A groin strain involves an injury to the muscle-tendon unit of the hip adductor muscles, which can range from overstretching to a tear. These muscles include the adductor longus, adductor brevis, adductor magnus, pectineus, gracilis, and obturator externus. The adductor longus muscle is the most frequently injured in acute adductor lesions and is often affected in acute and gradual-onset injuries. These muscles are critical for adduction of the thigh in open-chain motions and for stabilizing the lower extremity and pelvis in closed-chain motions. Acute adductor injuries are common in sports requiring kicking or fast changes of direction.
Key Symptoms:
Sharp pain in the groin/inner thigh. This pain is activity-related and often resolves with rest, but recurrence is common upon resuming sports. The pain can also radiate into the perineum, rectus muscles, inguinal ligament, and testicular area.
Pain on palpation of the adductor tendons or their insertion on the pubic bone. The adductor longus tendon's insertion is a key area for palpation, extending approximately 10 cm down into the muscle belly.
Pain during resisted adduction. This can be elicited by a resisted sit-up with legs extended or flexed, or specifically via the isometric adductor squeeze test performed on straight limbs. Pain and discomfort during this test can be rated on a numeric pain scale (0-10).
Swelling or bruising (if severe). Acute adductor ruptures can lead to a hematoma in the medial thigh within 24-48 hours, sometimes extending distally.
Loss of strength and function. A first-degree strain involves minimal loss of strength and restriction of motion, while a second-degree strain compromises muscle strength but not complete loss of function. A third-degree strain indicates complete disruption and loss of muscle function. Adductor-muscle weakness, particularly eccentric weakness, is commonly observed.
Differentiate from other conditions:
It is crucial to differentiate groin/adductor strains from other potential causes of groin pain, as multiple pathologies can coexist or present with similar symptoms. A thorough history, clinical examination, and imaging studies are important for an accurate diagnosis.
Conditions to differentiate from include:
Hip labral tears.
Sports hernias (athletic pubalgia). Athletic pubalgia involves weakening or tears in the abdominal wall muscles without a palpable hernia. It is often a clinical diagnosis of exclusion.
Pubic symphysis dysfunction/Osteitis Pubis. Osteitis pubis is an isolated or repetitive injury to the pubic symphysis and surrounding structures, often involving adductor muscles. While the term "osteitis pubis" has been used to describe radiological signs, some argue it should be reserved for complications due to surgery in retropubic regions, as adductor-related symptoms are often present and dominant in athletes diagnosed with it.
Hip flexor strain (Iliopsoas strain/tear). Iliopsoas-related pain was a primary clinical entity in 35% of patients in one study, and a major secondary entity in football players.
Femoroacetabular impingement (FAI). FAI can cause pain localized to the groin and is often diagnosed by activity-related pain, stiffness, and decreased hip range of motion, particularly internal rotation and flexion. It can coexist with athletic pubalgia.
Nerve entrapment (e.g., ilioinguinal, obturator, genitofemoral neuropathy). The ilioinguinal and genitofemoral nerves are considered key sensory nerves in chronic groin pain.
Other musculoskeletal causes such as bursitis, piriformis syndrome, and lumbar disc pathology.
Non-orthopaedic causes like urological or gastrointestinal issues.
Magnetic resonance imaging (MRI) is a preferred complementary test for diagnosis and classification, revealing the extent of tears, bone marrow edema, and other related pathologies. However, MRI findings lack specificity, and many patients with sports hernia may not show pathological findings on MRI. Clinical suspicion of intra-articular hip injury should prompt radiological and sometimes MRI assessment. Diagnostic anesthetic injections can also help determine the primary source of groin pain when symptoms overlap.
Rehabilitation Guide:
Effective rehabilitation for adductor strains and tears involves a systems approach incorporating primary, secondary, and tertiary prevention, focusing on specific exercises and loading strategies.
General Principles of Rehabilitation:
Active Exercises over Passive Modalities: Active exercises are significantly more effective than passive modalities (e.g., rest, massage, stretching, ice/heat, TENS) in enabling athletes to return to sport without groin pain.
