Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Adductor Strain Treatment & Management

  • Author: Marlon P Rimando, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Feb 10, 2016
 

Approach Considerations

The initial management of an adductor injury should include protection, rest, ice, compression, and elevation (PRICE). Painful activities should be avoided. The use of crutches during the first few days may be indicated to relieve pain. Use of steroid injections is controversial in adductor strains, because the potential exists for tendon rupture if the steroid is injected into the tendon itself. Obtain consultations as appropriate to rule out differential diagnoses.[16, 17, 18, 19, 20, 21]

Do not advance the athlete too quickly back to his/her sport, as the injury may become a chronic condition. Acute strains easily can become chronic strains if proper time is not allowed for healing. Chronic strains are much more difficult to manage.

Next

Physical Therapy

Some authorities believe that stretching in the acute phase may aggravate the condition and lead to a chronic lesion. Control of muscle spasms is important for rehabilitation. Spasms may be alleviated with medication and/or modalities (eg, ice, electrical muscle stimulation). Passive range-of-motion (PROM) exercises are initiated when the patient can perform them without pain. Active muscle exercises can be advanced slowly from isometric contractions without resistance, to isometrics with resistance, progressing eventually to dynamic exercises when tolerated with little or no pain.

Strengthening abdominal and hip flexor muscles is an essential part of rehabilitation of groin injuries. Coactivation of the abdominal muscles and the adductor muscles is a useful and functional exercise. Completing many repetitions increases the endurance of the adductor muscles. A fatigued muscle/tendon complex is more vulnerable to injury. The patient should aim to progress gradually to 30-40 repetitions. Proprioceptive exercises are recommended, along with stretching, as well as an aquatic training program if accessible. After several days, heat and support bandages are recommended.

Grade I strain

Pain-free hip stretching exercises can begin immediately. Pain-free progressive strengthening exercises can also be initiated immediately and can progress to include hip flexion (with knee straight and bent) and adduction.

Therapy may be advanced to include the slide board, plyometrics (lateral sliding, lateral lunges, and X lunges), and, finally, sport-specific functional drills. (See the images below of lateral and X lunges.) The athlete may not be required to miss competition time, depending on the severity of the injury.

Lateral lunge. Lateral lunge.
Lateral lunges. Lateral lunges.
Lateral lunges. Lateral lunges.
Lateral lunges. Lateral lunges.
Lateral lunges. Lateral lunges.
X lunges. Starting position. X lunges. Starting position.
X lunges. X lunges.
X lunges. Back to the starting position. X lunges. Back to the starting position.
X lunges. X lunges.

Grade II strain

Therapy should begin immediately with gentle pain-free active range-of-motion (AROM) exercises of the hip. Isometric exercises should be initiated as soon as the patient can perform them without pain.

After 1 week, pain-free slide board exercises and plyometrics can be initiated. Soon after the first week, sport-specific functional drills can begin. An athlete with a grade II strain may miss 3-14 days of competition, depending on the severity of the injury.

Grade III strain (nonsurgical)

Therapy includes PRICE plus a non–weight-bearing restriction for acute strains. Rest is required for 1-3 days, with continuous compression. If surgery is not indicated, pain-free isometric exercises and slow, pain-free AROM exercises can be started between days 3 and 5. The athlete should continue to use crutches until normal pain-free ambulation is possible.

Initiate pain-free stretching exercises, progressive-resistance strengthening exercises (without pain), and proprioceptive neuromuscular facilitation (PNF) between days 7 and 10.

Usually within 10 days after starting progressive-resistance strengthening exercises, the patient should be able to perform pain-free slide board exercises and plyometrics and eventually advance to sport-specific functional activities.

Chronic strain

Rest, ice, massage, and therapeutic ultrasonography have been recommended to treat long-standing groin pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) and steroid injections have been suggested but have not been supported by controlled trials. Forceful adductor stretch under general anesthetic has been recommended. A careful monitored program with a total cessation of the sports activity is necessary for the chronic adductor injury to heal and become pain-free.

The physical therapy program should consist of isometric exercises, strengthening of the hip- and pelvis-stabilizing muscles, and proprioceptive training. No increase in pain should be experienced during or after the exercises. The load of the exercises is gradually increased. Specific strengthening of the adductor muscles is then implemented.

Cycling can be used to maintain general conditioning, but running can begin only after the patient can perform the exercises at high intensity without pain. Sprinting and cutting activities may then follow. Sport-specific training is the final step before full return to sport. This part of the rehabilitation program may take 3-6 months.

