CLINICAL PATHWAYS AND THE RATIONALE BEHIND THEM

INTRODUCTION

Groin pain in athletes rarely presents as a single, easily bounded clinical problem. The region is anatomically dense, with muscular, tendinous, ligamentous, articular, and neural structures converging within a small area. Several of these structures share overlapping innervation and biomechanical function, which means pain generated by one structure is frequently felt, described, and even provoked as though it originated from another.

This anatomical overlap has direct clinical consequences. A rigid, one-size-fits-all diagnostic protocol struggles to accommodate the genuine variability seen in daily practice. Two athletes with almost identical pain distribution can present with entirely different underlying pathology, while two athletes with the same underlying pathology can describe strikingly different symptom patterns depending on sport, training load, and individual biomechanics.

The Doha Agreement provided a shared clinical language for this problem, defining adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain, while recognising hip-related groin pain and other causes¹. That vocabulary has improved both communication and research reporting. But classification answers only the first part of the clinical problem: knowing which entity best describes an athlete does not, by itself, determine what should happen next. Classification is therefore the starting point of clinical reasoning, not its endpoint. More than one entity may be present in the same athlete², and the clinically dominant presentation may change during rehabilitation, so reassessment may confirm, refine, or redirect the initial clinical interpretation.

For this reason, structured clinical pathways in this field function best as a decision framework rather than a fixed algorithm. This article presents five illustrative, composite cases, developed from patterns commonly encountered at Aspetar’s Sports Groin Pain Center, to demonstrate how history and clinical examination determine routing within this framework, and where the evidence supporting each branch is strong, extrapolated, or still emerging.

This account reflects institutional clinical experience rather than a validated external guideline. Where published evidence directly supports a decision point, this is stated explicitly. Elsewhere, the reasoning reflects accumulated clinical judgement developed through years of running a dedicated groin pain clinic.

FROM CLASSIFICATION TO CLINICAL DECISION-MAKING (Table 1)

Two features of this table deserve early comment. Most entities follow an open-ended rehabilitation course, adjusted according to clinical progress rather than a fixed calendar. The inguinal/nerve-related and Acute PLAC entities, however, carry a structured four-week review built in from the outset rather than left to emerge only if progress stalls in spite of appropriately delivered rehabilitation. At that review, escalation was considered when the predefined institutional criteria had not been achieved.

One clarification applies throughout. Classification identifies the dominant symptomatic presentation and organises diagnostic reasoning, monitoring, and decisions about imaging and intervention. The rehabilitation programme itself is built from the individual athlete's deficits, loading capacity and sport-specific demands rather than from the entity label.

Two further points apply across every branch. Before an athlete enters an entity-specific pathway, serious, referred and non-musculoskeletal causes should be considered where clinically appropriate: bone stress injury, intra-articular hip pathology, referred spinal symptoms, urogenital or visceral causes, and age-specific pathology.

The Doha framework also recognises ‘other causes’ of groin pain beyond its defined clinical entities. One potentially under-recognised presentation is pelvic floor dysfunction, particularly an overactive or non-relaxing pelvic floor, which should be considered in athletes with otherwise unexplained groin or pelvic pain, especially when pelvic or perineal symptoms coexist with urinary, bowel or sexual symptoms³. In such presentations, targeted pelvic floor assessment may add clinically relevant information and guide an appropriately individualised rehabilitation approach.

And when an athlete does not respond as expected, the appropriate question is not simply “What is the next treatment?” but also “Are we still on the right pathway?” Table 2 summarises the assessment components that inform this reasoning; it is a practical checklist rather than a set of diagnostic criteria.

CASE 1: A HANDBALL PLAYER WITH REPRODUCIBLE ADDUCTION PAIN

A 26-year-old handball player presents with a six-week history of medial groin pain. Onset was gradual, without a specific traumatic event, and symptoms have progressively worsened with cutting movements and change-of-direction drills, both central to his sport.

Palpation reproduces tenderness at the proximal adductor longus and gracilis attachments. The adductor squeeze test is positive at 0° and 45° of hip flexion. Hip range of motion is otherwise preserved, and there is no radiation, no neurological symptoms, and nothing in the history suggesting systemic involvement.