Progressive Loading: Rehabilitation programs should involve progressive loading and substantial time under tension for exercises. This allows for tissue repair and regeneration. Loads are gradually increased from light to moderate, and then to heavy, with emphasis on slow concentric, isometric, and eccentric contractions initially, progressing to faster movements.
Addressing Risk Factors: Rehabilitation addresses identified risk factors such as adductor weakness, muscle imbalances (adduction:abduction strength ratio), and previous injuries. The Copenhagen adductor exercise is a key component due to its evidence for increasing eccentric strength.
Focus on Strength, Endurance, Coordination, and Balance: Programs should focus on restoring musculotendinous endurance and strength, as well as neuromuscular control, balance, and coordination. Plyometric exercises are introduced in the sport-specific phase to improve neuromuscular coordination and joint stiffness.
Individualized and Criteria-Based Progression: Rehabilitation should be individualized and guided by continuous assessments, including monitoring pain, strength, and functional performance. Athletes can train with some pain (e.g., 3-5 on a 0-10 scale) as long as it does not persist or worsen notably.
Return to Sport (RTS) Phases: RTS is a gradual process typically divided into stages:
Return to Participation: Athletes perform agility drills and maximal actions (accelerating, decelerating, twisting, turning, jumping, landing, kicking) with proper form, minimal pain, and no visible compensations. Athletes should aim for 80-90% of full muscle strength before this phase.
Return to Sport/Training: Athletes progress from 30 to 90 minutes of individual or team training, participating for 1-3 weeks before full competition. Full muscle and functional recovery should be achieved.
Return to Performance: This phase can take 3-6 months post-RTS and requires consistent training and competition. Muscle strengthening programs should continue frequently (e.g., 3 times/week) until pre-injury performance is reached, then transition to maintenance (e.g., 1 session/week).
Specific Rehabilitation Considerations:
Acute Adductor Tears (Complete Tears): For complete adductor tears (e.g., Adductor Longus Tendon tears), both non-operative and surgical treatments are acceptable options.
Non-operative treatment with physical therapy averages 8.9 weeks for return to play. Recovery for partial acute adductor tears treated non-operatively ranges from 1 to 6.9 weeks depending on injury grade.
Surgical treatment for complete ALM tears reported an average return to play at 14.2 weeks. Greater stump retraction was observed in surgically treated cases.
Incomplete Adductor Tears: These are treated non-operatively with physical therapy in all studies reviewed, with average return-to-play times of 1 to 6.9 weeks based on injury grade.
Long-Standing Adductor-Related Groin Pain: These conditions are often more challenging, lasting over 6 weeks, and full recovery can take 6-9 months. Recovery times can be prolonged if combined with underlying pubic symphysis or bony reactions.
Recurrence Rate: The average recurrence rate for adductor injuries is 5% (range, 0%-19%), with many reinjuries occurring within the first 2 months of returning to full team training. Kicking-related injuries and premature return to sport are associated with increased reinjury rates.
Anatomy of the Adductor Muscles
The adductor group, often referred to as the inner thigh muscles, consists of several muscles: the adductor longus, adductor brevis, adductor magnus, gracilis, and pectineus.
Anatomical Attachments and Innervation:
The adductor longus muscle (ALM), the most frequently injured adductor, originates at the body of the pubis, where it merges with the rectus abdominis insertion, forming a common adductor–rectus abdominis aponeurosis. Its anterior tendinous part inserts into the pubic bone, with superficial fibers extending across the front of the symphysis to fuse with the distal rectus abdominis and external oblique aponeurosis. The ALM also inserts into the middle third of the femoral linea aspera.
All adductor muscles are primarily innervated by the posterior division of the obturator nerve, which arises from the second to fourth lumbar nerve roots. The tibial portion of the sciatic nerve also contributes to their innervation. An exception is the pectineus, which also receives innervation from the femoral nerve.
Functions of the Adductor Muscles:
Adduction of the thigh: This is their primary function in open-chain motions.
