The 5 steps for treating groin injuries in runners
- Maryke Louw
- Jul 17
- 14 min read
Updated: 3 hours ago
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.
In this article:
I've also made a video about this:
Step 1: What is causing your groin pain?
The groin is a very "busy" area, with lots of bones, ligaments, muscles, tendons, and nerves either attaching there or crossing over it, and any of these can be the cause of your pain. And each of these requires a slightly different treatment approach.
So the important first step in treating your groin injury is figuring out:
what structure is injured
and what factors combined to cause this injury in your case.
Now, I am immediately forced to contradict myself 🫣 The points listed above are what would happen in an ideal scenario, but because the groin is such a "busy" anatomical area, getting a very clear diagnosis is not always possible – sometimes the scans don't really indicate clear problems, or the tests don't really match a specific diagnosis.
If this happens to you, don't worry – this is quite common when it comes to groin injuries. The important thing is to then just rule out serious issues (like stress fractures or cancer), which is easily done via an MRI scan.
💡 If that comes back clear, then you focus on implementing Steps 2 to 5, strengthening the areas that your physio identified through your movement tests and use your symptoms to guide the progress of your rehab. I'll explain this in more detail later in this article.
Some of the most common causes of groin pain in runners are:
hip joint injuries, including labral tears (tears in the ring of cartilage that lines the hip socket) and osteoarthritis.
But you can also experience referred pain in your groin that comes from your lower back, organs, or nerves.
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:
determine what is injured and the likely cause in your specific case (this varies from person to person) by listening to how your injury developed, analysing your training schedule, and getting you to perform test movements – this is a standard part of our assessment during our video consultations
provide you with a treatment plan that addresses all the aspects, including how you should adjust your training, cross-training options, and what you need to do to strengthen your body while allowing your injury to recover.
Adductor-related groin pain
Adductor injuries are reported as the most common cause of groin pain in athletes.
Adductor tendinopathy, or tendonitis as it's sometimes called, is an overuse injury which most commonly affects the adductor longus tendon where it attaches to the pubic bone – which is also the area where you tend to feel the majority of the pain. The pain typically develops gradually over time and can spread to adjacent areas or the other leg if it's been present for a long time.
If your injury came on with a sudden, sharp pain, it's more likely that you've torn your adductor tendons or muscles.
Both adductor tears and tendinopathy can cause uncomfortable tightness or pain in the adductor muscles as they run down towards the inner knee.
With adductor tendinopathy, runners often find that they are able to "run it off", but that it hurts again after the run. As the injury gets worse, it might prevent them from running altogether. Adductor tears don't tend to have this warming-up effect – they tend to become more painful as your run progresses.
Research on elite ice hockey players found that players had a 17 times higher risk of suffering an adductor injury if their adductor strength was 80% or less than that of their abductors (outer hip/glute muscles). And research on soccer and Gaelic football players seems to support the suspicion that a mismatch in muscle strength might contribute.
Specific risk factors in runners have not yet been identified.
Hip flexor injuries
You have several muscles that help to flex (bend) your hip up, but the iliopsoas tendons are the ones most commonly affected when you have hip flexor tendinopathy. Strains or tears of the hip flexor muscles and tendons are not very common but can happen, and usually produce a sharp, sudden pain when they happen.
The iliopsoas is made up of two muscles – the iliacus, which attaches to the inside of the pelvis, and the psoas, which attaches to the vertebrae (the bones in your lower back). These muscles then run down and come together, with their lower tendons attaching to the inner front border of the femur (thigh bone).
The main pain from iliopsoas tendinopathy is felt more towards the front of the groin (compared to the adductors) and upper thigh. However, because the muscles attach to the inside back of the pelvis and lower back, you can also develop sacrum and lower back pain – long periods of sitting often also bring on the pain.
It's quite common to develop a snapping or clicking in the front of the groin (often loud enough to hear) when you have iliopsoas tendinopathy. When the tendons are injured, they cause the muscles to tighten up or brace, which then causes the tendons to pull tight and catch on the hip bone as you move your hip.
The snapping usually improves when you start some gentle strength training, focusing on the slow eccentric lengthening of the muscles. Active hip flexor stretches can sometimes also help, but it can flare your pain up if you're too aggressive with it.
It is currently thought that lumbo-pelvic stability (how your lower back and pelvis moves in relation to your legs) likely plays an important role in why iliopsoas tendinopathy develops. Research into the exact cause and treatment of this injury is basically non-existent.
Rectus abdominis tendinopathy
This overuse injury affects the tendons that attach the rectus abdominis muscles to the top edge of the pubic bones, in the area of the pubic symphysis (the joint at the front where your two pubic bones meet). The pain is usually felt in the lower abdominal area but often also refers into the inner groin and thigh.
