McHugh MP, Nicholas SJ, Tyler TF. Adductor Strains in Athletes. IJSPT.

2023;18(2):288-292. doi:10.26603/001c.72626

Clinical Viewpoint

Adductor Strains in Athletes

Malachy P McHugh1, Stephen J Nicholas1, Timothy F Tyler1
1 Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, Northwell Health
Keywords: adductor strains, groin pain, muscle strain
https://doi.org/10.26603/001c.72626

International Journal of Sports Physical Therapy

Vol. 18, Issue 2, 2023

Acute adductor injuries are a common occurrence in sport. The overall incidence of
adductor strains across 25 college sports was 1.29 injuries per 1000 exposures, with men’s
soccer (3.15) and men’s hockey (2.47) having the highest incidences. As with most muscle
strains there is a high rate of recurrence for adductor strains; 18% in professional soccer
and 24% in professional hockey. Effective treatment, with successful return to play, and
avoidance of reinjury, can be achieved with a proper understanding of the anatomy, a
thorough clinical exam yielding an accurate diagnosis, and an evidence-based treatment
approach, including return to play progression.

INTRODUCTION DIAGNOSIS

Acute adductor injuries are a common occurrence in sport. The diagnosis and treatment of adductor strains can be
The overall incidence of adductor strains across 25 college challenging. The term groin strain has been used to de-
sports was 1.29 injuries per 1000 exposures, with men’s scribe pain in or around the pubis, but it is important to dif-
soccer (3.15) and men’s hockey (2.47) having the highest ferentiate between adductor strains and other clinical enti-
incidences.1 As with most muscle strains there is a high ties in the pelvic region. Weir et al developed a taxonomy
rate of recurrence for adductor strains; 18% in professional to classify groin pain as adductor-related, iliopsoas-related,
soccer2 and 24% in professional hockey.3 Effective treat- inguinal-related, pubic-related, or hip-related.4 However,
ment, with successful return to play, and avoidance of rein- these conditions can be overlapping, further complicating
jury, can be achieved with a proper understanding of the the diagnosis and treatment approach. Inter-examiner
anatomy, a thorough clinical exam yielding an accurate di- agreement using this classification system was excellent
agnosis, and an evidence-based treatment approach, in- for athletes with a single entity but more difficult for ath-
cluding return to play progression. letes with multiple clinical entities.5 While most muscle
strains present with an acute onset of symptoms associated
ANATOMY with a distinct injury mechanism, adductor strains often
can have an insidious onset, and long-standing adductor-
The adductor muscle group is comprised of six muscles that related pain is not uncommon. Furthermore, even when
run along the medial thigh: adductor longus, adductor bre- the adductors are the primary source of symptoms, the
vis, adductor magnus, pectineus, gracilis, and obturator ex- injury could be a muscle or tendon injury. A tear at the
ternus. In general, these muscles attach proximally to the origin of the adductor longus tendon or adductor longus
anteroinferior part of the pelvis. They are innervated by tendinopathy are common. Treating a tendon injury as a
the obturator nerve, except the pectineus (femoral nerve) muscle strain can be counterproductive.
and part of the adductor magnus (sciatic nerve). As their In the absence of imaging the clinical diagnosis of an ad-
name suggests, the primary action of the adductor group is ductor strain can be made based on a combination of fac-
adduction of the thigh, however their actions include sev- tors relating to the timing of the onset of symptoms, the
eral secondary functions. They play an important role in location of the symptoms and the actions that most readily
trunk stabilization, contribute to flexion and extension of provoke the symptoms (Table 1).
the thigh when running, and are used in kicking a soccer The most straightforward presentation of an adductor
ball with the inside of the foot. The adductor muscle group strain is an athlete with an acute onset of pain in the ad-
may also act as lateral or medial hip rotators depending on ductor region necessitating removal from the game. On
the mechanical axis of the femur. The adductor muscles are exam there is tenderness on palpation of the adductor mus-
typically referred to as a group, but the adductor longus cles that is exacerbated with resisted adduction and passive
is the muscle most frequently involved in adductor-related stretch of the adductors.
groin pain. Timing of Symptoms: If an athlete presents with adduc-
tor-related pain the day after a game but had no symp-
toms during the game, this is more likely muscle damage,
which should resolve uneventfully. If an athlete presents
 Adductor Strains in Athletes

