NOT JUST A MINI-GROIN!

THE ADOLESCENT GROIN: WHY IS IT DIFFERENT?

Hip and groin injuries (HGIs) are common in sports that involve rapid changes of direction, acceleration, deceleration, and kicking, accounting for up to 11% of all injuries in multidirectional sports¹. In professional male football, teams sustain an average of seven HGIs per season, and more than half result in at least one week of time-loss^2,3. But how does this compare in youth sport?

Increasing age is associated with a higher incidence of HGIs, with risk rising by about 5% for each additional year¹. Even within youth sport, these injuries are more common in older adolescents than in younger players. In male youth football, HGIs account for 7% to 33% of all injuries⁴. However, there is a gap in the literature, since ‘groin pain’ as a clinical entity cannot be compared between adult and youth athletes: whereas adductor-related groin pain is the most common in adult players, growth-related conditions such as pelvic traction apophysitis appear to be the most burdensome in youth athletes.

During adolescence, the immature hip, groin, and pelvic region is especially vulnerable to the high training and competition demands of multidirectional sports⁵. Apophysitis is a condition unique to growing athletes, caused by traction at a developing growth plate, leading to pain and inflammation that usually develop gradually. In most cases, it is self-limiting and can be managed without stopping sport, using load modification and local pain-relief strategies. However, several clinical entities can cause hip and groin symptoms in young athletes, with different levels of risk and severity depending on the player’s maturation stage and the specific diagnosis. Mechanical stress at the apophysis—often labelled simply as ‘apophysitis’—should therefore be understood as a continuum, ranging from mild and often overlooked irritation to complete avulsion that may require surgical fixation.

These injuries are often underestimated by coaches and non-sports medical staff, and are frequently dismissed as ‘just growing pains’ or something the athlete should simply tolerate. In reality, effective management requires a solid understanding of adolescent growth and maturation, together with strong clinical knowledge and appropriate risk management.

GROWTH, MATURATION AND GROIN INJURIES: WHAT AND WHEN TO EXPECT

Adolescence represents a unique period for hip, groin and pelvic injuries in sport due to the interaction between rapid growth, skeletal immaturity and increasing demands. In recent years, growing attention has been directed towards the clinical burden of growth-related conditions affecting hip and pelvic structures in adolescent athletes. Traditionally, greater focus was placed on more recognised distal conditions such as Sever’s disease at the heel or Osgood-Schlatter disease at the knee. However, recent epidemiological studies have highlighted the important impact of injuries involving hip and pelvic apophyses, particularly at the anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), iliac crest, ischial tuberosity and pubic apophysis^6–8 (Figure 1).

Apophyses are tendon attachment sites in the immature skeleton associated with secondary ossification centres, which are areas of developing bone that have not yet fully fused, making them particularly sensitive to repeated traction forces. At the hip and pelvis, important muscles insert onto these structures, including the rectus femoris at the AIIS, the sartorius at the ASIS, and the adductor muscle group and lower abdominal structures at the pubic apophysis. During periods of maturation and incomplete ossification, these structures represent a relative weak point within the musculoskeletal system. Consequently, repetitive traction forces may result in apophysitis or, in more severe situations, partial or complete avulsion injuries. These injuries may become an important source of symptoms and time-loss during adolescence, particularly in sports involving repeated sprinting, kicking and explosive lower limb actions⁹.

Accordingly, hip, groin and pelvic apophyseal injuries appear to carry greater clinical impact than more distal apophyseal conditions^6–8. Recent evidence has shown that apophyseal injuries involving the hip and pelvis were both the most prevalent and burdensome lower limb apophyseal injuries in adolescent male academy football players, accounting for 56% of all apophyseal injuries and approximately 45 days lost per squad-season⁶. However, these studies are usually based only on injuries causing time-loss from sport participation. In practice, many adolescent athletes continue training and competing despite ongoing pain and symptoms, meaning that the real burden of hip and groin growth-related conditions is likely even greater than currently reported.

