 
 
Rehabilitation Protocol for Athletic Pubalgia (Non-Operative) 
  
This protocol is intended to guide clinicians through the non-operative course for groin pain in athletes. This protocol is 
criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings 
and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on 
surgeon’s preference, additional procedures performed, and/or complications. If a clinician requires assistance in the 
progression of a non-operative patient, they should consult with the referring physician. 
  
The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic 
interventions should be included and modified based on the progress of the patient and under the discretion of the 
clinician.  
  
Considerations for the non-operative treatment of groin pain in athletes 
Many different factors influence the non-operative treatment for groin pain in athlete’s rehabilitation outcomes, 
including a prior history of groin pain, severity of injury and number of structures injured (adductor related, inguinal 
related, pubic related or hip related). Therefore, this protocol will be criteria based and not time based as healing times 
can vary. It is recommended that clinicians collaborate closely with the referring physician regarding the above. 
 
Differential Diagnosis 
Groin pain in athlete’s is common problem that is known for its complexities due to the numerous structures that may 
be injured. Due to the number of potential structures injured, numerous terms have been used with varying 
interpretations. In fact, there are 33 different diagnostic terms used in the literature to describe groin pain in an athlete. 
In 2015 the DOHA agreement was a meeting that attempted to determine a standard terminology for this injury. They 
agreed groin pain in athletes is the preferred umbrella term with 3 subgroups (groin pain, hip joint related and other) 
outlined below. This protocol will focus treatment on the groin pain subgroup in athletes with groin pain. 
  
 
Groin Pain in Athletes 
Groin pain 
Hip joint related 
Other 
• Adductor related 
• Pubic related 
• Inguinal related 
• Iliopsoas related 
• Femoral Acetabular Impingement 
(FAI) 
• Labral pathology 
• Osteoarthritis of the hip (>50yo) 
• Nerve entrapment 
• Lumbar spine 
• Stress fracture 
• Avascular necrosis 
• Slipped capitol femoral epiphysis 
(<15yo) 
• Legg-Calve-Perthe’s disease 
(<10yo) 
 
 
 
 
 
 
 
 
 
 
 
PHASE I: Acute  
Rehabilitation 
Goals 
• Pain Control 
• Reduce Swelling 
• Improve muscle length of pelvic girdle musculature 
• Normalize Lumbopelvic ROM 
Precautions 
• Avoid lifting or other activities that increases intra-abdominal pressure  
 
Interventions 
Manual Therapy 
• STM along the adductor muscle group and associated pelvic musculature as needed 
• PROM of the hip 
• Lumbar and Hip mobilizations as needed 
 
Stretching 
• Gentle stretching 
Lumbar: trunk rotations  
Adductor: figure 4 
Hip flexor: Thomas 
Hip rotator: cross body 
Hamstring: supine 
 
Therapeutic Exercise 
• Isometrics of the adductors: ball squeeze hip extended and hook lying 
• TrA progressions 
• Quadruped Progressions 
• Bridge progressions 
• Side lying hip abduction 
• SLR 
• Prone hip extension 
• Proprioception: Single leg balance progressions 
• Functional: squat, step up 
 
Cardiovascular 
• Walking moderate pace  
• Elliptical 
• Bike 
• Pool treadmill 
 
Criteria to 
Progress 
• <2/10 Pain with exercises 
• <2/10 Pain with MMT 
• Symmetrical hip ROM 
 
 
PHASE II: Subacute 
Rehabilitation 
Goals 
• Initiate Progressive Resistive Exercises (PRE) 
• Initiate Return to running protocol 
 
Precautions 
• NA  
Additional 
Interventions 
*Continue with 
Phase I 
interventions 
Therapeutic Exercise 
• Core: Continue above progressions, plank progressions 
• Concentric Hip strengthening with PRE: 4 way standing,  
• Eccentric Hip strengthening: Copenhagen adduction progressions, Slide board 
• Concentric Rectus Abdominus (RA): straight and oblique crunch and full 
• Functional: Squat, Lunge Matrix, RDL with PRE 
• Proprioceptive: continue above progressions with airex 
 
 
 
Cardiovascular 
• Return to running protocol 
 
Criteria to 
Progress 
• Pain free jogging 
• Pain free exercises 
• Hip (flexion, abduction, adduction) LSI <20% 
 
 
PHASE III: Early Return to Sport 
Rehabilitation 
Goals 
• Normalize strength  
• Initiate plyometric program 
• Initiate Sprinting program 
• Initiate Agility program 
 
Precautions 
• NA  
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
• Functional: Continue with PRE as previously defined 
• Medicine ball routine: chest pass, side to side pass, Overhead pass 
• Plyometric protocol 
• Agility protocol 
• Return to sprinting protocol 
 
Criteria to 
Progress 
Return to Sport Criteria: 
• Clearance from MD and ALL milestones met 
• Completion of plyometric, sprinting and agility program 
• Functional Assessment: 
- Hip index (flexion, abduction, adduction, extension) ≥90%; HHD mean or isokinetic 
testing @ 60d/s  
- Adductor/Abductor ratio >80% using HHD  
- Hop Testing ≥90% compared to contra lateral side, demonstrating good landing mechanics  
• HAGOS questionnaire >90% 
 
PHASE IV: Unrestricted Return to Sport 
Rehabilitation 
Goals 
• Return to practice 
 
Additional 
Intervention 
*Continue with 
Phase I-III 
interventions 
• Return to practice/scrimmage 
• Multi-plane sport specific plyometrics program  
• Multi-plane sport specific agility program  
• Include hard cutting and pivoting depending on the individuals’ goals 
• Non-contact practice→ Full practice→ Full play  
 
Criteria to 
Progress 
• Last stage, no additional criteria 
Revised 1/2023 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
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