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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.
We have Pure Physiotherapy clinics across the country including Norwich, Bury St Edmunds, Manchester, Bolton, Sheffield and Wakefield. Please view our clinics to find the closest physiotherapy clinic for you.
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