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Adductor tendinopathy, Doha classification, Copenhagen loading and a clear return to play.

Groin pain is the athlete's classic riddle. A structured examination, honest imaging and progressive loading solve most of them.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against the Doha Agreement, BJSM consensus statements and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK sports medicine practice including Copenhagen adductor strengthening and staged return-to-play.

Key facts

Adductor tendinopathy at a glance.

The essentials, in plain English - what it is, how it is classified and how it is treated in the UK today.

  • What it is

    Overuse tendinopathy of the adductor group, most often adductor longus at its proximal enthesis on the pubic bone.

  • Doha classification

    Groin pain is grouped into adductor-related, iliopsoas-related, inguinal-related, pubic-related, hip-related and other causes.

  • Who gets it

    Common in football, ice hockey, running and hurdling - sports with cutting, kicking and repeated hip adduction.

  • Bedside test

    The adductor squeeze test at 0, 45 and 90 degrees of hip flexion is the workhorse screening manoeuvre.

  • Imaging

    Ultrasound for dynamic assessment and MRI for tendon grade, bone oedema and to rule out mimics.

  • First-line care

    Relative rest plus progressive loading with the Copenhagen adductor protocol - the best-evidenced conservative option.

Why this guide matters

A structured plan, not a guessing game.

Groin pain in athletes is often mislabelled. The Doha framework and a well-run rehab plan quietly do most of the work.

  • The Doha framework matters

    Naming the pain correctly - adductor, iliopsoas, inguinal, pubic, hip or other - sets the entire treatment plan.

  • Progressive loading beats rest

    The Copenhagen adductor programme has the strongest evidence. Passive rest alone rarely returns athletes to sport.

  • Surgery is a last option

    Adductor longus tenotomy or release helps a small number of chronic refractory cases - only after months of good rehab.

How the diagnosis is made

From first twinge to a clear plan.

The steps a UK sports medicine clinician will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and sport demands

    Onset, sport, position, kicking pattern, training load and the exact pain location - Doha categories are teased out here.

  2. 02

    Assessing

    Adductor squeeze test

    Squeezing a fist or ball between the knees at 0, 45 and 90 degrees of hip flexion - pain and weakness point to adductor-related groin pain.

  3. 03

    Assessing

    Resisted adduction and PROM

    Resisted adduction reproduces tendon pain. Passive hip range of motion checks for capsular restriction and hip-related causes.

  4. 04

    Confirming

    Palpation and mimics screen

    Palpation of the adductor longus origin, pubic symphysis, iliopsoas and inguinal canal - screening for sportsman hernia, osteitis pubis and hip labral tear.

  5. 05

    Confirming

    Ultrasound

    Dynamic ultrasound shows tendon thickening, hypoechoic change, neovascularity and any partial tearing at the enthesis.

  6. 06

    Confirming

    MRI for grade and oedema

    MRI grades the tendinopathy, shows adductor longus tear extent, and detects pubic bone marrow oedema, secondary cleft sign and adjacent osteitis pubis.

  7. 07

    Deciding

    Rule out competing diagnoses

    Sportsman hernia (inguinal-related), hip labral tear (hip-related) and osteitis pubis (pubic-related) all mimic adductor pain and change the treatment plan.

Typical timeline: a first visit to a settled plan in weeks, not months.

Symptoms

What adductor tendinopathy actually feels like.

The mix of adductor-origin pain, a positive squeeze test and dropping training tolerance - and the features that mean it is time to escalate.

  • Groin pain with kicking

    Sharp or aching pain at the adductor origin during kicking, sprinting or cutting - the classic footballer complaint.

  • Pain on the squeeze test

    Pain and weakness when squeezing the knees together - often the earliest objective sign.

  • Morning stiffness

    Stiffness at the top of the thigh in the morning or after training, easing with gentle movement.

  • Palpable tenderness

    Focal tenderness at the adductor longus enthesis on the inferior pubic ramus.

  • Weak resisted adduction

    Loss of strength on resisted adduction compared with the other side - a useful monitoring metric.

  • Pain radiating to perineum

    Referred discomfort into the perineum, scrotum or lower abdomen - overlaps with pubic and inguinal-related causes.

  • Reduced training tolerance

    Shorter runs, avoided sprints, missed sessions - a subtle sign that the tendon is not coping with load.

  • Red flag - acute pop with bruising

    A sudden pop, bruising and inability to weight-bear may signal an acute adductor longus rupture and needs urgent review.

Treatment

How adductor tendinopathy is treated in the UK.

Load management and Copenhagen strengthening first, targeted adjuncts next - and surgery only for chronic refractory disease.

  • Relative rest and load management

    Cut painful activities without full immobilisation - keep the tendon working within a tolerable envelope while you rebuild capacity.

  • Copenhagen adductor protocol

    Progressive adductor strengthening centred on the Copenhagen adduction exercise - the best-evidenced conservative programme for adductor-related groin pain.

  • Manual therapy and eccentric work

    Hands-on soft tissue work, hip mobility drills and eccentric loading to complement the strengthening plan.

  • Short-course NSAIDs

    Brief use of oral anti-inflammatories can calm a painful flare - a helper, not a fix, and never a substitute for loading.