Pelvic and Lower Extremity Stabilization: They are crucial for stabilizing the pelvis during single-leg activities and the lower extremity in closed-chain motions. This includes stabilizing and decelerating the body and pelvis during movements requiring changes of direction.
Deceleration and Force Production in Sport-Specific Movements: The adductors are highly active in sports involving kicking, skating, and changes of direction.
They are important for fast near-isometric and eccentric contractions during musculotendinous lengthening. High forces are developed, especially during eccentric movements like the backswing of a soccer kick or the lateral push in skating, which place elevated strain on the muscles and tendons around the pubic symphysis.
The adductor longus is important for hip flexion during kicking and for propulsion during sprinting and skating.
The adductor magnus plays a significant role as a hip extensor from a more flexed hip position. This function is particularly relevant in the stance limb during the push-off phase (e.g., initial acceleration during sprinting and skating) and when that limb acts as the stance limb opposite to the kicking side.
Bilateral Force Couple: The adductors can function almost like a "pair of scissors" and a bilateral force couple during actions such as sprinting, kicking, and skating, performing critical stabilizing and primary movement roles depending on the specific movement patterns of the sport.
Causes & Risk Factors
Adductor muscle injuries, commonly referred to as groin strains or inner thigh muscle injuries, are frequent in sports and can result from a combination of specific actions and underlying risk factors.
Common Causes
Acute adductor injuries are often a result of forceful actions that challenge the muscle-tendon unit:
Sudden Direction Changes (Sprinting, Lunging): Acute adductor injuries are common in sports activities that require fast changes of direction. The hip-adductor muscles are essential for stabilizing and decelerating the body and pelvis during these movements. High forces are developed during eccentric movements, such as the lateral push in skating or during braking and cutting actions. Eccentric overload during a change of direction is also a common mechanism for adductor longus ruptures.
Overstretching (e.g., Soccer Kicks, Lower Limb "Reaching"): Injuries can occur during sporting movements where the muscle is stretched during a forceful contraction. This includes the backswing of a soccer kick, which involves eccentric contractions and musculotendinous lengthening, placing elevated strain on the muscles and tendons around the pubic symphysis. Traumatic tendinous avulsions of the proximal adductor longus muscle (ALM) have been caused by overstretch while kicking.
Muscle Imbalances (Weakness, Asymmetry): A widely accepted theory for the pathogenesis of athletic pubalgia (a common cause of chronic groin pain) is an imbalance between the strong hip adductor muscles and the comparatively weaker lower abdominal muscles.
Adductor Weakness: Weak adductor muscles compared with the uninjured side are a significant risk factor for acute adductor injury. For instance, preseason hip adduction strength was found to be 18% lower in professional ice hockey players who later sustained groin strains.
Adductor-to-Abductor Strength Ratio: A low eccentric hip-adductor to -abductor strength ratio (e.g., less than 0.8) is associated with an increased risk for acute adductor strains, particularly in ice hockey.
Reduced Hip Range of Motion: Reduced rotational hip range of motion is also a risk factor for acute adductor injury. Decreased preseason hip abduction range of motion has been linked to subsequent groin strains in soccer players.
Previous Injury: A previous acute groin injury is a substantial risk factor for developing groin problems and increases the likelihood of recurrence. Recurrence rates for adductor injuries can range from 18% to 24% in various sports.
Rapid Changes in Training Load: Sudden increases in activity level, especially during the preseason or after low levels of off-season activity, contribute to injury risk due to rapid changes in training volume. An overuse pattern can also develop from a substantial workload over a sustained period or from returning to sport after an initial acute injury without adequate treatment.
Growth-Related Changes: Significant changes in hip-adductor forces occur during adolescent growth, which may increase stress on the adductor muscle-tendon complex and contribute to an increased risk of groin problems in young, growing athletes.
High-Risk Sports
Adductor muscle injuries are common in sports that involve kicking, skating, fast changes of direction, and rapid acceleration/deceleration.
