Adductor-Related Groin Pain
1. Introduction
Long-standing groin pain is a common complaint for athletes involved in a number of sports such as football, rugby and ice hockey, causing significant morbidity and loss of sporting activity (2). It remains a complex problem and can be difficult to diagnose as it affects a large anatomical region where many different factors can contribute to the overall symptom pattern (3). The pubic symphysis (connection at the front of the two pelvic bones) and the adductor muscles are among the many anatomical structures potentially involved in causing athletic groin pain (4). Acute injuries are much easier to manage and your musculoskeletal physiotherapist can generally diagnose by asking you about how your injury happened and the area of symptoms.
Frequently Asked Questions
- Adductor-related groin pain is localised discomfort to the inner upper thigh and groin.
- In the general population, it affects less than 1% of people.
- It is much more common in active, sporting individuals. In football, groin pain accounts for 4%–19% of all male injuries and 2%–14% of all female injuries (1).
- No.
- With the right rehabilitation approach, both acute and chronic adductor-related groin injuries generally recover well.
- Adductor-related groin pain is not linked to other serious pathology.
- Those who are involved in a sport that requires a change of direction.
- Higher performance standards, it’s more common in serious or elite-level athletes.
- Reduced hip adduction flexibility.
- Weak hip muscles.
- Lack of sport conditioning relative to your sport and level of performance (1).
- Pain in the inner, upper thigh and into the groin.
- Pain when taking your leg out to the side.
- Pain when bringing legs together.
- Pain whilst running, sporting change of direction and hopping.
- Modify your activity.
- Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
- Advice by a qualified physiotherapist will be helpful in most cases.
- This will depend upon several factors including, but not limited to, other past or current injuries or conditions, stage of injury, adherence to rehabilitation etc.
- Initial recovery for an acute injury is usually within 4-8 weeks. Chronic injuries can take up to 6 – 12 months to recover (9).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain in the inner, upper thigh and into the groin.
- Pain when taking your leg out to the side.
- Pain when bringing legs together.
- Pain whilst running, sporting change of direction and hopping.
3. Causes
Symptoms usually develop alongside an increase in training load or activity, meaning they are most common in sporting individuals. As we stretch our legs wide in certain sports, the adductor muscles in the hip are important to stop the hip overstretching. If this muscle is de-conditioned to this position, not strong enough to manage the forces or not flexible enough to be forced into a stretch, you are likely to experience a strain of the muscle or tendon (1). If the tendon is put under these forces more frequently with less excessive forces, you may develop tendinopathy. This is when the adductor tendon specifically is irritated and generally will take more time to recover (7).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing an adductor-related groin injury. It does not mean everyone with these risk factors will develop symptoms.
- Those who are involved in a sport that requires a change of direction.
- Higher performance standards – more common in serious or elite-level athletes.
- Reduced hip adduction strength.
- Weak hip muscles.
- Lack of sport conditioning relative to your sport and level of performance (1).
5. Prevalence
An aggregated data analysis of 29 studies found a higher proportion of groin injuries in men (12.8%) than in women (6.9%). Groin injuries in male club football accounted for 4%–19% of all injuries and 2%–14% in women.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like an MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of your treatment, your physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your adductor injury. This will include activity modification strategies as well as other useful treatments aimed at reducing discomfort. Regular adherence to a condition-specific rehabilitation programme is important in the management of this condition. It should be noted that rehabilitation exercises are not always a quick fix but, if adhered to on a consistent basis (weeks to months), over time they have been shown to yield positive outcomes.
8. Rehabilitation
Most research is based on exercises to help prevent an adductor strain or tendon-related problem. Recovery can take a varied amount of time depending on the severity of the strain. Studies show that tissue remodelling and muscle atrophy take place several months after an acute muscle strain injury (9). This suggests that rehabilitation programmes should surpass the time of returning to hobbies/sport.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing adductor-related groin pain. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Adductor-Related Groin Pain
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on adductor strength. The Copenhagen adductor strengthening exercise programme, along with progressive glute and quad strength work, can be used to meet your goals (8). Try to keep the pain tolerable, no more than 3/10 on your perceived pin scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading of the muscles around the hip, back and lower limbs. As with the early programme, some pain is to be expected but ideally, we don’t want this to be any more than 3/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected hip complex. Some pain is acceptable but ideally, we do not want it to exceed 3/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to a sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting, and sprinting exercises (7).
As part of a multi-modal treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence. Assessment of movement quality should be used in combination with further tests like strength, flexibility and agility testing (10).
11. Other Treatment Options
There is a lack of data around adductor-related steroid injection, however, in a study of injections for athletic pubalgia, symptoms closely linked to adductor-related pain outcomes were positive and could offer an alternative to surgery (11).
There are concerns, however, with weakening the structure of the tendons, causing future problems. Therefore, conservative management should be the primary method of management and this should be exhausted before further intervention is considered.
References
- Wier et al. (2015) Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 49, 768-74.
- Branci S, Thorborg K, Nielsen MB, et al. (2005) Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature. Br J Sports Med. Wilson, JJ; Best TM. 47, 611–19.
- Orchard J, Seward H. (2002) Epidemiology of injuries in the Australian Football League, seasons 1997;2000. Br J Sports Med 36, 39–44.
- Br J Sports Med (1997) .Management of groin pain in athletes. 31, 97–101. 3.
- Renstrom PA. (1999) Groin injuries in sport: treatment strategies. Sports Med. 28, 137–44.
- “Common overuse tendon problems: A review and recommendations for treatment”. American Family Physician. 72, 811–8. PMID 16156339.
- Cook, J. L. & Purdam, C. R.. (2009) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43, 409-416.
- Joar Harøy, Benjamin Clarsen, Espen Guldahl Wiger & Mari Glomnes et al. (2017) The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial, bjsports. 098937
- Bayer et al. (2018) Role of tissue perfusion, muscle strength recovery, and pain in rehabilitation after acute muscle strain injury: A randomized controlled trial comparing early and delayed rehabilitation, J Med Sci Sports.
- Wilke et al, (2017). Return to Sports after Lower Extremity Injuries: Assessment of Movement Quality, 10.4236/health.
- Jose et al. (2015). Ultrasound-guided Corticosteroid Injection for the Treatment of Athletic Pubalgia: A Series of 12 Cases. Journal of medical ultrasound.
Other Conditions in
Hips & Pelvis, Upper Legs
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Proximal Hamstring Tendinopathy
Pain and weakness under the buttock or the back of your upper thigh caused by tendon issues.
Pelvic Girdle Pain
Typically seen in pregnancy causing pain, instability and limitation of mobility and functioning of the pelvic joints.
Pelvic Floor Dysfunction
The inability to effectively control the muscles of your pelvic floor, leading to issues with continence and pain.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Hip Replacement Surgery
Replacement of the hip ball and socket joint, typically as a result of severe osteoarthritis or trauma.
Hip Osteoarthritis
Common age-related changes to the structure of the hip joint may be associated with pain, stiffness and loss of function.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Adolescent Hip Dysplasia
A result of an abnormality of the hip joint anatomy resulting in pain in the hip with occasional instability.