Table 1. Clinical criteria for diagnosis of an adductor strain

Diagnostic Factors Likelihood of Adductor Strain

Acute Onset More Likely
Timing of Symptoms Delayed Onset Less Likely
Insidious Onset or Chronic Less Likely
Muscle (belly or MTJ) More Likely
Location of Symptoms Tendon Insertion Less Likely
At or Above Inguinal Crease Less Likely
Resisted Adduction More Likely
Provocation of Symptoms Passive Stretch More Likely
Sit Up Less Likely

MTJ=muscle-tendon junction

with a history of chronic adductor-related pain or intermit- grams with similar progressions have been described.8,9
tent adductor symptoms with activity, the index of suspi- Nonoperative treatment for adductor strains is standard
cion moves towards tendon injury. and can successfully return athletes to play with low risk
Location of Symptoms: The location of symptoms on of reinjury. A criterion-based rehabilitation program with
physical exam can be variable. Tenderness along the ad- 3 stages has been described9 whereby the athlete must be
ductor muscles to the proximal insertion is common. The clinically pain free (stage 1) before progressing to con-
more proximal the point of peak tenderness the more likely trolled sports training (stage 2) and then to full team train-
there is tendon involvement. Peak tenderness at the adduc- ing (stage 3). The time to return to play will be dependent
tor tendon origins with no discernible tenderness into the on the extent of injury. Athletes with complete tears (grade
muscle increases the likelihood of a tendon injury. Pain at 3 on MRI) unsurprisingly take longer to return to play.9
or above the inguinal crease points to athletic pubalgia, in- However, for partial tears the recovery time was similar be-
cluding related inguinal hernias.6 In cases where there is tween grades 1 and 2.9 The later stages of rehabilitation will
adductor muscle tenderness, with tenderness at the tendon vary depending on the sport the athlete is returning to, but
origin and tenderness in the inguinal region it is probably the same principles apply throughout the process regard-
best to focus on the more proximal symptoms. less of the sport.
Provocation of Symptoms: Obviously with any signifi- In the acute phase (24-48 hours) the goal is to limit the
cant adductor muscle strain there will be pain with resisted proliferation of the initial tissue disruption. Early and re-
adduction. Resisting a distally applied hip abduction force peated application of ice can reduce tissue metabolism and
with the knees extended may be more specific for an ad- limit tissue damage.10 In the subacute phase (2-7 days post
ductor strain than an adductor squeeze test with the knees injury) the goal is to protect the site of injury while the scar
flexed. However, the adductor squeeze test (with knees ex- forms between the fractured muscle fibers. However, immo-
tended or flexed) is used primarily to identify athletes with bilization can result in excessive scar tissue.11 Therefore,
groin or hip problems as opposed to specifically diagnose early mobilization avoiding excessive stress on the injured
an adductor strain.7 In fact, performing the adductor fibers is recommended.
squeeze test with knees flexed, while performing a sit up, Reactivation of the adductors with hip adduction exer-
called the Resisted Adduction Sit Up Test (RASUT), identi- cises can progress along a continuum from low intensity
fies athletic pubalgia.6 Adductor muscle pain with passive submaximal isometric and concentric contractions at short
hip abduction may be indicative of a significant muscle muscle lengths, to high intensity maximal eccentric con-
strain, especially if symptoms occur with only moderate tractions at long muscle lengths (Table 2). This progression
muscle stretch. As the magnitude of the stretch increases of hip adduction strengthening exercises should account for
it can become more difficult to differentiate normal stretch the combinations of contraction intensity, muscle length
discomfort from pain due to a muscle injury. Additionally, and contraction mode.
with greater motion the discomfort may be at the tendon Maximal voluntary force production is lowest for con-
origin and resisted adduction will be necessary to test for centric contractions and highest for eccentric contractions
muscle involvement. Thus, resisted adduction tests may be and therefore, maximal isolated eccentric contractions are
more useful in diagnosing an adductor strain than passive categorized at a higher level than maximal isotonic con-
stretches. tractions. However, isotonic contractions that are per-
formed in the full available range of motion (ROM) can in-
TREATMENT volve reinjury risk in the transition from the eccentric to
concentric phase, as this occurs at a long muscle length,
While there have been no randomized clinical trials testing where there is significant passive tension on the muscles,
different treatment programs for adductor strains, pro- and the contractile ability is compromised by the length-
tension relationship. The Copenhagen adductor exercise

International Journal of Sports Physical Therapy

 Adductor Strains in Athletes

Table 2. Progression of muscle contractions in rehabilitation of adductor strains

