Hip Flexor Pain: What's Actually Being Overloaded

Hip Flexor Pain: What's Actually Being Overloaded

Hip flexor and groin strains are among the most common lower limb injuries in sport — and among the most mismanaged. The "groin" isn't a single structure; it's a region that includes the adductors, hip flexors (primarily iliopsoas and rectus femoris), the inguinal structures, and the pubic symphysis. Getting the treatment right requires knowing which tissue is actually involved.¹

Most groin pain in athletes involves the adductor longus, the iliopsoas, or sometimes both — often with contributions from the pubic region and the low back depending on how the load has been distributed. A thorough assessment distinguishes between these structures, because the rehab approach differs significantly between an acute adductor strain and a chronic iliopsoas tendinopathy.

Why the Groin Is Vulnerable

The hip is a powerful joint asked to transmit enormous forces during sprinting, kicking, cutting, and lateral movement. The muscles that cross it — particularly the adductors — work both as prime movers and as stabilizers, absorbing force eccentrically as well as generating it concentrically. When the workload spikes faster than the tissue is conditioned for, that's where strains happen.²

Sports with high rates of groin injury — ice hockey, soccer, Australian rules football — share a common feature: rapid direction changes and explosive hip loading, often with fatigued musculature late in training blocks or competitive seasons. The injury risk is highest when accumulated load is high and the tissue hasn't had adequate recovery.³

The Kinetic Chain Above and Below

Groin injuries rarely happen in isolation. Weakness or restricted mobility in the hip abductors and external rotators creates compensatory demand on the adductors during lateral movement. Limited hip extension — often related to hip flexor tightness or thoracolumbar stiffness — forces the low back and pelvis to work harder during running and kicking, increasing load at the pubic symphysis and proximal adductor attachment.

The lower abdominals are also part of this system. The transverse abdominis and internal oblique share fascial connections with the adductor longus at the pubic symphysis. When abdominal control is poor, the adductors are recruited to compensate for pelvic stability — a role they're not optimized for over repeated high-load movements.

Acute vs. Chronic: Different Problems, Different Plans

An acute adductor strain presents with immediate pain, often during a sudden acceleration or direction change. The tissue is disrupted, and the initial priority is managing load — not complete rest, but a reduction in provocative activity while the healing process begins. Early isometric loading is well tolerated and helps maintain tissue organization through the repair phase.

Chronic groin pain — the kind that's been grumbling for weeks or months — is a different picture. It usually represents a tendinopathy: the tissue has undergone degenerative changes in response to accumulated overload without sufficient recovery. Rest makes it feel better temporarily but doesn't rebuild the tissue's capacity. Progressive, targeted loading of the affected structure is the cornerstone of treatment.²

What Recovery Actually Looks Like

There are no bad exercises for the hip and groin — only too much too soon.³ Rehabilitation starts with identifying the specific structure involved, establishing a tolerable baseline of loading, and building systematically from there. For adductor pathology, this typically means isometric adduction holds → Copenhagen adduction exercise → sport-specific loading. For iliopsoas tendinopathy, it involves progressive hip flexion loading starting well below the provocative range.

Return to full sport should be criterion-based, not time-based. Hip adductor and abductor strength symmetry, pain-free provocative testing, and completion of a graded return-to-sport protocol are more reliable markers of readiness than calendar weeks.¹

Prevention is also addressable. The Copenhagen adductor exercise has been shown in large-scale trials to significantly reduce adductor injury rates in football players when included in preseason and in-season programs — a low-volume, high-return addition to any training program that involves lateral movement.⁴

At Boreal Spine & Sport, groin and hip flexor assessments include a full kinetic chain evaluation — examining hip mobility, abductor and abdominal function, pelvic control, and movement patterns — to identify the contributing factors and build a program that addresses the actual loading problem.

References

1. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768–774.
2. Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients. Br J Sports Med. 2007;41(4):247–252.
3. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–280.
4. Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players. Br J Sports Med. 2019;53(3):150–157.