Adductor Strain

Aka: Adductor Strain, Adductor Tendinitis, Adductor Tendinopathy, Groin Pull

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II. Epidemiology

  1. Most common musculoskeletal cause of Groin Pain in sports
  2. High Incidence in soccer, hockey and track

III. Pathophysiology

  1. Muscle stretched or overloaded beyond normal range
    1. Kicking
    2. Directional changes
    3. Sprinting
    4. Jumping
  2. Strain of adductor Muscles of the hip
    1. Common Muscles involved
      1. Adductor longus Muscle
      2. Gracilis Muscle
    2. Other Muscles less frequently involved
      1. Adductor magnus Muscle
      2. Adductor brevis Muscle
      3. Iliopsoas Muscle
      4. Rectus femoris Muscle
      5. Sartorius Muscle

IV. History

  1. See Hip Pain

V. Symptoms

  1. Acute proximal Muscle pain over medial thigh
  2. Pain and stiffness in groin worse after Exercise
  3. Radiation of pain
    1. Along course of medial thigh
    2. Rectus abdominis

VI. Exam

  1. See Hip Exam

VII. Signs

  1. Local swelling and Bruising may be seen
  2. Focal tenderness over adductor Muscles (esp. adductor longus)
  3. Provocative maneuvers
    1. Resisted hip adduction and passive hip abduction
    2. See Hip Adduction Test

VIII. Differential Diagnosis

  1. See Groin Injuries in Athletes
  2. See Hip Pain Causes
  3. Sports Hernia
  4. Osteitis Pubis

IX. Imaging

  1. Indicated in refractory cases
  2. Pelvic MRI Imaging (if not responding to conservative therapy)
    1. High False Positive Rate (correlate MRI with related findings in a symptomatic athlete)
    2. Pubic body subchondral Bone Marrow edema
    3. Rectus abdominis and Adductor Aponeurosis or capsule tear
    4. Soft tissue edema
  3. Dynamic Ultrasound
    1. May identify Muscle and tendon tears

X. Management: Approach

  1. Determine biomechanical forces predisposing to injury
    1. Foot and lower leg malalignment
    2. Leg Length Discrepancy
    3. Muscular imbalance
    4. Gait Abnormality
  2. Identify tear location
    1. Acute tear at musculotendinous junction
      1. Aggressive rehabilitation program
    2. Acute partial tear of tendon insertion at pubic bone
      1. Requires period of rest before physical therapy
  3. Determine Chronicity of Injury
    1. See management strategies below

XI. Management: Acute

  1. General Measures
    1. NSAIDs for first 7 to 10 days
    2. Rest from provocative activities for 10 to 14 days
      1. Longer rest needed for tear at tendon insertion
      2. Cross-training with other aerobic Exercise throughout rehabilitation period
    3. RICE-M
      1. Cold therapy initially
      2. Heat therapy may be used chronically after 72 hours
      3. Compression Shorts or hip spica wrap
  2. Physical Therapy (Holmich Protocol) and Manual Therapy
    1. Initial goals
      1. Restore range of motion
      2. Prevent atrophy
    2. Next goals
      1. Regain strength (return to sport when 70% regained)
      2. Regain flexibility and endurance
  3. Specialty referral Indications
    1. No improvement after 8-12 weeks of physical therapy
  4. Other measures in refractory cases
    1. Dextrose Prolotherapy
    2. Adductor tendon release
  5. Avoid local Ultrasound
    1. Risk of bleeding
    2. Risk of mutagenesis due to proximity to genitalia

XII. Management: Chronic

  1. Stretching Program
  2. Low intensity Isotonic Exercise
  3. Consider active training Exercise program
  4. Consider surgical tenotomy

XIII. Course: Period of rehabilitation to return to sport

  1. Acute strains: 4-8 weeks until return to sport
  2. Chronic strains: up to 6 months

XIV. References

  1. Schleihauf (2019) Crit Dec Emerg Med 33(5): 19-28
  2. Akermark (1992) Am J Sports Med 20:640-3 [PubMed]
  3. Holmich (1999) Lancet 353:439-43 [PubMed]
  4. Maloy (2025) Am Fam Physician 111(4): 337-43 [PubMed]
  5. Morelli (2001) Am Fam Physician 64(8):1405-14 [PubMed]

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