This presentation corresponds closely to the recognised clinical pattern of adductor-related groin pain. Routing into the adductor-related branch follows directly from these findings. Hölmich's randomised trial demonstrated that structured active exercise substantially outperforms passive treatment in athletes with long-standing adductor-related groin pain⁴, and structured active rehabilitation remains the anchor of management here, although the trial evidence comes from athletes with longer symptom duration.

One point deserves emphasis, because it is easily lost. The adductor-related classification identifies where the athlete's familiar symptoms are reproduced; it does not establish why that region became overloaded, and it does not specify a predefined exercise programme. Rehabilitation therefore combined progressive restoration of adductor capacity with attention to the individual biomechanical, load-related and sport-specific contributors relevant to this athlete. The classification informs the starting point of rehabilitation; it does not prescribe the programme.

Recurrence risk was discussed with the athlete as part of the initial consultation, not deferred to a later stage. Previous groin injury is one of the most consistently reported risk factors for subsequent groin problems in athletes^5,6. This informed both the rehabilitation goals and the criteria used to define readiness for return to sport, which required progressive restoration of training intensity and volume and of sport-specific and competition-specific loading, rather than symptom resolution or isolated strength recovery alone.

CASE 2: A DISTANCE RUNNER WITH PAIN RESISTANT TO CATEGORISATION

A 22-year-old distance runner presents with an eight-week history of deep, central groin pain. Onset was gradual, without a specific triggering event, and symptoms have progressed alongside an increase in running volume.

Given the combination of a running athlete, persistent deep groin pain and a recent increase in load, a stress-related bony process was considered and addressed by imaging before rehabilitation was progressed.

On examination, the pain pattern differs meaningfully from Case 1. Rather than a discrete point of tenderness at a muscle-tendon junction, the athlete describes a deeper, more central discomfort, and palpation confirms this: her familiar pain is reproduced directly over the pubic symphysis and the immediately adjacent bone, rather than at the adductor origin a few centimetres laterally.

Resisted adduction and the squeeze test reproduce only mild, centrally located pubic discomfort rather than the sharply localised adductor pain of Case 1, and the symphysis and adjacent bone remain the clearly dominant site reproducing her familiar symptoms. Palpation of the inguinal canal is unremarkable, and coughing and Valsalva do not reproduce her familiar pain. Hip range of motion and rotation are preserved, which makes a dominant hip-joint or iliopsoas contribution less likely, although it does not exclude intra-articular hip pathology.

Taken together, these findings supported a predominantly pubic-related clinical presentation rather than an adductor-related one. Rehabilitation remained individualised, with an initial loading emphasis on restoring tolerance across the symphysis and abdominal wall while progressively reintroducing running volume.

This distinction matters for anyone learning to apply the pathway. The two presentations sit only a few centimetres apart anatomically, and it is common, particularly for less experienced clinicians, to treat them as interchangeable simply because both fall under the broad heading of “groin pain.” Identifying which presentation dominates may influence the initial loading emphasis and how symptoms are monitored during rehabilitation. It does not mean the two require entirely separate programmes: adductor-related and pubic-related presentations frequently share underlying biomechanical drivers, which is part of why they so commonly occur together, and their rehabilitation content overlaps considerably.

CASE 3: AN ACUTE ADDUCTOR AVULSION WITH A BUILT-IN SAFEGUARD

A 28-year-old footballer experienced a sudden, sharp pain at the pubic attachment of the adductor longus while striking the ball, and was unable to continue playing. Examination the following day identified localised swelling and bruising at the pubic attachment, acute tenderness on resisted adduction, and a palpable defect suggestive of a partial tear at the enthesis.

This acute, traumatic mechanism, with a discrete injury event and localisation at the pubic attachment, routes the athlete into the Acute PLAC pathway. This entity reflects a relatively recent shift in anatomical understanding. For a long time, an acute injury at this location was treated as a simple adductor longus enthesis tear. More recent anatomical work has shown this to be an oversimplification: the adductor longus tendon at its pubic attachment does not act in isolation, but connects directly to the pyramidalis muscle and the anterior pubic ligament, forming a single functional complex now referred to as the PLAC, the pyramidalis–anterior pubic ligament–adductor longus complex⁷.

