Groin pain and sports hernia

Marc Darrow, MD, JD.

Persistent groin pain can interfere with walking, climbing hills, working, and returning to sport. Some patients improve with rehabilitation or selected injections, but the first task is to identify what is hurting. “Groin pain” names a region, not a single diagnosis.

Why hip, groin, and back symptoms can overlap

The groin contains closely connected muscles, tendons, ligaments, nerves, and structures related to the hip and abdominal wall. Problems can follow a distinct injury or develop gradually through repetitive loading. Several structures may be symptomatic at the same time.

A review of hip and groin pain in professional athletes emphasizes the overlap of symptoms and the importance of matching clinical findings with appropriate imaging. Its observations explain why the location of pain alone may not identify the injured structure. (1)

Another review describes a systematic assessment of the hip, lumbar spine, lower abdomen, and pelvis. The history and physical examination guide the investigation, while imaging or selected diagnostic injections may add information. A tender area is useful to identify, but it does not by itself establish the full diagnosis. (2)

Marc Darrow’s clinical emphasis is to identify the source of pain before choosing a procedure. This remains relevant when an MRI shows arthritis, a labral tear, or a tendon abnormality. The finding should explain the symptoms and functional limitations, rather than become the entire treatment plan.

A useful framework: which type of groin pain is present?

The Doha agreement classifies athletic groin pain into adductor-related, iliopsoas-related, inguinal-related, and pubic-related clinical entities, alongside hip-related and other causes. More than one category can apply to the same person. (3)

Adductor-related pain involves the inner-thigh region and may be provoked by loading those muscles. Iliopsoas-related pain concerns the hip-flexor region. Inguinal-related pain involves the groin canal region, while pubic-related pain centers around the pubic symphysis and nearby bone.

These categories organize the assessment; they do not replace it. Pain with squeezing the legs together, raising a knee, coughing, pivoting, or walking uphill can guide further examination. No one movement should be used to diagnose every case.

Hip pain at the front, side, or back asks different questions

A clinical review distinguishes anterior hip and groin pain from posterior buttock pain and lateral hip pain. Hip arthritis or a labral disorder may produce anterior symptoms; lumbar, sacroiliac, and other conditions may contribute to posterior symptoms; lateral pain may involve greater trochanteric structures. These are patterns to investigate, not rigid rules. (4)

The site’s hip pain overview and sacroiliac pain article address related diagnostic possibilities.

Imaging can help identify a fracture, stress injury, joint disorder, or tendon problem. Ultrasound and MRI provide different information. A normal X-ray does not exclude every soft-tissue or bone-stress problem, and an abnormal scan does not determine the treatment by itself.

Can the pain come from the spine?

Referred pain from the lumbar spine is one possibility. A small study investigated five selected patients with groin pain and single-level lower lumbar disc degeneration but no identified hip-joint abnormality. Diagnostic procedures and subsequent fusion were associated with findings supporting a disc-related source in those patients. (5)

That study cannot establish how commonly discs cause groin pain or justify fusion for unexplained groin symptoms. It supports considering the spine when the overall assessment makes that plausible, including in someone without prominent low back pain.

Pelvic ligament attachments, muscles, and fascia can also be considered. Enthesopathy describes a disorder where a tendon or ligament attaches to bone. It should not become a catch-all explanation that rules out joint, nerve, abdominal, or bone disease without assessment.

Altered walking can change the demands on the groin

Some patients describe groin symptoms after a period of limping, back pain, reduced hip movement, or walking in a protective boot after another injury. A change in gait can alter loading across the hip and pelvis, making the timing clinically relevant.

The sequence does not prove that the boot or back condition caused the groin injury. The assessment still needs to consider local tissue problems and other explanations. Restoring comfortable walking mechanics may be important, but it should fit the reason for the symptoms and any precautions for the original injury.

For a hiker, uneven footing, long strides uphill, and fatigue can expose a limitation that is less noticeable during short level walks. The activity that brings on symptoms helps define what function needs rebuilding.