Hip, groin and pelvic apophyseal injuries become progressively more common during mid-to-late adolescence, particularly in sports involving repeated sprinting, kicking, jumping and explosive changes of direction. In football academy settings, these injuries are most frequently observed from approximately U13 onwards^6–8, coinciding with periods of increased vulnerability related to the maturation and ossification status of different secondary ossification centres⁹. Importantly, pelvic apophyses do not mature simultaneously, and different structures may therefore become vulnerable at different stages of adolescent development (Table 1).

Accordingly, injury patterns vary according to the specific apophysis involved. AIIS injuries represent one of the most characteristic and clinically relevant pelvic apophyseal injuries in adolescent football, particularly during mid-adolescence, whereas ASIS, iliac crest tend to occur later, likely reflecting the later maturation of these structures. Pubic-related apophyseal injuries appear later in development, typically from around U16 and potentially persisting into early adulthood (up to 20–25 years), in line with the delayed ossification of the pubic symphysis. As a result, many adolescent and young adult athletes remain skeletally immature at this region, and pubic apophysitis is likely an under-recognised cause of groin pain¹⁰, potentially explaining cases often labelled as pubalgia or adductor-related groin pain. Clinically, pubic pain in athletes under approximately 20–22 years should be interpreted cautiously, as it may frequently represent an apophyseal condition rather than adult-type pathology. Although less epidemiological data are available in female athletes, similar maturation-related patterns likely exist, potentially occurring one to two years earlier due to differences in skeletal maturation timing.

Can age and maturation status help injury diagnosis?

Growth and maturation characteristics may substantially influence the timing and presentation of apophyseal injuries. Although these injuries tend to follow relatively predictable age-related patterns, athletes of the same chronological age may be at very different stages of biological maturation and therefore present different periods of vulnerability for growth-related injuries. Directly assessing the maturation status of individual ossification centres in day-to-day practice is challenging. However, skeletal maturation is closely related to somatic maturation, which refers to the biological process of growth and physical development throughout adolescence. Assesing somatic maturation is non-invasive, easier to monitor in sport settings and is commonly studied using the concepts of maturation status, timing and tempo.

Somatic maturity status describes where an athlete is positioned relative to peak height velocity (PHV), the period of fastest growth during adolescence, and typically classifies athletes as pre-PHV, circa-PHV, post-PHV or adult. Different apophyseal injuries tend to predominate at different maturation stages¹¹ (Figure 2). During pre-PHV stages, distal conditions such as Sever’s disease or Osgood-Schlatter disease are more common, although hip apophyseal injuries such as AIIS injuries may also occur. Around circa-PHV, when growth velocity is highest, AIIS and ischial apophyseal injuries appear particularly common. In contrast, ASIS injuries tend to become more frequent during post-PHV stages. Pubic-related apophyseal injuries appear more relevant closer to adult stage, as they may occur when athletes are close to or have already reached adult height, with longitudinal growth largely complete but the pubic apophysis still maturing due to its delayed ossification.

Somatic maturity timing refers to the age at which maturation events occur, particularly PHV. Average age at PHV is typically around 13.8 years in males and 11.8 years in females, although substantial inter-individual variability exists. Consequently, athletes who mature earlier or later than their peers may experience periods of apophyseal vulnerability at different chronological ages and competitive categories¹¹. For example, AIIS injuries, which typically have their greatest impact around U13–U14, may still be observed in U15–U16 players with later maturation timing. Similarly, pubic-related apophyseal injuries, which are usually more relevant in U16–U21 players, may appear earlier in early-maturing athletes and, conversely, may persist beyond 21 years of age in later-maturing individuals due to the delayed ossification of the pubic symphysis.

Finally, maturation tempo describes how rapidly an athlete progresses through maturation. Athletes experiencing faster growth velocities around PHV may present substantially greater injury burden from growth-related injuries, with some studies reporting approximately fourfold greater burden in players with more pronounced or quick PHV¹².

