Adductor tendinopathy

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This article focuses on adductor tendinopathy, a groin-related injury. Groin pain is often frustrating and can be debilitating if left ignored and untreated. It is always recommended to see a healthcare professional who can offer a comprehensive assessment, diagnosis, and treatment plan to suit your individual needs. 

What are adductors? 

Adductors are a group of muscles on the inner thigh (adductor magnus, adductor longus, adductor brevis, gracilis) that allow the ability to move the leg back to midline from a side stretched position as well as aiding in pelvis stability. Tendons connect these muscles to the pelvis at their origins and onto the inner thigh bone (femur) and lower leg bone (tibia). 

What causes adductor tendinopathy? 

When the adductor muscles are contracted during movement, stress is placed on their respective tendons. If this stress is too forceful, fast, or prolonged, there is risk of damage. This concept is central to tendinopathy injuries and is the principle of repetitive overuse – the tendon has been consistently loaded in a way that it cannot handle. This causes degeneration and disorganisation of the tendon fibres and can result in weakness, pain and tearing. Depending on what stage of damage to the tendon has occurred will also determine the ability for the tendon to heal. 

Risk factors for injury 

Although repetitive overload is at the root cause of tendinopathy injuries, there are additional risk factors for the adductors that can make injury more likely. Those involved in sports that require direction changes at speed, quick acceleration, kicking and side-to-side movement are more at risk of groin injuries. These injuries occur between 2-7% in all athletes, with more injuries reported in soccer (12-13%), and three-quarters being male. Overstretching of the adductor muscles may also make them more susceptible to injury. Other risk factors include inadequate warming up, age-related weakness, genetics, obesity and physical inactivity. 

Signs and Symptoms 

What can you expect to experience? 

● Sharp pain and/or dull ache. 

● Tenderness when pressing/poking where the adductors attach to the pelvis, i.e. along your underwear line 

● Pain when you stretch your adductors/groin area.

● Pain and/or weakness on contracting (for example: squeezing your legs together). ● 24 hour pattern 

○ Pain may feel worse when first starting an activity or exercise, then better during, then worsens after cooling down or the following day 

○ Night – Generally OK 

○ AM – May feel stiff after sleeping 

○ PM – Pain may be activity dependent 

● Easing factors 

○ Rest 

○ Ice packs 

○ Panadol or Neurofen 

○ Massage 

● Other aggravating factors 

○ Kicking (especially across the body) 

○ Side to side movements 

○ Activities that require quick changes of direction 

○ Groin stretching 

Effective early treatment = Good outcomes 

Outcomes related to pain reduction, return to function, and return to sport are achievable if picked up early and managed by your physiotherapist. Depending on the severity of your injury, it can take up to 1-2 months to return to function/sport/normal activities. However if left unmanaged, or if there is further insult to the tendons, recovery can be prolonged. These types of long-standing tendinopathies can take many months to rehabilitate, as the aim is to resolve any vulnerabilities that can lead to a rupture of the already weakened tendon. 

Typical Treatment Approaches 

Exercise Therapy 

Research tells us that exercise is a cornerstone of treatment, which may seem counter intuitive as it may be during exercise that pain was initially felt. However, there is strong evidence that tendons benefit greatly from movement, resistance and force production which is what they are designed for. However, it isn’t as simple as continuing to fight through the pain in the same exercise routine, but rather a combination of strengthening, mobilising and activity modification such as removing the abusive load. This has been shown to be more effective than a treatment that consists of restricted activity, corticosteroid injections and anti-inflammatory medication use. One study following this procedure showed that 79% of active therapy group participants returned to sport at an equal or higher pre-injury level, compared to only 14% of participants who underwent more passive therapy. Initial decreases in frequency and intensity of activity are recommended however full cessation of activity is not recommended as it may prolong recovery.

There are likely a variety of reasons why adductor tendinopathy occurs, and discussion with a physiotherapist can help identify these and help correct them. With that being said, some common exercises for adductor tendinopathy management are provided below and can be adapted to target the adductor muscles with varying levels of intensity. Treatment choices and progressions can be split into phases with a goal for each, such as the first phase (acute) addressing pain then the next range of motion, then endurance, strength, power and then finally motor control. Markers such as pain or strength targets can then be used to identify when to progress or possibly when to regress exercise and then reassess. Characteristics of rehabilitation exercises vary and can include isometrics (static strengthening exercises) in the early stages which are proven to be safe and effective early on in tendinopathy management. Later on in the rehab process, strength and power can also be addressed by introducing higher loads to improve tendon organisation and further increase the tendons loading capacity. 

Complementary Components 

Other evidence based complementary components to an exercise program include: ● Global strengthening of muscles including the core and deep hip stabilisers if identified as weak 

● Balance training using equipment such as a wobble board 

● Heat packs/warm baths 

● Manual therapy performed by the therapist 

● A graduated return to activity such as running 

● Performing a 10 minute gradual warm up prior to activity 

● Cross training to maintain some fitness whilst recovering. 

If the issue is persistent and not responding to other more conservative options other strategies may include: 

● Non-steroidal anti-inflammatories, although these are typically not necessary due to the non-inflammatory nature of the condition, it may be recommended that you approach your GP or pharmacist for further details if they may be of benefit. 

● Local corticosteroid injections may be provided from a GP. However, studies on the effect of corticosteroid injections in the treatment of tendinopathies tend to show worse long-term outcomes compared to conservative treatments although decreasing pain in the short term. 

References 

1. Brukner et al (2017). Brukner & Khan’s clinical sports medicine (5th ed.), 1064. Australia: McGraw Hill Education. 

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11. Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. The American Journal of Sports Medicine. 2015 2015/07/01;43(7):1704-11. 

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