GROIN PAIN: MUCH DONE, MORE TO DO

Groin pain remains one of the most challenging problems encountered in sport. Over a decade ago, the Doha Agreement represented an important step forward for our field.

Today, it is appropriate to ask a different question: where do we go from here? The field has unquestionably moved forward. We understand more about the clinical presentation and natural history of groin pain, the interaction between strength, movement and sporting exposure, and the role of exercise-based rehabilitation. In addition, our assessment tools have improved. Imaging has become increasingly sophisticated. Objective strength and biomechanical testing are becoming more accessible, while our understanding of return-to-sport decision-making and the demands imposed by running, kicking, change of direction and high-intensity sport continues to develop.

At the same time, considerable uncertainty remains. Groin pain is heterogeneous. Different athletes with apparently similar diagnoses may present with very different impairments, sporting demands and responses to loading. Imaging findings do not always explain symptoms or determine prognosis. There remains limited evidence to define precisely which assessment findings should dictate particular interventions, how individual deficits should be prioritised, or exactly when an athlete is ready to progress through rehabilitation and ultimately return to performance.

It is within this tension between what we know and what we still need to understand that the targeted topic on Decoding Groin Pain has been developed.

Acute groin injuries are given specific attention within this edition, with a criteria-based approach to diagnosis, rehabilitation progression and return to sport. This provides a practical pathway from the early management of the injury through restoration of capacity and progressive exposure to the demands of training and competition.

A further feature of this edition is the introduction, for the first time in the Aspetar Sports Medicine Journal, of the Aspetar Way for both Acute Groin Injury and Athletic Groin Pain. This describes how the multidisciplinary team at Aspetar currently approaches the assessment and management of groin injuries, combining the best available evidence with clinical expertise and experience developed through the management of large numbers of athletes. It is not intended as a rigid protocol or as a claim that there is one correct approach, but rather as a transparent clinical framework that reflects current practice, acknowledges areas where evidence remains limited and can evolve as our understanding improves and provides a framework for practitioners to reflect their practice and systems against.

This also points towards the work required over the next decade. Future research must move beyond simply identifying associations towards determining which findings meaningfully influence prognosis and treatment. We need better phenotyping of athletes with groin pain, stronger prospective studies, clearer rehabilitation progression criteria and a greater understanding of how strength, biomechanics, tissue capacity and sporting exposure interact. Advances in imaging, wearable technology and biomechanical analysis offer exciting opportunities, but their value will ultimately depend on whether they improve clinical decisions and athlete outcomes. Most importantly, progress will continue to depend on collaboration across disciplines.

We would like to thank all of the authors who contributed their expertise to this special edition, the reviewers who challenged and strengthened their work, and Professor Popovic, Editor-in-Chief, and the entire Aspetar Sports Medicine Journal team for their support in bringing the edition together.

Finally, we would like to give particular thanks to the Aspetar Rehabilitation Department and our Director of Rehabilitation, Riadh Miladi, for his support and vision to deliver best practice but also share our knowledge and learnings as far and wide as possible. Much of the rehabilitation thinking presented within this edition has emerged from years of discussion, debate, assessment, treatment and shared learning within the department. The willingness of colleagues to challenge ideas, share experience and continually question how we can provide better care for athletes has been fundamental to the development of the approaches described here.

Enda King PhD

Visiting Consultant Elite Performance and Development, Aspetar

Professor, University of Leeds

Dermot Simpson

Senior Physiotherapist