Continuing Education Activity
An adductor strain is one of the most common soft tissue injuries in athletes and represents the leading cause of medial leg and groin pain. Adductor strain frequently occurs in sports that involve repetitive kicking motions or rapid changes in direction, such as soccer and hockey. The severity of an adductor strain can vary widely, ranging from mild inflammation of muscle fibers to a complete tendon rupture at its attachment site. Prognosis is therefore variable and dependent on the extent of the injury. Most cases are managed conservatively through rest, ice, compression, elevation, and structured rehabilitation programs. However, conservative care is not always sufficient to restore full function, and more invasive treatments such as corticosteroid injections or surgical repair may be required. A comprehensive understanding of the causes, epidemiology, clinical presentation, evaluation, and prognosis of adductor strains is essential for effective management and improved recovery outcomes.
This course provides healthcare professionals with practical knowledge and tools to evaluate, treat, and manage adductor strains across various severities. Participants learn to apply conservative and advanced treatment strategies appropriately while considering prognosis based on the specific presentation. In addition, the course highlights the importance of interprofessional collaboration among clinicians, pharmacists, physical therapists, and laboratory specialists. By engaging a coordinated team approach, management plans can be better tailored to the individual athlete, ensuring accurate diagnosis, effective rehabilitation, and timely referral for advanced care when necessary. Interprofessional coordination enhances patient outcomes by reducing recovery time, minimizing recurrence, and supporting a safe return to athletic activity.
Objectives:
Create individualized rehabilitation plans for athletes with adductor strains, incorporating structured exercises to restore function and prevent recurrence.
Identify clinical signs of adductor strains, including medial leg and groin pain, to ensure accurate diagnosis in athletes with repetitive kicking or directional changes.
Determine the need for radiological imaging, such as magnetic resonance imaging or x-ray, to identify bony complications like avulsion fractures, which occur in up to 20% of adductor strain cases.
Collaborate as an interprofessional healthcare team to recognize patients who do not respond to initial treatment and coordinate timely referrals to physical therapists, sports medicine physicians, and orthopedic surgeons to optimize recovery outcomes.
Access free multiple choice questions on this topic.
Introduction
An adductor strain or injury to the adductor muscle group is a common cause of medial leg and groin pain, especially among athletes. The adductor complex includes the 3 adductor muscles (magnus, longus, and brevis), of which the adductor longus is most commonly injured. All 3 muscles primarily provide adduction of the thigh. The adductor longus also provides some medial rotation. In open-chain movement, the adductor magnus primarily adducts the hip, while in closed-chain movement, it helps stabilize the pelvis and lower extremity during the stance phase of gait (see Image. Medial Compartment of the Thigh). Because the adductor magnus attaches to the ischial tuberosity, the muscle also contributes to hip extension.[1][2]
The adductor muscle complex:
Adductor Magnus
Origin: Inferior pubic ramus, ischial tuberosity
Insertion: Linea aspera, adductor tubercle
The adductor complex is supported by 3 additional muscles that contribute to hip adduction:
Gracilis
Also assists with internal rotation and hip flexion
Origin: Inferior pubic symphysis, pubic arch
Insertion: Proximal medial tibia, pes anserine
Obturator Externus
Contributes to external rotation
Origin: Obturator foramen
Insertion: Posterior aspect of the greater trochanter
The obturator nerve (L2 to L4), arising from the lumbar plexus, innervates most of the adductor musculature. The adductor magnus is also innervated by the tibial nerve (L4 through S3), and the pectineus is often innervated by the femoral nerve (L2 to L3).
Etiology
Adductor strains are frequent injuries, particularly among soccer and hockey players. Other sports with a high incidence include American football, basketball, tennis, figure skating, baseball, horseback riding, karate, and softball. Major risk factors include a history of hip or groin injury, which is considered the most significant, as well as age, weak adductor muscles, muscle fatigue, limited range of motion, and insufficient stretching of the adductor complex. Biomechanical issues, such as excessive pronation or leg-length discrepancy, may also increase susceptibility.[3][4] The typical mechanism of injury involves a sudden change in direction, causing rapid hip adduction against an opposing abduction force that stresses the tendon. The most common scenario is sudden acceleration during sprinting, while jumping, or overstretching the adductor tendon, which is a less frequent cause.