Considering these maturation-related differences, monitoring growth and maturation characteristics may help practitioners identify athletes at greater risk for apophyseal injuries, support earlier diagnosis and guide more individualised training load management and injury prevention strategies during adolescence.

INJURY MANAGEMENT

Apophyseal injuries of the hip and pelvis are a clinically significant yet frequently underdiagnosed cause of groin pain in the skeletally immature athlete. Signs of apophyseal irregularity on imaging are a normal accompaniment of rapid skeletal growth, 'benign apophysitis’ not pathology per se³⁰. The apophysis is often weaker than the surrounding musculotendinous unit^13,14, making it susceptible to repetitive microtrauma (traction apophysitis) or acute forceful muscle contraction causing frank avulsion fractures. Accurate anatomical knowledge, timely imaging, and structured management are essential for diagnosis and return to sport.

Hip & groin apophyseal injuries

Table 2 summarises all pelvic and groin apophyseal sites, pain location, injury type, and relative frequency and impact. (Table 2)

Most common: AIIS and ASIS

Antero-inferior iliac spine (AIIS) is the most common traction apophysitis of the pelvis, especially in kicking sports. AIIS avulsion is the most frequently reported pelvic apophyseal avulsion, accounting for 30–37% of cases^15,16. Injury occurs during explosive hip flexion against an extended knee, the kicking or sprinting mechanism producing sudden anterior groin pain and a palpable fragment. AP pelvis radiography confirms displacement; MRI is preferred for soft tissue detail and exclusion of concurrent pathology¹⁷. The Morita classification (Types I–III) guides management: the majority are treated conservatively with 2–4 weeks of protected weight-bearing and return to sport by 8–12 weeks. Surgery is reserved for displacement >2–3 cm or neurovascular compromise^17,18.

Anterior-superior iliac spine (ASIS) avulsions (22–30% of cases) arise from sudden hip extension with knee flexion, injuring the sartorius origin [15]. Clinical features include anterolateral iliac tenderness, antalgic gait, and pain on resisted hip and knee flexion¹³. Management mirrors that of AIIS injuries, with operative fixation reserved for significantly displaced fragments.

Moderately common: Ischial Tuberosity and Iliac Crest

Ischial tuberosity apophysitis is common in sports requiring high intensity kicking and sprinting. Although less frequent, it’s often more burdensome than other pelvic apophyseal injuries, with symptoms extending for weeks until the athlete is able to recover full function. Ischial tuberosity avulsions (15–25%) are the hallmark injury of dance and gymnastics, caused by eccentric hamstring loading during hip flexion with an extended knee^15,19. Patients report an audible 'pop' with acute posterior buttock pain; straight-leg raise reproduces symptoms. Displacement >1.5–2 cm warrants surgical consideration, though conservative management is successful in most cases¹⁹.

Iliac crest apophysitis presents insidiously in distance runners with lateral hip pain reproduced by resisted abduction. Management is conservative: load modification and hip stabiliser strengthening¹⁴.

Least common and rare injuries

- Lesser trochanter and greater trochanter

Chronic iliopsoas apophysitis at the lesser trochanteric physis presents insidiously with anterior groin pain, coxa saltans interna, and Thomas test positivity. MRI shows physeal oedema without displacement²⁷. Management is conservative: relative rest, iliopsoas stretching, and progressive core loading. The oncological red flag for lesions in older adolescents applies here equally^20,27. Lesser trochanter avulsions result from violent iliopsoas contraction. Critically, any such injury in an athlete older than 16–18 years without a clear sporting mechanism must prompt oncological workup to exclude pathological fracture through skeletal metastasis²⁰.

Isolated greater trochanter injuries are rare, typically involving gluteus medius or piriformis after direct trauma or repetitive abductor loading.

