Groin pain when you run, and the four things it usually is

Groin pain used to be a naming disaster. Sportsman's hernia, athletic pubalgia, Gilmore's groin, osteitis pubis, adductor strain, all used loosely and often for overlapping things. Two clinicians could examine the same person and write down different diagnoses.

In November 2014, twenty-four experts from fourteen countries spent a day fixing it.

The agreement

Basing it on history and examination rather than imaging was the important decision. A scan of a groin in an active person tends to show several things at once, and picking which one is responsible from the pictures alone does not work.

Two of the authors work in Copenhagen, incidentally. A good chunk of the research behind this area is Danish.

Adductor-related

The common one in runners.

Pain on the inside of the groin, along the line of the adductor tendons where they attach near the pubic bone. Tender when you press there. Reproduced when you squeeze your knees together against resistance, which is the test most clinicians use first.

It tends to build rather than arrive, and it is provoked by changes of direction, by hill running, and by anything asking the adductors to work hard while lengthened.

Load management and progressive adductor strengthening is the direction of travel, as with most tendon-type problems. It is slow, and it responds to being loaded rather than rested.

Iliopsoas-related

Deeper, higher, at the front. The hip flexor, which is the muscle that swings your leg through.

Sore when you lift the knee against resistance, and often sore on stretching into hip extension, which for a runner means the back leg at the end of the push-off. Uphill running and fast running both ask more of it.

This tendon wraps around the front of the pelvis on its way through, and the same compression principle we describe for the gluteal tendon and the hamstring attachment applies here too². Deep hip flexion presses it against bone. Long stretches held at the end of range are usually the wrong move early on.

Inguinal and pubic

Inguinal-related sits in the region of the inguinal canal, without a palpable hernia. It is more common in sports with cutting and kicking than in straight-line running, but runners do get it.

Pubic-related is pain over the pubic bone itself, right at the midline, tender when pressed directly there. That one needs care, because bone stress at the pubic ramus sits in the same place and is a different problem with a different timeline.

Both of these are further outside what can be sorted out from an article, and both need an examination.

Hip-related

The second of the three headings, and a genuinely different thing.

Deep pain at the front of the groin, sometimes described by cupping a hand around the front of the hip. It can come with catching, clicking, stiffness, or a restricted feeling when you bring the knee up and across. It is often worse after sitting, and worse with deep flexion.

The plan for this is not the plan for a tendon. It is worth separating early rather than doing six weeks of adductor work for a hip joint.

Why runners get it at all

Less often than footballers, which is why there is less runner-specific research on it³. When runners do get it, the pattern is familiar: a jump in volume, a new emphasis on hills or speed, or a return after time off during which the adductors and hip flexors lost capacity that the rest of the leg kept.

Runners who also play something with cutting and changing direction are the more common presentation, and the other sport is usually where the load came from.

When to get it looked at

The bulge one needs a doctor rather than a physiotherapist. So does testicular pain.