This distinction is not merely academic. An injury at this site can involve any combination of these structures rather than one, and six patterns of PLAC injury have been described on MRI, defined by the status of the adductor longus fibrocartilage, the pyramidalis and the pectineus⁸. Isolated adductor longus injury is the exception rather than the rule. Treating every acute injury at this location as an isolated adductor tear therefore risks underestimating what is often a more complex, multi-structure injury. MRI describes the pattern and extent of injury, including whether more than one structure is involved, rather than determining routing, which the mechanism and examination have already established. The patterns are descriptive: they have not been shown to predict recovery trajectory or the need for surgery.

In our institutional pathway, acute PLAC injuries carried a predefined four-week review, providing a scheduled opportunity to confirm that recovery was progressing as expected and to reassess the initial interpretation. Although these injuries frequently progress well with conservative management, the review provided a structured clinical checkpoint. The four-week review therefore functions as a built-in safeguard against silent stagnation, rather than a routine follow-up appointment or a step on the way to surgery.

Where the criteria have not been achieved despite an appropriately delivered rehabilitation programme, the response is still not automatic escalation. The sequence is to reconsider the extent of injury and the initial clinical interpretation, review the rehabilitation programme, consider whether further imaging or multidisciplinary discussion would add information, and only then consider escalation where clinically justified. Conservative management remains central, and specialist surgical consideration is reserved for selected athletes who do not progress.

CASE 4: WHEN THE PAIN POINTS TOWARD A NERVE, NOT A TENDON

A 29-year-old field hockey player presents with a ten-week history of groin discomfort that has proven difficult to characterise. The pain is described as a burning, electric sensation radiating from the inguinal region toward the upper medial thigh, worsened by hip extension and by prolonged standing, and occasionally accompanied by localised numbness.

On examination, the picture is dominated more by what is absent than by what is found. Palpation over the inguinal canal produces only mild, poorly localised discomfort, without a clear structural trigger point. Resisted adduction, resisted sit-up testing, and hip flexor strength testing are all unremarkable, making the adductor, pubic, and iliopsoas presentations described in the earlier cases unlikely to be dominant. Sensory examination along the distribution of the ilioinguinal nerve reveals a patch of altered sensation.

Inguinal-related and nerve-related presentations overlap substantially and are managed within a single pathway at our centre; the ilioinguinal, iliohypogastric and genitofemoral nerves traverse this region with considerable individual variation and overlapping sensory territories⁹. Within that pathway, neuropathic features modify assessment and management: burning or electric pain quality, altered sensation, radiation beyond a single muscle group, and a recognisable cutaneous distribution¹⁰. Provocation by sustained positions is often present but is not specific, since musculotendinous problems may be provoked in the same way. Rehabilitation remains first-line management, and the same structured four-week review applies as in the Acute PLAC branch.

Unlike the previous cases, however, the diagnostic uncertainty here does not need to wait for a rehabilitation trial to run its course. Where the clinical picture already raises a meaningful nerve-mediated hypothesis, as it does here, an early ultrasound-guided local anaesthetic block can be performed before the four-week review, rather than being reserved until the four-week review or subsequent escalation. Rehabilitation proceeds either way; the block is performed alongside it rather than deciding whether it goes ahead. Its value is that clarifying a nerve contribution early informs how the presentation is interpreted and monitored, and which interventional options are relevant.

The block is a diagnostic clarification step rather than a treatment and is interpreted by reassessing the athlete's characteristic symptom or provocative manoeuvre within the expected anaesthetic window. A clear and substantial temporary reduction in the athlete's familiar pain supports a nerve-mediated contribution. No validated numerical threshold was used in this pathway, and a supportive response increases the likelihood of that contribution rather than establishing the diagnosis. Any diagnostic benefit should not be mistaken for a sustained treatment effect.

