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Assessment and management of adductor strain

Article  in  Saudi Journal of Sports Medicine · June 2017

DOI: 10.4103/1319-6308.207576

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Case Report

Assessment and management of adductor strain

ABSTRACT
Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, adductor muscle strain is one of these
most common injuries in athletes who are involved in sports requiring sudden change of direction. High forces occur in the adductor tendons
when the athlete must shift direction suddenly in the opposite direction. As a result, the adductor muscles contract to generate opposing
forces. An adductor strain that is treated improperly can become chronic and career threatening. Despite the identification of risk factors and
strengthening intervention for athletes, adductor strains continue to occur throughout sport. The prevention and management of groin injury
remains a substantial issue. The purpose of this article is to let the readers know regarding the conservative treatment options for adductor
strain and provide recommendations for sports medicine clinicians for improved treatment and patient outcomes.

Keywords: Adductor muscle strain, shift direction, Taekwondo

INTRODUCTION Potential risk factors of adductor related strains are

Adductor muscle strain is a tear or rupture to any one of
the five adductor muscles (pectineus, adductor brevis and
adductor longus, gracilis and adductor magnus). The most
common sports that put athletes at risk for adductor strains
are football, soccer, hockey, basketball, tennis, figure skating,
baseball, horseback riding, karate, softball, and cricket.[1,2]
PATHOPHYSIOLOGY
In general, groin injuries make up 2%–5% of all sport‑induced
injuries, of which adductor strain is the usual musculoskeletal
etiology of the pain.[3] The arrangement and fusion of
adductor muscles, their fibrocartilaginous entheses and
differences in vascularity of their proximal tendons may be
important anatomical considerations in the pathogenesis
and pattern of adductor-related groin pain.[4] The adductor
longus is a commonly injured muscle in sport activities.[5-9] The
adductor tendons have a small insertion area that attaches
to the periosteum-free bone. This transitional zone is
characterized by a poor blood supply and rich nerve supply,
which is the cause of high level of perceived pain and poor
healing in adductor strains.
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different forms of sports, high level of play, age and core
stability.[10-12] Other Risk factors for adductor strain include
adductor tightness, previous adductor injury,[13] and hip
adductor-toabductor strength imbalance. [14] Common
mechanism of the injury is sudden change of direction[15] or
violent external rotation with abduction at hip joint while the
foot is planted on ground.[16] Strains are usually easily diagnosed
on physical examination with pain on palpation of the involved
muscle and pain on adduction against resistance.[17] When the
muscle is activated, muscle strain injury occurs, most often
during eccentric contraction. Pre-season hip strength testing of
professional players can identify players at risk of developing
adductor muscle strains.[3]
DISCUSSION
In this case, a 20‑year‑old female, flyweight category,
Taekwondo player was assessed who had a complaint of
Prachi Khandekar
Department of Physiotherapy, Rajeev Gandhi College, Bhopal,
Madhya Pradesh, India
Address for correspondence: Dr. Prachi Khandekar,
Department of Physiotherapy, Rajeev Gandhi College, E‑8, Trilanga
Colony, Shahpura, Bhopal, Madhya Pradesh, India.
E‑mail: dr.prachiphysio@gmail.com
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DOI:
10.4103/1319-6308.207576 How to cite this article: Khandekar P. Assessment and management of
adductor strain. Saudi J Sports Med 2017;17:118-20.

