Groin pain is one of the most diagnostically complex presentations in musculoskeletal practice. The differential diagnosis includes adductor tendinopathy, osteitis pubis, hip labral pathology, inguinal hernia, sportsman's hernia, iliopsoas pathology, and referred lumbar pain — and several of these frequently coexist in the same patient. Afferentology doesn't care to identify the damaged tissue, we want to fix the weakness that allowed the tissue to be damaged.
The adductors are the most consistently underassessed muscles in pelvic stability. They are regarded primarily as hip adductors, not as pelvic stabilisers. This is incorrect. The adductor magnus, through its attachment at the pubic ramus and its fascial connection to the pelvic floor, is a primary compression generator across the pubic symphysis. The adductor longus and brevis provide the pubic ramus with tensile restraint against lateral shear. When these muscles are inhibited the pubic symphysis loses its primary muscular support. Any damage that develops is a consequence of this mechanical failure, not an independent pathology.
The Adductors as Pelvic Stabilisers: What Standard Assessment Misses
The adductor group is supplied by the obturator nerve from L2-L4, with the adductor magnus additionally receiving sciatic nerve supply at L4-S1. In walking and running, the adductors control abduction — they are eccentrically active during the stance phase, preventing excessive lateral pelvis shift. When their motor neuron supply is reduced this eccentric control is lost. The pubic symphysis is exposed to uncontrolled shear. The adductor tendon origin at the pubic ramus absorbs the load the muscles should have managed eccentrically. The patient presents with adductor tendinopathy, osteitis pubis pattern pain, or chronic groin ache — all of which are structural consequences of the adductor motor neuron failure.
The inguinal region is one of the most mechanoreceptor-rich areas in the body. The inguinal canal, inguinal ligament, round ligament in females, and spermatic cord structures in males contain afferent fibres that project to the L1-L2 cord level. Any afferent irritant in this region — a subclinical inguinal hernia, a previous hernia repair mesh, an inguinal lymph node under pressure, or a groin scar — generates withdrawal reflex activity at L1-L2 that, via propriospinal tracts, inhibits the adductors at L2-L4 and the lower abdominals at T12-L1.
"The adductors are not simply hip adductors. They are the primary compression generators across the pubic symphysis. When they are inhibited — by an inguinal hernia, a scar, or a lower abdominal afferent source — the pubic symphysis is mechanically unsupported. What follows is not a coincidence. It is a predictable structural consequence of a neurological failure at the obturator nerve origin."
The Software Test: Protective Reflex Testing
PRT for groin pain involves testing the adductors as a group, but often at different degrees of flexion. Any weakness found is compared with other weaknesses and hypertonicities of the antagonists and synergists. This is often where hidden inguinal ligament disruptions are found. The most valuable test is teh inguinal hernia test where the patient pull their leg into it's end range of motion by pulling the leg out and up as far as possible to at least 45 degrees out and up. When the inguinal challenge restores adductor tone, the inguinal source is confirmed. Lumbar disc levels at L2-L3 are challenged if the inguinal source does not fully restore the inhibition pattern, and the pubic symphasis is also checked for stability.
In patients with an identified inguinal source, the adductor tone restoration following the afferent challenge is typically complete and immediate.
Clinical Takeaways
Groin pain is not an adductor problem. It is an inguinal ligament problem expressing at an adductor tendon.
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