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. [23, 24, 25, 26, 27, 28]
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.
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. [29, 30]
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.
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.
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. [16, 31, 32]
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. [33, 34, 35]
A tenotomy is described in an article by Martems et al. [36] 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). [37]
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.
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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.