Previous
Next

Steroids

Use of steroid injections is controversial in adductor strains, because the potential exists for tendon rupture if the steroid is injected into the tendon itself. Renstrom advocates injection of local anesthetic with or without corticosteroids into the tendon periosteal area if conservative treatment has been unsuccessful for 2-4 months. This treatment should be combined with 1-2 weeks of rest from activity after injection.[12, 22, 23]

Previous
Next

Surgical Approach to Rupture and Chronic Strains

Surgery is indicated in acute strains only when there is rupture and in select chronic strains that are refractory to conservative treatment. In the surgical procedure, the patient is in the supine position with the knee in 90° of flexion and the hip in 45° of flexion. The adductor longus tendon is identified, and a skin incision is made. A discoloration of the tendon or a swelling indicates an old partial rupture. The tendon then is opened longitudinally. Occasionally, granulation tissue is found and excised. If there are no findings in the tendon, a tenotomy may be performed.[24, 25, 26]

A tenotomy is described in an article by Martems et al.[27] The region is infiltrated with lidocaine and epinephrine. A stab wound is made just underneath the adductor longus muscle, close to the os pubis. The insertion of the gracilis muscle and a portion of the adductor brevis are sectioned subcutaneously. The adductor longus tendon is left intact. A compression bandage is then applied for 24 hours. The patient may walk after 2 days and may resume running within pain limits 5 weeks postoperatively. The usual time to return to unrestricted sports activities is 10-12 weeks. In this study, there was no loss of power in the surgical group compared with the control group.

Although surgery has traditionally been recommended for adductor tendon rupture, a question exists as to whether attachment of the proximal adductor longus tendon to the pubis is necessary for high-level physical functioniong. In a study of 19 National Football League players with adductor tendon rupture, 14 of whom were treated nonoperatively and 5 of whom underwent surgical tendon repair with suture anchors, Schlegel et al determined that the players who received nonoperative therapy tended to return to play sooner than those who were surgically treated (mean time to return: 6.1 wk vs 12 wk, respectively).[28]

Previous
Next

Complications

Proper treatment of an acute adductor strain is important to prevent complications and development of a chronic strain. If the athlete develops chronic symptoms, his/her length of rehabilitation becomes prolonged and return to participation is delayed. A common complication that results is a tight weak adductor muscle, which is prone to recurring strains when the athlete returns to activity.

Previous
 
 
Contributor Information and Disclosures
Author

Marlon P Rimando, MD Assistant Clinical Professor, Department of Medicine, University of Hawaii, John A Burns School of Medicine

Marlon P Rimando, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, National Strength and Conditioning Association

Disclosure: Nothing to disclose.

Coauthor(s)

Bruce B Fry, DO Director, Division of Physical Medicine and Rehabilitation, Knoxville Orthopedic Clinic, St Mary's Hospital

Bruce B Fry, DO is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, North American Spine Society, American Society of Interventional Pain Physicians, International Spine Intervention Society

Disclosure: Nothing to disclose.

Robert Brunner, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham School of Medicine

Robert Brunner, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Medical Association, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Martin K Childers, DO, PhD Associate Professor, Department of Neurology, Wake Forest University Health Services

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

References
  1. Feeley BT, Powell JW, Muller MS, et al. Hip injuries and labral tears in the national football league. Am J Sports Med. 2008 Nov. 36(11):2187-95. [Medline].

  2. Hanna CM, Fulcher ML, Elley CR, et al. Normative values of hip strength in adult male association football players assessed by handheld dynamometry. J Sci Med Sport. 2009 Jun 30. [Medline].

  3. Davis JA, Stringer MD, Woodley SJ. New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. Br J Sports Med. 2011 Oct 17. [Medline].

  4. Hureibi KA, McLatchie GR. Groin pain in athletes. Scott Med J. 2010 May. 55(2):8-11. [Medline].

  5. LeCroy CM, Reedy MK, Seaber AV. Limited sarcomere extensibility and strain injury in rabbit skeletal muscle. Trans Orthop Res Soc. 1989. 14:316.

  6. Estwanik JJ, Sloane B, Rosenberg MA. Groin Strain and other Possible Causes of Groin Pain. Sports Med. 1990. 18:59-65.

  7. Ziprin P, Williams P, Foster ME. External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete. Br J Surg. 1999 Apr. 86(4):566-8. [Medline].

  8. Rassner L. Lumbar plexus nerve entrapment syndromes as a cause of groin pain in athletes. Curr Sports Med Rep. 2011 Mar-Apr. 10(2):115-20. [Medline].

