Adductor tendinitis or tendinopathy

Adductor tendinopathy is an irritation of the tendons that attach the groin muscles to the pelvis. It causes pain on the inner thigh. This injury often affects people who play hockey or soccer. The good news is that for athletes with persistent groin pain related to the adductors, an active physical therapy program focused on strengthening and coordination yields better results than primarily passive treatments in reducing pain and promoting a return to sports; however, the evidence is based on only two trials deemed to be of low quality by a Cochrane review.^{1, 2}

What is Adductor Tendinopathy?

Adductor tendinopathy is an irritation of one or more tendons of the groin muscles. These muscles allow you to bring your legs together. They also play an important role in pelvic stability.

The adductor muscles form a group of five muscles on the inner thigh. The adductor longus, adductor brevis, adductor magnus, pectineus, and gracilis all attach to the pubis. They then extend down towards the femur or tibia. Their tendons, located near the groin, withstand significant forces during changes in direction.

A tendon is the fibrous structure that connects a muscle to a bone. When a muscle contracts, the force is transmitted through the tendon, which pulls on the bone to create movement; a tendon also plays a role in storing and releasing energy.³ The adductor tendons are particularly stressed in sports that require rapid lateral movements.

What is the difference between tendinitis and tendinopathy?

For a long time, it was believed that all tendon pain was caused by inflammation, which gave rise to the term “tendinitis.” We now know that a painful tendon primarily changes in its structure and load-bearing capacity, and that inflammatory processes also play a role, though their significance varies depending on the condition and its stage.^{4, 5} That is why we now refer to it as tendinopathy, a term that simply means “tendon problem.” The term tendinopathy (tendon pain) describes pain without necessarily indicating inflammation. Tendinitis implies actual inflammation of the tendon.^{6, 7}

In practice, the distinction doesn't really matter for treatment. The approach to care remains similar, whether there's inflammation or not. This is why the two terms are often used interchangeably.

What are the causes of adductor tendinopathy?

Adductor tendinopathy occurs when the tendons in the groin are subjected to repetitive stress that exceeds their ability to adapt—a threshold that varies from person to person and remains poorly defined in the literature.^{8, 9} The main causes are too rapid an increase in load or repetitive movements with a large range of motion.

Training Overload

Increasing the intensity or volume of activity too quickly often exceeds the tendons’ tolerance, even though no universal threshold for intensity or volume has been established in the literature.^{10, 9} Returning to a hockey season after the summer without adequate preparation is a classic example. Tendons need time to adapt to new demands; this has been shown in studies of healthy tendons, particularly the Achilles tendon and the patellar tendon, although direct evidence for the adductor tendons has yet to be established.¹⁰

Repetitive Movements

Movements that repeatedly spread and bring the legs together heavily strain the adductors. Skating movements, soccer kicks, and sprints with changes of direction place significant stress on these tendons.

Typical Development Examples

The following situations can increase the strain on the adductors:

• Resuming hockey after several months off
• Suddenly increasing cross-country skiing volume
• Starting a new soccer season without preparation
• Transitioning from treadmill running to outdoor running on uneven terrain

What are the risk factors for adductor tendinopathy?

Weaker adductor muscles are associated with groin injuries in athletes, but the specific risk factors for adductor tendinopathy remain unclear. This association does not prove that weakness causes the injury.¹¹

Personal Factors

Among athletes, men are affected more often than women, as shown by a systematic review of groin injuries in general in high-level team sports; however, there are no separate data specifically for adductor tendinopathy.¹² Adductor tendinopathy can affect active adults and athletes, although no specific age group has been clearly identified.

Sports Factors

The following sports engage the adductors through repetitive movements or changes in direction:

• Ice hockey (repeated skating movements)
• Soccer (kicking the ball, changes of direction)
• Cross-country skiing (classic style and skate style)
• Running (sprinting and trail running)
• Racquet sports (lateral movements)

Biomechanical factors

A study of professional hockey players found a link between the strength ratio of the adductors and abductors—the muscles that spread the thigh apart—and the risk of muscle strain.¹³ A more recent review did not find this association for groin injuries. Therefore, it does not support presenting this imbalance as a recognized cause of tendinopathy.¹¹

What are the symptoms of adductor tendinopathy?

