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The Case:
M is 20, is a collegiate midfielder, in his third year, and has been playing through the pain for eleven weeks… a deep ache along the inner thigh that starts twenty minutes into training and lingers all day, dating back to a preseason block that jumped from three sessions a week to nine in about ten days. Worse cutting off the left, worse striking long diagonals off the inside of the left foot, and straight-line sprinting is fine. I asked him to point with one finger and he put it on the proximal adductor mass. Then he paused and said, "Sometimes it's here too," and dragged his finger up toward the anterior hip. So the examination question was no longer which single structure is the problem. It was which structures are involved, and in what order.
That is a different question than most of us are trained to ask about the groin. And many clinicians are afraid to ask anything related to the groin. Don’t be them. You are a clinician!!!
The Trap
Every medial thigh complaint in a soccer player gets labeled a groin strain, treated as one muscle, and rehabbed with stretching until it stops hurting at rest. The athlete points at his inner thigh, we palpate, we find tenderness somewhere in the adductor mass, and we stop — which is the error, because palpating one tender structure ended the examination instead of starting it. Tenderness tells you a tissue is irritable. It does not tell you it is the only irritable one, and in the athletic groin it very rarely is. "Groin strain" is not a diagnosis. It is a region with at least four distinct clinical entities living in it, and then we stretch the one we found, which feeds an already load-intolerant proximal insertion, buys ten minutes of relief, and restarts the cycle.
The Workup
Resisted adduction at 45 degrees (squeeze test) — positive. Immediate familiar pain at the proximal adductor longus with an obvious side-to-side strength deficit. This is your anchor test for the adductor entity. Familiar pain plus a measurable deficit gives you your primary driver. No reproduction here and the adductor is not your problem, whatever palpation told you.
Resisted adduction at 0 degrees — positive. Same location, slightly less intense. Testing two positions is not redundant. Reproduction across angles argues for genuine load intolerance rather than a positional artifact, and the extended position biases toward the adductor longus specifically.
Resisted hip flexion, seated — positive. And here is where the case turns. It reproduced the anterior hip pain — the second spot he pointed to — and did nothing to the medial groin. This is the test that finds the second entity. Skip it and you treat half the problem, then blame compliance when he stalls at week six.
Hip flexor stretch, modified Thomas — positive for anterior hip, negative for rectus femoris. Paired with resisted hip flexion, this meets criteria for the iliopsoas entity. Hip flexor tests do not reliably separate iliopsoas from proximal rectus femoris on their own, so get more than one data point before you name the structure. With FADIR negative and internal rotation symmetrical, intra-articular hip is off the table.
Pubic symphysis and inguinal canal palpation — both negative. No symphyseal or pubic bone tenderness, no canal tenderness, no defect, no cough impulse. That clears the pubic-related and inguinal-related entities — and document the negative symphysis explicitly, because it is your defense later when imaging turns up incidental bone marrow edema and someone wants to redirect the case toward the pubis.
The discriminator: resisted ADDUCTION finds the adductor. Resisted hip FLEXION finds the ilio-psoas. The entities are not mutually exclusive — the framework explicitly allows more than one in the same athlete, which is exactly what M has.
So the job is not to pick one. The job is to rank them. Adductor primary, ilio-psoas secondary, and that ranking drives every decision that follows.
The Plan
Foundation: Start loading on day one. Not after the pain settles — waiting for a quiet adductor is how eleven weeks becomes eleven months. Isometric adduction is the workhorse and it doubles as analgesia, with a low-level hip flexor isometric that addresses the iliopsoas without provoking it. No aggressive static adductor stretching in the first two phases. Range comes back with strength, not before it.
Loading: This is the treatment, and the dose that changes outcomes is higher and longer than what most athletes get handed. Build the Copenhagen progression from short lever to unsupported, advancing only when every rep is controlled and there is no next-morning soreness. Add controlled-eccentric adduction, rebuild the anterior chain that has been compensating for eleven weeks, and introduce the frontal plane under load.
Sport-specific: Finish the Copenhagen progression at long lever before you go anywhere near match speed. Then bounding with a stuck landing, then deceleration built from straight line to 45s to 90s, then the provoking task rebuilt specifically — progressive ball striking off the inside of the foot from half power to full. In soccer the provoker is cutting and striking, not running. If your return testing is straight-line conditioning, you are testing the one thing that was never the problem.
Every session opens with a squeeze test. Ten seconds, same position, same effort cue. It is not just a diagnostic — it is your daily readiness metric, and it shows you a flare coming 48 hours early.
Clinical pearl: Ask the athlete to point with one finger, then pause and ask again. In the athletic groin the second location is where the case turns, and it is almost never volunteered.
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The Practice
The Performance Doctor: Three things in this case protect the practice, and none of them are a technique.
The first is the timeline you say out loud. M was going to ask when he could play, and the honest answer for an eleven-week groin is eight to twelve weeks of properly dosed loading. There is real pressure to say four to six because it is more palatable and you hope he surprises you. Do not. An athlete told twelve weeks who returns in nine feels like he beat it. An athlete told six who is still restricted at ten loses faith in the plan, starts freelancing his rehab, and goes shopping for a clinician who will tell him what he wants to hear. The timeline is a clinical finding, not a negotiation.
The second is the permission conversation, and it belongs in visit one. The athletic trainer sent him, the coach wants to know, the strength staff needs to know what he can and cannot do — and M is a legal adult with his own right to decide what gets shared. Those interests usually align. Where they do not, the athlete decides. Functional information goes out with permission: what he can train, what he avoids, what the progression looks like. Anything touching his standing on the roster gets handled carefully. Set that rule before there is anything sensitive to disclose. It is far easier to establish when nothing is riding on it.
The third is knowing when to stop a service you are billing for. The needling here has one stated job: reduce guarding so he loads better that session. If after three or four sessions he is not loading better, it failed its purpose and it should stop. The pressure not to stop is real — he likes it, it feels like treatment, it fills a visit, it generates revenue. That exact combination is why the endpoint gets set in advance. State the purpose of an intervention before you start it, define what success looks like, and hold yourself to the review. That discipline is what makes a collegiate athletic department send you the next eleven athletes.
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Every patient is unique. The framework tells you where to look. Your hands and your questions tell you what you found.
In health and strength,
Dr. Thomas Kauffman, DC, CDNP, CSCS, USAW
The Clinical Coach™ a SmartCARE Education™ publication
The Clinical Coach™ is a clinical education publication produced by SmartCARE Education™. Content is for educational purposes and CE credit. Always exercise independent clinical judgment with individual patients.
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