THE ASPETAR WAY
THE WHY?
The Acute Groin Injury
Acute groin injuries are among the most common and disruptive time-loss injuries in multidirectional sport, with the adductor longus by far the most frequently injured structure1,2. Comparable burdens are reported across football, ice hockey and the rugby codes, where rapid, forceful adductor loading under abduction and external rotation during reaching, kicking, skating, cutting or collision represents a common injury mechanism1–4.
Previous groin injury, reduced adductor strength and reduced hip internal rotation range of motion (ROM) are all associated risk factors1,5 while deficits in strength, ROM, motor control and sport-specific load-tolerance often outlast the resolution of pain6,7.
Recent interest in pyramidalis–anterior pubic ligament–adductor longus complex (PLAC) injuries has further highlighted that not all acute groin presentations share the same injury characteristics or return to sport trajectories8–11. These realities highlight the need for a structured, applied rehabilitation pathway which recognises the complexity of acute groin injury and return to performance6,12.
Contemporary best practice increasingly recognises rehabilitation as a continuum of progressive sport exposure, integrating rehabilitation components concurrently and incrementally rather than treating return to sport as a binary endpoint or delaying exposure until predetermined time thresholds are reached.
This article presents the current Aspetar approach to acute groin rehabilitation – The Aspetar Way: Acute Groin Injury Rehabilitation Pathway. The full pathway is available via the QR code at the end of this paper; the surrounding text provides the historical context, clinical rationale and practical implementation that make it meaningful in daily practice. The pathway provides a framework to standardise comprehensive care while allowing ongoing reflection, refinement, and evolution of practice through the integration of emerging evidence, clinical expertise, and insights gained from complex or atypical cases (Figure 1).
HISTORICAL CONTEXT
Aspetar has a long-standing clinical interest in the athletic groin, and this pathway represents the latest iteration of work spanning more than a decade. The Doha agreement on terminology and definitions in groin pain in athletes13 established a common clinical language for adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain, while earlier work by Hölmich, 2007 introduced a clinical-entity approach that continues to inform assessment and management today.
The original Aspetar adductor pathway provided the first structured, institution-wide approach to acute groin injury rehabilitation, emphasising progressive adductor loading, objective strength assessment through hand-held dynamometry, range of motion and pain-provocation testing as progression criteria7,15,16. The current pathway builds on these foundations and follows the same developmental approach as the Aspetar Hamstring and Rectus Femoris pathways17,18, reflecting the collective contributions of past and present Aspetar clinicians.
DEVELOPMENT OF THE PATHWAY
The Aspetar Way: Acute Groin Pathway was developed using the Knowledge-to-Action (KTA) framework19, consistent with the development of the Aspetar Hamstring and Rectus Femoris pathways17,18. A senior steering group conducted a targeted narrative review, adapted relevant evidence to the local context, and refined successive iterations through departmental implementation and feedback.
Three clinical and performance challenges informed the pathway design. First, re-injury rates remain high, with time-based progression failing to consistently reduce recurrence or prevent progression to more chronic athletic groin pain presentations7. Second, previous protocols have often prioritised symptom resolution over sport-specific demands such as high-speed running, change of direction, and kicking exposure17,18,20. Third, the weekly distribution of rehabilitation load remains relatively unexplored, despite being a major source of variability in applied practice. The current pathway integrates these elements within a single framework to support consistent practice and future research. While the pathway is designed primarily with field-based and court sports in mind, the principles can be readily adopted to wider sporting populations.
Three principles underpin the pathway: begin with the end in mind, reverse engineering the athlete’s sporting demands into phase-specific targets; individualise rehabilitation, using assessment to inform exercise selection and progression; and progress by criteria- rather than time, using clinical, field and laboratory measures aligned with the demands of each subsequent phase17,18.
THE ACUTE GROIN PATHWAY
The pathway is a structured, criteria-based framework comprising eight interconnected sections; assessment, milestones, strength, motor control, explosiveness & reactive strength, running & change of direction, sport-specific (including kicking where appropriate), and the weekly schedule (the Aspetar Week). It is delivered across six sequential phases, five guiding the athlete from injury to return to competition, with the final phase centred around sustained performance upon return (Figure 2).
