Treating Adductor Related Groin Pain. Not just a pain in the hip!
Groin pain is a common clinical entity faced by clinicians, particularly those who treat athletes. To complicate matters, distinguishing adductor related groin pain (ARGP) from other differential diagnoses can be challenging as multiple structures coexist around the anterior pelvis. Clinical features include (16):
- Pain on palpation of the adductor tendons
- Reproduction of symptoms with adductor contraction
- Pain with passive stretching
The prevalence of groin injury is approximately 13% and 7% in men and women respectively, especially in those with strength deficits (19). Furthermore, those with previous injury are 2-4x more likely to develop a recurrence so it is imperative that rehabilitation is progressive and exposes the musculature towards the stressors associated with their sport. For further information around ARGP, check out this Masterclass by Dr. Andrea Mosler on groin pain in athletes.
When looking to rehab the adductor musculature, we must consider the multiple functions they have upon the movement and stability of the hip and include this in our exercise programme.
Triplanar demand is placed through the adductors which may explain why injuries account for around 69% of groin pain. In particular, adductor longus is most susceptible due to a lack of mechanical advantage coupled with a small insertion and reduced vascularity which is likely to slow down recovery following microtrauma (13).
Rehabilitating injuries is likely to follow more of a linear periodisation programme, especially during the initial to intermediate stages as the capacity of the musculotendinous unit will not be able to withstand more advanced and higher intensity training.
Periodised programming has consistently been found to elicit greater adaptations in muscular strength and hypertrophy because of the following benefits (5):
- Progressive, neuromuscular overload
- Managing fatigue
- Preventing plateau
Following the initial phase of acute injury management, focus should turn towards progressively loading the adductors and surrounding muscles with the aim of improving strength asymmetries. This is vital because ADD/ABD strength ratio of <80% is thought to predispose athletes to a 17x greater risk of groin injury (5). More recently, a modified rehabilitation programme focusing on; a) intersegmental control, b) linear running mechanics and load tolerance and c) multidirectional movements coupled with high-speed sprinting has led to faster return to play (RTP), averaging around 9-10 weeks (8, 1).
Isometrics are often a staple in most programmes and appear to be efficacious in the treatment of ARGP. For example, in field sports the adductors will have to isometrically contract on the stance leg during kicking to stabilise the pelvis. Three exercises with EMG’s >60% which are thought to elicit strength gains are (13):
- Isometric hip adduction – ball between knees (108%)
- Isometric hip adduction – ball between ankles (86%)
- Copenhagens (108%)
Some additional isometric exercise examples can be found below;
Sagittal plane loading of the adductors is another training method which is emphasised during the earlier stages of rehabilitation as this is considered less provocative than frontal plane exercises (7).
The abdominals work antagonistically to the adductors during movements such as kicking whereby they have to eccentrically oppose movement of the leg to help maintain pelvic stability. Research has found that footballers may have reduced eccentric abdominal strength which can compromise pelvic stability, imparting greater load through the pubic symphysis and adductor musculature which may increase the risk of injury (10, 15).
Below are some examples. These can be added as accessories to a workout, performed in isolation or I quite like to implement 2-3 prior to workout / training session as part of a warm-up.
Frontal plane exercises
Following a period of sagittal loading coupled with symptoms settling, frontal plane exercises can be integrated into the programme and are integral as a large percentage of injuries will occur during eccentric loading of the adductors within this plane (i.e. rapid hip abduction, kicking and change of direction). Examples include:
- Lateral step ups
- Lateral step downs
- Lateral lunge (98%)
- Open chain adduction – banded / cable-pulley (103%)
Serner et al., (2013)
Patients should possess an adequate amount of muscular strength, particularly under eccentric load in order to tolerate plyometric and ballistic-based exercises which utilise stretch-shortening-cycle (SSC) and reactive strength (9). The following principles should be applied to encourage this:
- Loads of >80% 1RM to promote neural drive and motor unit recruitment
- Mid-high weekly set ranges, no more than 15 per muscle (12, 6).
- No more than x2 sessions/week with at least 48 hours recovery.
Below are some anecdotal targets which athletes can aim towards as part of their strength training.
1.6x bodyweight in weightlifting derivatives is considered optimal before commencing power-based training as individuals with greater muscle strength possess better physiological attributes for improving power (9, 3).
Those with ARGP have reduced reactive strength with longer ground contact times vs uninjured athletes (1). Exposing athletes towards training modalities such as ballistic strengthening and plyometrics can improve rate of force development. This transfers to sporting activities and is a key component of rehabilitation which improves intermuscular coordination and neural drive which ensures athletes possess the physiological attributes before commencing sprinting and change of direction drills (4, 8).
Considerations for training power
- Lighter loads = faster velocities = more applicable to sporting scenarios
- Short + rapid contractions – 100-250mms for activities like sprinting and jumping
- Quality > quantity (avoid high volumes of training to minimise neuromuscular fatigue)
Other considerations from above
- Putting the brakes on (landing drills) – developing eccentric strength to attenuate load
- Progress from bilateral > unilateral > to greater heights
- Using the accelerator – maximum concentric contraction following eccentric loading to fully utilise SSC and promote gains in muscular power which correlate to sporting activity.
- Consider training these throughout all planes
- Progress from bilateral > unilateral.
- Triple hop test (measure distance)
- Countermovement jump (measure ground reaction forces)
- Lateral hop test (look at ground contact times)
In terms of programming, this goes beyond the scope of this blog. I do, however, really like the work by King et al (2018) and Baida and colleagues (2021) which encourage a graded approach to running.