- Pubic symphysis apophysitis: ‘The Osgood-Schlatter of the pelvis’

Pubic symphyseal apophysitis is aptly described as the 'Osgood-Schlatter of the pelvis'^21,22. The competing pull of the adductors inferiorly and rectus abdominis superiorly creates a 'pubic tug-of-war,' driving physeal inflammation²². Adolescents present with medial groin pain on adductor squeeze and single-leg loading. MRI shows pubic bone marrow oedema; radiography demonstrates symphyseal irregularity²¹. Management is conservative (6–12 weeks rest, adductor and core rehabilitation); corticosteroid injection may relieve refractory symptoms. Infective osteitis pubis must be excluded^14,22.

- Van Neck-Odelberg apophysitis

Van Neck-Odelberg disease affects the ischiopubic synchondrosis in children aged 4–11, causing eccentric irregular enlargement that mimics osteomyelitis or Ewing sarcoma, an important diagnostic pitfall to avoid unnecessary biopsy^23,24. It is self-limiting; treatment is activity modification and reassurance²³.

- Triradiate cartilage stress

Physeal stress injury of the triradiate cartilage, the Y-shaped acetabular physis, is exceedingly rare but carries serious consequences: premature closure risks acetabular dysplasia and early osteoarthritis²⁵. MRI is the diagnostic modality of choice. Immediate sport cessation, 3–6 months of monitoring, and urgent paediatric orthopaedic referral are mandatory^25,26.

Apophyseal Injury management

a. Prevention: Longitudinal Growth Surveillance

A proactive approach through regular growth surveillance should include: (1) 1 to 3-monthly serial height measurements to estimate PHV proximity; (2) Tanner staging to contextualize risk; (3) pre-participation imaging at high-risk apophyseal sites; and (4) 20–40% reduction in high-intensity traction loading during peri-PHV windows^30,31. This framework analogous to growth monitoring in paediatric endocrinology, together with good training programming, has the potential to substantially reduce avulsion fractures and chronic apophysitis in competitive young athletes.

b. Traffic Light Model

The Traffic Light Model stratifies injury severity into three actionable zones, directly guiding management intensity and return-to-sport decisions^28,29:

• GREEN — Mild apophysitis: Modified training with 30–50% load reduction; clinical review every 2 weeks; imaging only if atypical²⁸.
• AMBER — Moderate / non-displaced avulsion: Relative rest 2–4 weeks; MRI to confirm status; physiotherapy rehabilitation; return to sport after pain-free functional testing^28,29.
• RED — Displaced avulsion / high-risk physeal injury: Full sport cessation; surgical orthopaedic referral; structured post-operative rehabilitation; return-to-sport milestones at ≥12–16 weeks^17,18,29.

c. Structured Follow-Up to Limit Time Loss

Fortnightly clinical review in the acute phase, then monthly with functional testing enables real-time load titration, avoiding both premature return (re-injury risk) and excessive restriction (unnecessary time loss). Imaging reassessment at 6 weeks is recommended for moderate and severe injuries before progression toward sport^17,28,29.

APOPHYSEAL INJURIES: PRACTICAL IMAGING PEARLS ACROSS THE INJURY CONTINUUM

Imaging plays a central role in the diagnosis and follow-up of apophyseal injuries, with each modality providing complementary information depending on the site, timing, and severity of injury^30,31. Imaging findings reflect a biologic and biomechanical continuum ranging from stress-related traction changes to structural failure and subsequent remodeling, rather than isolated entities^32,33,34.

Radiographs remain the first-line imaging modality and are particularly useful to assess apophyseal maturation, cortical irregularity, fragmentation, and fragment displacement in avulsion injuries³⁵. However, radiographs may be normal in early stress-related injury patterns. Ultrasound provides a dynamic point-of-care assessment of the immature apophyseal complex and may demonstrate cortical irregularity, surrounding soft tissue edema, and hypervascularity on Doppler imaging, although findings remain operator dependent³⁸. MRI is the most sensitive technique for detecting early injury and for characterizing the full extent of osseous, physeal, and soft tissue involvement³². CT may be useful in selected cases requiring detailed osseous characterization or preoperative planning³². Figures 3-7 show examples of different imaging modalities in pelvic apophyseal injuries.