Adductor tendinopathy causes pain in the groin or inner thigh. This pain usually develops gradually, increasing with certain movements and decreasing with rest.

Pain location

Pain is typically located:

• In the groin, near the pubic bone
• Inner upper thigh
• Sometimes, the pain can radiate to the inside of the knee

Movements that increase pain

The following activities typically worsen symptoms:

• Getting in or out of the car
• Lifting the leg to put on socks or pants
• Walking with long strides
• Climbing stairs by skipping steps
• Skating or cross-country skiing
• Kicking a soccer ball
• Squeezing the thighs together

Typical progression

Pain often starts during or after sports activities. Initially, it quickly goes away with rest. Without treatment, it can become persistent and limit daily activities.

How to diagnose adductor tendinopathy?

The diagnosis is based on a clinical examination; imaging is generally not necessary to confirm it.¹⁴ Up to 71 percent of asymptomatic soccer players show at least one abnormality on magnetic resonance imaging (MRI), which limits the value of imaging alone in explaining symptoms.¹⁵

Clinical evaluation

The examination includes:

• Questions about the onset of symptoms and activities performed
• Palpation of the adductor tendons near the pubic bone
• Adductor strength tests (squeezing against resistance)
• Tendon tension tests (passive stretching)
• Assessment of Hip Range of Motion

Role of imaging

Ultrasound or MRI are generally not necessary to confirm the diagnosis. An MRI may be helpful in cases of uncertainty or if symptoms do not improve with treatment, and its results should be interpreted in conjunction with the clinical examination, as abnormalities are common even in the absence of pain.^{16, 15}

Conditions to differentiate

Several other problems can cause similar groin pain:

• Inguinal hernia
• Pubic stress fracture
• Osteitis pubis (inflammation of the pubic bone)
• Hip problem, such as a labral tear (the cartilage rim around the joint) orosteoarthritis
• Pain that originates in the back and is felt in the groin (this is known as referred pain)

Your physical therapist will look for signs of these problems and refer you for a medical evaluation or further testing if necessary.

When should you see a physiotherapist for adductor tendinopathy?

You should see a physical therapist if your groin pain persists or limits your activities. You do not need to see a doctor before seeing a physical therapist.

Signs that warrant a consultation

Consult if you experience:

• Persistent groin pain during or after exercise.
• Pain that returns every time you resume the activity
• Pain that limits your daily movements
• Inability to return to your usual sport level

Direct access to physiotherapy

In Quebec, you can consult a physiotherapist directly without a medical prescription. If your condition requires a medical evaluation, your physiotherapist will refer you to the appropriate professional.

What are the physiotherapy treatments for adductor tendinopathy?

Physical therapy treatment combines adjusting the intensity of exercise, progressive strengthening, and exercises selected based on the issues identified during the evaluation. The goal is to restore the tendon’s ability to withstand the desired activities.

Treatment for tendinopathy includes exercise programs and gradual loading. Studies have not determined which option is best for everyone.⁴ For persistent adductor pain, a systematic review found the evidence to be limited and generally of low quality; strengthening is among the most well-supported interventions but carries a low level of recommendation.¹⁷

Comprehensive assessment

Your physiotherapist will assess:

• Your hip joint mobility
• Your sensitivity, your strength, and signs that might indicate nerve involvement
• The quality of your functional movements
• Your muscle strength and pelvic stability

Rehabilitation program

Treatment generally includes three phases:

• Temporary modification of pain-provoking activities
• Adductor isometric exercises (contraction without movement)
• Hip mobilization if necessary

• Adductor strengthening exercises with progressive loading
• Work on pelvic stabilizing muscles (glutes, abdominals)
• Adapting the exercises to the difficulties observed during the assessment

• Sport-Specific Exercises
• Gradual return to training
• Relapse prevention program

Complementary Techniques

Depending on your needs, your physiotherapist may also use:

• Manual therapy to improve hip mobility
• Muscle release techniques
• Temporary supportive taping

What can you do at home for adductor tendinopathy?

