Written by Andreas Serner, Switzerland, Willem Heijboer, The Netherlands, Zarko Vuckovic, Qatar, and Adam Weir, The Netherlands
Category: Sports Rehab

Volume 10 | Targeted Topic - Hot Topics in Football Medicine | 2021
Volume 10 - Targeted Topic - Hot Topics in Football Medicine

– Written by Andreas Serner, Switzerland, Willem Heijboer, The Netherlands, Zarko Vuckovic, Qatar, and Adam Weir, The Netherlands




Almost all football players will experience some degree of groin pain at some stage in their career. During a season around half of players will have groin pain1, and if you ask a team in any given week, about 20% of the players will have some groin problems - even more in the beginning of a season2,3. So, for most football players groin pain isn’t really a big deal, it’s just part of the game. But that’s only until it becomes too bad. The usual pattern will be a gradual onset of discomfort that can turn into increasing pain, which can later start to affect the player’s performance, and subsequently lead to reduced participation or stop them from playing altogether. This happens to about 20% of all players per season1,4. If players have pushed themselves through the pain for longer, the timeline for full recovery usually also gets longer. Progression is very precarious. In the early stages it can be difficult for a player to know if their type and level of discomfort or pain will resolve easily or could be more concerning. If nothing is done, the result is often that a player will continue playing as long as they are able to or until they are forced to stop. This is the turning point when groin pain becomes a big deal.

Monitoring for ongoing symptoms is essential, but that unfortunately still doesn’t capture all groin injuries. Acute groin injuries (with a sudden onset) do not usually have a clear warning sign. We found that only 15 percent of players who had acute adductor injuries felt any discomfort or pain on the day of their injury, or even in the week before5. So rather than creeping up on a player, these injuries happen out of the blue resulting in immediate time-loss. Acute groin injuries happen to 2-4 players per team per season4,6.



Given the amount of groin pain in both men’s and women’s football, any respectable team should have a prevention strategy. While it is generally considered by coaches and medical staff that training planning is an important factor influencing injury occurrence, evidence for specific modifications aimed at reducing groin pain is lacking. Anecdotally, fluctuations in the amount of kicking and change of direction drills can increase the risk of groin pain. Knowledge about this is still very limited, but scientific advances that could influence training planning are expected in the near future. Currently there are several laboratory studies, which investigated movement and muscles during different types of kicking7–11. Additionally, average kicking amounts and intensity in matches have been estimated, including position-specific overviews12. Movement analysis of change of direction may also be able to provide further insight in load transfer across the groin area and potentially influence training to reduce groin injury risk13. This currently remains theoretical.

Monitoring of movement and load in relation to groin injuries is quite far behind some other areas. Most notably the amount of accelerations and high-speed running, which can be related to hamstring injury prevention, is a basic element of training assessment and planning in elite football and has been for quite some time. We expect an increasing use of technology to measure both foot and ball movements during play. This will enable assessment of kick velocity, ball speed, ball touches, ball releases, ball possession, shot distance, and more. Hopefully this will provide further insight into how training planning can improve our ability to reduce groin pain and injury incidence. Until then, we have to rely on theory and experience, and instead look at the other side of the load vs capacity scale for scientific evidence.

Increasing the capacity of players to handle the load they are exposed to during sport has proven effective in reducing injuries across different injury types. Structured exercise programmes can reduce groin injuries in football. As a first step, a general warm-up programme is essential. The FIFA 11+ injury prevention programme has shown reduction of groin injuries by 39% across studies14. New research is developing the FIFA 11+  with easier implementation, where part of the programme can be performed after training or at home with the same effects15,16. Structured warm-up is a basic element of most elite and sub-elite teams, but groin injury rates are still high. Therefore, additional options need to be considered. 

Low adductor strength is the most consistent modifiable risk factor for groin pain17. The FIFA 11+ does not include an exercise targeting the adductors and does not improve adductor strength18.Adding an adductor resistance exercise to the training should therefore be relevant. Performing just one simple adductor exercise with a single set a few times a week in the preseason and once a week during the season, reduced the prevalence of groin problems in football players by almost 50%, and substantial groin problems by 30%19.The Copenhagen Adduction exercise is an easy choice, as it does not require equipment and can be performed by anyone anywhere20. Additionally, there could potentially be an even larger if players would perform it more, as the strengthening effect increases considerably with a higher exercise volume21. Despite good effects, implementation in practice is still inadequate22. This unfortunately goes for most resistance exercises, which do not have a sufficiently clear or large performance improvement focus. Performance investigations are still lacking for specific resistance exercises for muscles in the groin area, so implementation strategies probably require more creative approaches related to the specific team contexts. Additional strategies beyond resistance exercises are also necessary.   