From an imaging perspective, apophyseal injuries may be understood as recurrent traction-related disorders progressing through different imaging appearances. Early patterns are dominated by bone marrow edema and subtle periapophyseal inflammatory changes without cortical disruption, usually reflecting repetitive mechanical overload³². With increasing stress, physeal widening and fluid-like signal abnormalities may develop, representing early structural compromise with increased susceptibility to avulsion injury^31,32.

More advanced injuries demonstrate structural failure with variable degrees of cortical disruption and displacement. In minimally displaced injuries, partial biomechanical continuity may persist despite fracture. In contrast, larger displaced avulsion injuries reflect greater mechanical instability and are associated with prolonged recovery and higher likelihood of surgical treatment, particularly when displacement exceeds approximately 15 mm^40,41. Importantly, many acute avulsion injuries occur on a background of chronic traction-related adaptation, including sclerosis, irregularity, or fragmentation, supporting the concept of a progressive injury continuum rather than separate entities^33,34.

Healing also follows dynamic imaging changes over time⁴². Early follow-up studies are typically dominated by edema and reparative hyperemia, whereas later stages demonstrate progressive fibrocartilaginous and subsequent osseous bridging, followed by structural remodeling and eventual restoration of cortical continuity. Persistent low-grade edema or residual deformity may remain visible despite clinical recovery and should not automatically be interpreted as ongoing instability^42,43. Imaging interpretation should therefore always be integrated with symptoms, physical examination, and sport-specific functional progression.

Recognition of these practical imaging patterns may help radiologists provide clinically meaningful reports by improving severity assessment, guiding follow-up recommendations, and facilitating communication with sports physicians, orthopedic surgeons, and rehabilitation teams. Key imaging features across the injury continuum are summarized in Table 3. Future imaging-based approaches will likely move beyond isolated diagnostic categories and increasingly integrate structural, biologic, and functional information to better characterize injury progression and healing response⁴⁴.

CONCLUSION

Hip, groin and pelvic pain in adolescent athletes cannot be interpreted simply as a smaller version of adult groin injury. Growth, maturation and skeletal immaturity fundamentally shape both the epidemiology and presentation of these conditions. In youth sport, apophyseal injuries appear to be among the most clinically important causes of hip and groin symptoms, particularly during periods of rapid growth and around peak height velocity, when the apophysis becomes a temporary weak point exposed to high traction loads.

These injuries follow recognizable age- and site-specific patterns. AIIS and ASIS injuries are the most frequent, but clinicians must also recognize less common presentations such as ischial tuberosity, pubic symphysis, lesser trochanter and triradiate cartilage injuries, some of which carry substantial consequences if missed. This reinforces the importance of combining clinical history, pain location, mechanism of injury, and maturation status when establishing diagnosis and estimating risk.

Finally, effective care depends on early recognition, appropriate imaging, and structured management. Imaging should be interpreted along an injury continuum, from reversible traction overload to displaced avulsion and healing, rather than as isolated entities. In practical terms, longitudinal growth surveillance, timely load modification, and a severity-based management model can improve decision-making, reduce time loss, and help prevent progression to more serious injury. Overall, understanding adolescent-specific biology is essential for safer diagnosis, treatment and return-to-sport decisions in young athletes.

Ultimately, we’re dealing with the athlete of the future… and with the future of the athlete.

Acknowledgments:

The authors thank Agustín Marrero, MD for their assistance in the collection and selection of some representative cases used to illustrate this manuscript.

Daniel Martinez-Silvan PT

Lead Physiotherapist

Abdallah Rejeb PT, PhD

Physiotherapist

Aspetar Orthopaedic and Sports Medicine Hospital

Aspire Academy

Doha, Qatar

Xabier Monasterio PT, PhD

Physiotherapist

University of The Basque Country

Athletic Club Bilbao

Bilbao, Spain

Jaime Isern-Kebschull MD, PhD

Radiologist

Department of Radiology

Hospital Clinic

University of Barcelona

Barcelona, Spain

Contacts: daniel.silvan@aspetar.com

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Header Image by Franco Monsalvo (Cropped)