Sports hernia is not the same as a conventional hernia

The terms “sports hernia,” athletic pubalgia, and inguinal disruption have been used for overlapping groin and lower-abdominal pain presentations. They should not be assumed to identify one structure or a true hernia with a palpable bulge.

A true inguinal or femoral hernia requires its own assessment. Tendon or abdominal-wall pain also does not exclude a hernia, hip disorder, or another condition occurring alongside it.

A comprehensive review of groin pain stresses that musculoskeletal and nonorthopedic conditions must both be considered. Urinary, abdominal, vascular, infectious, and other causes may need attention depending on the symptoms. An orthopedic injection is not an appropriate substitute for that evaluation. (6)

Sudden severe pain, inability to bear weight, fever, a painful or trapped abdominal bulge, or associated acute testicular pain requires prompt assessment. A rapidly worsening pattern should not be dismissed as an ordinary muscle strain.

Osteitis pubis and pain at the pubic attachments

Osteitis pubis concerns painful changes around the pubic symphysis and adjacent bone. It has been described in athletes involved in kicking, acceleration, deceleration, and direction changes, including soccer, rugby, football, and distance running. Symptoms can overlap with adductor or lower-abdominal pain. (7)

It is different from simply assuming that every tender pubic attachment is inflamed. Imaging may help assess the area and exclude alternatives. A bone-stress injury or infection would require a different interpretation from an overuse tendon disorder.

This distinction matters when exercise or injections are being considered. A treatment intended for a tendon attachment should not be used as though it addresses every cause of pain around the pubic bone.

New 2026 research reinforces the need for a specific diagnosis

A 2026 systematic review examined iliopsoas-related groin pain, including problems in native hips and after hip surgery. It found substantial diagnostic and treatment uncertainty: symptoms overlapped with other conditions, the diagnostic studies had high risk of bias, and outcomes depended on the underlying cause. (8)

An injection can sometimes provide diagnostic information or temporary relief without resolving a mechanically driven problem. In particular, research after hip replacement should not be generalized automatically to an overuse injury in a recreational hiker, or vice versa.

The review supports a diagnosis-specific discussion. It does not establish that one test, scan finding, or injection is enough to explain every iliopsoas-related presentation.

Exercise has direct evidence for longstanding adductor-related pain

A randomized trial of 68 athletes compared an active strength-and-coordination program with physiotherapy without active training. Twenty-three participants in the active group returned to sport without groin pain, compared with four in the comparison group. The trial concerned longstanding adductor-related pain, not all groin diagnoses. (9)

This supports rehabilitation as an important part of care for that population. It does not mean that a person with an unexplained stress injury or acute severe pain should exercise through it.

The distinction between passive treatment and rebuilding capacity is useful for hikers. Symptom relief may help daily activity, but a multi-day trip also requires strength, endurance, movement control, and the ability to recover between consecutive days of loading.

What does prolotherapy research show?

In a consecutive case series, 75 athletes were enrolled and 72 completed the minimum treatment protocol. Treatment involved dextrose injections around abdominal and adductor attachments at the pubis. Sixty-six returned to unrestricted sport. (10)

This is encouraging observational evidence. There was no randomized control group, and the participants were predominantly elite rugby and soccer players. The results cannot establish the contribution of the injections independently of other factors or predict success for every recreational hiker.

The study tested dextrose. It should not be presented as evidence that PRP, bone marrow concentrate, or a donor-derived product produces the same result, works faster, or requires fewer sessions.

A 2026 narrative review also discusses prolotherapy for chronic musculoskeletal pelvic pain, including groin pain. It describes a potential role in selected patients while calling for prospective studies to clarify treatment. A narrative review does not add the certainty of a large randomized trial. (11)

PRP evidence includes individual cases, not a reliable recovery timetable

PRP is prepared from the patient’s blood and contains concentrated platelets and signaling proteins. A biological rationale for tissue repair is different from proof that a particular groin injury will heal after injection.