Epidemiology
Among European football (soccer) players, adductor muscle injuries were the second most commonly injured muscle group (23%), behind hamstrings (37%). In another study of soccer players, adductor pain or strain represented 9% to 18% of all injuries. Adductor strains accounted for 51% of all groin pain in sub-elite men's soccer players. In ice hockey, adductor injuries are responsible for 10% of all injuries, with similar prevalence observed in basketball and rugby.[5] Men sustain adductor injuries about 2 to 3 times more often than women. This is explained by men's higher participation in high-risk sports such as football and ice hockey, and by the greater kicking and skating forces generated by men during play.[6]
Pathophysiology
Most muscle tendon strains occur if the muscle is forcibly stretched while being concentrically contracted. The greatest eccentric tension is placed on the adductor complex when the leg is in external rotation and abduction. Adductor injuries typically occur when the athlete pushes off in the opposite direction. As a result, the adductor muscles contract to generate eccentric and concentric opposing forces. The dominant leg is more commonly injured and likely to sustain significant injury.
This can be seen, for example, if a soccer player attempts to kick a ball with an externally rotated leg using the inside of their foot. If their leg swinging in adduction meets a significant resistive abductive force, such as another player, this can place a significant load on the adductor complex, leading to injury. The musculotendinous junction is the most common injury site in a muscle strain. The adductor tendons have a small insertion zone, which is characterized by an area of poor blood supply and rich nerve supply, which helps explain the increased degree of perceived pain.
The adductor longus is the most commonly injured muscle and accounts for 62% to 90% of cases. The hypothesis is that this occurs due to its low tendon-to-muscle ratio at the origin. Rugby players with an adductor-abductor strength ratio of less than 80% are 17 times more likely to sustain an adductor injury.[7] Twenty-five percent of adductor longus injuries involve the proximal origin at the pubic bone, 31% are at the proximal tendon insertion, and 37% are at the distal insertion. Intramuscular adductor longus belly injuries are relatively uncommon occurring in less than 1% of cases. In terms of the other adductor muscles, 23% of injuries involve the adductor brevis, 5% and 10% gracilis, and the remaining 5% to 10% involve the adductor magnus, pectineus, or obturator externus muscles.[8]
History and Physical
Patients often describe a sudden onset of pain during a specific activity rather than a more insidious onset. Specific activities that bring on the pain include sprinting, kicking, and a sudden change in direction. They describe the pain as severe, located in the groin region or medial thigh, and worse with activity. Patients who are more active and play sports might also experience warning signs before the first onset of pain, such as a reduction in sprinting ability or reduced kicking power.
Individuals can sustain injury anywhere along the medial compartment of the thigh along the adductor complex. The clinician may observe bruising or swelling in moderate to severe injuries. Typically, there is an area of point tenderness or localized tenderness. They may also be tender along the proximal attachment of the pubic ramus. The adductor squeeze test is the most sensitive physical examination for adductor strain. This involves the patient lying supine with the hips flexed at 45° to 90° and attempting to squeeze the knees together against resistance. A reproduction of pain is considered to be indicative of adductor injury.
Evaluation
Evaluation of an adductor strain begins with radiographic imaging. X-rays are the initial modality of choice, including anteroposterior views of the pelvis and a frog-leg view of the affected hip. Although an x-ray is usually normal in an isolated adductor strain, it may reveal associated findings such as an avulsion fracture, osteitis pubis, or heterotopic ossification. Magnetic resonance imaging (MRI) is the most sensitive modality for evaluating adductor injuries. MRI can detect muscle edema and hemorrhage at the injury site, and it is frequently used to grade the severity of the strain and estimate the likely recovery time.
Adductor strains are commonly classified into 3 grades. Grade 1 involves diffuse intramuscular hyperintensity representing edema without architectural disruption and typically presents with pain but minimal loss of strength or range of motion. Grade 2 involves partial tears with intramuscular fluid collections and presents with pain and loss of strength. Grade 3 is a complete musculotendinous disruption or avulsion from the tendon attachment. Ultrasound can also be employed to identify the location and extent of the injury and may be used for periodic assessment during the recovery process.
Treatment / Management
Most adductor strains are managed conservatively. Initial management includes relative rest from sports, ice, compression, analgesia, and physical therapy. Analgesia typically includes acetaminophen and nonsteroidal anti-inflammatory medications. The rehabilitation program should include stretching the range of motion and strengthening the affected leg and core, accompanied by a gradual return to sport. Acute injuries may return as quickly as 4 weeks to 8 weeks, while chronic strains may take many months to achieve desired results.[9][10][11]
Other forms of nonsurgical treatment include corticosteroid injections, platelet-rich plasma injections, and prolotherapy.[12][13] Surgery is recommended in cases where there is significant avulsion from the pubic bone (typically at least 2 cm), if there are associated injuries such as abdominal wall defects seen in sports hernia/athletic pubalgia, or if conservative management fails. Surgery involves either cutting the adductor tendon from the pubic bone to release tension (adductor tenotomy) or repairing a complete tendon rupture with suturing.
