Groin pull and adductor muscle injury

Picture: The adductor muscles on the inside of the thigh
Adductor muscles are stabilizer muscles that provide stability when we walk, run, and step forward sideways or backward.  Without adductor muscles, if we were to lift a foot off the ground, our legs would splay apart and we would crash to the ground. 

Adductor muscles don't make movement happen

The adductor muscles of the hip don't make movement happen. What they do is brace against, and eccentrically control, excess movement. With the help of adductor muscles we walk, run, change direction and lower ourselves to the ground, all without continually dropping into the splits, and all in a superbly smooth and coordinated fashion.

Adductor muscle bracing and eccentric control requires a massive amount of strength and a reasonable amount of flexibility. The stronger the other muscles around the hip joint, the stronger the adductor muscles must be to control them. But weight training programs often neglect this.

Eccentric control can be described as smooth lengthening under load. Adductor muscle eccentric control should be practised and trained at every strength and conditioning session.

Adductor injuries are common; even when not painful they can limit performance

Groin pain is a problem for soccer players who sprint, kick, cut and twist as part of their sport. Studies suggest the incidence in male soccer players to be 18% of all injuries each year⁽¹⁾.  Not covered in these injury statistics is the milder, ongoing groin and adductor strain that we learn to live with.  This is the sort of pain that is vague, hard to pinpoint, and not localised to the inner thigh.  It’s not sufficiently bad to trigger a visit to the therapist. Nevertheless it takes the edge off our performance.

Transfer of pain from adductors to tummy muscles and pubic bone

This sort of chronic adductor muscle pain might be felt in the abdominal muscles and lower abdominal organs away from where the actual problem is.  It might contribute to premenstrual pain.  If there’s pain in the abdominals or lower abdomen, it might never occur to you that you need physiotherapy and weight room conditioning for your adductor muscles!

 

Movements that damage adductor muscles

The movement that hurts soccer players is the sideswipe kick where the instep of the boot contacts the ball. 

Sprinters also have groin pulls and adductor injuries, and all the more so if they have strengthened their backs and buttocks in the weight room but have neglected to balance this up with adductor muscle work.  The movement that hurts a sprinter’s adductor muscles is at toe-off when the adductors forcibly contract to reverse the action of the Gluteus maximus (Glute action is abduction, external rotation and extension), and then return the leg to the front and centre line of the body.  This same action occurs in ice hockey players, who are the most groin pull prone of all competitive athletes.

The third situation where groin pull occurs, is sudden slips and falls.

All these forms of injury can be prevented or minimised with preconditioning strength mobility and massage work.

Description of adductor stabilizer function & how to train it

Adductors stabilize by working against and balancing the powerful action of the muscles at the other side of the hip joint (the gluteals), that propel us forward and from side to side.

Adductor stabilizer action breaks down into three components
An adductor muscles must:-

1. Slow (by eccentric contraction) the leg from moving away from the centreline of the body. They must be both long and strong to do this, and eccentric (lengthening under load) resistance work is the best way to improve this action.
2. Stop (by isometric contraction) the leg from moving away from the centreline of the body. Isometric (or nil movement) contraction is the best way to heal the pubic bone aponeurosis and its insertions on to the pubic bone.
3. Pull the leg toward the centreline of the body (using concentric muscle contraction). A strong slow concentric training is the best and safest way to re-train this action.

Anatomy lesson:  you can’t separate pain and disfunction in hip adductors from pain and disfunction in abdominal muscles

The picture below shows us the adductor muscles, and the abdominal muscles, and the aponeurosis that connects the two.  The aponeurosis links the adductors with the pubic bone and the abdominal muscles. The linkage transfers lines of force, and also damage scarring and pain, between the three areas. The aponeurosis can also be damaged and painful. Fortunately the same exercises that normalize and strengthen adductors will normalize and strengthen the aponeurosis and surrounding parts as well.

Aponeurosis defined:-

aponeurosis, a flat sheet or ribbon of tendonlike material that anchors a muscle or connects it with the part that the muscle moves. The aponeurosis is composed of  dense  fibrous  connective tissue containing fibroblasts (collagen-secreting spindle-shaped cells) and bundles of collagenous fibres in ordered arrays. Aponeuroses are structurally similar to tendons and ligaments.

Encyclopedia Britannica
https://www.britannica.com/science/aponeurosis

Picture 2:  Close up of the aponeurosis (the strong connective tissue sheet) that connects the abdominals with the adductors

 

The importance of the pubic aponeurosis

The pubic aponeurosis connects the adductor muscles to the pubic bone and to the abdominal muscles.  The aponeurosis connection is important for three reasons:-

1. The aponeurosis transmits forces in the adductor muscles to the pubic bones and the abdominal muscles. 
   By physically linking the pubic bone with the two sets of muscles, the aponeurosis shares and transmits forces between the three.  Since forces are shared and transmitted, damage in the form of connective tissue tears, scars and tight bands are also shared and transmitted.  This means that if one part of the area of the aponeurosis is damaged, the other parts are likely to damage as well.
   