Athletes initially focus on a linear running programme which progressively builds in duration and speed. Once completed, they commence linear sprinting which starts at sub-maximal levels and progresses to maximal intensity. During this stage, the therapist may wish to consider an undulating periodisation programme whereby the volume and intensity of sessions are frequently changed in accordance to the players schedule.
An example of how this may look is:
- Day 1 – lower-limb strengthening session
- Day 2 – sub-maximal aerobic endurance session
- Day 3 – plyometrics with abdominal accessory work
- Day 4 – rest
Athletes are then encouraged to subjectively rate the intensity and symptom response of the session, those which are deemed ‘green’ is considered a marker for the athlete to progress.
Change of direction (COD)
COD drills should focus on a variety of cutting manoeuvres with acceleration and deceleration which look to heavily load the adductor musculature in lengthened positions. The rationale is to progress the difficulty of each exercise so there is high physical demand placed upon the athlete accompanied by unexpected stimuli which would replicate a competitive scenario. Examples of this may include:
- Y-drill’s 3x10m with 2 minute rests:
- Spatial uncertainty, player sprints and has to cut last minute following instruction
- Universal uncertainty – involves opposition, player must react to unexpected stimulus
- Calculating volume in a session = sets x reps x distance (no more than 500m per session)
- 1:5-8 work rest ratio
- Same emphasis as plyometrics, taxing on the neuromuscular system so will require 48hrs between sessions.
Return to Play (RTP)
There will be significant variation regarding criteria which is dependent upon the sport. A Delphi survey agreed that assessment of strength, performance tests and sport-specific skills should support the RTP decision (18). This appears to be in agreement with Serner et al., (2020) who recommend three phases for effective RTP in football:
- Clinically pain free
- Controlled sports training
- Full team training which resulted in reduced reinjury rates compared to additional studies (14).
Calculate hip ADD/ABD ratio, >90% is considered appropriate for RTP whilst looking to minimise any strength asymmetries (15). Other examples of testing include:
This will vary depending on the type of sport and amount of equipment available:
- 40m timed sprint
- Illinois Agility Test – using a football for dribbling
- Countermovement jumps / lateral and forward hops (ground reaction forces + contact times)
For footballers, kicking imparts large compressive load through the adductor enthesis due to the eccentric loading during the wind-up motion followed by a powerful concentric contraction as the player strikes the ball. This is likely to become particularly challenging when performed under fatigue (2). Examples would include:
- Gentle passing > longer distance passing > maximal intensity shooting
- Jumping through all planes
- Shooting scenarios
I hope you’ve found this blog useful on treating ARGP. For more information, I highly recommend checking the Groin pain in athletes: unravelling the mystery Masterclass by Dr. Andrea Mosler’s
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- Baida et al., (2021) Hipmuscle strength explains only 11% of the improvement in HAGOS with an intersegmental approach to successful rehabilitation of athletic groin pain, The American Journal of Sports Medicine, 49(11), pp. 2994-3003.
- Charnock et al., (2009) Adductor longus mechanics during the maximal effort soccer kick, Sports Biomechanics, 8(3), pp. 223-234.
- Cormie et al., (2011) Developing maximal neuromuscular power: Part 1 – Biological basis of maximal power production, Sports Medicine, pp. 17-38.
- Cormie et al., (2011) Developing maximal neuromuscular power: Part 2 training considerations for improving maximal power production, Sports Medicine, 41(2), pp. 126-146.
- Evans (2019) Periodized resistance training for enhancing skeletal muscle hypertrophy and strength: a mini review, Frontiers in Physiology, 10(13), pp. 1-10.
- Fyfe et al., (2021) Minimal-dose resistance training for improving muscle mass, strength and function: A narrative review of current evidence and practical considerations, Journal of Sports Medicine, 52(3), pp. 463-479
- Grimaldi, A. (2018) Understanding tendinopathies of the hip and pelvis. Book four: Iliopsoas and adductor related groin pain, pp. 1-88.
- King et al., (2018) Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: a prospective cohort of 205 patients, British Journal of Sports Medicine, pp. 1054-1062.
- Maestroni et al., (2020) Strength and power training in rehabilitation: Underpinning principles and practical strategies to return athletes to high performance, Journal of Sports Medicine, 50(2), pp. 239-252.
- Mohammed and Elsais (2018) Abdominal/Adductor strength imbalance in soccer players with osteitis pubis, Journal of Mens Health, 14(3), pp. 33-40.
- Neumann et al., (2010) Kinesiology of the Hip: A focus on muscular actions, JOSPT, 40(2), pp. 82-95.
- Ralston et al., (2017) The effect of weekly set volume on strength gain; A meta-analysis, Journal of Sports Medicine, pp. 2585-2601
- Serner et al., (2013) EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries, The BMJ, 48(14), pp. 1108-1114.
- Serner et al., (2020) Return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes: A prospective cohort study, Orthopaedic Journal of Sports Medicine, 8(1),
- Thorborg et al., (2011) Hip adduction and abduction strength profiles in elite soccer players, The American Journal of Sports Medicine, pp. 121-126.
- Thorborg et al., (2018) Clinical examination, diagnostic imaging and testing of athletes with groin pain: An evidence-based approach to effective management, JOSPT, 48(4), pp. 239-249.
- Tyler et al., (2001) The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players, American Journal of Sports Medicine, 29(2), pp. 124-128.
- Vergani et al., (2022) Return to play in long-standing adductor related groin pain: A Delphi survey among experts, Sports Medicine – Open, pp. 1-11.
- Walden et al., (2015) The epidemiology of groin injury in senior football: A systematic review of prospective studies, British Journal of Sports Medicine, vol 49, pp. 792-797.
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