The groin region represents one of the most complex diagnostic challenges in sports medicine due to its overlapping symptoms, frequent coexistence of multiple pathologies, and the influence of speciality - or imaging-driven diagnostic bias. An anatomy-driven approach can significantly enhance diagnostic accuracy and guide targeted management strategies.

This presentation explores the role of the Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC) concept in refining the interpretation of groin pain, particularly following adductor longus avulsions. The PLAC classification effectively captures the anatomical and pathological complexity of these injuries and provides structured guidance for surgical decision-making. A dedicated groin MRI protocol combined with a three-step assessment framework allows both novice and experienced clinicians to achieve diagnostic findings that correlate strongly with intraoperative observations.

Dynamic ultrasound remains the modality of choice for assessing structural abnormalities of the posterior wall, including direct and indirect hernias, bulging, and widening.

Abdominal neuropathy, frequently involving the ilioinguinal, iliohypogastric, or genital branch of the genitofemoral nerve, often presents with non-dermatomal pain distributions. Selective ultrasound-guided nerve blocks can unmap these atypical pain patterns, providing both diagnostic clarity and therapeutic benefit. Obturator neuropathy, involving either or both branches, can also be elucidated through selective nerve blocks when neurophysiology proves inconclusive.

Adductor-related pain at the intersection of the gracilis, adductor brevis, and adductor magnus muscles is frequently associated with axial loss of internal rotation on a background of femoroacetabular impingement.

In professional athletes, treatment strategies must also consider seasonal timing and player availability. Selective neurolysis may serve as a valuable bridging strategy in athletes with posterior wall abnormalities and concurrent abdominal neuropathy, reducing performance-limiting pain and improving abdominal muscle coordination until definitive surgery can be performed. Attention to secondary pain development, arising from compensatory mechanisms, is essential for comprehensive management.

This lecture will outline a structured strategy to determine when surgical, non-surgical, or intermediate management is most appropriate, integrating anatomy-driven assessment with pragmatic clinical decision-making to optimise outcomes in athletic groin pain.