The pathway uses clinical, field and laboratory criteria that progress alongside the athlete through rehabilitation. Early milestones are centred on pain response, range of motion and strength symmetry, whereas later phases incorporate sport-specific field measures and laboratory assessments of strength, power and reactive performance. Progression generally requires achievement across these domains, although decisions are ultimately guided by clinical reasoning and the individual athlete context.
Clinical Assessment
Clinical assessment sits at the heart of the Aspetar Way and is structured to deliver both depth and consistency. The subjective assessment is organised across six domains- injury information, past history, pain, other symptoms, training load and player beliefs; ensuring that the context around the injury- not just the injury itself, is captured from the first contact. Objective testing follows a daily and twice weekly cadence (Figure 2), with phase-specific milestones progressing alongside the athlete through rehabilitation. The daily and twice-weekly clinical tests were selected because they are practical for repeated monitoring and capture key domains of recovery: pain, hip range of motion, inner- and outer-range isometric and eccentric adductor strength and adductor capacity, rather than relying on a single endpoint. Strength assessment progresses from isometric to eccentric testing, as eccentric strength has been shown to normalise later within rehabilitation and identify limb-symmetry deficits once isometric strength has restored9.
Motor control assessment is integrated from the outset, providing additional insight into movement and mobility deficits across the hip, lumbar spine, and wider kinetic chain, as discussed below and in more detail in the subsequent Athletic Groin Pain Pathway article (Page 506) (Figure 3).
Clinical Pearl — Rehabilitation is built on informed decisions. A structured assessment framework connects early impairment to individual return-to-performance demands.
Clinical Pearl — Measure what matters. The value of assessment lies not just in collecting data, but in identifying the key factors that influence recovery and performance.
See Pathway pp. 6–13 — Section 1: Clinical Assessment (subjective and objective assessment, palpation, ROM, strength, pain provocation, neurological screening, historical GPS and kicking data).
Motor Control
Motor control plays a central role in hip and groin rehabilitation, where rehabilitation targeting deficits in intersegmental control has been shown to improve clinical outcomes in athletic groin pain21. The motor control stream comprises both compound movements (e.g., squat, split squat, lateral lunge and single-leg calf raise) and more isolated hip and trunk exercises targeting key contributors to hip and lumbopelvic function.
Exercise selection is guided by a three-point scoring system drawn from break tests, active-versus-passive ROM, and movement quality. Rather than following a rigid progression, exercises are modified through changes in position, cueing, external load, or task complexity to provide an appropriate stimulus for motor learning. Motor control is most prominent in the early phases of rehabilitation and provides a competency-based foundation for subsequent strength development. A detailed description of the motor control framework is provided in the accompanying Athletic Groin Pain article (Page 506).
Clinical Pearl — Restoration of coordinated lumbopelvic and hip control should precede substantial increases in external loading, providing a stable foundation for subsequent strength progressions, running and sport-specific tasks.
Clinical Pearl — Motor control assessments should inform clinical decision-making rather than serve as absolute return-to-sport criteria. Findings should be interpreted alongside strength, running capacity, functional performance, and athlete symptoms.
See Pathway pp. 17–33 — Section 4: Motor Control (compound and isolated motor control assessments and progressions, coaching cues, consistent compensation strategies and constraints).
Strength
While efficient motor control is being established, progressive strength training is the primary focus to optimise tissue resilience following acute groin injury. Persistent deficits in hip adductor strength are consistently observed following athletic groin pain and are associated with impaired function and an increased risk of recurrent injury22–24.
However, rehabilitation should extend beyond isolated adductor strengthening, as force production during athletic tasks depends on the coordinated contribution of the hip flexors, trunk, hip abductors and rotators, and lower-limb kinetic chain through range.