Abdominal tendinopathy has been paid very little attention in the research, so we don't really know what the risk factors are for getting this, but it's thought that a mismatch of strength between the adductor muscles (that pull on the bottom of the pubic bones) and the rectus abdominis (that pulls on the top) might contribute.
The position of your pelvis (how it is tilted and moves) affects the length of the rectus abdominis and therefore its ability to create effective muscle contraction, which might mean that having poor core and lumbo-pelvic control may also play a role in runners.
Osteitis pubis
Osteitis pubis is an injury that actually consists of a combination of injuries. MRI scans usually show:
bone oedema (swelling in the bone) close to the pubic symphysis (where your pubic bones meet at the front);
the joint itself shows signs of wear,
and the abdominal tendons (abdominal tendinopathy or tears)
as well as adductor tendons (adductor tendinopathy or tears) are often also affected.
This injury usually develops gradually over several weeks or months, typically in a runner who has been ignoring their groin pain and trying to train through it.
Anatomy studies are currently having a bit of a disagreement about whether there's a direct fascia connection between the adductor tendons and your abdominal muscles. Regardless of whether there is or not, one thing is certain – athletes frequently have a combination of injuries affecting their adductor tendons and abdominal tendons both.
This is likely because they attach on opposite ends (top vs. bottom) of the pubic symphysis, pulling in opposite directions, working together to stabilise this area. This means that injury in one area might eventually lead to overload and injury in adjacent areas if it is left untreated.
Hip impingement (femoroacetabular impingement syndrome, or FAIS)
The main pain from hip impingement is felt deep in the front of the groin, but it can refer towards the outer hip and also a bit down the thigh.
Lifting your knee up towards your chest (hip flexion) and crossing it over the midline usually causes a painful pinch on the affected hip, and these movements can be quite limited.
Your hip joint is a ball-and-socket joint – the ball being formed by the head of the femur, and the socket being an indentation in your pelvis called the acetabulum. FAIS develops when you have extra bone growth in the neck of your femur (known as a cam morphology) or on the rim of the acetabulum (pincer morphology), which causes the femur to bump into the edge of the acetabulum as you lift your leg forward.
Research has shown that this extra bone growth develops during the growing years in children who do high volumes of sports that involve strong twisting and turning movements, e.g. soccer and ice hockey – one reason why overloading a child's sporting schedule is not a good idea.
💡 Having these bony changes, doesn't mean that you'll definitely get hip pain – it just increases the likelihood.
Having good muscle strength around the pelvis can help. If the muscles around your hips and pelvis aren't strong enough, and you're getting excessive pelvic tilt while running, it can increase the likelihood of the bones bumping into one another when you have a cam or pincer morphology.
Hip joint injuries
I'm lumping injuries that affect the hip joint under one heading because their symptoms can feel very similar, and you do really need scans to distinguish between them.
When the hip joint is the culprit, the main pain is usually felt over the front of the groin or outer hip in a C-shaped area. The most restricted and painful movements (compared to your other hip) are usually trying to turn your hip in while simultaneously bending it up.
People often assume that they will need surgery if they hear they have an injury like a labrum tear, but in a recent research review that included 29 studies with a total of 2573 participants and 4410 hips reported that over 50% of people who don't have any pain in their hips walk around with torn labrums. This means that, while a labrum tear might cause some pain when it first happens, it can calm down and your hip can regained it's full pain-free function despite the tear still being present.
Bone stress reactions and stress fractures
Stress fractures in the neck or shaft of the femur and the pubic bones can also cause groin pain. This is usually not the type of pain that improves during exercise – it tends to become more painful, and there might also be pain at night.
The physio or doctor you consult might pick up from your history and symptoms that there is a risk that this is a stress fracture causing your pain, but sometimes the pain mimics other injuries. So, if your groin pain has been going on for several weeks and is not improving or even getting worse despite applying the correct treatment, it might be worth getting an MRI scan to rule out any bone stress injuries.
X-rays are not really useful in this case, because they don't tend to show recent stress fractures – you really do need an MRI scan to see them.
Step 2: Relative rest
Yes, your injury will likely require a bit of rest to recover, BUT you don't always have to rest it completely. Research has shown that for most injuries (stress fractures being one exception), it actually helps recovery when a person continues all exercise that does not significantly trigger their pain or other symptoms.
To figure out what you can do, you need to:
know what type of injury you have, because this determines how much discomfort is OK
know what your baseline discomfort is day-to-day if you don't exercise or work that area
observe what you feel while doing the activity, plus how your symptoms react in the 24 hours afterwards.
