Three common sources of groin pain around the hip

Groin pain near the hip has three main origins — adductor tendons, the hip flexor (iliopsoas) group, and the hip joint itself — and which one applies changes everything about management. Misattributing the source is common: soft-tissue problems are sometimes managed as joint disease, while a progressive condition such as femoroacetabular impingement (FAI) or early osteoarthritis is overlooked beneath a label of 'groin strain'.

The Doha Consensus Agreement, the internationally accepted clinical framework for groin pain, defines five distinct non-red-flag entities. Three of them overlap most frequently in hip practice and are the focus here: adductor-related pain, hip flexor-related pain, and hip-related (intra-articular) pain. Each arises from a different anatomical structure, is provoked by different movements, and follows a different treatment pathway — from guided tendon injection for adductor or psoas pathology through to hip-specific assessment and management when the joint itself is the source.

Crucially, a scan showing a structural finding does not on its own confirm a diagnosis. The Warwick Agreement is explicit: symptoms, clinical signs, and imaging must all point in the same direction before a hip joint diagnosis such as FAI syndrome can be made. Examination is where these three sources are first separated.

Adductor-related groin pain and how it behaves

The adductor muscles occupy the medial (inner) compartment of the thigh, with adductor longus — the most frequently strained of the group — attaching at the pubic bone. Pain arising from this region tends to localise at the inner thigh or the pubic attachment itself, and is typically provoked by activities that load the adductors: kicking, sprinting, pivoting, or any sharp change of direction. Adductor-related pain is the most common groin pain entity in athletes, but the same pattern occurs in any active adult whose hip and groin are under repetitive or unaccustomed load.

The primary clinical test is the adductor squeeze test, in which the examiner resists the patient's attempt to push their knees together. In a study of 150 male recreational runners with groin pain, the test provoked symptoms in 94.7% of those with adductor pathology — making it a reliable first-line screen. Side-to-side adduction strength asymmetry is an equally consistent finding: data from the FORCe cohort (190 football players with hip and groin symptoms lasting more than six months) confirmed that hip adduction strength deficit was the most reproducible marker across both sexes and sport codes, and directly informs the structure of rehabilitation.

Adductor-related pain does not always arrive in isolation. It frequently coexists with osteitis pubis (bone stress at the pubic symphysis) and sometimes with underlying FAI, where abnormal hip joint morphology may increase load on the medial tendons. When these overlap, addressing the adductor in isolation often leaves the clinical picture unresolved.

That interplay with the broader kinetic chain also helps explain high recurrence rates. A 2025 biomechanics study in male soccer players with a history of adductor groin pain found impaired trunk-pelvis rotation and altered stance-leg loading — a motor-control deficit across the whole chain — rather than localised muscle weakness alone. Rehabilitation programmes that focus only on rest and adductor isolation may therefore miss the underlying driver in cases that keep returning.

Hip flexor pain and the iliopsoas pattern

Unlike the inner-thigh ache of adductor pathology, hip flexor pain sits at the front of the groin — deep, sometimes pressing into the upper thigh — and is driven by the iliopsoas tendon rather than the medial muscle group. The distinction in location alone is a useful first filter.

The provoking movements are also different. Pain typically surfaces when rising from a chair, climbing stairs, running at pace or uphill, or during resisted hip flexion — activities that load the iliopsoas through its arc of movement. A hallmark feature is the snapping hip: a click or thud felt (and often heard) at the front of the hip, caused by the iliopsoas tendon flicking over a bony prominence as the leg moves. Not every patient has a name for it, but most recognise the description immediately. This snapping is absent in both adductor and true intra-articular problems, which gives it real diagnostic value.

The hip joint itself can contribute to iliopsoas irritation. Cam or pincer morphology — bony abnormalities at the femoral head or socket — can alter the mechanics of the psoas tendon as it passes close to the joint capsule, generating anterior groin pain that overlaps with joint-origin symptoms. When the snapping pattern coexists with deep, activity-related groin pain that does not fully resolve, a full hip assessment is warranted to determine whether underlying joint morphology is a factor. Guided injection into the tendon sheath is one management option when conservative measures stall, but identifying whether the joint is driving the picture comes first.

When deep hip joint pain is the real source

True intra-articular hip pain occupies the same anterior groin territory as iliopsoas discomfort, but the two are separated by what provokes them. Joint-origin pain — from FAI syndrome, a labral tear, or early osteoarthritis — tends to surface during prolonged sitting, rising from a low chair, getting in and out of a car, or the first few minutes of activity after rest. Sport-specific loading can aggravate it too, but it is the everyday postural triggers that most patients notice first.

The structural causes fall into three overlapping groups. FAI syndrome arises from bony abnormalities at the hip joint: cam morphology places an excess of bone at the femoral head-neck junction; pincer morphology occurs when the acetabular socket provides too much coverage. Either variant causes abnormal contact between bone surfaces during hip movement, loading the labrum and underlying cartilage. Labral tears frequently accompany FAI but can also occur independently; early osteoarthritis represents a later stage of the same deteriorative process. Evidence from a widely cited review links untreated FAI to accelerated cartilage loss and a measurable increase in the likelihood of developing hip osteoarthritis — which is why assessment and appropriate management matter beyond symptom control alone.

Mechanical sensations — a click, catch, or locking sensation felt deep within the joint — point toward a labral or intra-articular source and are not a feature of adductor or iliopsoas problems.