One published case involved a professional hockey player with inguinal disruption and a rectus abdominis tear. Treatment combined two PRP injections with manual therapy and exercise. The player returned to his prior performance level in approximately three and a half weeks. Because this was one case with several treatments, it cannot isolate PRP’s effect or establish a standard return date. (12)

Another case report described a lacrosse player treated with ultrasound-guided needle tenotomy and PRP for distal rectus abdominis tendinopathy. The player returned to pain-free sport. The combination of procedures and single-patient design again limit conclusions about PRP alone. (13)

These reports belong in the discussion as examples of observed recovery. They do not provide a success rate or establish that surgery can always be avoided.

Adductor tendinopathy and broader PRP research

A review of hip and pelvic PRP applications discusses reports involving hamstring and adductor longus tendinopathy, including a large mixed-tendon series. Improvement in a subgroup is not the same as a randomized trial devoted to adductor-related groin pain. The review itself identifies important evidence gaps. (14)

A 2024 case report described a 17-year-old soccer player receiving ultrasound-guided PRP and a phased physical therapy program. He returned to sport at six weeks and reported further recovery at follow-up. That is another individual outcome; it does not establish PRP superiority over exercise or a six-week schedule for adults preparing for mountain hiking. (15)

The practical question is whether evidence applies to the diagnosed tissue problem. Results from an injection into the hip joint, for example, cannot automatically be used to justify an injection around an adductor attachment.

What about bone marrow or other cell-based injections?

Bone marrow aspirate and concentrate contain mixtures of cells and other components. They are different from PRP, purified cell populations, and donor-derived tissue products.

The reports discussed here do not establish that a cell-based procedure is necessary for chronic groin pain, better than dextrose or PRP, or able to shorten recovery. Evidence from other tendons or joints does not settle those questions for a particular pelvic injury.

Bruce’s description of treatment cannot verify the composition of his injections or demonstrate tissue regeneration. A credible treatment explanation should identify the preparation, target, expected outcome, and limits of the relevant evidence.

When should surgery remain part of the discussion?

A true hernia, significant mechanical hip problem, or another structural condition may warrant surgical assessment. The presence of groin pain alone does not establish that hip surgery is necessary; equally, identifying a painful tendon does not prove that surgery for a separate problem is unnecessary.

Before proceeding, the proposed operation should have a clear target that fits the symptoms. Appropriate nonsurgical care may still be reasonable, but repeated injections should not delay assessment of a condition that requires a different approach.

Returning to hiking: build the demands separately

Bruce described several weeks of treatment followed by additional recovery before his long trip. His experience emphasizes preparation, but it cannot establish the time another person needs.

A practical progression may begin with comfortable daily activities and short walks on level ground. Distance, hills, uneven terrain, and pack weight create different demands and can be increased gradually as tolerated. This is an illustrative progression, not a validated protocol for a specific diagnosis or injection.

Long descents can be demanding even when climbing feels comfortable. A heavy backpack or repeated long days may expose limitations that are not apparent during a single short walk. Preparing for consecutive days of activity is therefore a different goal from completing one pain-free outing.

Symptoms during activity, later that day, and the following morning all provide information about tolerance. A marked flare, a new limp, loss of strength, or pain that is becoming more persistent deserves reassessment rather than automatic escalation of training.

What should count as a useful result?

Less pain, better sleep, stronger and more comfortable movement, and a sustained return to valued activity are meaningful outcomes. They do not by themselves prove normal tendon structure, restored cartilage, or correction of every underlying mechanical problem.

Persistent symptoms also do not automatically mean that more injections are required. They may reflect an incomplete diagnosis, an unsuitable treatment target, inadequate capacity for the intended activity, or another condition.

Bruce’s hike is a useful illustration of a personal goal achieved. The broader lesson is to identify the groin pain source, match the evidence to that diagnosis, and rebuild the capacity the intended activity demands.

References