Adductor strain

An adductor strain is an injury to the muscles on the inner thigh, often felt near the groin. The pain may begin during a change of direction or a kick. An evaluation helps distinguish this strain from other causes of groin pain.

Adductor injuries are common in professional soccer. Over a seven-season period, the 628 hip or groin injuries accounted for 12 to 16 percent of all injuries per season. The adductors were the most commonly affected muscle group among the 18 diagnoses recorded¹. Return to sport depends on the extent of the injury and the specific movements that need to be regained. In a systematic review, partial tears treated with physical therapy resulted in a return to play between one and seven weeks, depending on the grade—that is, the severity—of the injury².

This guide describes the possible signs of an adductor injury, the components of the evaluation, and the general principles of rehabilitation.

What is an Adductor Strain?

An adductor strain is an injury to one or more of the muscles that pull the thigh toward the center of the body. The injury can affect the muscle itself, its junction with the tendon, or the tendon’s attachment to the bone. The tendon connects the muscle to the bone. Sudden pain on the inner thigh may indicate this problem, but a physical exam will also rule out other possible causes.

The adductors are a group of five muscles in the inner thigh compartment: the pectineus, the long adductor, the short adductor, the gracilis, and the adductor magnus³ :

The adductor longus was the most commonly injured muscle in a group of 71 male athletes: it accounted for 62 of the 111 injuries observed via magnetic resonance imaging, also known as MRI.⁵ Three sites stood out: two junctions between the muscle and the tendon, and the proximal attachment near the pelvis⁵. These results describe this athletic population.

What Causes an Adductor Strain?

An adductor strain can occur when a sudden force is applied to the muscle as it is being stretched, such as during a change of direction or a kick. In an analysis of 17 videos of long adductor injuries in professional soccer players, the movements observed included changes of direction, kicks, movements to reach the ball, and jumps⁶. The video describes the movement; it does not directly measure the forces acting on the muscle.

Changes of direction and kicking motions are often reported in connection with adductor injuries, but the exact load varies depending on the movement and the individual. In this video analysis, changes of direction accounted for 35% of the 17 cases filmed, and kicking motions accounted for 29%⁶.

Typical injury situations:

• Quick changes in direction during sports (soccer, hockey, basketball)
• Side kick or cross-kick in soccer
• Sprinting acceleration, especially during explosive starts
• Forced split when the leg slips or gets stuck
• Falling with legs spread apart, particularly during collisions

Adductor strains most often occur during sports activities. In American college sports tracked over six seasons, the highest rates of adductor strains were observed in men’s soccer and hockey⁷. The incidence of groin injuries in soccer varies depending on the population, gender, definition, and surveillance method.⁸

Who is at risk of an adductor strain?

Several studies have shown that athletes who have previously suffered a groin injury or who have weaker adductor muscles are at higher risk of a new groin injury. Sports involving changes in direction and kicking put this area at particular risk. A review of 30 studies on acute injuries included 594 men, primarily in soccer, but also in basketball, futsal, American football, hockey, and handball². The results from this group do not represent everyone.

A statistical correlation does not allow us to predict who will get injured. Your physical therapist can assess your strength, your previous injury, and the demands of your sport to determine which areas to focus on.

A gradual warm-up before exercise helps you get back into the swing of sports. Prevention programs often address several factors at once, making it difficult to isolate the effect of the warm-up. Weak adductors are among the factors associated with groin injuries.⁹ Among 508 male amateur soccer players, weakness identified during examination was associated with injuries during the season, with an adjusted odds ratio of 4.28¹¹. This measure compares injury odds—that is, the number of cases relative to non-cases—while accounting for other factors. It does not directly correspond to a fourfold increase in risk.

A Copenhagen-based exercise-based strengthening program reduced groin-related problems reported during the season in a trial involving male soccer players.¹² The exercise works the muscles that bring the thigh inward, using the upper leg for support while lying on one’s side. Another trial, conducted with 24 players under the age of 19 over eight weeks, observed an improvement in adductor strength with a progressive program of this exercise¹³. Strength and injury frequency are two distinct outcomes.