Even with perfect prevention exercise implementation groin problems will still be an issue to some extent. To minimize time-loss resulting from groin pain, it is important to monitor the players’ condition. The earlier you detect symptoms, the more time you have to intervene. Without being prompted, players are unlikely to report problems until they perceive their performance on the pitch is considerably affected. Beyond a simple occasional question, there are standardised approaches which have been shown to be relevant. 

Previous injury is a risk factor for most injuries in football, and this is also the case  for groin pain17.  Just looking at past injury is an insufficient predictor of who will experience pain during a season. Asking about the duration of symptoms in the previous season can help detect which players which are more likely to be affected in the new season, and who could need closer monitoring. Overall, the longer duration of groin pain in the previous season, the greater chance of symptoms in the new season1, and the more severe the symptoms were in the pre-season the larger risk of time-loss injury during a season23.Despite the associations of this pre-season information and injury, the predictive (and therefore practical) value is limited24.

Continuous monitoring can provide a better insight into which players could need a higher focus. Whenever monitoring test are implemented, a key element is that they have to be very quick to perform. A simple approach of asking four standardized questions related to problems influencing participation, training volume, performance, and pain, has been shown to have a decent predictive power of a subsequent time-loss injury25. This can provide a quick and easy insight into which players need further assessment and potential modification of their training. 

Quick and easy clinical testing can also provide relevant information. Pain on a 0-10 scale during a simple adductor squeeze correlates well the level of symptoms during sport26. Players with a pain level of 0-2 can be considered to have normal function, a pain level of 3-5 indicates a moderate level of symptoms that requires further assessment, and with a pain level of 6 or more, you can expect that a player has a considerable amount of symptoms during football, to an extent where they probably should not be playing26.

Adding a dynamometer to the squeeze test may provide even further information. There is some evidence that adductor strength decreases in the weeks preceding a time-loss groin injury27. Implementing in-season strength monitoring is becoming more common in elite football. For example, a specific cut-off value for reductions in adductor strength of >15% have been used as part of an alert system leading to further assessment of individual players and potential intervention28. Initial results indicate a good effect of this approach, but the normal weekly variation in adductor strength is still unknown, as well as a cut-off values for when changes in adduction strength lead to subsequent groin problems.



Despite all this knowledge players still get injured. In these cases, we need to provide a diagnosis, treatment plan, and expectations. Once we enter this realm  we can see that it has historically been influenced by  many different opinions, with experts using and recommending different terminology29.Some clinicians do not feel comfortable examining the area due to the close proximity to or involvement of the genitals. Inexperience may lead clinicians to be less critical of recommended approaches and less reflective of their own examination. Additionally, there is no gold standard examination test for groin pain. Fortunately, most experts agree that history and clinical examination remain the foundation for the diagnosis of athletes with groin pain. Not long ago, a group of international experts in groin pain from different specialties, countries, ages, and clinical and scientific backgrounds agreed on classifying groin pain using a clinical entity approach30. This is referred to as the Doha agreement classification system30. The system classifies history and clinical examination findings into one or more of the following clinical entities: adductor-, pubic, inguinal-, iliopsoas-, hip-related groin pain, or other causes. We have recently written an article in the Aspetar Journal on the diagnosis of groin pain, including description of clinically relevant anatomy and examination techniques. You can read more about this here.


We have been investigating the classification system further and have found that classifying using these clinical entities has excellent reliability between examiners when only one clinical entity is classified. There was lower reliability when multiple entities are involved, so caution is recommended when diagnosing more complicated cases31. We have also found that there has been a good international uptake of the classification system among clinicians working at FIFA Medical Centres of Excellence and the IOC research centres32. Some argue that the entity approach is not specific enough, but currently groin pain experts do not agree on suggested alterations of classification system32, so there is still a need for further original research studies to improve diagnosis.  

The clinical entities were developed for gradual onset/long-standing groin pain. For sudden onset pain (acute groin injuries), diagnoses are usually made for specific muscle injuries rather than clinical entities. If we consider a clinical entity approach for acute groin injuries, the classification could be a bit different with only three main clinical entities: adductor injuries, hip flexor injuries, and abdominal wall injuries. Adductor injuries are still the most common, and the adductor longus muscle is most frequently injured muscle, involved in 9 out of 10 adductor injuries33.The diagnosis of an acute adductor injuries can be made using a clinical examination with adductor palpation, adductor stretch, and adductor resistance tests, with similar methods as described for long-standing adductor-related groin pain34. These tests have a high accuracy (compared to imaging), which means the diagnosis of an acute adductor injury can be made through clinical examination only.