Soccer (Football): This is the most frequent sport associated with acute adductor injuries, accounting for 62% of patients in one systematic review. Adductor strains represent half of the acute injuries around the hip joint in soccer players. The incidence of acute adductor injuries in elite soccer players has been estimated at 0.61 injuries per 1000 hours of exposure, and groin injuries in general comprised 5% to 13% of all injuries in football studies. Adductor-related dysfunction is the most common primary clinical entity found in football players.
Hockey (Ice Hockey): Adductor strains are frequently encountered in ice hockey. Groin strains accounted for 10% of all injuries in elite Swedish ice hockey players and 43% of all muscle strains in elite Finnish ice hockey players. The incidence in a National Hockey League (NHL) team was 3.2 strains per 1000 player-game exposures.
Football (American Football): This sport frequently involves acute adductor injuries due to activities requiring kicking. In a systematic review, 3% of patients with acute adductor injuries were American football players.
Martial Arts (e.g., Taekwondo): Martial arts are listed among sports commonly involved in chronic lower abdomen and groin pain. Taekwondo is specifically mentioned as a sport where acute adductor injuries can occur, though less frequently than in other major sports. The "overstretching" mechanism, highly relevant to martial arts kicks, contributes to injuries in this category.
Other sports with a notable frequency of adductor injuries include:
Futsal: 6% of patients with acute adductor injuries in a review.
Basketball: 14% of patients with acute adductor injuries. Adductor strain injuries represent 22% of acute injuries around the hip joint in National Basketball Association (NBA) players.
Australian Rules Football: This sport has a notable incidence of 3.2 new injuries per club per season and is commonly involved in chronic groin pain cases.
Handball: 2% of patients with acute adductor injuries in a review.
Rugby: 1% of patients in a review, and also listed as a commonly involved sport for chronic groin pain.
Running: While iliopsoas-related pain is particularly prevalent among runners, it is a major contributing factor to groin pain. Long-distance runners are also susceptible to stress fractures in the pubic rami and femoral neck.
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Physiotherapy is critical for the effective management of adductor muscle injuries, often referred to as groin strains, as it plays a pivotal role in preventing recurrence, averting the development of chronic conditions like athletic pubalgia, and addressing compensatory injuries or muscle imbalances.
Preventing Recurrence
Without proper rehabilitation, groin strains frequently recur. A previous acute groin injury is a substantial risk factor for developing future groin problems. Studies have shown recurrence rates for adductor injuries ranging from 18% to 24% in sports such as soccer, Australian Rules football, collegiate ice hockey, and professional basketball. One study reported a reinjury rate of 19% in NBA athletes with adductor injuries, and another described a 7.4% reinjury rate within one year after treatment, with most reinjuries (5 of 6) occurring within the first two months of returning to full team training. Factors like kicking-related injury and premature return to sport are associated with increased reinjury rates after complete adductor longus muscle (ALM) tears. The high incidence of recurrent strains can often be attributed to incomplete rehabilitation or inadequate time for complete tissue repair.
Improperly treated adductor strains can progress to chronic and potentially career-threatening problems. When an athlete attempts to play through an adductor injury or does not receive adequate or appropriate management, a long-standing adductor injury can develop. This can lead to what is commonly known as athletic pubalgia (AP), which is increasingly recognized as a cause of chronic groin and adductor pain in athletes. AP is considered an overuse injury resulting from disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall.
A widely accepted theory for the pathogenesis of AP is a muscle imbalance between the strong hip adductor muscles and the comparatively weaker lower abdominal muscles. This imbalance creates shearing forces across the hemipelvis, potentially leading to attenuation or tearing of fascia and musculature. Long-standing problems involving the hip adductors often have a typical overuse pattern, potentially caused by a sudden increase in activity or a change in playing style. If early identification and rehabilitative management fail, more time off is needed to manage these more severe, long-standing problems. While conservative therapy is usually the initial approach for AP, evidence for its consistent success is lacking, and patients often require surgical intervention if nonoperative measures fail, underscoring the importance of preventing this progression in the first place.