The four strength streams included within the pathway (adductor, hip flexion, compound and agonist/supportive strengthening) were selected to address the principal impairments observed following acute groin injury. Isolated adductor loading restores force-generating capacity of the injured tissue progressing from short to long muscle-tendon unit lengths at high strain-rates which are often associated with injury mechanisms; hip flexor strengthening addresses the common loss of anterior hip strength and function, compound exercises develop integrated lower-limb force production across multiple joints, and agonist/supportive strengthening targets adjacent muscle groups that contribute to lumbopelvic stability, load transfer and movement efficiency. Collectively, these streams aim to restore muscle capacity across the kinetic chain while progressively exposing the injured tissues to increasing mechanical demand.
Exercise selection is based on the highest competency the athlete can demonstrate within the pain limits of the current rehabilitation phase. Progression is achieved by manipulating muscle length, contraction mode, movement velocity and external load to progressively increase tissue demand25. Longer muscle length training and eccentric overload become increasingly important during later rehabilitation to restore force production at extended muscle lengths and expose the musculotendinous unit to the high mechanical demands encountered during sprinting, cutting and kicking. Earlier exercises are retained and progressed to maintain training volume and reinforce movement competency. EMG evidence can help optimise exercise selection, while athlete-reported localisation of the training stimulus ("Where do you feel it?") provides an additional clinical check that the intended tissues are being effectively loaded.
Clinical Pearl — Strength rehabilitation should target the mechanisms of injury, not simply the injured muscle. Progressive loading at longer muscle-tendon unit lengths and higher contraction velocities better prepares the adductor complex for the demands of sprinting, cutting and kicking.
Clinical Pearl — Improvements in isolated adductor strength should not be the sole marker of successful rehabilitation. Athletes should demonstrate the capacity to generate and transfer force effectively through range across the hip, trunk and lower limb before progressing to high-speed sport-specific tasks.
See Pathway pp. 34–44 — Section 3: Strength Streams & Progressions (adductor, hip flexion, compound and agonist streams with level-by-level progressions, load, tempo and acceptable pain response).
Explosiveness & Reactive Strength
The ability and willingness to generate and re-direct force rapidly is routinely deconditioned after an acute groin injury and often neglected in rehabilitation. The pathway addresses this through two streams: kicking-pattern work and hopping. Progression is driven by muscle length (short®long), intent (submaximal/extensive®maximal/intensive) and speed (fast stretch-shortening cycle and fast ground-contact time).
Open-chain kicking-pattern work is particularly relevant for many sports, as common mechanisms of acute adductor longus injury involve hip extension, abduction and external rotation, knee flexion below 45°, and rapid muscle lengthening—characteristics replicated during kicking. Closed-chain “reaching for the ball” actions are also important, accounting for up to 65% of severe cases3. Similar explosive, asymmetrical adductor loading at or near end range occurs across a range of sports, including the AFL drop punt, rugby scrum and breakdown engagement, and the ice hockey skating push-off. These demands should therefore be systematically replicated within the explosiveness stream according to the athlete’s sport-specific requirements.
Velocity and force-based metrics from technologies such as linear position transducers, motorised resistance devices, inertial measurement units, and force platforms can be used to reinforce movement intent, quantify performance, and monitor fatigue-related reductions in output.
Clinical Pearl — Restoring adductor strength in controlled conditions does not ensure readiness for explosive sport. Progressive exposure to rapid force production, long muscle lengths, and sport-specific asymmetrical actions should be integrated throughout rehabilitation to replicate the mechanical demands of kicking, cutting, and contact situations.
See Pathway pp. 45–51 — Section 5: Explosiveness & Reactive Strength (kicking and hopping reactive-strength progressions, contraction mode, ground-contact time and acceptable pain response).
Running
Running is usually the highest-volume and highest-speed locomotor task the groin must tolerate on return to sport, and the pathway treats it accordingly. Running is separated into linear running and change of direction (COD), each comprising two equally important streams: mechanics and exposure. Mechanics focuses on the isolated and intersegmental control required for efficient running and COD, while exposure provides graded progression of speed, volume, intensity, and session content. With fatigue and overuse emerging as key factors in muscle injury risk26, addressing biomechanical deficits which may cause overload at the hip and groin region is important to allow athletes to tolerate increasing running exposure both within rehabilitation and return to play.