A supportive block also clarifies the options if conservative management proves insufficient. Where clinically relevant symptoms persist despite appropriate rehabilitation, an ultrasound-guided perineural corticosteroid injection and specialist surgical review are both reasonable considerations, and the balance between them is contextual rather than sequential, depending in part on the response to the treatment already delivered. Where surgery is clinically appropriate and the athlete has adequate recovery time, as in the off-season or a suitable break, it may be recommended directly; in-season, when surgery would remove the athlete from sport for a substantial period, the injection may instead serve as a temporary symptom-modifying measure alongside continued rehabilitation. Neither is a precondition for the other. A negative or equivocal block, by contrast, is equally informative: it prompts reconsideration of the working diagnosis rather than automatic progression toward further injection or surgery.

CASE 5: WHEN DYNAMIC IMAGING ADDS INFORMATION

A 27-year-old ice hockey player presents with an eight-week history of deep inguinal pain, worsened by sprinting and rapid changes of direction, without radiation and without bowel or urinary symptoms. Examination yields little, but not nothing. Resisted abdominal loading reproduces his familiar deep inguinal discomfort; palpation of the inguinal canal is otherwise unremarkable, scrotal invagination testing is equivocal, and no bulge or cough impulse is identified at rest or with Valsalva. Resisted adduction, hip flexor testing and hip examination are unremarkable, making adductor-, iliopsoas- and hip-related presentations unlikely to be dominant.

The absence of a palpable hernia does not exclude clinically relevant inguinal pathology. An important distinction applies here: posterior wall weakness or bulging is not the same thing as a frank direct or indirect anatomical inguinal hernia, and neither is synonymous with Doha inguinal-related groin pain, a clinical entity defined by inguinal canal tenderness without a palpable hernia. Posterior wall findings have been described in athletes without corresponding symptoms¹¹, and cannot be interpreted in isolation.

Dynamic ultrasound, performed with resisted sit-up and Valsalva manoeuvres, demonstrated bulging of the inguinal floor under load, absent on static examination. Dynamic ultrasound can demonstrate load-dependent abnormalities not apparent on static examination¹². A finding demonstrated under load is not, for that reason, automatically clinically significant.

What justified surgical assessment was not the imaging finding alone, but its concordance with the clinical picture: compatible symptoms and history, an examination that reproduced his familiar pain on abdominal loading, reasonable exclusion of the other entities, and a dynamic abnormality demonstrated under the loading conditions that reproduced his symptoms. The same finding in an athlete whose symptoms pointed elsewhere would not carry equal weight. This case is therefore not one of imaging replacing clinical reasoning, but of imaging adding information to an already plausible clinical hypothesis.

THE ROLE OF IMAGING ACROSS THE PATHWAY

Across most entities described in this pathway, imaging serves several defined purposes: exclusion of important alternative pathology, characterisation of injury extent or severity where this influences management or prognosis, support for the working clinical interpretation, and documentation of relevant findings. Imaging should be pathway-dependent rather than pathway-defining. It is obtained where history and examination indicate that it will add information, rather than routinely, and it may support the working clinical interpretation, refine it, or challenge it. What it does not do is define the clinical entity or trigger escalation on its own.

This position is grounded in the recurrent observation that positive imaging findings, particularly pubic bone marrow oedema and posterior wall changes on ultrasound, occur commonly in athletes without corresponding symptoms^11,13,14. This applies under load as well as at rest: a dynamic abnormality is not automatically more clinically significant than a static one. Allowing imaging findings to drive routing decisions risks systematic over-escalation of athletes who would otherwise respond adequately to rehabilitation (Table 3).

CONTEXTUAL FACTORS THAT MODIFY THE DEFAULT PATHWAY

Entity classification guides the initial routing decision. It does not, on its own, dictate identical management for every athlete assigned to the same branch (Table 4).

LIMITATIONS

This pathway reflects institutional clinical practice developed at a single centre, rather than a validated, externally endorsed guideline. Active rehabilitation is central across groin pain management, but the directness of the evidence varies: randomised trial evidence is clearest in long-standing adductor-related presentations, while the evidence across other presentations is less direct and more heterogeneous. The four-week criteria reflect internal clinical agreement rather than externally derived thresholds.

The illustrative cases are composites rather than individual patients, and detailed management of hip-related groin pain lies outside the scope of this article, although hip pathology remains an important coexisting contributor. How it translates elsewhere depends on caseload, access to imaging and injection expertise, and the monitoring available between reviews; reasonable variation between centres is expected, and several aspects of the pathway remain areas of ongoing refinement rather than settled practice.