Around one third of acute groin injuries affect the hip flexor muscles, which includes both injuries in the iliopsoas and the proximal rectus femoris muscle. The reason these two muscle injuries are grouped is because differentiating between them is difficult on initial clinical examination35.There is often widespread groin pain, which leads to specific clinical examination tests being positive for both locations. This results in general poor accuracy of the clinical examination tests34. A delayed clinical examination can be helpful, as pain extent usually decreases continuously in the days following injury36 leading to clearer localisation of pain and injury. If a fast differentiation is required, imaging will be helpful. Iliopsoas and rectus femoris injuries very rarely occur together37.

Pain in the lower abdominal wall area may be present in 10-20% of players with acute groin injuries and is often present in combination with a more severe injury in a different location (such as an adductor longus avulsion). Isolated acute lower abdominal wall or inguinal pain is rare, and even in combined injuries, positive imaging findings in the abdominal muscles are present less than 5% of the time33.



“We will know more about the injury after imaging” is a common expression in football when a player is injured. Unfortunately, this rarely applies to groin pain. In longstanding groin pain, imaging findings are rarely able to determine the cause of pain38. Similarly, expectations on the duration of return to play will rarely be influenced by the imaging findings.

Imaging often shows load-related changes. The challenge is to understand which of these related to the specific groin pain. When imaging of football players is compared to that of other athletes or sedentary people, there will often be findings that could be considered “abnormal”, but only few changes seem to be different between football players with groin pain and those without. There is evidence that the extent of pubic bone marrow oedema or a symphyseal disc protrusion are associated with adductor- and pubic-related groin pain38, but these findings are also found in players without groin pain, and not all players with groin pain have them. This makes it more challenging to give a specific diagnosis. The scientific relevance of imaging findings has been hampered by poor descriptions of clinical examination findings and diagnosis, and by poor study methodology39. As a result, the importance of specific imaging findings in players with groin pain is still unclear. Although it is unlikely that imaging will answer all the questions, there is a still good potential for imaging to improve our understanding of the variance in groin pain diagnoses and prognosis. Currently, imaging of players with longstanding groin pain is most helpful to rule out potential serious pathology. 

For players with acute groin pain, the relevance of imaging findings in the diagnosis is clearer. When imaging is positive for an acute muscle injury (indicating intramuscular oedema), it is generally accepted that this is a valid finding. MRI is slightly more sensitive than ultrasound for acute groin injuries35. Imaging can provide detailed information on injury location and injury extent, which can provide a specific diagnosis. There are several general muscle injury classification systems40, but with a recent improved understanding of the variance in anatomy between commonly injured muscles, it has been suggested that there should be muscle-specific classifications41. We have provided a detailed imaging descriptions of both acute adductor and hip flexor injuries33,37. About 90% of acute adductor injuries involve the adductor longus, while other adductor muscle injuries are rarer and are often combined with an adductor longus injury. We see that there are three characteristic locations of adductor longus injuries: (1) the proximal insertion, (2) the musculotendinous junction (MTJ) of the proximal tendon, and (3) the MTJ of the distal tendon. In the MTJ injuries at both the proximal and distal insertion, there is rarely any injury to the tendon structure itself, whereas at the proximal insertion, most injuries are complete avulsions of the proximal tendon attachment. These avulsions do not involve a bony avulsion, just the tendon insertion33

In addition to the diagnosis, imaging is often used to try and improve the estimation of prognosis. This is difficult because of large variations in recovery times between players with similar injuries. We have investigated details of the history, clinical examination, and MRI findings for athletes with acute adductor injuries who performed a standardised criteria-based rehabilitation protocol. We found that the strongest predictors of a longer time to return to sport after an acute adductor injury were palpation pain at the proximal adductor longus insertion, a palpable defect, and/or an injury at the bone-tendon junction on MRI. For athletes without any of these findings, even extensive clinical and MRI examination did not assist considerably in providing a more precise estimate of time to return to sport5.   

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. Most athletes with an MRI grade 3 adductor injury (avulsion of the proximal tendon) were clinically pain-free and returned to full team training within 3 months42.



Players can often still perform well for a considerable period despite having groin pain. Keeping the player on the pitch is often a key initial goal and the pain can sometimes be controlled by just modifying training. There is also evidence that manual muscle treatments and wearing compression shorts can give relevant reductions in pain level43–45. Close monitoring of these players is essential for a successful outcome, as prolonged periods of playing with pain can create a more persistent injury that will be increasingly difficult to treat. 