Addressing Compensatory Hip/Low Back Injuries
The groin region has complex anatomy, involving a confluence of structures and intricate biomechanics. Multiple origins of groin pain are common, with more than one-third of patients presenting with two or even three distinct clinical entities. For example, adductor-related pain and iliopsoas-related pain can coexist, indicating a high degree of dependence between these two muscles in relation to pelvic stability.
The pelvis is critical in sports biomechanics, as most movements rely on a well-balanced pelvis and the coordinated action of different muscle groups, ligaments, and joints. If one of these structures is injured and not functioning optimally, the balance around the pelvis can be disturbed, placing other pelvis-related structures at risk. This highlights the need for a comprehensive rehabilitation approach that goes beyond just the site of pain. Physiotherapy aims to normalize lower extremity muscle balance and protect the groin during energy transfer in sports participation.
The Role of Physiotherapy in Rehabilitation and Prevention
Progressive strength training and sport-specific loading are the treatments with the highest level of evidence for both acute and long-standing adductor-related problems. Early detection and appropriate management are crucial to prevent injuries from becoming chronic.
Key aspects of effective physiotherapy include:
Active Exercises: Rehabilitation programs utilizing active exercises are significantly more effective than passive modalities (e.g., massage, stretching without strengthening) in enabling athletes to return to sport without groin pain.
Targeted Strengthening: Programs should focus on adductor strengthening, with a particular emphasis on eccentric muscle function, as adduction weakness and a low eccentric hip-adductor to -abductor strength ratio are known risk factors. The Copenhagen adductor exercise is a well-documented and time-efficient approach for enhancing adductor strength and reducing groin problems.
Comprehensive Approach: Rehabilitation should address hip-adductor, gluteal, and trunk strength, as well as balance, coordination, and plyometrics. This systemic approach helps optimize sport-specific pelvic load transfer.
Monitoring and Progression: Physiotherapists monitor muscle strength and pain responses throughout rehabilitation, adjusting the loading program as needed. Athletes often have not fully recovered adductor strength upon returning to training, making continuous monitoring essential.
Gradual Return to Sport (RTS): The goal of rehabilitation is not just to return to sport but to achieve symptom-free pre-injury performance levels and reduce the risk of recurrence. This involves a gradual progression through different phases, with milestones for strength (aiming for ≥80% to 90% of full muscle strength) and pain reduction.
Patient Commitment: Effective rehabilitation requires the athlete's commitment and effort, as programs require progressive overload and can be long-term.
By addressing the underlying causes, strengthening the necessary muscle groups, and guiding a structured, progressive return to activity, physiotherapy is indispensable for achieving optimal recovery and preventing future injury in athletes with adductor problems.
Recovery Timeline by Severity
Physiotherapy is critical for the effective rehabilitation of adductor muscle injuries, influencing the recovery timeline and outcomes. The recovery period for groin strains, or adductor muscle injuries, varies significantly based on the severity of the tear, with different implications for non-operative and surgical management.
Here is a general recovery timeline based on the severity of the adductor muscle injury:
It is important to note that these timelines represent averages and can vary significantly among individuals based on the specific injury, athlete's commitment to rehabilitation, and other factors. While athletes with adductor ruptures and long-standing problems may sometimes return to sport (RTS) after 6 to 10 weeks, they might still have strength and functional deficits. The ultimate goal of rehabilitation is not just RTS but achieving symptom-free pre-injury performance levels and reducing the risk of recurrence.
Physiotherapy Treatment Plan
Physiotherapy is critical for the effective management of adductor muscle injuries (groin strains), as it influences the recovery timeline and helps prevent recurrence and progression to chronic conditions like athletic pubalgia. Optimal management of adductor-related pain in athletes is primarily based on specific exercises and loading strategies.
Phase 1: Acute Management (0–2 Weeks)
Goals: Reduce pain and swelling, and prevent excessive muscular inhibition or disuse effects while initiating tissue repair.