   
2. The physical connection provided by the aponeurosis also transmits and transfers pain signals away from the site of the main injury.
   If an injured adductor muscle is loaded stretched, or massaged, it may not directly feel sore, but may “ send the pain” into and even across the aponeurosis into the lower abdominals.  This is a well-known pain behaviour of the Adductor Magnus, which contributes to PMS pain in women. From personal experience, I've found that similar pain transferral from happens from other hip adductor muscles to abdominals. The Adductors Longus and Brevis, and the Pectineus, also "push" pain up into the abdominal muscles. The pain transfer is not as marked as with the Adductor Magnus, but it is still significant.
   
   
3. The best healing stimulus for the insertions of the aponeurosis, and for the aponeurosis itself, onto the pubic bone is when we apply isometric contraction. 
   We can comfortably and easily do this by pausing at any stage during adductor strength exercises to let the sustained pull do its healing work.

 

Copenhagen adductor self-test

The simplest and easiest to read self-test is the Copenhagen adductor exercise.  Just do the exercise and look for pain and/or weakness.  And take note of where the pain is.  If you’ve never the Copenhagen before, it might surprise you how weak and/or painful your inner thigh muscles are.  You might be surprised at how the adductor muscles send pain into the lower abdomen.

Exercises and drills that keep your adductors strain-free pain-free and functional

Exercise slowly and mindfully...
Exercises should not only strengthen the adductors. They should also enhance the stabiliser and coordination functions as well. The exercises will work best if you do them slow enough such that you have time to mindfully work on balance and co-ordination. The exercises will work best if you do them slow enough to give the brain time to learn and calibrate control of:-

• eccentric contraction (that's lengthening under load)
• isometric contraction (no movement)
• concentric contraction

No single exercise fits all situations...
Most of the adductor exercises that I cover also exercise other body parts. For example:

• The Copenhagen puts a high load on the shoulder girdle and the lower tummy, and would not be the first choice for a person with shoulder impingement or lower back pain or sacro-iliac pain.
• The pilates "hug-a-knee" inner thigh lift puts pressure on the side hip and often requires a cushion under the hip. It would not be the first choice for someone with Greater trochanteric pain syndrome.
• Many of the exercises put a twist or side pressure on the knee and would not be good for someone with a knee cartilage injury.

Try to do all the exercises, but don't persevere too long with what your body cannot do.

Sets and reps...
In any given workout session, do three sets of 10 for each leg. Don't just go through the motions. Make sure you put enough load on so that you know that you are working. Since you are programming complex motor control as well as doing strength work, do a mixture of adductor exercises at each session.

Periodisation...
In the course of a week do one to three adductor exercise sessions. One session per week is for maintenance, and three per week is for rapid improvement in strength and control.

 

Sports warmups

Leg swings:
Swing the leg side to side while facing and holding on to a fence.  If you hold your hips still this will put stronger movement into the adductor muscles.

Karaoke side step:
Skip sideways at medium speed and with control. If going left the right legs lifts and places in front of the left (high knee lift), then the right leg steps behind.
If you prevent the hip twist you will put stronger movement into the adductor muscles.

 

Strength workouts:

Copenhagen adductor exercise

Easy version:

With bent knee and shin bone resting on a padded seat

 

Harder version:

With a straight leg and an ankle resting on a padded seat

Take it slow because you are training control just as much as you are training strength, and slow resistance training (with no jerking and jarring at the end of the range of movement), is what stimulates the healing of the aponeurosis and its insertions onto the pubic bone.

Standing side swipe with band resistance

This looks like doing a soccer kick with the instep connecting with the ball.  Do it slowly for the reasons stated under Copenhagen adductor exercise above.  Do it with a minimum of help from hands holding onto a wall or chair back.  That way your ankles and other balance and support systems get a workout as well.

 

Pilates and yoga exercises for mat classes

The following poses can be turned into continuously moving exercises that improve strength and coordination, at the same time as improving flexibility:-

• Triangle pose
• Warrior pose

 

The following are good mat exercises:

• Sidelying adductor leg lift while hugging a bent knee close to your chest (you may need a cushion under your hip if you have a bony side hip)
• Bridge at 45 degrees with adductor leg lift
• Quadruped push a foot out to the side
• Variations on Iron man landing pose

 

 

References

Adductor rehab: keep on the ball with a criteria-based plan!
https://www.sportsinjurybulletin.com/adductor-rehab-keep-on-the-ball-with-a-criteria-based-plan/

Groin pain: risks and prevention
https://www.sportsinjurybulletin.com/groin-pain-risks-and-prevention/

Impact of a modified progressive Copenhagen adduction exercise programme on hip adduction strength and postexercise muscle soreness in professional footballers
https://bmjopensem.bmj.com/content/bmjosem/5/1/e000570.full.pdf

Osteitis pubis: a likely cause of groin pain
https://www.sportsinjurybulletin.com/osteitis-pubis-a-likely-cause-of-groin-pain/

Isokinetic imbalance of adductor-abductor hip muscles in professional soccer players with chronic adductor-related groin pain
https://pubmed.ncbi.nlm.nih.gov/27017973/

Abdominal tendinopathy – How to get rid of it
https://www.sports-injury-physio.com/post/abdominal-tendinopathy-how-to-get-rid-of-it

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