Adductor-Related Groin Pain
- Adductor (groin) strain is the COMMONEST cause of acute groin pain in athletes, and the muscle most often injured is the ADDUCTOR LONGUS, typically at its musculotendinous junction or its proximal enthesis on the pubis; it is especially common in sports involving cutting, kicking and rapid change of direction such as soccer/football, ice hockey and Australian football.
- The MECHANISM is a forceful ECCENTRIC contraction of the adductors - the muscle contracting while being lengthened - during cutting, change of direction, kicking or reaching/lunging for a ball; large eccentric contractions are known to cause or exacerbate the strain (for example during run-to-cut manoeuvres), which is the basis for eccentric-focused prevention and rehabilitation.
- The CLINICAL picture is acute medial GROIN pain (sometimes with a tearing sensation), tenderness over the adductor origin/musculotendinous junction, and pain reproduced by RESISTED ADDUCTION and by the adductor 'SQUEEZE TEST' (pain/weakness on squeezing the examiner's fist or a ball between the knees); strains are graded I-III by severity (I minor, II partial tear with weakness, III complete tear/avulsion).
- The Doha agreement on terminology places this within ADDUCTOR-RELATED groin pain, one of the defined clinical entities of groin pain in athletes (alongside iliopsoas-related, inguinal-related and pubic-related groin pain, plus hip-joint causes), which encourages a systematic approach and recognition that more than one entity may coexist.
- IMAGING is used to confirm and grade and to exclude other causes: ULTRASOUND and MRI show the site and grade of the adductor strain (and any avulsion or proximal tendon tear), while assessment should also consider the differential of groin pain - osteitis pubis, iliopsoas, sports hernia/inguinal disruption, hip-joint pathology (FAI/labral tear) and, importantly in adolescents, an apophyseal avulsion rather than a muscle strain.
- MANAGEMENT is predominantly CONSERVATIVE with a HIGH REINJURY RATE that makes rehabilitation quality critical: initial relative rest/ice/analgesia, then a PROGRESSIVE, ECCENTRIC-based strengthening and reconditioning programme (e.g. Copenhagen-adduction-type exercises) restoring adductor strength and the adductor-to-abductor ratio, with a criteria-based return to sport; validated rehab/reconditioning programmes can return professional players in around two weeks for lower-grade injuries, while complete tears/avulsions or refractory cases occasionally need surgery (tenotomy/repair).
- “Adductor strain = commonest acute groin injury; ADDUCTOR LONGUS the usual muscle (musculotendinous junction/enthesis); ECCENTRIC contraction during cutting/kicking.
- “Acute medial groin pain; pain on RESISTED ADDUCTION and the SQUEEZE test; graded I-III; Doha 'adductor-related groin pain'. Exclude apophyseal avulsion in adolescents, osteitis pubis, sports hernia, hip pathology.
- “Conservative with HIGH reinjury rate - progressive ECCENTRIC strengthening (Copenhagen adduction), criteria-based return; surgery only for complete tear/avulsion or refractory cases.
Acute medial groin pain after cutting/kicking; tenderness over the adductor longus origin/musculotendinous junction; pain on resisted adduction and the squeeze test.
High reinjury rate - rehabilitate with progressive eccentric strengthening and a criteria-based return. Exclude apophyseal avulsion (adolescents) and other groin-pain causes.
Mechanism, Assessment & Differential
Adductor (groin) strain is the commonest acute groin injury in athletes, usually involving the adductor longus at its musculotendinous junction or proximal enthesis, in cutting/kicking sports. The mechanism is a forceful eccentric contraction during cutting, change of direction, kicking or reaching for a ball - the muscle loaded while lengthening - and large eccentric contractions cause or exacerbate the strain. Clinically there is acute medial groin pain, adductor tenderness, and pain on resisted adduction and the squeeze test, graded I-III. The Doha agreement classifies this as adductor-related groin pain, one of the defined groin-pain entities (with iliopsoas-, inguinal-, pubic-related and hip causes), and more than one may coexist. Ultrasound/MRI confirm and grade; the differential includes osteitis pubis, iliopsoas, sports hernia, hip pathology and - importantly in adolescents - an apophyseal avulsion rather than a strain.
Management & Return to Play
- Acute phase: relative rest, ice, analgesia; protect from re-loading.