POLICE Protocol (Protect, Optimal Loading, Ice, Compression, Elevation): Initial management of acute adductor strains often includes rest and nonsteroidal anti-inflammatory drugs (NSAIDs), particularly if the injury is near the bone-tendon junction. The first 48 hours after injury typically involve RICE (rest, ice, compression, elevation). In the very early acute/subacute phase, the primary goals are protection of the injured structure, pain control, and reducing inflammation and edema.
Gentle Mobility: For acute injuries, light to moderate loads are applied with exercises designed to cause no or minimal pain provocation. Early rehabilitation includes pain-free hip passive range of motion and nonweightbearing hip progressive resistance exercises. For complete adductor longus muscle (ALM) tears treated non-operatively, initial rehabilitation may involve hip range of motion limited to 10-0-10 degrees for 1 to 3 weeks, with no active abduction/stretching or massage on the injury site to avoid calcification, and lymphatic drainage. By week 2, pool walking and stretching are introduced.
Phase 2: Strengthening (2–6 Weeks)
Goals: Gradually restore strength and control, and begin tissue regeneration through progressive loading.
Isometrics: Submaximal isometric adduction exercises should be initiated, progressing from knees bent to knees straight, aiming for maximal isometric adduction when pain-free. Isometric contractions with minimal or no pain need to be achieved as a primary goal in the acute/subacute phase.
Eccentrics:Progressive strength training and sport-specific loading have the highest level of evidence for adductor problems. Rehabilitation programs should emphasize eccentric muscle function, as adduction weakness and a low eccentric hip-adductor to -abductor strength ratio are known risk factors. The Copenhagen adductor exercise is a well-documented and time-efficient approach that specifically targets eccentric adductor strength and reduces groin problems. This exercise should be a consistent component of the program and can be progressed by increasing volume.
Hip Stability & Comprehensive Strengthening: Rehabilitation should address hip-adductor, gluteal, and trunk strength, as well as balance, coordination, and plyometrics. Exercises should include core strengthening, single-limb stance, and exercises targeting all hip and pelvic muscles using strength-training machines, side-lying exercises with limb weight, and standing exercises with elastic bands or cables. Bilateral activation is important, stimulating adductors as both prime movers and stabilizers.
Progressive Loading Principles: During this conditioning phase, loads progress from light (≤15-repetition maximum [RM]) to moderate (12–15 RM). Conditioning should focus on slow concentric, isometric, and eccentric contractions initially to avoid excessive load on musculotendinous structures. Clinical milestones for this phase include achieving lower extremity passive range of motion equal to that of the uninvolved side and involved adductor strength at least 75% that of the ipsilateral abductors.
Phase 3: Functional Return (6+ Weeks)
Goals: Optimize sport-specific pelvic load transfer and prepare for return to competition. The ultimate goal is to achieve symptom-free pre-injury performance levels and reduce the risk of recurrence.
Plyometrics:Plyometric exercises should be introduced, as they affect neuromuscular coordination and timing around the hip and knee, increasing hip adductor preactivity and coactivation. Examples include various jumping exercises. Early plyometrics may be introduced as early as week 2 for light activities.
Biomechanical Analysis & Sport-Specific Drills: Sport-specific training should include increasing load, intensity, speed, and volume of exercises. This involves activities like running, sprinting, and multidirectional running. Exercises should mimic sport-specific movements such as kicking or shooting, sprinting or fast skating, braking or cutting, and jumping or landing, with a focus on proper execution without compensatory strategies. Athletes may undergo video assessment of running/kicking form to identify and correct techniques. Monitoring strength and pain responses is crucial throughout rehabilitation.
Return to Sport Criteria & Progression: Athletes should aim for ≥80% to 90% of full muscle strength and no or minimal pain (0–2/10) during clinical examination, heavy strength training, and maximal sport-specific actions before entering the return-to-sport phase. Return to full team training for moderate incomplete injuries is around 6.9 weeks. For complete adductor longus tears treated non-operatively, average return to play is 8.9 weeks. Return to full team training for Grade 3 injuries typically averages 11 weeks (range, 5-32 weeks). Athletes often have not fully recovered adductor strength when returning to training, necessitating continuous monitoring. Full performance is often not achieved until 3 to 6 months after return to sport, requiring consistent training and competition.