For players with long-standing groin pain, the evidence for specific treatment options is unfortunately limited by poor research methodology29. For players with adductor-related groin pain, it is pretty clear that just doing passive treatments is insufficient, and that a progressive increase in load is essential29. Additionally, it seems that recent treatment programmes have been able to reduce expected timelines from around 4-5 months45,46 to around 2-3 months47,48. There is still a considerable variation between individual players’ recovery timelines, which has not been accounted for. Even groin pain experts struggle to provide a specific timeline for recovery for an individual player. In theory, the longer you set the expected timeline the more likely it is that the player will be fully recovered within expectations. In practice, setting a longer timeline will come with many challenges. Initially, it can be very difficult to understand that full recovery may be several months away when they were actually playing until recently. This will influence their trust in the provided advice and challenge the process. When timelines are uncertain, players will often seek several opinions. They will often be attracted to the clinicians who offer the shortest duration regardless of the approach. Opinions will also come from peers, who have had a similar injury or know of someone who has. So as a clinician it is essential to get a deeper understanding of how the individual player has been influenced, and what their expectations are. Managing a player with groin pain, is often much more difficult than managing a groin injury itself. If you work in a club, you may be the first contact, which makes things easier in this regard, but if you work in a clinic you are likely not the first to provide your opinion on the best approach. Early discussions about the pain, contributing factors, individual context (external pressure, relationships, previous treatment, etc.), and setting short term goals and realistic expectations is essential to success49

The variation in return to play times means that time-based rehabilitation approaches are not optimal. Previously, all players with groin pain would start at the same level: no football-specific drills, similar rehabilitation exercises, and identical progression timelines. This may work well for some, but not for others. Most players want to return to sport as fast as possible and adapting the treatment approach to an individual player is one way to improve recovery timelines. We have also experienced that many players can progress exercises relatively early in rehabilitation. Allowing or even pushing early progression according to exercise-specific ability rather than correlating clinical examination criteria has been key in optimizing recovery timelines. The alternative often focuses on players performing exercises completely pain free and that clinical examinations tests are pain free prior to progression. This can result in players being underloaded for a considerable period of time, and lead to steep increases in load in the end-stage rehabilitation, often with shorter periods of sports-specific training. This can in turn lead to inadequate load adaptation and increased recurrence risk. We believe the time spent at the highest possible level is essential for a successful return to sport and to return at a higher performance level (Figure 1). 

Rehabilitating football players will have several focus areas apart from injury specific exercises. Players can often perform many exercises at or close to normal training levels even early in the rehabilitation, and progression may be different for different exercises. Allowing separate progression within different exercises/focus areas when possible can also assist in returning the player at a higher level, and potentially reduce recovery time. For instance, a player may be able to perform high speed linear running, despite having considerable pain during isolated adductor exercises. Similarly, patients may be able to perform a deadlift at pre-injury load already in the beginning of the rehabilitation, despite not being able to run. As the key groin injury mechanisms in football are kicking and change of direction50, these should have a strong focus both in terms of actual functional progression (e.g. from dribbling, to short passing to kicking, low to high intensity change of direction to reactive agility exercises) and progression of specific strength exercises, which will include both an anterior and posterior muscle chain focus (Figure 2). We have published a general approach to this for acute adductor injuries42, but it may be more relevant for players with longstanding groin pain, due to the longer rehabilitation periods. 

The main risk with this approach is that when players experience how much they can actually do at a relatively early stage, they can decide to return to normal football training prematurely without understanding the recurrence risk. Clear return to play criteria are very helpful.  



Deciding on return to training and matches is a challenge in the rehabilitation process. Players can often play despite remaining symptoms, and it can be difficult to assess the risk of exacerbation or recurrence. The general groin re-injury risk in football is relatively high, especially the first two months after return to football4,6. A good rule of thumb is to start your re-injury risk assessment at 10% and then increase for each consideration you assess as being suboptimal. 

In acute injuries, we recommend not accepting any pain clinically or functionally. We know that muscle injury healing is usually not complete despite complete pain resolution51. So even when players are clinically and functionally pain free, we are sending them back with an increased re-injury risk. Just like the initial acute injury, a recurrence often happens without prior warning. A key clinical finding following muscle injuries is palpation pain, which can increase re-injury risk fourfold52. Palpation pain is one of the last pain assessments that resolves36 and therefore a good marker for readiness for high load activity. We have been using set criteria for acute adductor injuries, which have shown lower re-injury risk. This includes both clinical and functional pain resolution42. We believe these can also be transferred to rehabilitation of players with long-standing adductor-related groin pain, who will likely also benefit from additional criteria, such as specific strength and performance assessments.

In the end, the RTP decision will come down to what level of risk the player accepts as tolerable. Knowing that the player and clinicians may have completely different re-injury risk assessments53 is key and highlights the need for open discussions. In cases, where a clinician would usually not recommend return to play, the player may be influenced by several risk tolerance modifiers not related to the injury, such as the time of season, current match schedule, pressure from the coach, the players own desire to play, as well as potential financial and other conflicts of interest54.

