Groin Pain in Hockey Players: The Strength Ratio That Predicts It

Most hockey groin injuries feel like they arrive without warning. In a lot of cases, the risk was measurable weeks earlier.

Here is what the four groin patterns are, why the strength ratio carries so much weight in hockey, and what the prevention evidence honestly supports.

Four kinds of groin pain, sorted without a scan

Groin pain used to be a single vague label. The Doha agreement replaced that with four defined clinical entities: adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain.

The key feature of that system is how the sorting happens. A 2024 narrative review in Cureus describes the classification as based on history and physical examination rather than on imaging. A scan can add information in specific situations, and it does not decide the category.

For the adductor-related group, the definition is straightforward. There is tenderness over the adductor region, and there is pain when the athlete squeezes the legs together against resistance. Both parts need to be present.

This matters more than it sounds, because the four groups respond to different work. An iliopsoas-related problem at the front of the hip needs a different plan from an adductor-related one, and a pubic-related problem needs a different plan again. Treating all groin pain with the same set of exercises is why some cases drag on for months.

Why the adductors take the load in skating

Skating is close to a purpose-built test of the adductor muscles. Each stride pushes the leg out and away from the body, and the adductors then pull it back under the athlete to set up the next push. Do that a few thousand times a game, then repeat across a season.

The numbers follow the mechanics. The Cureus review reports that chronic groin pain accounts for up to 15 percent of all injuries in athletes, and that adductor-related pain represents up to two thirds of groin pain cases. In professional soccer, adductor injuries made up 23 percent of all muscle injuries, with an average absence of 14 days.

The anatomy explains why the same spot keeps failing. The adductor longus attaches at the back into the pubic bone through a piece of fibrocartilage measuring roughly 1.5 cm by 1.9 to 2.5 cm. That attachment sits inside a shared structure known as the pyramidalis-anterior pubic ligament-adductor longus complex, or PLAC, where several tissues meet at one small area of bone.

The tissue makeup changes fast along the muscle. Near the origin, the tendon-to-muscle ratio runs from 38 percent to 62 percent. Move 2 cm away from the origin and the muscle area is already around 73 percent. So a small change in where the pain sits means a real change in which tissue is involved, which is one reason careful palpation still matters in an era of easy imaging.

The 17 times figure

The single most useful piece of information in this whole area, for hockey specifically, is a strength ratio.

The Cureus review reports that elite hockey players face a 17 times higher risk of groin injury when adductor strength is 80 percent or less of abductor strength. Adductor strength is how hard you can squeeze the legs together. Abductor strength is how hard you can push them apart. The ratio between them describes whether the inside of the hip is keeping up with the outside.

Two things make this valuable in practice. It is measurable in a clinic in a few minutes, and it is measurable in a player who has no symptoms at all. Most screening in sport happens after something hurts. This one runs before.

It also gives a clear target. If the ratio is low, the work is obvious: load the adductors progressively until the ratio comes back up. That is a far more specific instruction than telling an athlete to stretch their groin more.

The same logic of measuring first and loading toward a target shows up across sports rehabilitation, and it is the basis of criteria-based return to sport decisions.

What the prevention evidence actually says

Here is where being precise matters, because the strongest prevention trial in this area was not run on hockey players.

The Adductor Strengthening Programme trial, published in the British Journal of Sports Medicine in 2019, was a cluster-randomised controlled trial across 35 semiprofessional Norwegian football teams. Eighteen teams with 339 players took the programme. Seventeen teams with 313 players continued as usual.

The programme was deliberately small. One exercise with three progression levels, done three times a week through a preseason of 6 to 8 weeks, then once a week during the competitive season.

Average prevalence of groin problems was 13.5 percent in the intervention group against 21.3 percent in the control group. That worked out to a 41 percent lower risk, with an odds ratio of 0.59 (95 percent CI 0.40 to 0.86, p=0.008).

Those players were male footballers. Nobody has run the same trial in hockey, so applying the result to a hockey roster is an informed decision rather than a demonstrated one. The adductor demands of skating are at least as high as in football, the exercise costs nothing, and the risk of doing it is low. That reasoning is sound, and it is still reasoning rather than direct evidence.

On exercise selection, the Cureus review reports that combining the Copenhagen adduction exercise with other specific exercises has shown the highest efficiency in preventing injuries. Our detailed guide to groin strain rehab and Copenhagen adduction covers how the levels progress.

Recurrence is the real problem

A first groin injury is inconvenient. The pattern that follows it is the expensive part.

The Cureus review reports that soccer players with a prior groin injury carry a two times higher risk of reinjury, and that more than one third of adductor injuries are recurrent. That is not a small tail of unlucky cases. It is a third of everyone.

The usual explanation is a return that was timed by the calendar and by how the groin felt, without checking whether strength and control had come back to the level the sport demands. Pain settles well before capacity returns. An athlete who feels fine at 80 percent strength will skate on it, and the tissue meets the same loads that beat it the first time.

This is why the exit test from rehab matters as much as the entry assessment. Testing the adductor to abductor ratio at the end gives an objective number rather than a feeling.

What treatment looks like, and how long it takes

For an athlete already in pain, the direction of the evidence is toward active work.

The Cureus review compares approaches directly. With active training, 79 percent returned to play at a median of 18.5 weeks. With passive therapy, 14 percent returned. Programmes focused on intersegmental control, meaning coordinated control across the trunk, pelvis, and hip rather than isolated muscle work, reported return-to-play rates of 73 percent at a mean of 9.9 weeks.

Those timelines are longer than most athletes expect, and they describe chronic adductor-related groin pain rather than a simple acute strain. An acute strain in professional soccer averaged 14 days of absence. A groin that has been sore for months is a different problem with a different clock.

Surgery exists for cases that do not respond. The review reports return to play at nine weeks after a partial adductor release and 12 weeks after a complete release. Those figures describe the operative pathway, and the large majority of athletes never need it.

Where the hip joint itself is involved rather than the muscle attachment, the assessment changes again, which is covered in our guide to hip impingement and conservative care.

When to get it looked at

Groin pain that has been present for more than a couple of weeks, that hurts when you squeeze your legs together, or that has come back after a previous groin injury is worth having assessed. So is groin pain that changes your stride or makes you shorten your shifts.

Some situations need medical attention rather than a physiotherapy booking. Groin pain with fever, with unexplained weight loss, with a hard lump, with numbness in the groin or inner thigh, or that follows a significant fall or collision and prevents weight bearing should go to your physician or to Lions Gate Hospital.

If your groin has been niggling all season, or you want the strength ratio measured before it becomes a problem, book a 30-minute assessment and we will test where the pain is coming from and what your numbers look like. You can see what we treat or reach the clinic here.

This article is general information, not personal medical advice. A regulated practitioner can confirm whether the patterns described apply to you.

Sources

• Athletes With Adductor-Related Groin Pain: A Narrative Review (Cureus, 2024)
• Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial (British Journal of Sports Medicine, 2019)
• College of Health and Care Professionals of BC public registry

This article is for general information only and does not constitute medical advice, diagnosis, or treatment. Individual presentations vary, and assessment findings and treatment plans differ from person to person. If you are experiencing severe symptoms, neurological changes (numbness, weakness, bowel or bladder changes), or a significant trauma, contact your physician or emergency services. Care at Medstar Sport Physio & Health is provided by practitioners registered with their respective British Columbia regulatory colleges.