Manual Therapy Techniques
Soft Tissue Release: Early phase rehabilitation protocols may include massage. However, rehabilitation programs utilizing active exercises are significantly more effective than passive modalities (e.g., massage, stretching without strengthening) in enabling athletes to return to sport without groin pain, with an odds ratio of 12.7. Manual stretching may be introduced later in rehabilitation, around week 6 for non-operative cases of complete ALM avulsion.
Dry Needling & Injections: The role of steroid injections in adductor strains remains controversial, with some studies suggesting limited benefit for chronic cases with long-standing symptoms. For athletic pubalgia, ultrasound-guided steroid injections into the rectus abdominis insertion or adductor tendon might be helpful, but there is not enough evidence regarding their short- and long-term efficacy. There is also no study on the results of platelet-rich plasma (PRP) injections for acute adductor injuries in the reviewed literature. Surgical intervention for chronic adductor tears may involve tenotomy, and for athletic pubalgia, it can involve adductor releases or injections with steroid or PRP at the time of surgery if the adductor longus is involved.
Prevention Strategies
Preventing groin strains (adductor muscle injuries) in athletes involves a multifaceted approach, primarily focusing on addressing identified risk factors through targeted exercises and loading strategies.
Key Prevention Strategies
Dynamic Warm-Up:
A comprehensive 20-minute alternative warm-up program developed for adult male professional soccer players was found to reduce groin injuries by 28%. This program incorporates dynamic stretching, core strengthening, and pelvic proprioceptive exercises to encourage a neutral pelvis during dynamic activities.
Specific warm-up components mentioned include biking, adductor stretching, sumo squats, side lunges, and kneeling pelvic tilts.
The FIFA 11+ program also includes a warm-up phase as part of its comprehensive injury prevention strategy.
Strengthen:
Adductor Strengthening: This is a critical component, with evidence suggesting that progressive strength training and sport-specific loading are the treatments with the highest level of evidence for adductor problems.
Adductor weakness compared with the uninjured side is a significant risk factor for acute adductor injury.
The Copenhagen adductor exercise is highlighted as the most time-efficient approach for prevention, specifically targeting eccentric muscle function, which is a main risk factor for groin injury. This exercise can be easily progressed by increasing volume.
Intervention programs focusing on adductor strengthening have been shown to decrease the incidence of adductor strains in professional ice hockey players. For instance, a program for athletes with an adductor-to-abductor strength ratio of less than 80% significantly reduced injury incidence.
Isometrics (e.g., adductor squeezes, submaximal isometric adduction with knees bent then straight) should be initiated and progressed to maximal isometric adduction when pain-free.
Eccentric exercises (e.g., side-lying leg lowers, standing adduction with cable or resistance band, sliding board exercises) are crucial for restoring strength and control.
Glutes/Core (Hip Stability):
Addressing hip-adductor, gluteal, and trunk strength, as well as balance, coordination, and plyometrics, using specific exercises and loading strategies is mandatory for prevention.
Rehabilitation programs should include core strengthening, exercises that target all hip and pelvic muscles using strength-training machines, side-lying exercises with limb weight, and standing exercises with elastic bands or cables.
The aforementioned 20-minute warm-up for soccer players included core strengthening and exercises to encourage neutral pelvis during dynamic activities by engaging various abdominal muscles, abductors, adductors, and hip rotators.
Examples of exercises consistent with strengthening the hip and core muscles, like clamshells and banded lateral walks, align with the need for comprehensive hip and pelvic stability.
Mobility:
Reduced rotational hip range of motion and decreased range of motion are identified as risk factors for adductor strains.
A primary focus of an adductor injury prevention program should be improving range of motion and strength of the adductor tendons.
General flexibility programs and adductor stretching are included in prevention and early rehabilitation protocols.