Linear running is often introduced early in Reload through running mechanics drills and slow jogging, with ‘true running’ (>40% MSS or 12 km·h–¹) beginning in Accumulation alongside progressive COD mechanics work. Curvilinear running, which substantially increases frontal- and transverse plane hip loading on the inside limb, is introduced in Transition as a separate progression once high-intensity linear running has been tolerated without symptom provocation.
By Simulation, athletes are routinely exposed to peak one- and five-minute worst-case scenarios drawn from their own match data at ≥100% of match demands, using GPS-based external load monitoring calibrated to the athlete's sport and competitive demands rather than generic thresholds27.
Clinical Pearl — Running mechanics and running exposure should progress together. Addressing movement deficits while gradually increasing external load helps reduce excessive hip and groin stress during return to sport.
Clinical Pearl — Successful return to running requires more than restoring speed. Athletes must progressively rebuild tolerance to the volume, intensity, and movement demands of competition through structured exposure.
See Pathway pp. 54–61 — Section 6: Running & Change of Direction (linear, curvilinear and change-of-direction exposure, GPS metrics and example session content across all phases).
Sport Specific – Kicking
Kicking is an important demand of the athletic groin and a common mechanism of acute groin injury3; graded kicking exposure is therefore central to the pathway. Similar to the principle discussed within running, kicking is considered from a mechanics and exposure perspective.
Kicking mechanics focuses on optimising hip and groin mobility and lumbopelvic control, which together may enhance kicking performance while reducing stress on the hip and groin region during football-specific actions. Research examining the football kick has demonstrated that reductions in Sports-Specific Range of Motion (SSROM) impair the storage and release of energy through the tension arc28. This may compromise movement efficiency and increase the functional demands placed on the adductor muscles.
Similarly, lumbopelvic control appears to play an important role in efficient force transfer during kicking. Biomechanical studies have shown that spinal flexion and posterior pelvic tilt occur as coupled movements immediately prior to ball contact29. Furthermore, football players with a history of groin injury demonstrate reduced posterior pelvic tilt during kicking tasks compared with uninjured players30. Limitations in pelvic movement may therefore impair energy transfer throughout the kinetic chain, encouraging compensatory movement strategies and further increasing loading demands on the adductor muscles. Similar to mobility interventions, lumbopelvic control training (as part of the overall motor control stream), can be incorporated flexibly across both training and recovery days.
Kicking exposure is categorised into four intensity bands: low, medium, high, and maximal, using velocity-based analysis from a validated foot-mounted IMU (e.g., Playermaker™) or ball/foot-velocity system where available, with distance, intensity, and technique-based measures providing a pragmatic alternative.
The application of these principles varies considerably across sporting codes. In the rugby codes, kicking for goal and clearing kicks under pressure remain highly demanding despite lower kicking volumes, while in soccer and Gaelic football, cross body kicking actions, both from the ground and from the hand or air, impose distinct multiplanar demands on the hip and pelvis. In American Football and Australian Rules Football, the punt kick warrants particular consideration: the explosive hip flexion extension arc, weight bearing landing demands on the contralateral limb, and cumulative kicking volumes, often exceeding 50–80 kicks per session, create a unique loading profile that must be considered from the outset of rehabilitation.
These sport specific demands should guide the progression of kicking exposure throughout rehabilitation.
For sports in which on-ball kicking is not a primary movement pattern, such as ice hockey or athletics, cable-based kicking progressions remain the principal explosive adductor stimulus throughout rehabilitation, with sport-specific locomotor actions reintroduced progressively during the Transition and Simulation phases. Cable-based kicking progressions (forward, 45°, side-foot, cross-body and volley) begin in Accumulation as the first explosive adductor stimulus and progress into higher intensity on-ball kicking through Transition.
Progression is governed by mechanical demand such as kick type, intensity and velocity rather than volume alone. Angle progression precedes increases in speed, load or volume. Cross-body and volley exposures are not performed on consecutive days, and maximal-demand kicking is delayed until the Simulation phase. Kicking volume is individualised to the athlete's positional role and sport and continues to be monitored through the Resilience phase.
See Pathway pp. 48,50,52-53 — Section 7: Sport Specific – Kicking (intensity categorisation, cable-based progressions, side-foot, instep, cross-body and volley streams).
