The 5 steps to treating groin injuries in runners

Your groin is a bit like King's Cross station in London, with several different structures crossing and attaching in that area. In this article we’ll discuss the most common causes of groin pain in runners and running sports and give you some tips on how to get it better. Remember, if you need more help with an injury, you're welcome to consult our team of sports physios online via video call.

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In this article:

• What structures can cause groin pain?

• The 5 steps to treating groin injuries

• How we can help

Here's a recorded video of a livestream that Maryke did on this topic:

What structures can cause groin pain?

The groin area is a very “busy” area, with lots of bones, ligaments, muscles, tendons, and nerves either attaching there or crossing over it, and any of them can be the cause of your pain. This article focuses on only the most common causes of groin pain that we see in runners/running sports.

1. Hip joint impingement (Femoroacetabular impingement)

When we run and walk, our legs are meant to move in pretty much a straight line. In some people their hips may turn in too much when they run, causing the bones in the groin to press against each other. If this happens, often it can cause inflammation and pain deep in the groin. This type of injury usually causes a gradual build-up of pain over several days or weeks.

The shape of your hip bone and socket may also predispose you to getting this injury, but don't worry about this too much. If you've been able to run pain free in the past, you should be able to get back to pain free running regardless of the shape of your bones as long as you follow the correct rehab plan.

How to fix it: The main cause of this is usually a lack of good muscle strength and pelvic stability, which can easily be fixed by following a rehab programme that focuses on strength and control in progressively more challenging positions.

2. Muscle strains/tears

A strain or tear in any of the muscles that attach around the groin area can cause pain there. The most common ones are the hip flexors (iliopsoas, rectus femoris), adductor muscles and abdominal muscles (rectus abdominus).

You can usually tell that you’ve torn or strained something if the pain comes on very suddenly and is quite sharp. But ligament strains can feel very similar and there are specific tests that physios can help you perform to distinguish between muscle strains and ligament strains.

How to fix this: Muscle strains recover relatively quickly, but they have a tendency to recur if you don't strengthen the injured area properly before you go back to running or sport. So make sure that you progress your strength training to include heavier loads before you ease back into activity.

3. Gilmore’s groin / Sportsman’s hernia

Gilmore’s groin or Sportsman’s hernia causes pain deep in the groin area. It can start suddenly or develop slowly over time, and it usually affects people who play sports that involve a lot of twisting movements, e.g. football. It's not that common in runners.

It’s not a true hernia, and you don’t get a bulge like you would with a normal hernia. They’re not really sure about what exactly causes the pain, but most athletes with this condition seem to have a tear in some of the ligaments and tendons deep inside the inguinal area.

How to fix this: The first line of treatment for Gilmore’s groin is to follow a carefully graded strengthening programme for at least 12 to 24 weeks. If this isn’t successful, you may benefit from surgery to fix or trim the ligaments or tendons that are causing the problem.

4. Adductor tendinopathy

Adductor tendinopathy, or tendonitis. as it’s sometimes called, is a very common cause of groin pain in runners. This condition affects the adductor tendons close to where they attach onto your pubic bone and can be very painful. Watch the video below if you would like a detailed explanation of the treatment for adductor tendinopathy.

The pain can come on gradually over a period of days/weeks or during a run. Sometimes, you may only feel the pain the day after a hard training session. Initially, runners find that they may be able to “run it off”, but that it then hurts again after the run. As the injury gets worse, it may stop them from running altogether.

You can develop adductor tendinopathy or tendinitis for several reasons, but the main ones we see in our online clinic include if your hip/pelvic stability is poor or if you push your training too much, not allowing enough recovery time or suddenly do a lot of downhill running.

How to fix this: The best treatment for adductor tendinopathy is a combination of relative rest and strength training. We've shared some tips on exercises for adductor tendinopathy here.

5. Osteitis pubis

Osteitis pubis is another type of over-use injury in the groin. It’s caused by a lack of stability in the core, pelvis, and hip muscles, which causes the tendons and even the pubic bone to take too much strain. This injury usually develops gradually over several weeks or months and typically in a runner who has been ignoring their groin pain and has been trying to train through it.

MRI scans usually show bone oedema (swelling in the bone) over the pubic area, and the abdominal (abdominal tendinopathy or tears) and adductor tendons (adductor tendinopathy or tears) are often also affected.

