Groin Strains
Adductor strains common in hockey and soccer
Overview
The Science of Groin Strains
Link copiedGroin strains involve injury to the muscle group, which includes the adductor longus, magnus, brevis, gracilis, and pectineus. The adductor longus is most frequently injured (62-90% of cases), typically at the where muscle fibers transition to tendon.
These injuries occur during high-velocity movements when the muscle undergoes - lengthening under load. The mechanism typically involves forceful hip adduction against an force, or sudden acceleration during sprinting. Sports like soccer, hockey, and football place athletes at highest risk due to the rapid direction changes, kicking motions, and explosive movements required.
When the adductor muscle-tendon complex is overloaded beyond its capacity, microscopic tears develop in the muscle fibers. In acute strains, this creates immediate pain and functional limitation. When inadequately rehabilitated or subjected to chronic overload, the tissue can develop changes including (tendon attachment inflammation), bone marrow edema, and in severe cases, complete rupture requiring surgical repair.
According to the 2014 Doha Agreement classification system, groin strains fall under "adductor-related groin pain" - characterized by tenderness over the adductor muscles and pain provoked by resisted adduction testing. This classification helps distinguish adductor strains from other groin pain causes like hip joint , inguinal canal issues, or pubic .
Overview
Contributing Factors
Link copiedThe muscles work primarily to pull your leg toward the midline, but their role extends far beyond this simple action. During running and cutting movements, they act as powerful stabilizers of the pelvis and hip, controlling rotation and preventing excessive . When you sprint, the adductors work eccentrically to decelerate your leg during the swing phase, absorbing enormous forces.
The greatest injury risk occurs during movements that combine hip extension, abduction, and external rotation while the adductors are contracting. Think of the final moments of a kick in soccer, or the push-off phase in skating - your leg is extended and spread wide while the adductors are trying to bring it back. This creates high tensile loads at the .
Muscle imbalances significantly increase injury risk. When adductor strength falls below 80% of your hip abductor strength, the risk of groin strain increases substantially. Previous injuries create scar tissue that is less elastic than healthy muscle, making reinjury more likely if rehabilitation is incomplete. Fatigue compounds the problem - tired muscles lose their ability to absorb energy efficiently, transferring more stress to the tendon attachment points.
Kicking mechanics in soccer players show that peak adductor activation occurs during the follow-through phase when the leg is decelerating from high velocity. Ice hockey players face similar forces during crossover skating and rapid directional changes. These sport-specific movement patterns explain why groin strains account for 23% of all muscle injuries in European soccer players.
Symptoms
Clinical Presentation
Link copiedPrimary Symptoms
Associated Symptoms
Typical pattern
Acute onset during explosive movement or kicking. Pain worsens with activities requiring or acceleration. Morning stiffness improves with gentle movement. Chronic cases may develop insidious pain during or after sports activities.
Symptoms
Differential Diagnosis
Link copiedConditions with similar presentations:
Sports Hernia (Athletic Pubalgia)
Key differences: Deep groin pain near inguinal canal, pain with coughing/sneezing, tenderness over posterior inguinal wall
Hip Labral Tear
Key differences: Clicking or catching sensation, positive FABER test, groin pain with hip flexion and rotation
Osteitis Pubis
Key differences: Central pubic bone tenderness, gradual onset, pain radiating to both groins
Iliopsoas Strain
Key differences: Pain with hip flexion and stretching, tenderness anterior to hip joint
When to seek professional help
Research
Key Research & Evidence
Peer-reviewed studies supporting the treatment approach.
Harøy J, Clarsen B, Wiger EG, et al. · 2019
Copenhagen Adduction Exercise Protocol for Groin Injury Prevention
British Journal of Sports Medicine · n=660 male soccer players
Key findings
41% reduction in groin injury incidence in intervention group performing Copenhagen exercises 2-3x weekly. Effect maintained throughout season with high compliance rates
Clinical relevance
Demonstrates specific exercise protocol that significantly reduces injury risk in high-risk athletic populations
Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med. 2019;53(3):150-157.
Bisciotti GN, Chamari K, Cena E, et al. · 2021
Conservative Treatment of Longstanding Adductor-Related Groin Pain: Systematic Review
Journal of Sport Rehabilitation · n=Systematic review of multiple studies
Key findings
Active exercise and multimodal programs (manual therapy plus strengthening) carry the strongest evidence for longstanding adductor-related groin pain; compression therapy and prolotherapy are reported as options with only limited or moderate supporting evidence
Clinical relevance
Establishes evidence hierarchy for treatment options in chronic/longstanding groin pain cases
Bisciotti GN, Chamari K, Cena E, et al. The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review. Biol Sport. 2021;38(1):45-63.
Serner A, Weir A, Tol JL, et al. · 2020
Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries
Orthopaedic Journal of Sports Medicine · n=Prospective cohort of male athletes with acute adductor injuries
Key findings
A criteria-based progression (pain-free function, restored strength, and sport-specific testing) returned athletes to sport with a low reinjury rate, supporting return decisions based on meeting functional criteria rather than fixed time frames
Clinical relevance
Demonstrates superiority of functional criteria over arbitrary time-based return to sport decisions
Serner A, Weir A, Tol JL, Thorborg K, Lanzinger S, Otten R, Holmich P. Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study. Orthop J Sports Med. 2020;8(1):2325967119897247.