Differential Diagnosis
The musculoskeletal differential diagnosis of groin pain is broad and includes:
Iliopsoas bursitis
Osteitis pubis
Sacroiliac dysfunction
Mechanical low back pain
Nonmusculoskeletal causes of groin pain include:
Prognosis
The prognosis for adductor strains is generally favorable. Most athletes return to play with minimal pain and normal function if provided appropriate rest and rehabilitation. If they return to play too soon or if rehabilitation is inadequate, their pain may lead to chronic injury. The average return to full activity with conservatively managed grade 3 adductor tears is 9 weeks, while it is 14 weeks for individuals who have surgery.[13]
Around 20% of athletes have a recurrence of the injury. Furthermore, they are more likely to have an adductor strain in the opposite leg due to strength and movement imbalances created by the initial injury. Renstrom et al found that 42% of athletes with muscle-tendon groin injuries could not return to physical activity more than 20 weeks after the initial injury. However, an active training program directed at strengthening and conditioning the pelvic muscles, especially the adductor muscles, is very effective at treating patients with long-standing, adductor-related groin pain.[14][15]
Complications
Complications of adductor strains extend beyond acute pain and missed playing time. Athletes may experience persistent weakness, reduced hip stability, impaired kicking power, and limitations in agility or daily activities. In some cases, chronic groin pain can develop, increasing the risk of recurrent strains and prolonging recovery. Anatomical complications such as osteitis pubis or heterotopic ossification can further delay return to play.
Effective management and prevention require interprofessional collaboration among clinicians, physical therapists, athletic trainers, and strength coaches. Adductor strengthening programs aimed at maintaining at least 80% of the strength of the abductors have been shown to significantly reduce the risk of injury. For example, a 6-week preseason strengthening program among National Hockey League players with weak adductors decreased adductor strain incidence from 3.2 to 0.71 injuries per 1000 player-game exposures.[16] Coordinated care ensures safe rehabilitation, minimizes recurrence, and supports optimal functional outcomes.
Deterrence and Patient Education
Patients should be educated on the comprehensive management of an acute adductor strain, emphasizing protection of the injured tissue, rest, ice, compression, and elevation to limit inflammation and promote early healing. They should avoid activities that stress the adductors to prevent exacerbation and delayed recovery. Rehabilitation should follow a structured, progressive approach. Early phases focus on pain-free range of motion and gentle stretching, followed by progressive strengthening of the adductor and supporting muscle groups to restore muscular balance. Neuromuscular control and functional exercises targeting dynamic stability and sport-specific movements should be incorporated as tolerance improves. Return to play should be guided by an objective assessment of strength, flexibility, and functional performance, in conjunction with clinician and physical therapist evaluation, to reduce the risk of reinjury and support long-term athletic performance.
Pearls and Other Issues
Key facts to keep in mind about adductor strains include the following:
Adductor strains are a common source of groin pain and injury in athletes.
Risk factors include prior hip or groin injuries, age, adductor weakness, muscle fatigue, limited range of motion, and insufficient stretching of the adductor muscle group.
The majority of cases can be managed conservatively by a primary care clinician, who will use rest and ice and prescribe physical therapy to guide patients through an individualized, graded return to activity process.
Patients who do not respond to initial treatment may require referral to an orthopedic or sports medicine specialist for further evaluation and management, after nonmusculoskeletal causes have been ruled out.
Enhancing Healthcare Team Outcomes
Management of adductor strains often begins with conservative care, including rest, physical therapy, and a structured, graded return to activity. Most patients respond well to these interventions without the need for specialist referral. However, involving additional healthcare professionals becomes essential to ensure comprehensive care when recovery is slow or incomplete.
An interprofessional team can optimize patient outcomes in more complex or refractory cases. Radiologists support accurate imaging and diagnosis, orthopedic surgeons and sports medicine clinicians provide advanced treatment planning, and physical therapists guide rehabilitation and functional recovery. Nurses and pharmacists collaborate to manage pain safely and monitor medication use. Effective communication, care coordination, and shared decision-making among team members enhance patient-centered care, reduce complications, and support a timely and safe return to activity.
Medial Compartment of the Thigh. Shown in this illustration are the pectineus (cut), obturator externus, adductor magnus, adductor brevis, and adductor longus. Pubic bone origin and femoral insertion are also indicated. Henry Vandyke Carter, Public Domain, (more...)
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Disclosure: Kaesi Opara declares no relevant financial relationships with ineligible companies.
Disclosure: Seth Pinkerman declares no relevant financial relationships with ineligible companies.
Disclosure: Kimberly Kaiser declares no relevant financial relationships with ineligible companies.
