History
Generally, symptoms are more diffuse, with typical complaints of pain and stiffness in the groin region in the morning and at the beginning of athletic activity. Initial intense pain lasts less than a second. This initial pain is soon replaced with an intense, dull ache. Pain severity can vary with different patients. Pain and stiffness often resolve after a period of warming up but often recur after athletic activity.
Typical findings include tenderness at the origin of the adductor longus and/or the gracilis located at the inferior pubic ramus, as well as pain with resisted adduction. Groin pain can represent a number of different diagnoses, and all differential diagnoses should be kept in mind when assessing the patient. Obtain information about the mechanism of injury and loss of function, as well as about the location, quality, duration, and severity of pain. The aggravating and alleviating factors also should be noted.
Usually, pain is described at the site of the adductor longus tendon proximally, especially with rapid adduction of the thigh. As the injury becomes more chronic, pain may radiate distally along the medial aspect of the thigh and/or proximally toward the rectus abdominis. Acute injuries are described as a sudden ripping or stabbing pain in the groin, and chronic injuries are described as a diffuse dull ache.
Exercise-induced medial thigh pain over the area of the adductors, especially after kicking and twisting, may indicate obturator neuropathy. Pain at the symphysis pubis or scrotum may be more consistent with osteitis pubis. Conjoined tendon lesions present as pain that radiates upward into the rectus abdominis or laterally along the inguinal ligament; exquisite tenderness is present at the site of the injury.
True loss of function is not observed unless a grade III tear is present. In the case of a severe tear, loss of hip adduction occurs. Loss of function also should alert the physician to possible nerve involvement (obturator nerve entrapment).
Physical Examination
The acute adductor strain commonly occurs at the musculotendinous junction. Tenderness, swelling, and ecchymosis can be observed at the superior medial thigh. Sometimes, a defect in the muscle can be palpated. Pain is noted with resisted adduction and full passive abduction of the hip.
A pure hip adductor strain can be distinguished from combination injuries involving the hip flexors (ie, iliopsoas, rectus femoris) by having the patient lie in the supine position. If more discomfort is reproduced with resistive adduction when the knee and hip are extended than if the hip and knee are flexed, a pure hip adductor strain can be assumed.
Physical findings can help distinguish adductor strains from other causes of groin pain, such as the following:
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Iliopsoas strain: hip flexion against resistance is painful; tenderness is difficult to localize because the insertion of the iliopsoas is deep
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Osteitis pubis: tenderness of the symphysis pubis and possible loss of full rotation of one or both hip joints are noted
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Conjoined tendon lesions (ie, sportsman's hernia): exquisite tenderness upon palpation at the inguinal canal; having the patient cough reproduces pain
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Obturator neuropathy: adductor muscle weakness, muscle spasm, and paresthesia over the medial aspect of the distal thigh may be present; loss of adductor tendon reflex with preservation of other muscle stretch reflexes often is observed; a positive Howship-Romberg sign (medial knee pain induced by forced hip abduction, extension, and internal rotation) sometimes is observed
If a mass is felt in the middle to upper thigh, the physician must consider a rupture at the distal musculotendinous junction. Tumor and hernia also should be ruled out. These conditions warrant a surgical consultation.
Obturator nerve entrapment should be suspected if there is exercise-induced medial thigh pain that starts at the origin of the adductor longus and radiates distally along the medial thigh. Denervation of the adductor muscles is seen on needle electromyography (EMG). The treatment for obturator nerve entrapment is nonoperative, with surgical neurolysis in recalcitrant cases.
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Lateral lunge.
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Lateral lunges.
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Lateral lunges.
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Lateral lunges.
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Lateral lunges.
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X lunges. Starting position.
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X lunges.
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X lunges. Back to the starting position.
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X lunges.
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Hip flexor stretch.
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Hip flexor stretch, isolation of the rectus femoris.
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Elastic bandage applied to give pain relief from an adductor strain.