Regardless of the re-injury risk assessment, it is important to advise, and monitor if possible, with a continuous focus on preventing re-injury. This goes beyond the immediate period following return to play, as players are still at increased re-injury risk the following season1,55



Exercise-based rehabilitation is often but not always successful and surgery is rarely the first choice, especially for recreational players. There are different surgical indications and the type of surgery depends on which clinical entity is involved. Contextual factors are important, along with the injury itself, in influencing the decision and timing of surgery. Reasons for considering surgery are; insufficient progress during rehabilitation, lack of player compliance with an exercise-based treatment program, multiple pain recurrences, or other non-injury related decision modifiers.  

There are two main surgical approaches: An adductor longus release (partial or complete) for adductor-related groin pain, and an inguinal-repair (various techniques) for inguinal-related groin pain. While there are few high-quality studies on surgical treatment, current evidence does suggest these approaches are generally successful29,56.   

Adductor longus tenotomy (release of the tendon, but not the muscular attachment) for players with long-standing adductor longus insertion pain who were considered to have failed non-surgical treatment had an almost perfect return to sport rate with an average of 9.2 weeks to return to the same level of sports as prior to the injury57. Surgery is sometimes chosen to provide a more definite recovery timeline (as some studies for rehabilitation of adductor related groin pain show large variance and sometimes very long recovery times) and because of a perceived lower reinjury risk. However, similar to exercise-based treatment, partial tenotomies also have a considerable range in the time to return to play (2-24 weeks), although around 3 out of 4 players return between 6-12 weeks57. Long-term follow-up studies on recurrence following adductor tenotomies are lacking, but it is worth noting that 30% of players participating in the referenced study had a previous groin repair meaning that recurrence risk is clearly not completely eliminated57. In the future randomised studies where surgery is compared to optimized rehabilitation would be useful to inform practice. 

Acute groin injuries have good prognosis without surgical treatment. Some surgeons who encounter acute proximal adductor longus tendon avulsions choose to perform surgical reattachment. This is a topic of current debate. In these proximal tendon avulsions, there are good results for both exercise-based treatment and for surgical reattachment. There are currently no randomized controlled trials comparing the two approaches, but both are reported separately to achieve higher than 95% return to play rates63. The main difference is that exercise-based treatment lead to a considerably shorter time to return to play of around 2-3 months compared to 3-5 months63–65. Given the good follow up outcomes with low injury risk, exercise-based treatment should be the first choice for adductor longus avulsions. In rare cases with delayed or inadequate muscle/tendon loading during rehabilitation there might be excessive/suboptimal scar tissue formation leading to ongoing discomfort and affected performance, where surgical debridement might be considered.

For players with inguinal-related groin pain, inguinal surgery has a high success rate (>90%)58. Different surgeons use different surgical procedures, but a recent randomized controlled trial comparing two types of inguinal repair (open non-mesh vs endoscopic mesh repair) did not show significant differences in return to sport rates or times59. When comparing inguinal surgery to a standardized exercise-based treatment programme, a randomized controlled trial showed a much higher return to sport rates within 3 months in favour of the surgical intervention (90% vs 23%)60. A different lower quality study on exercise-based treatment showed good to excellent results in 75% of players after 8 weeks of treatment61. While it is our experience that improved exercise-based treatment programmes have better results, there is currently no evidence that provides clear time-lines for non-surgical management of players with inguinal-related groin pain. In contrast, surgical intervention offers return to play for most players within 3 months, and for many players even in 4 weeks58,59,62. For elite football players, where longer recovery times can have greater consequences, the potential of a faster return to play following inguinal surgery should be discussed at an early stage. For injured players returning to play sooner, or minimizing the risk of recurrence, could have great financial rewards and often players are not given adequate time for complete rehabilitation. These are the times where more than ever contextual factors might be influencing medical decisions. Professional players are often risk tolerant and open to earlier surgical intervention than amateurs.

It is important to note that even in cases that end up having any type of surgery, early post-operative exercise-based rehabilitation is important to achieve optimal results, and that potential surgical complications are poorly reported in the literature.



If you work with football players, you need to understand groin pain prevention, diagnosis, and management. The good news is that you can prevent many groin problems by implementing a single resistance exercise. For further prevention, the evidence is poor, but advances in our understanding of injury mechanisms and load management will hopefully allow further improvements. 

The bad news is that players will still get injured. Early detection and intervention are important to reduce the injury burden. When a player is out of play, a diagnostic classification using clinical entities is useful, and criteria-based progression of exercise-based treatment should be the first choice. Fortunately, if the groin pain does not resolve, surgical interventions also have good results.


Andreas Serner, P.T., Ph.D.

Medical Researcher

Fédération Internationale de Football Association (FIFA)

Zurich, Switzerland


Adam Weir, M.B.B.S., Ph.D.

Sports medicine physician 

Erasmus MC, University Medical Centre Rotterdam, The Netherlands.