💡 If you've not been able to get a clear diagnosis despite having a thorough assessment and scans – so all serious injuries have been ruled out – then treating it according to how your symptoms react in a similar way to tendinopathy pain usually works well.
The level of discomfort that is OK during and in the 24 hours after an activity will depend on the type of injury you have:
Tendinopathy or tendonitis: An activity is usually pitched at the right level if it does not increase your symptoms significantly above your baseline during and in the 24 hours after. In other words, it's OK to be a bit more aware of the area, but it should not be a significant increase. You can find more detailed advice on how to judge this for different tendons in the links below.
The same advice applies to joint injuries: If you choose the correct activity level, you will find that your baseline pain and stiffness actually improves while you're doing it and then remains better for several hours or days after.
Muscle strains or tears: You really don't want to feel anything you would class as discomfort or pain during exercise or afterwards (normal sensations of movement, or feeling the muscle working, are fine).
The same goes for stress fractures: You should not be feeling any pain or discomfort in the area of the injury during or after an activity. With stress fractures, your aim should be to get your baseline to zero pain and no increase above that when you do things.
Your physio can help you figure out what exercises and cardio workouts you can continue or try out that will keep you within these safe limits. This is why we tend to spend quite a lot of time during our video calls getting to grips with what exact symptoms our patients experience during various activities and how it affects their symptoms the following day – this information is crucial for ensuring the rehab plan is pitched at the right level.
We also teach our patients how to decide for themselves what is good vs. what should be adjusted or avoided, because circumstances can change quite quickly depending on what else life throws at you.
Relative rest can be a very effective way to maintain your fitness and sanity while actually strengthening your injury!
Step 3: Build strength and control
All types of groin (and hip) injuries usually benefit from:
making sure the muscles on all sides of the pelvis and hips are strong
good core strength
good lumbo-pelvic control – the ability to keep your lower back and pelvis stable while moving your legs
exercises that develop good leg control and balance – this helps to optimise your movement patterns for running
adequate flexibility in all directions – you don't have to be super flexible, but it can cause trouble if your legs can't move far enough in certain directions.
💡 What's important is that the exercises you start with must match your injury's current capacity (strength and endurance). If they are too advanced or strong, it will just cause more irritation and increase your pain. And every person's injury is usually a bit different in terms of its tolerance or capacity.
Certain injuries, like tendinopathies, don't like it when you stretch the injured area during the early days of recovery – avoiding the urge to stretch your tight adductors can help them to recover more quickly, for example.
Your physio will also fine-tune the rehab plan depending on the specific injury you have or any specific weaknesses they identified when they tested your movement, e.g. adding in more targeted, eccentric-focused adductor exercises if you have adductor tendinopathy, for example.
So, although the ultimate goal of the rehab plans for all types of groin injuries is similar, how you reach that goal, the types of exercise you do, and at what point you start them will vary depending on the structure that is injured, your injury's specific tolerance, and how your body responds to the exercises.
Step 4: Progress your rehab plan to match your goal
We're often consulted by runners who have completed a rehab plan but then found that their groin pain returned as soon as they started running again. Often, when we check their rehab and what they've been doing, we find that they did build some strength and control, but not really enough to meet the demands of running.
💡 And it's not always just about lifting heavy weights – it is also about how long you've been doing it for. It takes at least 12 weeks of consistent strength training to see proper gains – this period will be shorter or longer depending on your starting strength and tolerance.
If you have a tendon injury or osteitis pubis that has dragged on for several months before starting rehab, it usually takes at least six months but sometimes even nine or more to get back to normal running volumes.
You must tick all three of these boxes to be ready to ease into running:
tolerate heavy strength training (the amount of weight will depend on factors like the area that is injured and your size – your physio will set you appropriate targets)
have good movement control
have a minimum level of flexibility in all directions.
Step 5: Gradual return to running
This is another thing that runners often get wrong, so please be careful when you go back to running. Your first few runs should ideally be run-walks, where you alternate short periods of running and walking.
💡 Five miles might sound like nothing to you if you're used to averaging 40 or 50 miles a week, but injuries often take a few weeks to build up to having the tolerance for continuous running.
A run-walk session has two benefits:
If you do aggravate your injury, you usually just annoy it rather than making it properly angry, which means that can settle down again within a few days. If, on the other hand, you've gone and done a full-on run, you might end up flaring it up for a week or more.
A run-walk session is a great way to gain the last bit of strength your legs that only running can provide, and most of our patients find that they can progress to a continuous 20-minute run within two or three weeks of starting to run-walk.
👉 How quickly you can progress your run-walk and how conservative you have to be will depend on your unique situation – here's an example of a very conservative run-walk plan that works well for injuries that flare up easily.
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 help with an 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 20 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