118 © 2017 Saudi Journal of Sports Medicine | Published by Wolters Kluwer - Medknow
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Khandekar: Assessment and management of adductor strain: A case report
pain in the groin region on the right side which started
during stretching. She had difficulty in performing kicking
activities since then. The patient came to the center with
the complaint of pain in the groin region on right side, which
started while performing stretching exercise during warm‑up
period. As reported by the patient, she had an incidence of
medial meniscus tear 1‑month back and took physiotherapy
for that. Her pain recovered and she again started her training
schedule gradually. She had no history of diabetes, asthma,
hypertension, gynecological abnormalities, visceral pain,
or any history of hernias. Moreover, as reported, she was
a nonsmoker, nonalcoholic, and nonvegetarian. When her
occupational history was taken, she was a university level
player with 2 years of experience. She was training on irregular
surface since 7 months with a high intensity, and duration of
training was long (approximately 2:30 h/two times a day). She
performed warm‑up and cool‑down activity as per the session.
The pain history was onset ‑ sudden, duration ‑ since 2 days,
type ‑ dull aching, localized, site ‑ in groin region on the right
side with severity on visual analog scale ‑ 5 on activity and
2 at rest. There was no radiation of pain. It was aggravated
by stretching exercises of hip adductors during warm‑up and
cool‑down period and kicking activities. Pain was relieved by
rest and icing. Predisposing factors were practicing on rough
terrain. There were no sleep disturbances due to pain. On
palpation, there was local tenderness of Grade 1.
On general examination, the built was found to be
ectomorphic. Posture evaluation in antero-posterior view
showed normal alignment with no significant deviations, in
lateral view there was normal alignment with no significant
deviations, in posterior view also normal alignment with no
significant deviations was observed. Gait evaluation revealed
no significant deviations. On local examination there was
no swelling, scar, and wound. Shoes were examined which
showed no corrective insole and no wear–tear. The range
of motion and end feel was checked which was found to be
about normal and the manual muscle testing done according
to the Oxford grading was found to be above average.
The test for flexibility reviled normal length of iliopsoas
bilaterally through Thomas test, normal length of rectus
femoris bilaterally through Ely’s test, normal length of tensor
fascia latae bilaterally through Ober’s test, and normal length
of piriformis bilaterally through piriformis test. Hamstring
muscle was tight on the right side assessed through active
knee extension test.
The special test done for checking involvement of adductor
muscles was Squeeze test which came out to be positive.
Saudi Journal of Sports Medicine / Volume 17 / Issue 2 / May-August 2017
Resisted isometric testing of right‑sided adductor muscles
also came out to be positive. Other tests done to rule out
other hip joint, pelvis, or sacroiliac joint pathology were
Faber’s test, hip quadrant test, Trendelenburg test, cough
impulse test, Gaenslen’s test, and Craig’s test, which were all
negative. There was no leg length discrepancy. In addition,
the femoral nerve involvement came out to be negative.
A digital X‑ray was also performed which did not reveal any
chance of stress fracture.
DIFFERENTIAL DIAGNOSIS
A digital X‑ray was also performed which did not reveal any
chance of stress fracture. The findings reviled and hence
it was confirmed that it is not a visceral pain (pain was
localized), nerve irritation (no burning or radiation of pain),
hernia (pain was not positive with cough impulse), osteitis
pubis, and pubic stress symphysis (normal radiographic
appearances).
TREATMENT OPTIONS
A physiotherapy management program was planned with
short‑term goals such as to reduce pain, reduce tenderness,
maintain the cardiovascular fitness, improve the strength,
improve proprioception and balance and long‑term goals
such as maintain proprioception and balance, maintain
the strength and improve sport‑specific skills, and return
to sport.
In the initial phase rest, ice massage: 3–4 times a day for
10 min, active pain‑free exercises such as hip flexion and
extension in different positions were given. Adductor
isometrics were advised. Strengthening was gradually
progressed through active adduction–abduction, resisted
flexion and adduction with resistance band, wall squat
exercises, one‑leg squat exercises, and muscle energy
techniques.
To maintain flexibility around the hip‑knee joints and lumbar
spine joint, hamstring stretching, supine gluteus stretching,
hip flexor stretching, gentle adductor stretching, and iliotibial
band stretching were done. Functional strengthening was
done with static bicycling, jogging, abdominal stabilization
exercises, drop squats, and eccentric adductor strengthening
exercises 3–4 times a week. For proprioceptive training, sand
walking, one‑leg standing, tandem walking, and wobble
board exercises were given 3–4 times on alternate days of
the week. Sports‑specific skills were improved with exercises
such as running straight line, running figure of 8, and kicking
with weight balls.
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Khandekar: Assessment and management of adductor strain: A case report
Moreover, a home exercise program included icing, exercises
and stretching regimes, proper rest, and proper warm‑up and
cool‑down session. A caution was given to not practice on
hard surfaces, wear proper guards as required, and maintain
a balanced diet and adequate hydration.
PROGNOSIS
A systematic approach was followed in management as
a result of which she willingly returned to practice. On
examination, the pain on the visual analog scale was found to
be 1/10 on rest and 3/10 on activity. Her range of motion and
muscle strength was improved. There was a marked decrease
in tenderness. There was a positive feedback regarding the
exercise as well as training session.
CONCLUSION
Adductor muscle strain is the most common cause of
groin pain among athletes, especially in sports that require
kicking, quick accelerations/decelerations, and sudden
direction changes, such as soccer and football. These injuries
are overlooked most of the times. Hence, a well‑defined
early assessment is necessary as it does not hinder the
athlete’s sporting activity and shall not convert into a
career‑threatening injury.
Designing a strengthening program to address which muscles
are weak and which muscles are tight is of great essence. This
should generally include strengthening of the muscles around
pelvis and core strength. This should be incorporated with
stretches to be completed following all training sessions.
This will prevent any joint stiffness and allow your muscles
and nerves to move at their optimal length.
Financial support and sponsorship
Nil.
120 Saudi Journal of Sports Medicine / Volume 17 / Issue 2 / May-August 2017
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Conflicts of interest
There are no conflicts of interest.
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