Management
Evidence-Based Management
Treatment strategies with the strongest support in the current literature.
Primary approach
Progressive strength training with emphasis and early active loading can support faster, more durable return to sport than prolonged rest, with progression guided by functional criteria
Complementary
Multimodal programs combining , compression therapy, and active exercise show 70-75% return to sport rates at 6 months with lower recurrence than single-intervention approaches
Prevention & long-term
protocol reduces groin injury incidence by 41% in soccer players when performed 2-3 times weekly during preseason and in-season training
Detailed management strategies
POLICE Protocol (First 48-72 Hours)
Protection, Optimal Loading, Ice, Compression, Elevation. Early optimal loading (gentle pain-free movement) within 2-3 days promotes better healing than complete rest. Ice 15-20 minutes every 2-3 hours for first 2 days
Important precautions
- Avoid complete immobilization - gentle loading encouraged early
- Ice through towel to prevent skin damage
- Pain-free movement starts within 48-72 hours
Isometric Adduction Exercises (Starting Day 3-7)
Pain-free (squeezing pillow between knees) promote healing without excessive tissue stress. Maintains muscle activation and reduces atrophy
Important precautions
- Stay well below pain threshold
- Hold 20 seconds, 5 sets, multiple times daily
- No progression if pain increases
Gradual Return to Activity
Progressive loading prepares tissue for sport demands. Follow physiotherapist-prescribed progression from walking to jogging to sprinting to sport-specific movements
Important precautions
- Meet each milestone before advancing
- Pain should not exceed 3/10 during activity
- No pain increase day after exercise
Management
Treatment Techniques
Evidence-based manual therapy and intervention approaches.
Treatment approaches supported by current research and clinical guidelines
Recommended treatment approaches
Treatment approaches are individualized to each patient's needs and goals. All interventions require explicit informed consent, and treatment plans are collaboratively modified based on your preferences and response to care.
Sports Rehabilitation & Return to Sport
Evidence-based recovery programs for athletes to safely return to sport after injury.
Soft Tissue & Myofascial Therapy
Targeted hands-on techniques to address muscle tension, pain, and movement restrictions.
Cupping Therapy
Technique using controlled suction to address muscle tension and localized pain.
Post-Surgical Rehabilitation
Evidence-based recovery programs following surgery to restore function and strength.
Rehabilitation
A Typical Rehabilitation Progression
Three phases, from settling symptoms to returning to full activity.
Recovery from Groin Strains is usually staged: calm the symptoms first, then rebuild the strength and capacity of the area, then return to your full activities. The three phases below show the kind of progression the evidence supports and that I commonly work through in clinic. They are here to show you what the road can look like, not to act as a personal program.
- Phase 1
Protect, Load Gently, and Establish Pain-Free Isometrics (Days 1 to 14)
The 2023 Sports Health clinical concepts paper and the earlier Hölmich protocol agree on one thing: early pain-free loading beats prolonged rest. Pain-free within the first few days sets the floor for the whole programme. This phase is about keeping the tissue active while it knits, not resting it flat.
Examples, not a prescription
- Short-lever ball squeeze between the knees in hook-lying, 5 sets of 20 seconds at sub-maximal effort, twice daily
- Long-lever ball squeeze with legs straight, same dose, once daily tolerance is established
- Side-lying active hip adduction through a short pain-free range, 2 sets of 8 to 10
- Stationary bike or light walk for aerobic maintenance if pain-free
- Ice after session if it helps symptoms, compression shorts if tolerated
Ready to progress when
Pain-free long-lever isometric squeeze at moderate effort, walking fully pain-free, tenderness over the adductor longus clearly reduced.
- Phase 2
Strength Through Range and the Copenhagen Progression (Weeks 2 to 6)
The is the standout evidence for rebuilding adductor capacity and preventing recurrence. Harøy et al. (BJSM 2019) showed a 41 percent reduction in groin injury incidence in male footballers using this protocol twice to three times weekly. The Hölmich protocol (Lancet 1999) is the older cousin and still the backbone for longstanding cases. Range, load, and work all progress together.
Examples, not a prescription
- Copenhagen adduction exercise starting at short-lever (knee support), progressing to long-lever, 3 sets of 6 to 10 per side, 2 to 3 sessions per week
- Sidelying hip adduction with light ankle weight, 3 sets of 8 to 12
- Cable or band standing hip adduction, 3 sets of 10
- Sliding disc lateral lunge with emphasis on eccentric control, 3 sets of 6 to 8 per side
- Low-intensity jogging introduced when single-leg hopping is symptom-free
Ready to progress when
Long-lever Copenhagen adduction for 3 sets of 8 pain-free, symmetric single-leg hop and lateral hop without pain, sprint-tempo straight-line running tolerated.
