Common, and most of it doesn't stop playStrong evidence
Counting only injuries that stop play misses most groin pain. In 240 Norwegian players followed every week through 6 weeks of matches, "The average weekly prevalence of any groin problem and substantial groin problem for all male players was 29% (range, 23%-32% across different levels) and 10% (7%-13%), respectively", and "Time-loss definition as used in previous injury surveillance studies captured only one-third of the male groin problems registered with the new method". In 407 Spanish amateur men over a season, "The traditional time-loss measure only captured 10% of all groin problems".
In 434 Dutch amateur women, "The prevalence of hip/groin injury was 40%, non-time-loss hip/groin injury was 36% and time-loss hip/groin injury was 11%", and in Swiss elite women, "Of the 45 hip and groin problems recorded in 37 players, only 5 (11.1%) resulted in time-loss". Across 34 studies of senior club football, "Groin injuries are frequent in senior football and are more common in men than women": 0.83 against 0.35 injuries per 1,000 hours. Across 44 studies of professional men, "Minor injuries (1-3 days of time loss) were the most common".
Sources 1, 2, 3, 4, 5, 6
When it costs time, usually days to a few weeksStrong evidence
In elite men's clubs, "Hip and groin injuries contributed 1812 out of 12 736 injuries (14%), with adductor-related injury as the most common of hip and groin injuries (n=1139, 63%)", and "More than half of the injuries (53%) were classified as moderate or severe (absence of more than a week), the mean absence per injury being 15 days". After a sudden adductor strain, "Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks" (MRI is magnetic resonance imaging), and "The overall 1-year reinjury rate was 8%".
Sources 7, 8, 9
Where it hurts names it: the Doha agreementStrong evidence
Twenty-four experts from 14 countries agreed three groups: four named by where it hurts and which test brings it on (adductor-related, iliopsoas-related, inguinal-related and pubic-related), hip-related groin pain, and other causes. For example, "Adductor-related groin pain: Adductor tenderness AND pain on resisted adduction testing" and "Inguinal-related groin pain: Pain in inguinal canal region AND tenderness of the inguinal canal". The group preferred "Groin pain in athletes" as the umbrella term.
Source 10
Kicking, turning and the kicking legEmerging evidence
In 998 Danish amateur men, "Adductor-related groin injury was the most common clinical presentation of groin injuries in male soccer players and the cause of long injury time, especially when combined with abdominal-related injury", and "The dominant leg was significantly more often injured". On video, sudden adductor longus strains in professional men came from changing direction (35%), kicking (29%), reaching (24%) and jumping (12%), mostly without contact: "A rapid muscle activation during a rapid muscle lengthening appears to be the fundamental injury mechanism for acute adductor longus injuries". In a lab study, the standing leg's inner thigh muscles worked harder the faster the ball was kicked.
In 110 athletes seen within a week of a sudden groin injury, "The most frequent injury mechanism in soccer was kicking (40%), and change of direction was most frequent in other sports (31%)"; adductor injuries were two-thirds, with hip flexor injuries next. A review notes that "Quadriceps muscle strains frequently occur in sports that require repetitive kicking and sprinting, and are common in football in its different forms around the world" (the rectus femoris crosses the front of the hip), and the American Academy of Orthopaedic Surgeons (AAOS) says "The lower abdominal muscles and hip flexor muscles are often involved in a hip strain".
Sources 11, 12, 13, 14, 15, 16
A sports hernia isn't a true herniaStrong evidence
The AAOS says a sports hernia "most often occurs during sports that require sudden changes of direction or intense twisting movements", and that "A sports hernia does not cause a visible bulge in the groin, like the more common inguinal hernia does". The British Hernia Society's consensus: "The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists". The Doha experts agreed that "there is no occult inguinal hernia present".
A true hernia is different: the NHS says a hernia can cause a bulge or lump in the groin that gets bigger when you cough, sneeze or cry and smaller when you lie down, and a femoral hernia, a small lump at the top of the thigh, "needs treatment in hospital"; "Femoral hernias mainly happen in women over 50 years old".
Sources 17, 18, 10, 19, 20
The pubic bone: changes on X-ray are common without painEmerging evidence
In 24 professional players with osteitis pubis, "12 of these patients showed complete clinical recovery without any symptoms after 18 months, while in 8 patients partial recovery with persistence of groin pain during higher sports activity was observed". Bone changes on X-ray are common in footballers without pain: "In conclusion, pubic-related radiographic findings are not associated with groin pain or disability".