How to recognize the symptoms of an adductor strain?

An adductor strain often causes sudden pain in the groin or inner thigh during physical activity. The pain may make it difficult to walk, spread the legs apart, or squeeze the thighs together. The diagnosis is based on the patient’s symptoms and a physical examination. Among 110 male athletes evaluated for acute groin pain, certain imaging studies showed no acute injury¹⁴. A bruise, also known as an ecchymosis, and swelling may appear after the injury. Their absence does not rule out an injury, and their size alone is not sufficient to determine its severity.

Typical signs:

• Sudden, localized pain in the groin at the time of injury
• Popping or tearing sensation in the groin
• Difficulty walking, especially with long strides
• Pain during specific movements: getting into a car, lifting the leg, squeezing the thighs together
• Swelling or bruising may appear on the inner thigh in the days following the injury.
• Tenderness to the touch near the groin or along the inner thigh

The pain may radiate toward the inside of the knee. The examination specifically looks for tenderness in the adductors and pain during contraction against resistance. In a study of 81 male athletes with acute groin pain, three positive adductor tests each corresponded to an MRI-visible lesion in approximately 80 to 81 percent of cases. The review of clinical tests supports their usefulness, while showing that no single sign is infallible. An earlier study of 25 soccer players found low overall agreement between clinical diagnoses and diagnostic imaging studies¹⁵. The methods and causes of pain studied differed.

What are the different grades of severity for a muscle strain?

Adductor strains are often classified into three grades: a mild injury (Grade 1), a partial tear (Grade 2), and a complete tear or tendon avulsion (Grade 3). Definitions vary depending on the classification system used. The table shows the MRI classification of a cohort of 81 athletes¹⁶. Other classifications include the mechanism, the site, and previous injuries¹⁷.

Not all classification systems describe injuries in the same way. Pain and strength are used to measure your abilities; they do not directly indicate the extent of a tear.¹⁸

Return to sports depends on the site, extent, and treatment of the injury, as well as the demands of the sport and the criteria being measured; a specific injury category does not determine the individual recovery time. Among 81 male athletes monitored using progression criteria, MRI grades 0 through 2 did not differ significantly in terms of recovery time, whereas grade 3 took significantly longer¹⁶.

Many adductor injuries can be treated without surgery. The choice of treatment depends, in particular, on the location and extent of the injury, as well as the activities the patient hopes to resume. In a systematic review, all of the partial tears included had been treated with physical therapy. For a complete rupture of the adductor longus tendon, treatment with or without surgery could allow a return to sports². A medical evaluation helps determine the appropriate treatment option.

How does a physiotherapist diagnose an adductor strain?

The physical therapist diagnoses an adductor strain based on the onset of symptoms, an examination of the thigh, and contraction and stretching tests. The therapist also rules out other causes of groin pain. A clinical examination may be sufficient for a typical acute injury; imaging is helpful when the diagnosis, location, or extent remain uncertain. A study of clinical examinations following acute injury supports this approach. For pain persisting for more than six weeks, a review of five studies found that the tests were less well validated¹⁹. That review did not address acute groin strains.

The evaluation includes:

• The onset and progression of symptoms: the action taken at the time of the injury, the sensation experienced, and any changes since then
• Physical examination: palpation of the groin and inner thigh, observation of gait
• Strength tests: squeezing the thighs together against resistance, a test of adductor contraction
• Stretching tests: pain when the physical therapist gently moves your leg outward without you tensing your muscles

The need for imaging or a medical opinion depends on the nature of the injury, the symptoms, the course of the condition, and the diagnostic question; a clinical examination is not sufficient in all situations.²⁰ In a study of 110 athletes, imaging revealed no acute lesions in 22% of magnetic resonance imaging (MRI) scans and in 25% of ultrasound examinations¹⁴.

Our physical therapists assess your pain, your strength, and the activities you are able to perform. They will recommend a medical evaluation or imaging if a significant tear or another underlying cause is suspected. Among imaging tests, an MRI allows for a detailed examination of muscles and tendons; X-rays and ultrasounds provide answers to other questions depending on the situation²¹.

