Last updated: August 2023
Understanding classifications of groin pain is key to successful recovery.
Groin pain is a prevalent and often complicated issue experienced by athletes, especially those engaged in dynamic ground-based sports such as Jiu-Jitsu. These athletes often experience sharp shifts in direction and rapid leg movements that could lead to different types of groin injuries.
Diagnosing and treating groin pain can be challenging due to overlapping symptoms and the potential for multiple pathologies. However, the Doha agreement, a consensus met by 24 international experts in 2014, helped address the confusion surrounding groin-related injuries.
Building upon the evidence from systematic reviews and the Doha agreement, groin pain has now been classified into four primary clinical entities:
Adductor-Related Groin Pain (Blue):
Adductors, comprising primarily of the adductor longus, magnus, and brevis, are muscles that pull the leg toward the body. An injury to these muscles can cause discomfort during resisted movements or upon applying pressure on the muscles and their tendons, often radiating down the inside of the thigh.
Signs & Symptoms: Athletes experiencing adductor-related pain may initially feel a sense of tightness or stiffness during activities, and will have adductor tenderness and pain on resisted adduction testing. Jiu-Jitsu athletes may experience reduced range of motion during open guard or guard retention, or discomfort squeezing and maintaining closed guard.
Management: Management of adductor-related pain often involves active rehabilitation, including general exercises and specific strengthening. Research suggests that active rehabilitation can be equally, if not more, effective than passive treatments like rest or shock wave therapy. A surgical option is available, but caution is advised due to potential muscle weakness post-surgery and often unnecessary.
Iliopsoas-Related Groin Pain (Green):
The iliopsoas, consisting of the iliacus and psoas major muscles, are involved in hip flexion. Injuries in this area often result from overuse, such as repetitive kicking or sprinting actions. In jiu-jitsu, this overuse may result from repeated hip flexion as part of guard retention on maintaining positions in leg lock exchanges who are new to the technical requirements of these actions.
Signs & Symptoms: Pain due to iliopsoas injuries is typically felt around the hip's front, closer to the hip than the groin or pubic bone. The primary symptoms include pain upon applying pressure on the muscles or discomfort while stretching or resisting hip flexion. The ache often feels deep and challenging to pinpoint.
Management: Treatment options include patient-tailored exercise programs emphasising hip, gluteal, and hip flexor strength. A surgical approach to release the iliopsoas tendons is also possible, although it can lead to muscle weakness and should only be considered if no significant improvements are seen within three months of starting a comprehensive exercised based rehabilitation plan.
Inguinal-Related Groin Pain (Purple):
The inguinal ligament hosts various nerves, blood vessels, and muscle tendons. An injury in this area can lead to pain, especially when the abdominal muscles are engaged, or pressure is applied along the ligament.
Signs & Symptoms: Inguinal-related injuries often cause pain toward the end of an activity, which occurs earlier as the injury worsens. The pain can be bilateral and is often exacerbated by increased intra-abdominal pressure (aggravated with abdominal resistance or Valsalva/cough/sneeze). Athletes will experience pain in the inguinal canal region and tenderness of the inguinal canal. No palpable inguinal hernia is present (this should be considered, but not within the inguinal-related groin pain).
Management: Treatment options are both surgical and non-surgical, with the latter including specific exercises to strengthen the weak areas, potentially combined with injections based on the individual presentation. A surgical option like laparoscopic hernia surgery can be considered if non-surgical treatments fail, but potential complications should be considered.
Pubic-Related Groin Pain (Yellow):
The pubic symphysis is where the two pelvic bones meet at the front of the pelvis. Its a cartilaginous joint that allows small amounts of movement between the pelvic bones and absorbs force while walking.
Signs & Symptoms: Local tenderness of the pubic symphysis and the immediately adjacent bone. When injured, this joint can be extremely painful to touch, which is the primary diagnostic indication.
Management: Treatment often involves modifying actions that put a load on the pubic symphysis, uniquely tailored to each patient and their specific activities. As pubic-related pain can mimic adductor-related pain, a supervised active rehabilitation program that monitors adductor, abdominal, and gluteal loads is commonly used.
A note on the hip joint
Pain from the hip joint should always be considered a possible cause of groin pain. Understanding the onset, nature and location of the pain and mechanical symptoms such as catching, locking, clicking or giving way can indicate the presence of hip pathology which may be the cause of, or coexist with, groin pain.
What are the other possible causes of groin pain?
A thorough history and comprehensive physical examination that goes beyond just the musculoskeletal system. The Doha agreement highlights some other possible causes of groin pain not to be missed in jiu-jitsu athletes, especially when symptoms do not fit neatly into one of the commonly defined clinical categories (table 1).
What's the take-home message?
Groin pain is a frequent issue that Jiu-Jitsu athletes face due to the rigorous physical demands of their sport.
Understanding the four main categories of groin injuries - adductor-related, iliopsoas-related, inguinal-related, and pubic-related - can provide a significant advantage in effectively managing this pain.
Each category has unique characteristics, signs, symptoms, and treatment options, allowing for more personalised and effective pain management strategies.
Active rehabilitation, focused strength training, and careful monitoring of movements that exacerbate the pain are key treatment options.
Need help with your groin pain? Contact Tim or consider a telehealth consultation to discuss your recovery.
References and Further Reading
Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, Lovell G, Meyers WC, Muschaweck U, Orchard J, Paajanen H, Philippon M, Reboul G, Robinson P, Schache AG, Schilders E, Serner A, Silvers H, Thorborg K, Tyler T, Verrall G, de Vos RJ, Vuckovic Z, Hölmich P. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015 Jun;49(12):768-74. doi: 10.1136/bjsports-2015-094869. PMID: 26031643; PMCID: PMC4484366.