- Phase 3
Sport-Specific Reloading and Return to Play (Weeks 6 to 12 or longer)
The Serner et al. (OJSM 2020) criteria-based model drives this phase: do not return by the calendar, return by meeting strength, hop, and sport-specific performance criteria. Kicking, cutting, and sprinting demand different qualities and are phased in deliberately.
Examples, not a prescription
- Accelerations and decelerations at progressing speeds, including change-of-direction drills
- Controlled kicking progression starting with short-range passing, building to long kicks
- Heavy resisted hip adduction at 80 percent plus adductor-to- symmetry, 4 sets of 6
- Sport-specific intervals and small-sided drills before full training
- Continuation of Copenhagen adduction exercise twice weekly long term as prevention
Ready to progress when
Adductor-to-abductor strength ratio at or above 80 percent, symptom-free full training, and a maintenance plan including Copenhagen adduction twice weekly through the season.
Management
Prognosis & Recovery
What outcomes and recovery factors typically look like.
Expected timeline
Grade 1 strains: 1-2 weeks for return to sport. Grade 2 strains: 3-6 weeks. Grade 3 complete ruptures: 8-12 weeks. Longstanding pain: 3-4 months for full resolution
Natural history
Most acute strains heal with appropriate rehabilitation. Premature return to sport leads to 30-40% reinjury rates. Chronic cases often have underlying strength deficits or biomechanical issues requiring longer rehabilitation
Factors affecting recovery
Management
Measuring Progress
How to track the recovery arc week to week.
Day-to-day tracking
I track what changes day to day: pain interference with key tasks, movement quality during functional tests, and your confidence with daily activities
Assessment tools
Condition-specific questionnaires when useful (like the Oswestry for back pain or DASH for shoulder conditions)
Activity targets
One activity target that matches your goal - whether that's returning to sport, work tasks, or daily activities without limitation
Management
Frequently Asked Questions
Common concerns and answers about this condition.
How long before I am back playing?
How long before I am back playing?
Depends on grade. Grade 1 typically gets back in 1 to 3 weeks, grade 2 in 2 to 6 weeks, and partial or high-grade tears in 2 to 3 months (King et al., Sports Health 2023). The criteria matter more than the calendar. Returning when pain-free but weak is the single biggest reason groin strains recur.
Is this a pulled muscle or a sports hernia?
Is this a pulled muscle or a sports hernia?
Different problems, and they need different plans. A classic adductor strain is tender right over the adductor longus origin and reproduces with resisted . A sports hernia (inguinal-related groin pain in the Doha classification) sits deeper, around the inguinal canal, often flares with coughing, sneezing, or sit-ups, and does not reproduce cleanly with a simple squeeze test. Serner et al. (AJSM 2015) showed that clinical examination maps well to imaging for adductor injuries but misses more with other groin pain entities, which is why history and exam have to work together.
Should I rest or should I train?
Should I rest or should I train?
Rest the first two or three days while things are acutely painful. After that, pain-free loading beats continued rest. The Hölmich protocol showed decades ago that active training returned athletes with longstanding pain to sport at a much higher rate than passive physiotherapy, and the same early-loading pattern shows up across more recent guidelines.
What is the Copenhagen adduction exercise and do I have to do it?
What is the Copenhagen adduction exercise and do I have to do it?
It is a side-lying, partner-supported (or bench-supported) exercise that loads the adductors through a long lever in a controlled . Harøy et al. (BJSM 2019) showed a 41 percent reduction in groin injury incidence across a full football season in men using it two to three times per week. I build it into almost every groin rehab and leave it in as long-term prevention for anyone in kicking or cutting sports.
Why does it still hurt weeks later?
Why does it still hurt weeks later?
Usually one of three things: the load was advanced too fast, the loading plan was under-dosed (light bands for a kicking athlete is not enough), or the diagnosis is not isolated strain. Persistent pain beyond six to eight weeks is a reason to re-examine and sometimes image. Chronic cases often sit in adductor-related groin pain plus a second entity like pubic-related pain, which changes the programme.
Do I need an MRI?
Do I need an MRI?
Not for most acute strains. The diagnosis is clinical, and imaging rarely changes the plan in the first few weeks. I consider imaging for a high-grade injury with extensive bruising, for suspected bony or tendon , when symptoms fail to settle with appropriate loading, or when the history points to inguinal or pubic involvement rather than pure adductor strain.
Can I prevent this happening again?
Can I prevent this happening again?
Largely yes. Two things drive recurrence: incomplete rehab (returning before strength and hop symmetry are back) and losing adductor loading during the season. Keep the in twice weekly. Keep strength at or above 80 percent of strength. Warm up properly before kicking sessions. The data on the first point is consistent across modern groin literature.
Related Conditions
Conditions I commonly see alongside, or confused with, this one.
- Shares symptoms
Hip Labral Tears
Both cause groin pain; important to differentiate muscle strain from labral pathology
- Shares symptoms
Femoroacetabular Impingement (FAI)
Both cause groin/hip flexor pain; FAI can predispose to muscle strains
- Biomechanically linked
Hamstring Strains
Both are common sports injuries affecting hip/thigh muscles with similar mechanisms