The Aspetar Week
The Aspetar Week provides a practical framework for sequencing rehabilitation across a typical training week, rather than a fixed template to be copied verbatim into every environment. It is designed to reflect the demands of the rehabilitation setting and the level of support available to the athlete, allowing clinicians to adjust the frequency and distribution of strength, motor control, running, and kicking work across phases. Strength is typically delivered five times per week in Foundation and three times per week in Reload and Accumulation, motor control is emphasised early and may taper as competency improves, kicking is introduced in Accumulation and progressed through Transition and Simulation, and running is built from Reload to five sessions per week in Simulation. This layout is intended to reduce the interference effect by placing higher-demand tasks such as sprinting, cutting, and maximal kicking when the athlete is least fatigued, while preserving recovery between demanding sessions. Delivery of the Aspetar Week should be individualised to each environment, with the goal of matching the athlete’s regular training microcycle by the Simulation phase.
CLINICAL REASONING AND DECISION-MAKING
Progression is driven by assessment and load tolerance, rather than time. Each phase is anchored by subjective, clinical, field, and laboratory based criteria, with thresholds aligned to the demands of the subsequent phase rather than a fixed standard. Subjective symptoms, pain provocation, range of motion, strength, and sport specific performance are assessed longitudinally to guide progression and identify barriers to recovery.
Pain is used as an informative guide rather than an absolute constraint, and it is important to distinguish between pain during activity, pain after activity, and the 24-hour response. A mild-intensity, in-session response appropriate to each phase that resolves within 24 hours and does not compromise movement quality can be considered acceptable, whereas increases in resting pain, palpation sensitivity, or movement limitation warrant temporary load modification. This approach keeps rehabilitation close to the boundary of tissue tolerance without provoking symptom escalation.
Performance testing through Aspetar’s RAMAL biomechanics laboratory adds kinetic and kinematic depth at the transition into higher-demand work. Countermovement jump, drop-jump, isokinetic knee-flexion and extension torque, linear running and change of direction assessment are used to evaluate broader athletic qualities alongside local tissue recovery. Field-based milestones; maximum sprint speed, maximal acceleration, GPS-derived distance metrics and worst-case-scenario exposure ensure the athlete is tested against their own match demand, not a generic standard. Where access to such technology is limited, practitioners should strive to achieve the highest level of assessment possible within the constraints of their clinical environment
Clinical reasoning remains central, as progression decisions are rarely binary and no single assessment determines readiness in isolation. An over emphasis on factors such as strength resolution may mask persistent deficits in motor control and biomechanics which may still leave the athlete at risk for future injury. Clinical, laboratory, motor control, and field based findings are interpreted collectively alongside psychological readiness and contextual factors such as season timing, competition demands, and individual risk-tolerance. Decisions are therefore shared across the multidisciplinary team, with the athlete actively involved throughout the rehabilitation process.
Clinical Pearl — No single test determines readiness. Return-to-sport decisions should integrate clinical findings, performance data, movement quality, and athlete context rather than relying on any isolated measure.
Clinical Pearl — Restore quality, not just quantity. Restoration of strength and running exposure alone does not guarantee readiness. Rehabilitation must address movement quality, sport-specific demands, and the athlete’s ability to repeatedly tolerate load.
RETURN TO PERFORMANCE AND RESILIENCE
Return to Performance and Resilience
The Simulation phase systematically prepares the athlete for the demands of competition within a semi-controlled rehabilitation environment. Athletes are progressively exposed to reactive, high-intensity and worst-case-scenario tasks, including chaotic change of direction, contested sport-specific scenarios, and running loads that match or exceed competition demands. Within a field-sport club environment, this phase typically coincides with progression through modified to full training. Progression is therefore determined by the athlete’s performance capacity, robustness and ability to repeatedly tolerate these demands, rather than symptom resolution alone.
The final phase of the pathway is deliberately termed Resilience, rather than return to play. Return to sport is a single moment in an athlete’s career; resilience reflects the demands placed on the athlete in performing through the weeks, months and seasons that follow. This phase provides an opportunity to address residual performance deficits, consolidate confidence in maximal-demand tasks such as kicking, sprinting and reactive change of direction and establish individualised long-term monitoring strategies aimed at reducing re-injury risk.