Aspetar – Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Sport medicine and exercise clinic Haarlem (SBK)

Haarlem, The Netherlands


Zarko Vuckovic, MD 

General Surgeon 

Aspetar – Orthopaedic and Sports Medicine Hospital

Doha, Qatar


Willem Heijboer, PT, MSc

Physiotherapist & PhD candidate

Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Academic Center for Evidence Based Medicine, IOC Center, ACHSS

Amsterdam, The Netherlands 


Rotterdam/Barendrecht, The Netherlands






  1. Thorborg K, Rathleff MS, Petersen P, et al. Prevalence and severity of hip and groin pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J Med Sci Sports 2015;:n/a-n/a. doi:10.1111/sms.12623
  2. Harøy J, Clarsen B, Thorborg K, et al. Groin Problems in Male Soccer Players Are More Common Than Previously Reported. Am J Sports Med 2017;45:1304–8. doi:10.1177/0363546516687539
  3. Esteve E, Clausen MB, Rathleff MS, et al. Prevalence and severity of groin problems in Spanish football: A prospective study beyond the time-loss approach. Scand J Med Sci Sports 2020;30:914–21. doi:10.1111/sms.13615
  4. Werner J, Hägglund M, Ekstrand J, et al. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men’s professional football: the 15-year prospective UEFA Elite Club Injury Study. British Journal of Sports Medicine 2019;53:539–46. doi:10.1136/bjsports-2017-097796
  5. Serner A, Weir A, Tol JL, et al. Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study. Am J Sports Med 2020;48:1151–9. doi:10.1177/0363546520908610
  6. Mosler AB, Weir A, Eirale C, et al. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. Br J Sports Med Published Online First: 30 June 2017. doi:10.1136/bjsports-2016-097277
  7. Charnock BL, Lewis CL, Garrett WE, et al. Adductor longus mechanics during the maximal effort soccer kick. Sports Biomech 2009;8:223–34.
  8. Dupré T, Funken J, Müller R, et al. Does inside passing contribute to the high incidence of groin injuries in soccer? A biomechanical analysis. J Sports Sci 2018;36:1827–35. doi:10.1080/02640414.2017.1423193
  9. Dørge HC, Andersen T, Sørensen H, et al. EMG activity of the iliopsoas muscle and leg kinetics during the soccer place kick. Scandinavian journal of medicine & science in sports 1999;9:195–200.
  10. Fullenkamp AM, Campbell BM, Laurent CM, et al. The Contribution of Trunk Axial Kinematics to Poststrike Ball Velocity During Maximal Instep Soccer Kicking. J Appl Biomech 2015;31:370–6. doi:10.1123/jab.2014-0188
  11. Langhout R, Tak I, van der Westen R, et al. Range of motion of body segments is larger during the maximal instep kick than during the submaximal kick in experienced football players. J Sports Med Phys Fitness 2017;57:388–95. doi:10.23736/S0022-4707.16.06107-7
  12. Whiteley R, Farooq A, Johnson A. Development of a data-based interval kicking program for preparation and rehabilitation purposes in professional football. Science and Medicine in Football 2017;1:107–16. doi:10.1080/24733938.2017.1288919
  13. Daniels KAJ, King E, Richter C, et al. Changes in the kinetics and kinematics of a reactive cut maneuver after successful athletic groin pain rehabilitation. Scand J Med Sci Sports 2021;31:839–47. doi:10.1111/sms.13860
  14. Thorborg K, Krommes KK, Esteve E, et al. Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med 2017;51:562–71. doi:10.1136/bjsports-2016-097066
  15. Whalan M, Lovell R, Steele JR, et al. Rescheduling Part 2 of the 11+ reduces injury burden and increases compliance in semi-professional football. Scand J Med Sci Sports 2019;29:1941–51. doi:10.1111/sms.13532
  16. Veith S, Whalan M, Williams S, et al. Part 2 of the 11+ as an effective home-based exercise programme in elite academy football (soccer) players: a one-club matched-paired randomised controlled trial. Science and Medicine in Football 2021;5:339–46. doi:10.1080/24733938.2021.1874616
  17. Whittaker JL, Small C, Maffey L, et al. Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med 2015;49:803–9. doi:10.1136/bjsports-2014-094287
  18. Harøy J, Thorborg K, Serner A, et al. Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players: A Randomized Controlled Trial. Am J Sports Med 2017;:0363546517720194. doi:10.1177/0363546517720194
  19. Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. British Journal of Sports Medicine 2019;53:150–7. doi:10.1136/bjsports-2017-098937
  20. Serner A, Jakobsen MD, Andersen LL, et al. EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. Br J Sports Med 2014;48:1108–14. doi:10.1136/bjsports-2012-091746
  21. Ishøi L, Thorborg K. Copenhagen adduction exercise can increase eccentric strength and mitigate the risk of groin problems: but how much is enough! Br J Sports Med 2021;55:1066–7. doi:10.1136/bjsports-2020-103564