Progression Contraction Intensity Muscle Length Contraction Mode

Isolated Concentric
Level 1 Low (<30% MVC) Short (initial 3rd ROM)
Isometric
Level 2 Moderate (30-60% MVC) Intermediate (middle 3rd ROM) Isotonic
Level 3 High (>60% MVC) Long (final 3rd ROM) Isolated Eccentric

was developed as an isolated eccentric exercise, but can be the right side will equal the force on the left side. This limi-
performed as an isometric exercise, and as an isotonic ex- tation is not overcome by separating the legs and squeezing
ercise. Regardless of contraction mode it is a high inten- a frame with a force transducer on each side, as is described
sity exercise, and it is difficult to modify intensity. Perform- using the ForceFrame device (Vald Performance, Queens-
ing the Copenhagen adductor exercise isotonically involves land, Australia).14 It follows that squeeze tests have not
a lot of stress in the eccentric to concentric transition be- been shown to be effective at identifying strength deficits
cause it occurs at a longer muscle length than during the between limbs but have been effective at identifying ath-
concentric to eccentric transition. Therefore, the exercise letes with groin and hip pathology versus healthy athletes.7
should be progressed carefully, starting at short muscle The neurophysiological limitation of comparing
lengths with isometric contractions. The Copenhagen ad- strength between limbs while performing simultaneous
ductor exercise is primarily beneficial as an exercise for maximal efforts with both limbs, is referred to as the bi-
healthy adults to prevent adductor strains and other groin lateral deficit.15 The bilateral deficit phenomenon is char-
injuries. It’s effectiveness in adductor strain rehabilitation acterized by a lower force generated when two limbs per-
is not as well established but it has been used in successful form a maximal effort bilaterally compared with the sum of
adductor strain rehabilitation.9,12 the forces generated by the two limbs when performing the
effort unilaterally. While the bilateral deficit has not been
RETURN TO SPORT STRENGTH TESTING studied specifically for clinical assessment of weakness no
studies have validated bilateral testing for identifying uni-
Readiness for return to sport can be established using gen- lateral weakness.
eral agility tests (e.g. Illinois agility test) and sports specific While these two limitations (Newton’s third law and bi-
tests that stress the adductor region. However, it is impor- lateral deficit) highlight the importance of unilateral test-
tant to consider the isolated function of the hip adduc- ing for hip adduction strength assessments, it is important
tors to ensure that the repair process occurs with a com- to emphasize the role of stabilization for achieving a valid
plete restoration of the function of the injured structure. result. In testing hip adduction strength in side-lying, the
Therefore, an objective validated assessment of hip adduc- subject can oppose their hip adduction force (upwardly di-
tion strength is essential, and it is beneficial to assess the rected force) with their torso and shoulder pressing against
strength in comparison to the antagonist hip abductors. the table they are side-lying on (downward directed force)
Such testing can be performed on an isokinetic dynamome- (Figure 1). However, if one tests hip adduction strength
ter, but availability and limited validation bring both prac- unilaterally in supine, one must provide an opposing force
tical and scientific limitations. Testing with a hand-held to stabilize the torso to allow the subject to generate a max-
dynamometer for sidelying hip adduction and abduction imal effort without rotating the upper body away from the
has been validated12,13 and offers a more practical solution. direction of the adduction force. Such tests performed with-
The key requirements for hip adduction strength testing out stabilization against the countermovement may be reli-
are that (1) a comparison can be made between the involved able, but they are not valid tests of the maximal adduction
and noninvolved sides, (2) a comparison can be made be- strength.
tween the agonist (adductors) and antagonist (abductors) The importance of being able to test the hip abductors in
muscle groups, and (3) that the unit of measurement for addition to the adductors is that weak adductors relative to
strength allows comparisons across populations (e.g. com- abductors can be a risk factor for a future adductor strain.13
parison to uninjured teammates). Therefore, the rehabilitation process should restore a bal-
In comparing strength between legs, it is essential that ance between the agonists and antagonists in addition to
each side is tested independently. Squeeze tests where both balancing the involved and noninvolved sides. Lastly, it
limbs contract maximally at the same time cannot be used may be important to compare hip adduction strength in the
to assess symmetry in adduction strength between limbs. rehabilitating athlete to their peers, to ensure that strength
The laws of physics and neurophysiology invalidate such matches the requirements for the sport. In this regard the
tests. Newton’s third law states that for every action (force) standard unit of measurement for hip adduction strength
there is an equal and opposite reaction. If one squeezes a is Newton-meters per kilogram body mass (Nm/kg). Hip
dynamometer between the knees in the bent knee adduc- adduction force in Newtons, or Newtons relative to body
tion squeeze test, or between the feet in the straight leg weight do not provide a valid comparison between individ-
squeeze test, Newton’s third law dictates that the force on uals varying in stature and weight.

