GROIN & HIP PAIN ASSESSMENT GUIDELINE

Start with where the pain is

Groin and hip pain can arise from several different structures, and similar symptoms may have very different causes. A useful first step is to classify the pain by location:

Anterior hip or groin pain is more suggestive of hip-related pathology. Possible causes include hip flexor injury, iliopsoas-related pain, labral pathology, femoroacetabular impingement, osteoarthritis or stress fracture.

Lateral hip pain may involve structures around the greater trochanter, including the gluteal tendons, while neurological presentations such as meralgia paraesthetica should also remain on the differential.

Posterior hip pain increases the likelihood of a lumbar spine, sacroiliac joint or posterior muscular source rather than the hip joint itself.

Location does not provide the diagnosis, but it helps organise the clinical reasoning process before individual structures are tested.

Age, activity and sport change the differential

The same groin pain means something different in a 15-year-old footballer, a 25-year-old runner and a 65-year-old adult.

In adolescents, conditions such as apophysitis, avulsion injuries and slipped capital femoral epiphysis need to be considered.

In young adults, femoroacetabular impingement and labral pathology become more relevant, particularly in sports requiring repeated hip flexion, rotation and cutting.

In older adults, the likelihood of osteoarthritis, femoral neck fracture and avascular necrosis increases.

Sport also provides useful clues. Kicking and twisting sports expose the hip and groin to repeated rotational stress, while endurance activities can increase the risk of stress fractures and other overload presentations.

A recent increase in training volume or intensity should always raise suspicion for an overload-related problem regardless of the sport.

Screen red flags before treating it as a routine sports injury

Not all groin pain is musculoskeletal.

Stress fracture, infection, inflammatory disease, avascular necrosis, tumours and intra-abdominal or gynaecological conditions can all present with pain in the hip or groin region.

Important warning signs include:

• persistent night or resting pain

• unexplained weight change

• fever or systemic symptoms

• history of cancer

• significant trauma

• corticosteroid use or heavy alcohol exposure

• inability to weight-bear

• symptoms inconsistent with a typical mechanical presentation

Mechanical symptoms such as locking, catching or giving way may also increase suspicion of intra-articular pathology such as a labral injury.

The purpose of screening is not to diagnose every medical condition in the clinic, but to recognise when the presentation no longer fits routine musculoskeletal rehabilitation and further investigation is required.

Use a structured groin examination

The Doha agreement provides a useful framework for classifying athletic groin pain according to the structures reproducing the patient's symptoms.

Common clinical entities include:

Adductor-related groin pain
Symptoms are reproduced around the adductor origin or muscle, usually alongside pain with resisted adduction.

Iliopsoas-related groin pain
Pain is located more anteriorly and may be associated with hip-flexor loading or stretching.

Inguinal-related groin pain
Symptoms are reproduced around the inguinal canal without a clearly identifiable hernia.

Pubic-related groin pain
Tenderness is centred around the pubic symphysis and adjacent structures.

Palpation should therefore be systematic rather than simply targeting the area the patient identifies as painful.

Strength testing is also valuable, particularly when performed objectively with a dynamometer. Comparing hip adduction and abduction strength between sides can help identify meaningful deficits, although sport-specific differences should be considered rather than applying the same strength ratio to every athlete.

No single special test gives the diagnosis

Hip special tests are useful, but their limitations matter.

The FADDIR test is relatively sensitive but poorly specific. A negative result may therefore help reduce suspicion of intra-articular pathology, while a positive result does not tell us exactly what structure is responsible.

The FABER test is better viewed as a general provocation and range-of-motion test rather than a standalone diagnostic tool.

For adductor-related symptoms, the Copenhagen five-second squeeze test can provide useful information when interpreted alongside palpation, history and strength testing.

The key principle is that special tests should contribute to a clinical pattern rather than replace clinical reasoning.

Is the pain actually coming from the hip?

One of the most important parts of assessment is distinguishing hip pathology from the lumbar spine or sacroiliac joint.

Hip internal rotation can be particularly informative. Restricted and painful internal rotation increases suspicion of hip-related pathology such as osteoarthritis or labral involvement.

Lumbar testing may include the straight-leg raise, slump and toe-touch tests, while clusters of sacroiliac provocation tests are more useful than relying on an isolated SIJ test.

Again, the pattern matters more than any single result.

Consider the patient's anatomy before trying to “correct” mobility

Not every rotational difference is caused by muscle tightness.

Differences in femoral version can significantly influence hip internal and external rotation. Some people naturally have greater internal rotation, while others have greater external rotation because of their bony anatomy.

Before aggressively trying to increase a supposedly restricted movement, the clinician should consider whether the difference represents modifiable soft-tissue restriction or simply the individual's structure.

Rehabilitation should adapt to the patient's morphology rather than forcing every hip toward the same theoretical range of motion.

Greater trochanteric pain: loading is not the whole story

For greater trochanteric pain syndrome, education and load management can themselves produce meaningful improvement.

Targeted gluteal strengthening may provide additional benefit for some patients, but the response is not universal.

This reinforces a broader rehabilitation principle: exercise should be prescribed because it addresses an identified problem, not simply because a structure is painful.

Rehabilitation can be a genuine alternative to surgery

In athletic groin pain, surgery is not automatically the faster route back to sport.

The guide highlights evidence showing broadly similar return-to-play rates between surgical and rehabilitation approaches. For pubic-related groin pain, rehabilitation was associated with a substantially faster return to play in the reviewed evidence.

This supports providing an adequately dosed rehabilitation programme before moving toward surgery in appropriate cases.

Build the diagnosis from the whole picture

Groin and hip pain should rarely be diagnosed from one painful structure or one positive test.

A stronger process is:

location → patient factors → red flags → palpation → range of motion → strength → special tests → functional testing.

The aim is not simply to identify where it hurts, but to determine which clinical pattern best explains the symptoms, whether the hip is truly the primary source, and whether the patient can safely progress into rehabilitation.

That structured reasoning is what turns a collection of tests into a meaningful clinical assessment.