Visible changes on an MRI may also be present without pain. One study found such changes in male soccer players and other athletes who had no symptoms.²² A review of thirteen studies confirms that changes in the adductors and pubic region are common in people without pain, with frequencies that vary widely. Images should therefore be interpreted in conjunction with the physical examination and symptoms²³.

When to consult a physiotherapist for an adductor strain?

You should see a physical therapist if groin pain limits your ability to walk or play sports. The physical therapist will assess the injury and guide your return to activity. Certain symptoms, such as those described below, require immediate or prompt medical evaluation instead.

• Sudden groin pain during sports
• Difficulty walking normally
• Visible bruising on the inner thigh

• Intense pain that prevents you from walking or putting weight on your leg: get evaluated at the emergency room.
• If you notice a swelling in the groin, see a doctor right away to determine the cause.
• Urinary or testicular symptoms: Seek medical advice immediately. Sudden, severe pain in a testicle requires immediate evaluation in the emergency room. These symptoms may require urgent treatment.

The consultation allows us to assess pain and range of motion, identify signs that require medical evaluation or imaging, and plan a return to activities.

How to treat an adductor strain?

Treatment for an adductor strain combines temporary avoidance of painful movements, progressive exercises, and a gradual return to walking and then sports. The physical therapist will tailor the exercises to your pain level and abilities. The PEACE and LOVE framework outlines some of these recommendations²⁴. These are recommendations from authors for soft-tissue injuries, not a protocol proven to accelerate healing for every adductor strain. The following tables adapt these principles to this specific area.

Phase 1, based on tolerance

Gradual resumption based on tolerance

How does physical therapy rehabilitation work?

Physical therapy rehabilitation progresses from simple movements and contractions to strengthening, running, and the movements specific to your sport. The physical therapist assesses your pain and functional abilities before increasing the difficulty. In studies of male soccer players, the most commonly cited criteria for returning to play after an adductor injury are pain-free testing, restoration of strength, and at least one full training session. The strength of the evidence varies depending on the criterion²⁵.

A case series followed 205 people with persistent sports-related groin pain, with a variety of diagnoses. Their ability to participate in their activities improved after a rehabilitation program that focused on body coordination, running, and changes of direction.²⁶ In total, 73% had resumed sports without pain after an average of 9.9 weeks. The study did not include a comparison group; therefore, the improvements cannot be attributed solely to the program²⁶.

Phase 1: Protection and mobility based on tolerance

• Short walks, depending on pain levels and the ability to put weight on the foot
• Gentle adductor contractions, such as bringing your thighs together against light resistance without moving your hips
• Small hip movements, such as gently spreading your leg and then bringing it back to a comfortable position

Phase 2: Gradual intensification once the basic exercises are tolerated

• Strengthening by bringing the leg toward a resistance, then controlling its return
• Standing adduction with a resistance band, that is, bringing the leg toward the center of the body
• Glute and core exercises selected to address specific challenges, such as balancing on one leg
• Stationary cycling, swimming

Phase 3: Return to function when strength, range of motion, and changes in direction meet the established criteria

• More challenging adduction exercises, including a Copenhagen variation, once the previous exercises are well tolerated
• Slow running, followed by gradual accelerations and sprints depending on the sport
• Planned changes in direction, or changes in response to a signal or an opponent
• Sport-Specific Exercises

Phase 4: Return to Sport

• Strength, sprint, and change-of-direction tests to assess playing ability
• Resumption of training, followed by games, was decided in consultation with the physical therapist and the team based on test results and the demands of the sport
• A maintenance program tailored to the demands of sports, with no guarantee of preventing relapses

Strengthening can continue after returning to play. A study of male soccer players found fewer groin-related problems reported during the season when following the Copenhagen program. The findings pertained to all such problems, not just recurrent groin strains.

What to do at home for an adductor strain?

Home care involves temporarily limiting activities that worsen pain and continuing to move within your comfort level. Walk short distances if you can bear weight on your leg. Your physical therapist can show you basic exercises and adjust their intensity. Pain that prevents you from bearing weight requires a medical evaluation.