  9. Ryan J, DeBurca N, Mc Creesh K. Risk factors for groin/hip injuries in field-based sports: a systematic review. Br J Sports Med. 2014 Jul. 48(14):1089-96. [Medline].

  10. Serner A, Tol JL, Jomaah N, et al. Diagnosis of Acute Groin Injuries: A Prospective Study of 110 Athletes. Am J Sports Med. 2015 Aug. 43 (8):1857-64. [Medline].

  11. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport. 1995. 27:76-79.

  12. Renstrom P, Peterson L. Groin injuries in athletes. Br J Sports Med. 1980 Mar. 14(1):30-6. [Medline]. [Full Text].

  13. Kalebo P, Karlsson J, Sward L. Ultrasonography of chronic tendon injuries in the groin. Am J Sports Med. 1992 Nov-Dec. 20(6):634-9. [Medline].

  14. Briggs RC, Kolbjornsen PH, Southall RC. Osteitis pubis, Tc-99m MDP, and professional hockey players. Clin Nucl Med. 1992 Nov. 17(11):861-3. [Medline].

  15. Falvey EC, King E, Kinsella S, Franklyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients-clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med. 2015 Nov 30. [Medline].

  16. Dahan R. Rehabilitation of Muscle-Tendon Injuries to the Hip, Pelvis, and Groin Areas. Vol 5. 1997:326-333.

  17. DePalma B, Prentice WE, eds. Rehabilitation of groin, hip, and thigh injuries. In: Rehabilitation Techniques in Sports Medicine. 3rd ed. 1999:411-443.

  18. Lynch SA, Renstrom PA. Groin injuries in sport: treatment strategies. Sports Med. 1999 Aug. 28(2):137-44. [Medline].

  19. Swain R, Snodgrass S. Managing groin pain: even when the cause is not obvious. Phys Sports Med. 1995. 23(11):55-66.

  20. Weir A, Jansen JA, van de Port IG, Van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Man Ther. 2011 Apr. 16(2):148-54. [Medline].

  21. Weir A, Jansen J, van Keulen J, Mens J, Backx F, Stam H. Short and mid-term results of a comprehensive treatment program for longstanding adductor-related groin pain in athletes: a case series. Phys Ther Sport. 2010 Aug. 11(3):99-103. [Medline].

  22. Renstrom PA. Tendon and muscle injuries in the groin area. Clin Sports Med. 1992 Oct. 11(4):815-31. [Medline].

  23. Schilders E, Talbot JC, Robinson P, et al. Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am. 2009 Oct. 91(10):2455-60. [Medline].

  24. Akermark C. Surgery of the adductor longus. In: Proceedings of the American Academy of Orthopaedic Sports Medicine. Lake Tahoe:. 1982.

  25. Neuhaus P, Gabriel T, Maurer W. [Adductor insertion tendopathy, operative therapy and results]. Helv Chir Acta. 1983 Jan. 49(5):667-70. [Medline].

  26. Randin EL, Simon SR, Rose RM. Practical Biomechanics for the Orthopaedic Surgeon. NY:. John Wiley & Sons Inc. 1979:165.

  27. Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med. 1987 Jul-Aug. 15(4):353-6. [Medline].

  28. Schlegel TF, Bushnell BD, Godfrey J, et al. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med. 2009 Jul. 37(7):1394-9. [Medline].

  29. Glik JM. Muscle strains: prevention and treatment. In: The Physician and Sportsmedicine. Vol 11. 1980:73-77.

  30. Upton PA, Noakes TD, Juritz JM. Thermal pants may reduce the risk of recurrent hamstring injuries in rugby players. Br J Sports Med. 1996 Mar. 30(1):57-60. [Medline].

  31. Hrysomallis C. Hip adductors' strength, flexibility, and injury risk. J Strength Cond Res. 2009 Aug. 23(5):1514-7. [Medline].

  32. Wiktorsson-Moller M, Oberg B, Ekstrand J. Effects of warming up, massage, and stretching on range of motion and muscle strength in the lower extremity. Am J Sports Med. 1983 Jul-Aug. 11(4):249-52. [Medline].

 
Previous
Next
 
Lateral lunge.
Lateral lunges.
Lateral lunges.
Lateral lunges.
Lateral lunges.
X lunges. Starting position.
X lunges.
X lunges. Back to the starting position.
X lunges.
Hip flexor stretch.
Hip flexor stretch, isolation of the rectus femoris.
Elastic bandage applied to give pain relief from an adductor strain.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.