Sources 21, 22
The hip joint: a cam shape is common, and often doesn't hurtStrong evidence
A cam shape (a bump where the ball of the hip meets its neck) develops while the hip is growing: in Dutch academy boys, "Cam morphology developed from 12 to 13 years of age until growth plate closure around 18 years", and "In youth soccer players, cam deformities gradually develop during skeletal maturation and are probably stable from the time of growth plate closure". It often doesn't hurt: "Cam morphology was evident in 63% of hips in players without pain and 71% of symptomatic hips in players with hip and/or groin pain", and "Whether cam morphology results in symptoms is uncertain".
The AAOS says "exercise does not cause FAI"; the academy studies suggest heavy sport in the growing years shapes the hip, an association. FAI syndrome is diagnosed only when symptoms, examination and imaging agree: "To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings". It usually feels like a deep groin pinch on deep bending, sitting low or turning, sometimes with catching (the labrum).
Sources 23, 24, 25, 26, 27, 28, 29
Growing players: growth plates at the hip and pelvisEmerging evidence
In academies, growth plate injuries move up the body with age, "occurring most frequently in the ankle/foot in younger players (U9, U10 and U11), followed by the knee (U12) and hip/groin in older players (U15, U16 and U18)" (U9 means the under-9s), and in a Qatar academy "Hip-pelvic apophyseal injuries accounted for the largest injury burden".
A sudden pull can break a piece off. In 203 teenage avulsion fractures, "Soccer (74 cases) and gymnastics (55 cases) were the sports with the highest number of avulsion fractures documented", and in a US children's hospital "The most common mechanism of injury was sprinting/running (39%) followed by kicking (29%), but the mechanism varied by fracture type with 50% of AIIS avulsions caused by kicking" (the AIIS is the lower bony point at the front of the hip). The American Orthopaedic Society for Sports Medicine (AOSSM) says such a fracture happens "usually from a violent muscle contraction such as a kick". A child or teenager with a limp and groin, thigh or knee pain can have a slipped growth plate in the hip (SUFE), which is rare and urgent.
Sources 30, 31, 32, 33, 34
Who is at risk, and what usually happensEmerging evidence
"A univariate analysis showed that having had a previous groin injury almost doubles the risk of developing a new groin injury and playing at a higher level almost triples the risk of developing a groin injury"; in Swiss elite women, problems the season before were the strongest predictor; and "Three-quarters of the players with longstanding hip and groin injuries in the previous season have residual problems at the start of the following season".
NHS inform: "In many cases, new pain or a flare-up of long-standing hip problems should begin to settle within 6 weeks without the need to see a healthcare professional". For pubic-related pain, "Forty-two of 44 players of both study groups returned to football within 4 months after the beginning of therapy and had no recurrent groin pain within 1 year after trauma". For teenage avulsions, "In this series, nearly all pelvic avulsion fractures (97%) were managed successfully with a conservative approach", and across 14 studies "The rate of return to sports was 80% in conservative and 92% in operative treated patients (p = 0,03)", with surgery mainly for widely displaced pieces. No one can promise a date.
Sources 35, 4, 3, 36, 37, 33, 38
When it isn't football: the causes the warning signs cover
Some hip and groin pain has causes football didn't create, or needs more than a plan, and the warning signs follow the pages behind them. Severe hip pain after a fall, numbness after an injury or a hot, swollen hip follow the NHS hip pain and broken hip pages; a child's sudden hip, thigh or knee pain or limp follows the NHS pages on limping and hip pain in children, NHS inform's slipped growth plate page and a national study of slipped growth plates in Great Britain. A hernia with pain, a femoral hernia and sudden testicle pain follow the NHS hernia, femoral hernia and testicle pain pages; a teenage avulsion follows a series of 228 cases; and leg symptoms with numbness around the genitals or bottom follow the NHS sciatica page.
An infected pubic joint is described in a review of 100 cases and a review of osteitis pubis, a stressed growth plate on the pubic bone in a study of young footballers, and when long-standing groin or pubic pain needs a specialist in reviews of surgery and rehab and a cohort of academy players. When a sports hernia needs a surgeon follows a 30-year expert review, and a deep hip pinch two studies and a review of athletes' groin pain. An adductor tendon tear follows two studies of athletes, the night bone pain the NHS bone cancer page, the hip's loss of blood supply a UK review, and fainting or chest pain during exercise the NHS fainting and chest pain pages. The pain rules follow the LEAP trial's protocol, the osteoarthritis guideline of the National Institute for Health and Care Excellence (NICE), pain-monitoring studies, a femoral neck stress fracture review and a rehab cohort.
Sources 39, 19, 20, 33, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89