First phase based on symptoms and tolerance

• Adjust the walking distance based on pain and your ability to put weight on your foot
• Compression can be tried if it feels comfortable, but it is not required
• Adjust the exercises based on your symptoms. You can try applying ice briefly if it provides relief, placing a cloth between your skin and the ice. Begin the contractions demonstrated by the physical therapist when your pain and physical abilities allow.
• Reduce your activity if the pain remains more severe afterward or if walking becomes more difficult

When contractions are tolerable

Gentle contractions: When the assessment allows it, gently bring your thighs together against light resistance. The physical therapist will work with you to determine the duration and number of repetitions. Reduce the effort if pain increases during the exercise or remains more intense afterward.

Heart-pumping activities: Cycling or swimming can help you stay physically active as long as the movements you choose do not trigger pain. Adjust the duration and avoid movements that cause pain.

Progression: Gradually increase the resistance or duration with your physical therapist, then resume running and sports activities.

How long does it take to return to sports after an adductor strain?

Returning to sports after a partial adductor strain often takes a few weeks, while a complete tear may take several months. In a systematic review, the average recovery times ranged from one to 6.9 weeks for partial tears, depending on their grade². These timeframes describe the return to play, not a specific date when muscle healing is complete. Resuming daily walking depends largely on pain levels and the ability to bear weight. The table shows two milestones measured in the cohort of 81 male athletes. The median divides the participants into two halves: one half reaches the milestone before this time, the other after. Grade 0 corresponded to pain without an acute lesion visible on MRI; its timeframes were grouped with those of grades 1 and 2.

In this cohort of 81 athletes, pain-free testing and exercise protocols guided their progress. Athletes who had met the first set of pain-free criteria experienced fewer recurrences—5% compared with 21% among those who had not met them¹⁶. The study did not randomly compare two treatments; therefore, this association does not prove that these criteria alone explain the difference.

How can we reduce the modifiable risk factors associated with new groin pain?

Gradually strengthening the adductor muscles may reduce groin problems in male soccer players, according to a prevention trial. Sport-specific preparation and adjustments to training round out the program. The effectiveness of any single component—such as warming up alone—remains less clear.

• Strengthening the Adductors : Copenhagen exercises, a routine that strengthens the muscles that pull the thigh toward the center of the body, studied in particular among young soccer players¹³
• A reduced adduction strength compared to abduction has been associated with a higher incidence of injuries in a small cohort of professional hockey players; no universal threshold has been established.¹⁰
• Warm-up: progressive movements selected based on the sport, without guaranteeing a specific preventive effect
• Load Management: gradual increase in training intensity

In the trial involving male soccer players, the program called for three sessions per week during the preseason, followed by one session per week during the season. This protocol is not a one-size-fits-all approach, and its results focused on self-reported groin problems, not solely on recurrent groin strains.¹²

What should you know about adductor strains?

An adductor strain is an injury to the muscles on the inner thigh. Weight-bearing is generally resumed gradually, depending on the level of pain, strength, and specific sports movements, but the timeline varies depending on the severity of the injury.

• Groin pain can occur during athletic activity; this description alone is not sufficient to confirm an adductor injury.
• The recovery time varies depending on the extent of the injury and the level of activity to be resumed. A return to sports is based on strength tests and sports-specific movement assessments, not just on the number of days that have passed.
• After initial protection, movement and physical activity are gradually resumed depending on pain levels and the patient’s abilities. Modern management of muscle injuries favors this active approach. Evidence remains limited for several medications and injections proposed to speed up recovery²⁸.
• In a randomized trial involving 35 men’s semiprofessional soccer teams, the average weekly incidence of groin injuries was 13.5% with the strengthening program and 21.3% with the usual training regimen. The analysis found an odds ratio of 0.59, representing a 41% reduction in odds, which does not directly equate to a 41% reduction in risk¹².
• See a doctor for an evaluation; depending on the symptoms, medical evaluation or imaging may be necessary

References

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