The Doha agreement on terminology and definitions in groin pain in athletes is one of the key achievements of the Aspetar Sports groin Pain Center. The process leading up to the publication and the impact following played an important role in establishing Aspetar as a key institution in the field of groin pain in athletes. This article is an account of the process and reflection on the impact, written for this edition of the Aspetar journal.
In 2012 Aspetar established the sports groin pain center under the guidance of Dr Hakim Chalabi. Professor Per Holmich, one of the world’s leading experts, became the head of the Sports Groin Pain Center. A period of heavy investment in the center and recruitment lead to growth and numerous new initiatives. The clinical services were expanded, new research projects were set up and an annual conference about groin pain was run. At the end of 2012 Adam Weir started as the deputy head of the sports groin pain center.
The conferences held in 2012 and 2013 created an opportunity for clinicians and researchers in the field to meet, exchange ideas, discuss challenges and get to know each other. It became clear at the conferences that one of the challenges regarding groin pain on an internation level was the confusion surrounding taxonomy and terminology. This was also the case in clinical practice in Aspetar and the National Sports Medicine Programme. Doctors and physiotherapist from a huge range of countries work together in these organizations. The lack of clear terminology regarding how to describe a diagnosis often led to problems in communication. The same athlete being given different terms to describe the same clinical picture. Sometimes the same term being used to describe different clinical pictures.
The team at Sports Groin Pain Center identified this issue and set out to try and address it. Plans were made to host the 1st World Conference on Groin Pain in Athletes, which was held in November 2014. In the buildup to the conference the Aspetar journal published a special edition on groin pain:
https://journal.aspetar.com/en/journals/volume-3-targeted-topic-groin-pain
To give an overview of where we were after 2 years of the groin pain center. Experts in the field of hip and groin pain from different countries and backgrounds; sports physicians, physiotherapists, general surgeons, orthopedic surgeons, radiologists, anatomists, epidemiologists and bio-mechanists were invited to attend and present at the conference.
In the buildup to the conference several key systematic reviews were commissioned and completed to give a current overview of the scientific literature. These were presented at the conference and published in the British Journal of Sports Medicine. A Delphi study of the speakers at the conference was performed to get an overview of the current terminology and ideas regarding the classification of groin pain in athletes1. In one case 23 experts used 21 different terms to describe the diagnosis in an inguinal-related groin pain example!
After the conference an expert meeting was held at Aspetar where all the experts stayed on an extra day to agree upon a classification system for hip and groin pain in athletes. The day was chaired by Karim Khan and Peter Brukner and was a big success. The terminology and classification system agreed on was then published in the British Journal of Sports Medicine2. This has become a key publication in the field.
The Doha Agreement offers a framework for classifying long standing hip and groin pain in athletes. Groin pain has 4 defined clinical entities: adductor, iliopsoas, pubic and inguinal-related groin pain. It also includes the hip as a possible cause of groin pain and also lists many alternative differential diagnoses. It recommends a thorough history and clinical examination as being the key steps in practice. Vicky Earle was commissioned to summarize the findings in an anatomical drawing which has become iconic in the field.
Following the publication the article has helped to put Aspetar on the map as a leading center in the field of groin pain in Athletes. The article has been cited more than 500 times and downloaded more than 200,000 times.
A follow up study by Willem Heijboer as part of his PhD on groin pain while at Aspetar showed a good adoption among clinicians at the FIFA and IOC centers of excellence around the world3. And the recent ESKKA-EHPA-ESMA consensus on hip and groin pain in physical active adults adopted the use for groin pain4. The adoption is though far from universal and there has also been criticism.
Reflecting on the process and publication and ensuing use there were some other positive effects. Having clinicians and researchers meeting, getting to know each other and discussing cases and ideas established a sense of community. This led to many new collaborations and spin off projects. Interaction with colleagues with similar interests leads to new concepts and ideas. There remain many challenges, and many of these are discussed elsewhere in this special issue. Let’s hope that the field will continue to develop and that the future may allow for refinement of the classification.
Adam Weir MD
Sports medicine physician
Erasmus medical center – Rotterdam and Sport and Exercise Clinic Haarlem, The Netherlands
Former deputy head of Aspetar sports groin pain center.
Contact: adsinoz@hotmail.com
References
- Weir A, Holmich P, Schache AG, et al. Terminology and definitions on groin pain in athletes: building agreement using a short Delphi method. Br J Sports Med. Published Online First: 23 April 2015. doi: 10.1136/bjsports-2015-094807
- 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
- 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? J Sci Med Sport. 2021;S1440244021001766. doi: 10.1016/j.jsams.2021.06.014
- Hölmich P, Weir A, Papadopoulou T, et al. Hip and groin pain in physically active adults with a focus on terminology, clinical examination and imaging: A formal ESSKA-EHPA-ESMA Consensus. Knee Surg Sports Traumatol Arthrosc. 2026;34:3844–55. doi: 10.1002/ksa.70565