International Journal of Sports Physical Therapy

 Adductor Strains in Athletes

CONCLUSION

When an athlete can perform sports specific functional

testing symptom free at a performance level comparable
to uninjured peers and has normal hip adduction strength
(within 10% of the noninvolved side and within 10% of the
ipsilateral hip abductors) there should be low risk of rein-
jury on return to play. Importantly, by providing the athlete
with objective criteria on their readiness to play they will be
less likely to have fear avoidance upon return.

Figure 1. Hip adduction strength testing in side lying

using a hand-held dynamometer. The treatment table
stabilizes the upper body to oppose the upwardly
directed hip adduction force thereby enabling a
maximal effort.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(CCBY-NC-4.0). View this license’s legal deed at https://creativecommons.org/licenses/by-nc/4.0 and legal code at https://cre-
ativecommons.org/licenses/by-nc/4.0/legalcode for more information.

International Journal of Sports Physical Therapy

 Adductor Strains in Athletes

REFERENCES

1. Eckard TG, Padua DA, Dompier TP, et al. 9. Serner A, Hölmich P, Tol JL, et al. Progression of
Epidemiology of Hip Flexor and Hip Adductor Strains strength, flexibility, and palpation pain during
in National Collegiate Athletic Association Athletes, rehabilitation of athletes with acute adductor
2009/2010-2014/2015. Am J Sports Med. injuries: a prospective cohort study. J Orthop Sports
2017;45:2713-2722. Phys Ther. 2021;51(3):126-134. doi:10.2519/jospt.202
1.9951
2. Ekstrand J, Hägglund M, Waldén M. Epidemiology
of muscle injuries in professional football (soccer). 10. Kwiecien SY, McHugh MP. The cold truth: the role
Am J Sports Med. 2011;39(6):1226-1232. doi:10.1177/ of cryotherapy in the treatment of injury and
0363546510395879 recovery from exercise. Eur J Appl Physiol.
2021;121(8):2125-2142. doi:10.1007/s00421-021-046
3. Emery CA, Meeuwisse WH, Powell JW. Groin and 83-8
abdominal strain injuries in the National Hockey
League. Clin J Sport Med. 1999;9(3):151-156. doi:10.1 11. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo
097/00042752-199907000-00006 H, Järvinen M. Muscle injuries: biology and
treatment. Am J Sports Med. 2005;33(5):745-764. do
4. Weir A, et al. Doha agreement meeting on i:10.1177/0363546505274714
terminology and definitions in groin pain in athletes.
Br J Sports Med. 2015;49:768-774. 12. Serner A, Weir A, Tol JL, et al. Return to sport
after criteria-based rehabilitation of acute adductor
5. Heijboer WM, Weir A, Vuckovic Z, et al. Inter- injuries in male athletes: a prospective cohort study.
examiner reliability of the Doha agreement meeting Orthop J Sports Med. 2020;8(1):2325967119897247. do
classification system of groin pain in male athletes. i:10.1177/2325967119897247
Scand J Med Sci Sports. 2023;33(2):189-196. doi:10.11
11/sms.14248 13. Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP.
The association of hip strength and flexibility with
6. Galano GJ, Tyler TF, Stubbs T, et al. Resisted the incidence of adductor muscle strains in
adduction sit-up test (RASUT) as a screening tool for professional ice hockey players. Am J Sports Med.
pelvic versus hip pathology. J Hip Preserv Surg. 2001;29(2):124-128. doi:10.1177/03635465010290020
2021;8(4):331-336. doi:10.1093/jhps/hnab075 301

7. Mosler AB, Agricola R, Weir A, Hölmich P, Crossley 14. O’ Connor C, McIntyre M, Delahunt E, Thorborg
KM. Which factors differentiate athletes with hip/ K. Reliability and validity of common hip adduction
groin pain from those without? A systematic review strength measures: the ForceFrame strength testing
with meta-analysis. Br J Sports Med. system versus the sphygmomanometer. Phys Ther
2015;49(12):810-810. doi:10.1136/bjsports-2015-094 Sport. 2022;59:162-167. doi:10.1016/j.ptsp.2022.12.01
602 0

8. Nicholas SJ, Tyler TF. Adductor muscle strains in 15. Škarabot J, Cronin N, Strojnik V, Avela J. Bilateral
sport. Sports Med. 2002;32(5):339-344. doi:10.2165/0 deficit in maximal force production. Eur J Appl
0007256-200232050-00005 Physiol. 2016;116(11-12):2057-2084. doi:10.1007/s004
21-016-3458-z

International Journal of Sports Physical Therapy