  • Ultrasound-guided corticosteroid

    A selective option for stubborn pain that blocks rehab - image-guided, used sparingly given tendon-quality concerns.

  • Platelet-rich plasma (PRP)

    Autologous injection with variable evidence in adductor tendinopathy - considered case by case when standard care stalls.

  • Return-to-play progression

    Structured on-pitch rebuild - jogging, straight-line running, changes of direction, ball work, then contact and match play.

  • Surgery - adductor longus tenotomy

    For chronic refractory cases - open or partial adductor longus tenotomy or release, considered only after months of well-run rehab.

What this guide is based on

The sources behind every claim on this page.

Consensus statements and peer-reviewed sports medicine sources, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, sports physician or physiotherapist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • Weir A et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. BJSM 2015.

  • Serner A et al. Diagnostic criteria and imaging in athletes with groin pain. BJSM consensus updates.

  • Serner A et al. Copenhagen adductor exercise programme for adductor-related groin pain (evidence base).

  • Robinson P, Bradshaw A. MRI and ultrasound of the athletic groin - imaging protocols and grading.

Red flags

When groin pain needs urgent attention.

Most groin pain is manageable in primary care and physiotherapy. These are the situations that are not, and where a specialist opinion matters.

  • Acute adductor longus rupture

    A sudden pop, extensive bruising and marked weakness on adduction - needs prompt imaging and a surgical opinion in professional athletes.

  • Sportsman hernia (inguinal)

    Chronic groin pain with a tender posterior inguinal wall and pain on resisted sit-up - a different diagnosis under the Doha framework.

  • Osteitis pubis

    Pubic symphysis pain, bone marrow oedema on MRI and midline tenderness - the pubic-related category needs a slower load plan.

  • Hip labral tear

    Deep C-sign groin pain, clicking and impingement signs - a hip-related cause that MRI arthrogram helps confirm.

  • Stress fracture

    Night pain, focal bone tenderness and pain on hopping - needs MRI to exclude femoral neck or pubic ramus stress fracture.

  • Infection or septic arthritis

    Fever, severe rest pain and inability to weight-bear - a red flag requiring urgent secondary-care review.

  • Referred lumbar or SIJ pain

    Back-driven groin pain with no local tenderness - needs a spinal and sacroiliac assessment.

  • Malignancy in older athletes

    Unexplained groin pain, weight loss or a mass - warrants prompt imaging and specialist review.

  • Neuropathic groin pain

    Burning, sensory change or nerve-distribution pain - consider obturator or ilioinguinal nerve entrapment.

Living with it

A treatable injury, with a clear ladder.

Four things make the biggest difference week to week - respecting load, keeping the Copenhagen exercise in your programme, allowing eight to sixteen weeks, and reassessing honestly at three months.

A quiet reminder

Consistency beats intensity, every time.

Small, steady sessions kept up for months do more than a heroic fortnight that does not last.

  1. 01 Load

    Respect the loading window

    Train at a level the tendon tolerates and progress slowly. Boom-and-bust weeks are the fastest route to a recurrence.

  2. 02 Strength

    Copenhagen for life

    Keep the Copenhagen adduction exercise in the weekly programme once you are back - a small dose is cheap insurance.

  3. 03 Timeline

    Expect 8 to 16 weeks

    Well-run conservative care usually returns athletes to sport in eight to sixteen weeks. Chronic cases can be longer.

  4. 04 Escalate

    Reassess if stuck at 3 months

    If pain and function have not improved after twelve weeks of good rehab, image again and revisit the diagnosis before considering injection or surgery.

Frequently asked

Everything we get asked about adductor tendinopathy.

Quick answers on diagnosis, imaging, loading, injections and return to play.

  • What is adductor tendinopathy?

    It is an overuse injury of the adductor tendons, most often adductor longus at its origin on the pubic bone. Under the Doha Agreement it sits within adductor-related groin pain, one of six categories used to classify groin pain in athletes.

  • How is it diagnosed?

    Clinical assessment is the foundation - focal tenderness at the adductor origin, pain on the adductor squeeze test at 0, 45 and 90 degrees of hip flexion, and pain and weakness on resisted adduction. Ultrasound and MRI confirm the tendinopathy, grade it and rule out sportsman hernia, hip labral tear and osteitis pubis.

  • What is the Copenhagen adductor protocol?

    A progressive strengthening programme built around the Copenhagen adduction exercise - a side-lying exercise that loads the adductors heavily. It has the strongest evidence base for adductor-related groin pain and is the backbone of first-line care.

  • Do I need an injection?

    Usually not. Ultrasound-guided corticosteroid can calm a stubborn flare that is blocking rehab, but it is used sparingly because repeated steroid affects tendon quality. PRP has variable evidence and is considered case by case.

  • When is surgery considered?

    Surgery is reserved for chronic refractory cases that have not responded to at least three to six months of well-run rehab. An adductor longus tenotomy or partial release is the usual operation, and it is followed by a structured return-to-play programme.

  • How long until I can play again?

    Most athletes managed conservatively return to sport in eight to sixteen weeks. Chronic cases, complicated by osteitis pubis or a partial tear, can take longer. The return-to-play progression moves from jogging to straight-line running, changes of direction, ball work and finally contact and match play.

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