This is a question that I received from a 30-year-old man a couple of years ago. He started playing ice hockey a year earlier and decided he loved it. I don’t live in an area where ice hockey is very common, so I must admit that this was my first ice hockey injury. He had tenderness at the groin. More specifically he had tenderness where the adductors attach to the pelvis. It turns out that he had adductor tendinopathy and he let it go on for several months. It was going to be a long rehab. He did eventually return to ice hockey, but it took about 6 months. Read on for more information about adductor tendinopathy and how to treat it. Let’s start with anatomy!
What are the adductors?
The adductors are a group of 5 muscles. There are 3 short adductors and 2 long adductors. The short adductors are the pectineus, adductor brevis, and adductor longus. These muscles attach to the pelvis and extend to the inner thigh bone.
The 2 long adductors are the gracilis and adductor magnus. These muscles attach to the pelvis and extend to the knee. Together these muscles help to stabilize the pelvis and perform hip adduction (moving the leg towards the midline of the body). The adductor longus is the muscle that is most likely to be involved with adductor tendinopathy.
What is tendinopathy?
Before delving into the adductor tendinopathy, let’s review tendons. A tendon is the connective tissue that attaches the muscle to the bone. The area where the tendon connects to the bone is more susceptible to irritation and injury because it’s limited blood supply.
Tendinopathy is a term used to encompass any issue with the tendon. This includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However, because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks.
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overload of the tendon without sufficient time to rest and heal. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early-stage tendinosis can heal within 6 to 10 weeks, but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis, but the term tendonitis is often used to encompass both.
What is adductor tendinopathy?
Adductor tendinopathy is the irritation of the adductor tendons that attach to the pelvis. It is an overuse injury and is a common cause of groin pain in athletes. It occurs when excessive mechanical loads on the tendon cause damage. The common practice of playing through the pain does not allow time for the tendon damage to heal. This leads to disrepair and eventually degeneration of the tendon.
Which sports are at risk for adductor tendinopathy?
Sports that require a lot of adductor activation and sudden cutting and changes in direction while running fast increase the risk of adductor tendinopathy. These types of sports would include:
- Horseback riding
- Running
- Football
- Soccer
- Gymnastics
- Swimming
- Ice hockey
What are the symptoms of adductor tendinopathy?
There are several symptoms associated with adductor tendinopathy. These include:
- Groin pain or pain in the inner upper thigh
- Swelling or lump in one or more of the adductor muscles
- Stiffness in the groin area
- Pain with activation of the adductors
- Pain with sprinting, kicking, hopping, and side lunges
- Pain with stretching the adductors
Symptoms usually develop gradually. They will initially present with the start of the activity and then decrease. They will then progress to constant pain during the activity that decreases with rest. Without treatment or significant rest, they will progress to pain during activity and at rest.
What are the risk factors for adductor tendinopathy?
There are several risk factors associated with adductor tendinopathy. These include:
- Sudden increases in training
- Leg length difference
- Over stretching
- Obesity
- Insufficient warm up
- Fatigue
- Hip and abdominal muscle weakness
Who should I see?
- Physical therapy – This would be my first stop. Physical therapy can help decrease pain and inflammation with techniques including manual therapy and dry needling. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. With adductor tendinopathy (especially if you have had it for a long time) it is important to slowly increase the load on your adductor tendons. Your PT can help you add appropriate exercises at the appropriate time. This allows the adductors to strengthen while allowing the tendons to continue to heal. Your PT will also assess your training schedule and technique to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if the condition is not responding to physical therapy. Your physician can prescribe medication, give a steroid injection, or order imaging if needed. Surgery is an option if your condition does not respond to any conservative treatment.
What can I do?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat adductor tendinopathy. Basically, stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. This might include not participating in your sport or activity for a period or time. If you are not able to participate in your activity, then you can supplement with non-irritating activities such as biking, walking, or jogging while your tendon is healing.
- Ice – Ice can help decrease pain and swelling in the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Soft tissue mobilization – Soft tissue mobilization helps release the adductor muscle and decrease the stress on the tendon. Roll on a massage ball or trigger point roller on the painful area in the inner thigh. Spend a good 3 to 5 minutes rolling. Do not roll so hard that you bruise the area, but it should be a pretty painful sensation. Roll out the area no more than a few times a week.
- Stretching – Stretching should be avoided in the initial stages of recovery. It can cause further irritation to the tendon. However, once the pain has decreased, then you can begin gentle stretching. More aggressive stretching is appropriate once the pain and irritation subsides. Stretch the short and long adductors separately. See the video below.
- Strengthen the muscles around the adductors – It is important to strengthen the muscles around the hip. This includes your gluteal muscles, quadriceps, and the hamstrings. It is also important to strengthen your core muscles. All these muscles will help take some of the load off of the adductors. Using ankle weights and loop resistance bands can increase strength and difficulty.
- Strengthen the adductors – You will need to strengthen the adductors as well. This is to be slowly as to not place too much stress on the tendon too quickly. This is why having a physical therapist to guide you through the rehab process is essential. The first video is isometrics and can be done at the beginning of your healing process. The next video is more mid-stage strengthening and should only be performed when the pain has subsided significantly. There should be minimal soreness when performing the exercises and no pain afterwards. Using resistance bands and ankle weights can increase strength and difficulty of the exercises. See the videos below.
In review
- The adductors are a group of 5 muscles. These muscles work together to adduct the hip (bring it toward midline).
- There are 3 short adductors and 2 long adductors.
- The short adductors are pectineus, adductor brevis, and adductor longus.
- The 2 long adductors are gracilis and adductor magnus.
- Adductor tendinopathy is the irritation of the adductor tendons that attach to the pelvis. It is an overuse injury and is a common cause of groin pain in athletes.
- Sports that require a lot of adductor activation and sudden cutting and changes in direction while running fast increase the risk of adductor tendinopathy.
- Adductor tendinopathy causes pain in the groin or in the upper inside area of the thigh.
- It can be a very long rehab process, especially if it has been present for a long time. Do not play through the pain.
- Physical therapy is key in treating the pain and slowly increasing the tendons’ ability to handle the stress of sport or activity.
- Seeing an orthopedist would be the next step if your condition is not responding to PT.
- There are things that you can do to help your condition.
- Relative rest
- Ice
- Soft tissue mobilization
- Stretching – only begin this when the pain has decreased
- Strengthening of the muscles around the hip and pelvis
- Strengthening the adductors
As always, if you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additonal resources
https://www.physio-pedia.com/Adductor_Tendinopathy