  22. Harøy J, Wiger EG, Bahr R, et al. Implementation of the Adductor Strengthening Programme: Players primed for adoption but reluctant to maintain - A cross-sectional study. Scand J Med Sci Sports 2019;29:1092–100. doi:10.1111/sms.13444
  23. Bourne MN, Williams M, Jackson J, et al. Preseason Hip/Groin Strength and HAGOS Scores Are Associated With Subsequent Injury in Professional Male Soccer Players. J Orthop Sports Phys Ther 2020;50:234–42. doi:10.2519/jospt.2020.9022
  24. Bahr R. Why screening tests to predict injury do not work-and probably never will…: a critical review. Br J Sports Med 2016;50:776–80. doi:10.1136/bjsports-2016-096256
  25. Whalan M, Lovell R, Sampson JA. Do Niggles Matter? - Increased injury risk following physical complaints in football (soccer). Science and Medicine in Football 2020;4:216–24. doi:10.1080/24733938.2019.1705996
  26. Thorborg K, Branci S, Nielsen MP, et al. Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function. Br J Sports Med 2017;51:594–9. doi:10.1136/bjsports-2016-096675
  27. Crow JF, Pearce AJ, Veale JP, et al. Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players. J Sci Med Sport 2010;13:202–4. doi:10.1016/j.jsams.2009.03.007
  28. Wollin M, Thorborg K, Welvaert M, et al. In-season monitoring of hip and groin strength, health and function in elite youth soccer: Implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport 2018;21:988–93. doi:10.1016/j.jsams.2018.03.004
  29. Serner A, van Eijck CH, Beumer BR, et al. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med 2015;49:813. doi:10.1136/bjsports-2014-094256
  30. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015;49:768–74. doi:10.1136/bjsports-2015-094869
  31. Heijboer WMP, Weir A, Vuckovic Z, et al. Inter-examiner reliability of the Doha agreement meeting classification system of groin pain in athletes. In review 2021.
  32. Heijboer WMP, Weir A, Delahunt E, et al. A Delphi survey and international e-survey evaluating the Doha agreement meeting classification system in groin pain: Where are we 5 years later? Journal of Science and Medicine in Sport 2021;0. doi:10.1016/j.jsams.2021.06.014
  33. Serner A, Weir A, Tol JL, et al. Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes. Scand J Med Sci Sports 2018;28:667–76. doi:10.1111/sms.12936
  34. Serner A, Weir A, Tol JL, et al. Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings? Br J Sports Med 2016;50:1541–7. doi:10.1136/bjsports-2016-096290
  35. Serner A, Tol JL, Jomaah N, et al. Diagnosis of Acute Groin Injuries: A Prospective Study of 110 Athletes. Am J Sports Med 2015;43:1857–64. doi:10.1177/0363546515585123
  36. Serner A, Hölmich P, Tol JL, et al. Progression of Strength, Flexibility, and Palpation Pain During Rehabilitation of Athletes With Acute Adductor Injuries: A Prospective Cohort Study. J Orthop Sports Phys Ther 2021;51:126–34. doi:10.2519/jospt.2021.9951
  37. Serner A, Weir A, Tol JL, et al. Characteristics of acute groin injuries in the hip flexor muscles - a detailed MRI study in athletes. Scand J Med Sci Sports 2018;28:677–85. doi:10.1111/sms.12939
  38. Branci S, Thorborg K, Bech BH, et al. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med 2015;49:681–91. doi:10.1136/bjsports-2014-093710
  39. Branci S, Thorborg K, Nielsen MB, et al. Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature. Br J Sports Med 2013;47:611–9. doi:10.1136/bjsports-2012-091905
  40. Hamilton B, Valle X, Rodas G, et al. Classification and grading of muscle injuries: a narrative review. Br J Sports Med 2015;49:306. doi:10.1136/bjsports-2014-093551
  41. Balius R, Pedret C, Kassarjian A. Muscle Madness and Making a Case for Muscle-Specific Classification Systems: A Leap from Tissue Injury to Organ Injury and System Dysfunction. Sports Med 2021;51:193–7. doi:10.1007/s40279-020-01387-5
  42. Serner A, Weir A, Tol JL, et al. Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study. Orthop J Sports Med 2020;8:2325967119897247. doi:10.1177/2325967119897247
  43. Otten R, Stam S, Langhout R, et al. The effect of compression shorts on pain and performance in male football players with groin pain - A double blinded randomized controlled trial. Phys Ther Sport 2019;38:87–95. doi:10.1016/j.ptsp.2019.04.013
  44. Tak I, Langhout R, Bertrand B, et al. Manual therapy and early return to sport in football players with adductor-related groin pain: A prospective case series. Physiother Theory Pract 2020;36:1009–18. doi:10.1080/09593985.2018.1531096