- Progressive eccentric strengthening: the core of rehab - restore adductor strength and the adductor-to-abductor ratio (e.g. Copenhagen-adduction-type exercises) and reconditioning for the specific sport demands; validated reconditioning programmes can return professional players in about two weeks for lower-grade injuries.
- Criteria-based return to sport: pain-free, restored strength and sport-specific function - because the REINJURY rate is high if return is premature.
- Prevention: adductor-strengthening programmes (and addressing strength deficits/imbalance) reduce injury risk; directional compression shorts can reduce adductor loading during cutting.
- Surgery is uncommon: reserved for complete tears/avulsions or refractory adductor-related groin pain (e.g. tenotomy or repair)."
Two points matter in adductor/groin strain. First, in the SKELETALLY IMMATURE athlete the apophysis is the weak link, so what looks like an adductor 'strain' after a forceful kick or sprint may actually be an APOPHYSEAL AVULSION (e.g. of the pubic or ischial apophysis), which a plain radiograph will show - so do not assume a muscle strain in an adolescent without considering and, if needed, imaging for an avulsion. Second, adductor strains have a HIGH REINJURY rate, and the main determinant of a durable recovery is the quality of rehabilitation and the discipline of a criteria-based return, not just time: a progressive eccentric-strengthening programme that restores adductor strength and balance, with return only when pain-free and strong, is what prevents the frustrating cycle of reinjury.
Evidence & Key Studies
Validated rehab and reconditioning programme after adductor longus injury in professional soccer
- High rates of adductor injuries and reinjuries in soccer indicate that prevention and reconditioning programmes are needed to prepare athletes for the specific demands of the sport.
- An expert-validated rehabilitation and reconditioning programme, based on strengthening the injured muscle and retraining conditional capacities, aimed to reduce reinjury risk.
- When applied to professional players, return to full team training occurred at about 13 days on average.
Hip adductor activation during run-to-cut manoeuvres (mechanism and load reduction)
- Athletes in sports such as hockey and soccer are at high risk of groin/adductor strains, and large eccentric contractions are known to cause or exacerbate strain injuries.
- Run-to-cut manoeuvres load the adductor longus, consistent with the eccentric/cutting mechanism of injury.
- Wearing directional compression shorts reduced stance-limb hip adductor activity, suggesting a way to reduce adductor demand on return to activity.
According to PubMed, the high adductor injury/reinjury rate in soccer and the value of a validated, strengthening- based rehabilitation/reconditioning programme (with return to training in about two weeks for lower-grade injuries) come from the cited Jimenez-Rubio study; the eccentric/cutting mechanism (large eccentric contractions causing/exacerbating strain, adductor longus loading during run-to-cut, and adductor-load reduction with directional compression) from the cited Chaudhari study. The adductor longus as the usual site, the squeeze test and grading, the Doha adductor-related groin-pain framework, and the differential (including adolescent apophyseal avulsion) are standard, well-established teaching. (See also our Osteitis Pubis and Pelvic Apophyseal Avulsion Fractures topics.)
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A soccer player develops acute medial groin pain after a cutting movement. What is the likely diagnosis and how do you assess it?”
“How would you rehabilitate an adductor strain and reduce reinjury?”
Mnemonics & Memory Aids
ADDUCT
Hook:ADDUCT: Adductor longus, Direction-change mechanism, Doha entity, Use squeeze test, Consider avulsion in teens, Treat eccentrically (high reinjury).
What & mechanism
- Commonest acute groin injury; adductor longus usually (musculotendinous junction/enthesis)
- Eccentric contraction during cutting/kicking/change of direction
- Sports: soccer/football, ice hockey, AFL
Assessment
- Acute medial groin pain; adductor tenderness
- Pain on resisted adduction and the squeeze test; grade I-III
- Doha 'adductor-related groin pain'; ultrasound/MRI confirm and grade
Differential
- Adolescent apophyseal avulsion (image it), osteitis pubis
- Iliopsoas, sports hernia/inguinal disruption
- Hip-joint pathology (FAI/labral tear); entities may coexist
Management
- Acute: relative rest, ice, analgesia
- Progressive eccentric strengthening (Copenhagen adduction); restore adductor:abductor ratio
- Criteria-based return (high reinjury rate); surgery only for complete tear/avulsion or refractory