On examination, the FADIR test (the clinician passively moves the hip into flexion, adduction, and internal rotation together) reproduces the characteristic deep pinching pain when a joint source is present. However, a positive test supports the diagnosis; it does not confirm it. The Warwick Agreement is clear on this point: an MRI showing cam morphology, or a positive FADIR, is not sufficient on its own. A diagnosis of FAI syndrome requires symptoms, examination signs, and imaging findings together — a threshold that prevents over-treatment of incidental structural variants that may not be driving any symptoms at all.

How clinicians separate these causes in practice

The diagnostic process begins with a structured clinical history, because what provokes symptoms — not just where they sit — narrows the differential before a hand is laid on the patient. Onset pattern, aggravating movements, and whether mechanical sensations such as clicking or catching are present all guide the clinician toward the most likely source. When symptoms have persisted beyond six to eight weeks without improvement, a formal specialist assessment becomes the appropriate next step rather than continued self-management.

Examination follows a category-based logic. The adductor squeeze test targets medial compartment pathology; resisted hip flexion and the Modified Thomas Test load the iliopsoas complex; and the FADIR manoeuvre challenges the intra-articular space. Each test is interpreted in context — none stands alone as a definitive verdict. The Doha Consensus Agreement formalises this approach, classifying non-red-flag groin pain into five distinct clinical entities (adductor-related, pubic-related, hip flexor-related, inguinal-related, and hip-related), precisely because conflating them produces the wrong pathway.

What makes this assessment genuinely difficult is overlap. Osteitis pubis, adductor tendinopathy, and Gilmore's groin each produce tenderness around the pubic symphysis and can be clinically indistinguishable at first encounter. Cam or pincer morphology at the hip joint may simultaneously overload the adductor tendon or psoas tendon, meaning a bony structural issue drives soft-tissue pain. A patient may have more than one active source.

Imaging plays a supporting rather than leading role: plain X-ray identifies cam or pincer morphology and provides an overview of joint space; MRI or diagnostic ultrasound visualises the labrum, articular cartilage, and tendons. As the Warwick Agreement makes clear, an abnormal scan finding without corresponding clinical signs does not confirm a diagnosis — imaging is one input, not a verdict.

Where uncertainty remains after history, examination, and imaging, a diagnostic injection — local anaesthetic or corticosteroid placed precisely into the suspected structure — can confirm whether that structure is the dominant pain source by temporarily suppressing symptoms from it alone.

Treatment pathways once the cause is confirmed

Once the dominant source is confirmed, management pathways diverge by diagnosis.

Adductor-related pain leads with structured physiotherapy, though research in football players shows rehabilitation must address trunk-pelvis rotation and stance-leg loading — not adductor strength in isolation — to reduce recurrence. Where conservative care plateaus, ultrasound-guided injection into the adductor tendon sheath, or corticosteroid or PRP at the pubic symphysis for concurrent osteitis pubis, serves both a diagnostic and therapeutic role.

Hip flexor pain also begins with load modification. Reloading progresses from low-load seated hip flexion exercises through to resisted straight-leg raise and, eventually, dynamic activities such as stair-climbing and running. Where the psoas tendon remains symptomatic despite this graduated approach, an ultrasound-guided tendon sheath injection can settle inflammation and restore loading tolerance; in refractory cases, surgical tendon release may be warranted.

Intra-articular hip pathology follows a different branch. Earlier-stage FAI, labral pathology, or mild osteoarthritis is typically managed with physiotherapy and, where indicated, intra-articular injection — Arthrosamid or PRP — to reduce pain and support function. When joint damage is advanced and conservative measures are exhausted, hip replacement becomes the appropriate pathway.

Lincolnshire Hip accepts patients without referral for hip assessment at clinics in Grantham and Sleaford — a practical starting point when symptoms have persisted without a confirmed source.

One caveat applies across all three: if cam or pincer morphology is identified as the upstream driver of recurrent adductor or psoas loading, treating the soft tissue in isolation will not resolve the problem. Hip-specific assessment of the joint morphology is then warranted before further soft-tissue management is pursued.

1. [1] Femoroacetabular Impingement and Osteoarthritis of the Hip – PMC. (2015). https://pmc.ncbi.nlm.nih.gov/articles/PMC4677941/ https://pmc.ncbi.nlm.nih.gov/articles/PMC4677941/
2. [2] Effects of TECAR therapy on pain, ROM, strength and HAGOS in athletes with chronic adductor-related groin pain (RCT). (2025). https://doi.org/10.1186/s12891-025-08304-9 https://doi.org/10.1186/s12891-025-08304-9
3. [3] Prevalence of Adductor Muscle Strength and Hip Joint Mobility on Groin Pain in Male Sports Runners. (2025). https://doi.org/10.61919/j15dmm58 https://doi.org/10.61919/j15dmm58
4. [4] Association between hip/groin pain and hip strength in football players – FORCe cohort. (2023). https://doi.org/10.1016/j.jsams.2023.07.008 https://doi.org/10.1016/j.jsams.2023.07.008
5. [5] Effects of a History of Adductor-Related Groin Pain on Kicking Biomechanics and HAGOS Subscales in Male Soccer Players. (2025). https://doi.org/10.3390/app152212003 https://doi.org/10.3390/app152212003