Athlete-specific goal setting, or “beginning with the end in mind”, underpins the Resilience phase. The primary objective is to progressively extend robustness and performance capacity towards the most demanding scenarios encountered within the athlete's sport. These demands are influenced by factors such as competition level, playing style, positional requirements, and training load. For example, a wing back in professional football may compete in up to three matches per week while being exposed to substantial volumes of passing, crossing, reactive change of direction, and duelling31,32. Resilience programming should therefore progressively rebuild movement capacity while aligning with the physical demands of competition and the team's microcycle27.
To support this process, regular assessment and progression of the six components within the pathway (strength, motor control, explosiveness and reactive strength, running, sport-specific activities, and conditioning) remain fundamental to developing robustness and resilience. However, resilience extends beyond load tolerance alone and requires the structured planning, periodisation, and implementation of secondary prevention strategies within the sporting environment. During this phase, sports performance leads, while secondary prevention interventions must be integrated around key performance outputs such as matches and high-load training sessions.
Translating these principles into practice can be challenging. Strength training, running mechanics, motor control interventions (including sport-specific mobility and lumbopelvic control), and recovery strategies must all be coordinated around team activities while maintaining appropriate prioritisation. Consecutive days of loading place considerable strain on soft tissues, making recovery periods an important component of adaptation and tissue restoration. Although scheduling strength training before pitch-based activities may optimise strength development33, it can also contribute to fatigue and potentially increase injury risk. Therefore, when the objective is to maintain strength while preserving freshness and respecting recovery days, performing strength training immediately following field-based sessions is often recommended34.
Psychological readiness is equally important during this phase and is closely linked to long-term outcomes. Collaboration between the athlete, coach and multidisciplinary team helps build confidence in high-demand tasks and unrestricted participation. The Resilience phase is framed not simply as a test of readiness, but as an opportunity to demonstrate that the athlete is more robust and better prepared than before injury.
In summary, the Resilience phase requires a careful balance between restoring physical capacity, optimising performance and confidence, maintaining freshness, and minimising re-injury risk. Effective periodisation is fundamental to improve match availability while simultaneously developing strength, mobility, lumbopelvic control, and the other key components of the pathway.
FUTURE DIRECTIONS
The Aspetar Way: Acute Groin pathway is designed as a living framework that will continue to evolve alongside emerging evidence and clinical practice. Priorities include clarifying the prognostic relevance of different PLAC injury types, as it remains unclear whether specific injury patterns are associated with distinct recovery outcomes, refining kicking progressions through velocity and IMU based metrics, adapting the pathway for female athletes, and evaluating its application across sporting codes with differing locomotor and seasonal demands. Prospective evaluation of pathology-specific outcomes, including return to sport timelines, re-injury rates, and performance measures, together with collaboration across external centres, will be critical to testing and refining the pathway beyond the Aspetar setting.
CONCLUSION
Acute groin injuries are common, complex, and costly, requiring an approach that is sufficiently structured to provide consistency while remaining adaptable to the athlete, sport, and competitive context. The Aspetar Way: Acute Groin pathway integrates more than a decade of clinical experience with contemporary evidence on adductor injury, criteria based rehabilitation, and sport specific load management. It is intended as a framework for performance rehabilitation rather than a prescriptive protocol, supporting individualised decision-making and the progressive restoration of sporting performance, robustness, and long-term resilience.
See Pathway via QR code on this page — Full Acute Groin Pathway: complete pathway document and supporting references.
David Power1
Physiotherapist
Lindsay Bull1
Senior Physiotherapist
Dermot Simpson1
Senior Physiotherapist
Nick van der Horst2
First Team Physiotherapist
Enda King1,3
Visiting Consultant Elite Performance and Development
1. Aspetar Orthopaedic and Sports Medicine Hospital Doha, Qatar
2. PSV Eindhoven, Netherlands
3. University of Leeds
Contact: david.j.power33@gmail.com
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Header Image by Lars Bo Nielsen (Cropped)