These limitations are stated directly rather than implied, in the view that a structured pathway is strengthened, not weakened, by an accurate account of where its evidence is robust and where clinical judgement continues to fill genuine gaps in the literature.

CONCLUSION

Classification gave this field a common language, but it does not determine every subsequent decision. Identifying the dominant presentation tells the clinician where to begin; it does not explain why the region became overloaded, how rehabilitation should be built for that individual, or when the initial interpretation should be revisited. Imaging, where clinically indicated, may support, refine or challenge that interpretation, but is read alongside history and examination rather than in place of them.

None of this removes uncertainty from the consultation. The value of a clinical pathway lies not in eliminating uncertainty, but in providing a structure through which uncertainty can be recognised, reassessed and acted upon. A pathway should guide clinical reasoning without replacing it.

Milos Bojovic MD

PM&R Specialist / Sports Medicine Physician

Felipe Hardt MD

Sports Medicine Physician

Maria Romero MD

Sports Medicine Physician

Cristiano Eirale MD, PhD

Chief of Sports Medicine

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Contact: drbojovicmilos@gmail.com

References

1. Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774. doi:10.1136/bjsports-2015-094869
2. Taylor R, Vuckovic Z, Mosler A, Agricola R, Otten R, Jacobsen P, et al. Multidisciplinary assessment of 100 athletes with groin pain using the Doha agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clin J Sport Med. 2018;28(4):364-369. doi:10.1097/JSM.0000000000000469
3. Giagio S, Salvioli S, Pillastrini P, Innocenti T. Sport and pelvic floor dysfunction in male and female athletes: a scoping review. Neurourol Urodyn. 2021;40(1):55–64. doi:10.1002/nau.24564
4. Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):439-443. doi:10.1016/S0140-6736(98)03340-6
5. Langhout R, Tak I, van Beijsterveldt AM, Ricken M, Weir A, Barendrecht M, et al. Risk factors for groin injury and groin symptoms in elite-level soccer players: a cohort study in the Dutch professional leagues. J Orthop Sports Phys Ther. 2018;48(9):704-712. doi:10.2519/jospt.2018.7990
6. Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med. 2015;49(12):803-809. doi:10.1136/bjsports-2014-094287
7. Schilders E, Bharam S, Golan E, Dimitrakopoulou A, Mitchell A, Spaepen M, et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc. 2017;25(12):3969-3977. doi:10.1007/s00167-017-4688-2
8. Schilders E, Mitchell AWM, Johnson R, Dimitrakopoulou A, Kartsonaki C, Lee JC. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surg Sports Traumatol Arthrosc. 2021;29(8):2424-2436. doi:10.1007/s00167-020-06180-5
9. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001;108(6):1618-1623. doi:10.1097/00006534-200111000-00029
10. Vuckovic Z, Bojovic M. Neuropathic causes of groin pain in athletes: understanding nerve involvement. Int Orthop. 2025;49(4):845-852. doi:10.1007/s00264-025-06461-z
11. Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med. 1998;32(2):134-139. doi:10.1136/bjsm.32.2.134
12. Vasileff WK, Nekhline M, Kolowich PA, Talpos GB, Eyler WR, van Holsbeeck M. Inguinal hernia in athletes: role of dynamic ultrasound. Sports Health. 2017;9(5):414-421. doi:10.1177/1941738117717009
13. Silvis ML, Mosher TJ, Smetana BS, Chinchilli VM, Flemming DJ, Walker EA, et al. High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. Am J Sports Med. 2011;39(4):715-721. doi:10.1177/0363546510388931
14. Branci S, Thorborg K, Bech BH, Boesen M, Nielsen MB, Hölmich P. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med. 2015;49(10):681-691. doi:10.1136/bjsports-2014-093710
15. Eberbach H, Fürst-Meroth D, Kloos F, Leible M, Bohsung V, Bode L, et al. Long-standing pubic-related groin pain in professional academy soccer players: a prospective cohort study on possible risk factors, rehabilitation and return to play. BMC Musculoskelet Disord. 2021;22(1):958. doi:10.1186/s12891-021-04837-x

Header Image by Bob Stephan (Cropped)