While the provided sources do not explicitly mention "foam rolling adductors/IT band," the emphasis on improving flexibility and range of motion aligns with strategies to enhance mobility around the hip joint.
Additional Prevention Considerations
Risk Factors: Athletes with a previous acute groin injury, adductor weakness compared to the uninjured side, any injury in the previous season, and reduced rotational hip range of motion are at increased risk.
Systems Approach: Effective prevention involves a holistic "systems approach" that includes general load management, strength training, optimizing sport-specific pelvic load transfer, and individual screening of athletes for their adaptation to loads.
Early Detection: Applying periodic clinical screenings (including strength, pain, and performance assessments) can aid in secondary prevention by enabling early detection of issues.
Compliance: Simple, short exercise programs are more likely to be consistently followed by athletes, which is key for effectiveness.
Controversy: While many studies support adductor strengthening for prevention, randomized controlled trials have presented conflicting results regarding the efficacy of adductor strengthening programs in preventing specific acute adductor injuries, often due to reporting overall groin injury rates instead of just adductor injuries. Nevertheless, non-randomized trials have shown benefit.
FAQs About Groin Strains
Here are comprehensive answers to your frequently asked questions about groin strains, drawing upon the provided sources:
Q: Does foam rolling help?
A: The sources do not explicitly mention "foam rolling," but they discuss related concepts such as massage and the importance of mobility and flexibility in both preventing and rehabilitating adductor injuries.
For acute adductor strains, a post-injury program's initial phase (first 48 hours) can include massage alongside RICE (rest, ice, compression, elevation), and nonsteroidal anti-inflammatory drugs. Similarly, for in-season athletes with athletic pubalgia (AP), massage is listed as a first treatment option with NSAIDs, heat, and ice.
However, there are specific cautions depending on the severity and type of injury. For complete proximal adductor longus muscle (ALM) avulsion injuries, it is recommended to avoid massage at the injury site for the first 1 to 3 weeks to prevent calcification.
In the acute/subacute phase of adductor injury rehabilitation, a primary goal is the normalization of flexibility if it is limited, using exercises that cause no or minimal pain provocation. This suggests that gentle techniques that promote flexibility and reduce muscular inhibition may be beneficial once initial, intense pain and swelling have subsided.
Therefore, while "foam rolling" itself isn't named, the concept of gentle soft tissue work (like massage) can be beneficial once the acute phase and severe pain (especially in cases like avulsions) have passed, focusing on promoting flexibility without causing increased pain.
Q: Can stretching worsen a strain?
A: Yes, aggressive stretching can potentially worsen a groin strain, especially in the early stages or for certain types of injury. The sources emphasize a cautious and progressive approach to stretching and mobility:
For adductor strains near the bone-tendon junction (enthesopathy), physical therapy, including stretching, should be delayed until acute symptoms improve because these areas are less vascular and require some initial healing. Once symptoms have improved, gentle stretching should be introduced.
In contrast, if the tear is located closer to the musculotendinous junction or in the muscle belly, which are more vascular, early and aggressive rehabilitation can be instituted. This highlights that the type and location of the strain influence the appropriate timing and intensity of stretching.
Post-injury rehabilitation programs for adductor strains typically begin with hip passive range of motion in a pain-free range during the acute phase (first 48 hours), progressing to a more general flexibility program in the subacute phase.
During the acute/subacute phase of rehabilitation, a key goal is the "normalization of flexibility if limited," but this should be achieved with no or minimal pain provocation. This means stretching should only be performed within a comfortable range.
Avoiding "active abduction/stretching" is specifically advised for complete proximal ALM avulsions in the first 1 to 3 weeks post-injury.
In summary, it is crucial to avoid aggressive stretching early on after a groin strain. The focus should initially be on pain-free mobility, and stretching should be introduced gently and progressively, tailored to the specific injury type, location, and the athlete's pain levels.
Ready to Overcome Groin Pain?
At Vaughan Physiotherapy, we use:
🔹 Sport-specific testing (e.g., FIFA groin screening).
🔹 Eccentric loading protocols to rebuild tendon strength.
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