Why does it matter? British Journal of Sports Medicine, 50(19), 1162–1163. https://doi.org/10.1136/bjsports-2016-096831

Mosler, A. B., Kemp, J., King, M., et al. (2019). Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: Recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2019-101457

Reiman, M. P., Goode, A. P., Cook, C. E., Hölmich, P., & Thorborg, K. (2015). Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: A systematic review with meta-analysis. British Journal of Sports Medicine, 49(12), 811. https://doi.org/10.1136/bjsports-2014-094302