The Doha map of groin painStrong evidence
An international agreement (the Doha agreement) sorts groin pain in athletes by where it comes from, using the history and the examination: adductor-related (the inner thigh), iliopsoas-related (the hip flexor at the front of the hip), inguinal-related (the groin canal) and pubic-related (the pubic bone), then hip-related groin pain, then other causes. A "sports hernia" is inguinal-related groin pain, without a hernia you can feel.
Hip and groin injuries are about 1 in 9 new running injuries in pooled studies, and across 10 studies of 7,353 runners they were 11% of women's running injuries and 6% of men's.
Sources 1, 2, 3
The stress fracture that mustn't be missedEmerging evidence
Stress fractures of the hip (femoral neck) are about 3% of stress fractures in sport, and commonest in marathon and long-distance runners and in women. The pain is felt in the groin or the front of the hip, late in a run at first, then building until it limits the run, then with every step, at rest and at night. In a review, pain at the end of the hip's range was found in 79%, while a heel-strike test was positive in only 6%. Up to two-thirds show nothing on the first X-ray; magnetic resonance imaging (MRI) is the next test and is close to 100% accurate.
A crack on the upper (tension) side of the femoral neck, or one that has shifted, usually needs an operation, and carrying on running makes shifting more likely. About half of athletes don't get back to their previous level, up to 60% after a shifted fracture, while fractures caught early, before they shift, have done much better. Stress fractures of the lower pubic bones and the sacrum also happen in runners; they're lower risk, and MRI is the preferred test.
Sources 4, 5
Eating enough, periods and boneEmerging evidence
Eating too little for the training you do (low energy availability) harms health and performance in women and men; the International Olympic Committee calls it relative energy deficiency in sport (REDs). In 259 active girls and women, bone stress injuries rose from about 15 to 20% with one risk factor of the female athlete triad (disordered eating, periods stopping, low bone density) to 30 to 50% with several. In collegiate distance runners, there were 32 bone stress injuries per 100 athlete-years: 45 in women and 20 in men.
The higher risk of hip stress fractures in women is thought to come from the triad. The NHS says see a GP if you've missed your period 3 times in a row, and lists doing too much exercise and sudden weight loss among the causes of missed periods.
Sources 6, 7, 8, 4, 9
When a scan helps, and what it can't tell youEmerging evidence
For a suspected hip stress fracture, an X-ray comes first but often looks normal, and MRI is the next test; MRI is also the preferred test for stress injuries around the pelvis. Hip impingement (femoroacetabular impingement syndrome) needs symptoms, examination signs and imaging together, an international agreement says, so a scan finding alone doesn't make the diagnosis; the impingement and labral tear guides explain why.
Adductor and hip flexor injuries are diagnosed by examination. In acute adductor injuries, the MRI grade didn't change the return time for grades 0 to 2, while a complete tear took much longer.
Sources 4, 5, 10, 11
How it usually goesEmerging evidence
In new runners, hip flexor (iliopsoas) injuries took a middle of 71 days to recover and adductor tendon pain 101. After an acute adductor injury, male athletes were back in full training in a middle of 18 days for milder injuries and 78 for a complete tear. Long-standing adductor pain (a middle of 40 weeks in the Hölmich trial) was treated with an 8 to 12 week programme, and hip-related pain gets at least 3 months of exercise.
In pooled studies, 81% of runners returned to sport after a hip or groin injury. No one can promise a date.
Sources 12, 11, 13, 14, 3