  45. Weir A, Jansen JACG, van de Port IGL, et al. Manual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial. Manual Therapy 2011;16:148–54. doi:10.1016/j.math.2010.09.001
  46. Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353:439–43. doi:10.1016/S0140-6736(98)03340-6
  47. King E, Franklyn-Miller A, Richter C, et al. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. Br J Sports Med 2018;52:1054–62. doi:10.1136/bjsports-2016-097089
  48. Yousefzadeh A, Shadmehr A, Olyaei GR, et al. The Effect of Therapeutic Exercise on Long-Standing Adductor-Related Groin Pain in Athletes: Modified Hölmich Protocol. Rehabilitation Research and Practice 2018;2018:1–10. doi:10.1155/2018/8146819
  49. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50:853–64. doi:10.1136/bjsports-2016-096278
  50. Serner A, Mosler AB, Tol JL, et al. Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis. Br J Sports Med 2019;53:158–64. doi:10.1136/bjsports-2018-099246
  51. Reurink G, Goudswaard GJ, Tol JL, et al. MRI observations at return to play of clinically recovered hamstring injuries. Br J Sports Med 2014;48:1370–6. doi:10.1136/bjsports-2013-092450
  52. De Vos R-J, Reurink G, Goudswaard G-J, et al. Clinical findings just after return to play predict hamstring re-injury, but baseline MRI findings do not. British Journal of Sports Medicine 2014;48:1377–84. doi:10.1136/bjsports-2014-093737
  53. Shrier I, Serner A, Wangensteen A, et al. Measuring heterogeneity of reinjury risk assessments at the time of clearance to return to play: A feasibility study. J Sci Med Sport 2017;20:255–60. doi:10.1016/j.jsams.2016.08.007
  54. Shrier I. Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. Br J Sports Med 2015;49:1311–5. doi:10.1136/bjsports-2014-094569
  55. Esteve E, Casals M, Saez M, et al. Past-season, pre-season and in-season risk assessment of groin problems in male football players: a prospective full-season study. Br J Sports Med 2021;:bjsports-2020-102606. doi:10.1136/bjsports-2020-102606
  56. King E, Ward J, Small L, et al. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med 2015;49:1447–51. doi:10.1136/bjsports-2014-093715
  57. Schilders E, Dimitrakopoulou A, Cooke M, et al. Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes. Am J Sports Med 2013;41:603–7. doi:10.1177/0363546513475790
  58. Paajanen H, Montgomery A, Simon T, et al. Systematic review: laparoscopic treatment of long-standing groin pain in athletes. Br J Sports Med 2015;49:814–8. doi:10.1136/bjsports-2014-094544
  59. Sheen AJ, Montgomery A, Simon T, et al. Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman’s hernia. Br J Surg 2019;106:837–44. doi:10.1002/bjs.11226
  60. Paajanen H, Brinck T, Hermunen H, et al. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery 2011;150:99–107. doi:10.1016/j.surg.2011.02.016
  61. Abouelnaga WA, Aboelnour NH. Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial. Ann Rehabil Med 2019;43:305–13. doi:10.5535/arm.2019.43.3.305
  62. Muschaweck U, Berger L. Minimal Repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia 2010;14:27–33. doi:10.1007/s10029-009-0614-y
  63. Migliorini F, Maffulli N, Eschweiler J, et al. Surgical versus conservative management of traumatic proximal adductor longus avulsion injuries: A systematic review. Surgeon 2021;:S1479-666X(21)00036-6. doi:10.1016/j.surge.2021.01.015
  64. Serner A, Hölmich P, Arnaiz J, et al. One-Year Clinical and Imaging Follow-up After Exercise-Based Treatment for Acute Complete Adductor Longus Tendon Avulsions in Athletes: A Prospective Case Series. Am J Sports Med 2021;49:3004–13. doi:10.1177/03635465211015996
  65. Bharam S, Feghhi DP, Porter DA, et al. Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes. Orthop J Sports Med 2018;6. doi:10.1177/2325967118784898




Header image by Aaron Sholl (Cropped)


Figure 1: Illustration of rehabilitation progression with early increase in rehabilitation load and longer time closer to required playing level (green), compared to standard stepwise progression models (blue) and time-based or pain free progression focused rehabilitation. The figure also highlights how players with different starting points theoretically will have shorter time to return to sport (dotted lines).
Figure 2: IIllustration of how different exercise focus areas within rehabilitation may have different starting points and different courses of progression and should be considered individually depending on the individual players abilities. Focus areas may adjusted according to individual rehabilitation goals.


Volume 10 | Targeted Topic - Hot Topics in Football Medicine | 2021
Volume 10 - Targeted Topic - Hot Topics in Football Medicine

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