How to fix this: Just like with adductor tendinopathy, it's a combination of relative rest and slow progressive strength training that will restore your strength and get you back to running. However, you have to be careful with which exercises you choose to start with. To allow the pubic symphysis (the front of your pelvis) to recover, it's usually best to initially avoid any movements that cause rotation forces through the front of the pelvis.

The 5 steps to treating groin injuries

Step 1: Identify the cause of your pain

Getting your injury diagnosed and understanding what exactly caused the injury in the first place will stop you from wasting time on treatments and exercises that aren’t appropriate.

Unfortunately you cannot get an accurate diagnosis from Google but it is possible to get one via video call! A sports physio is a good person to consult about this, as they can:

1. Determine what is wrong by listening to how your injury developed, analysing your training schedule and getting you to perform certain test movements, all of which can easily be done via video call. We get all of our online patients to perform a full battery of tests in front of the camera to check their muscle strength and movement patterns. We often also get them to film themselves running on a treadmill so that we can play it back in slow motion and identify factors that could have contributed to their injury.

2. Provide you with a treatment plan that addresses all the aspects, including how you should adjust your training and what you need to do to strengthen your body and allow your injury to recover.

Step 2: Relative rest

Yes, your injury will likely require a bit of rest to recover BUT you don’t always have to use complete rest. We're firm believers in relative rest, which means that a person continues all exercise that does not trigger their pain.

For instance, if you can run 3 miles slowly without an increase in pain during or in the 24 hours after the run, then that is fine to do. But if it does cause your pain to increase, it may be a better option to run shorter distances or stick to cycling or swimming for a while.

There’s really no recipe for this. We tend to have a thorough discussion with our patients about when they feel pain and what happens with every type of exercise they do and then come up with a plan. This plan is also not cast in stone – we try and teach our patients how to decide for themselves what is good vs. what should be avoided.

Relative rest can be a very effective way to maintain your fitness and sanity while actually strengthening your injury!

Step 3: Build strength and flexibility

Some injuries, e.g. hip flexor strains, can be caused by not being flexible enough while others, e.g. adductor tendinopathy and osteitis pubis, are usually caused by a lack of muscle strength/control around the pelvis and trunk.

You can see how understanding your injury and its causes plays a key part in deciding what exercises you should do. That said, most groin injuries can usually benefit from improving core and glute strength.

The level of strength training that you start with is also important. Some injuries will allow you to immediately do heavy or strong core workouts while others will flare up if you’re not careful. The exercises that you choose to do should not cause any increase in your symptoms during or after doing them.

Step 4: Your exercises should be progressed over time

Your injury won’t get back to its full strength if you just do the same exercises all the time. Your strength training programme should be progressed over time as you recover and grow stronger.

We usually set our patients clear targets to hit so that they know when they’re ready to move on to the next step. For instance, if you can do single leg squats with extra weight and hop 20 times with good form and no pain, you may be ready to trial a short run/walk session.

Some options on Amazon for adding extra weight to your squats:

Step 5: Slow return to running

This is where most people get it wrong, so please be careful when you go back to running. Your first few runs should be run/walks where you alternate short periods of running and walking.

A run/walk session has two benefits:

1. If you do aggravate your injury, you usually just annoy it rather than properly making it angry, which means that it settles down again within a few days. If, on the other hand, you’ve gone and done a full-on run, you may end up flaring it up for a week or more.

2. A run/walk session is a great way to strengthen your legs, and most of our patients find that they can progress to a continuous 20 minute run within 2 or 3 weeks of starting to run/walk.

Of course, you have to make sure that you've built up to it by doing strength training and building your walking endurance.

How we can help

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate.

Research references:

1. Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon)

2. McAleer, S. S., et al. (2015). "Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy." Physical Therapy in Sport 16(3): 285-299.

3. Nakano, N., et al. (2017). "Current concepts in the diagnosis and management of extra-articular hip impingement syndromes." International Orthopaedics 41(7): 1321-1328.

4. Yousefzadeh, A., et al. (2018). "The Effect of Therapeutic Exercise on Long-Standing Adductor-Related Groin Pain in Athletes: Modified Hölmich Protocol." Rehabilitation research and practice 2018.