You can adjust any activities that increase your groin pain and continue with the recommended exercises as tolerated. Complete rest is not recommended, but temporarily modifying your activities is essential.

Recommended adjustments

Here are tips for daily management:

• Temporarily avoid movements that significantly increase pain
• Choose an activity that you can handle well, and adjust its duration or intensity if the pain increases
• Take frequent breaks if prolonged sitting worsens your symptoms
• Avoid aggressive groin stretches (stretching can further irritate a painful tendon)

What to Avoid

Common mistakes to avoid:

• Aggressively stretching the groin
• Resuming sports as soon as pain slightly decreases
• Ignoring the pain and continuing activity as if nothing is wrong
• Stopping all activity for an extended period without adjusting your program with your physical therapist

Signs of improvement

You are on the right track if:

• Pain gradually decreases over several weeks
• You can resume light activities without worsening your condition
• Morning pain lessens or disappears

When to consult if there's no improvement

If you don't see any improvement despite consistent, active management, consult a physical therapist. A professional evaluation will help identify the factors that are slowing your recovery and develop a tailored program.

How long does it take for adductor tendinopathy to heal?

The recovery time for persistent groin pain related to the adductors varies from person to person; no single timeframe can be guaranteed. An 8- to 12-week active exercise program focused on strengthening the adductors and abdominal muscles can help treat this pain.¹ This timeframe refers to the exercise program, not a recovery date. A full return to sports may take longer, and recovery time varies depending on the severity and duration of symptoms prior to the start of treatment.

How can I track my recovery?

Your physical therapist will tailor the program based on the following factors:

• Changes in Your Pain
• Your exercise tolerance
• Your ability to resume athletic activities

A new evaluation may be helpful in the following situations:

• Symptoms persist despite a tailored treatment plan
• The pain changes or gets worse
• Getting back into sports remains difficult

Return to sport

Returning to sports is a step-by-step process: start with a gradual return to low-intensity training, then gradually increase the volume and intensity—based on your tolerance—until you’re ready to compete again, when strength tests and sports movements are pain-free.¹⁸

To guide a return to sports, it is helpful to measure the strength of the muscles that bring the thigh closer to the other leg¹⁸, along with performance tests and sport-specific movements; no single test is sufficient on its own, according to a consensus reached through a structured consultation with a group of experts.¹⁹

How to prevent adductor tendinopathy?

Prevention relies on proper preparation and a gradual progression of activities. Strengthening the hip muscles and listening to the body’s signals are generally considered protective measures in clinical practice. Among male semiprofessional soccer players, the average proportion of players reporting a groin problem during the season was 13.5% in the group following a program based on the Copenhagen adduction exercise, compared with 21.3% in the control group.²⁰

This exercise strengthens the adductors, the muscles on the inner thigh. Weaker adductors are associated with groin injuries in athletes, although a cause-and-effect relationship has not been proven.

Prevention Strategies

• Increase your training volume gradually and avoid sudden, significant increases in load.
• Allow yourself a preparation period before sports seasons
• Alternate intense training days with recovery days

• Include adductor exercises in your routine
• Also strengthen your glutes and core muscles
• Tailor your hip exercises to your abilities and the demands of your sport

• Specifically prepare your groin muscles before activity
• Include dynamic movements that engage the adductors
• Avoid prolonged static stretches before sport

Copenhagen Water Supply Program for Water Suppliers

A positive trial among male semiprofessional soccer players showed fewer groin problems with a strengthening program based onthe Copenhagen adduction exercise. However, a recent systematic review with a meta-analysis concludes that its overall preventive effect on groin injuries remains uncertain, as the observed reduction was not statistically significant and the overall quality of the evidence was deemed very low.^{20, 21} This exercise involves holding the body in a side plank position while resting on the inside of the foot, which is elevated on a bench. It effectively strengthens the adductors in a functional position²²: Among male soccer players, five studies have shown an increase in adduction strength and high adductor activity with this exercise; however, whether these findings apply to other populations remains to be confirmed.²³

Sources

The sources for this article include clinical studies, reviews, and a consensus on adductor-related groin pain.

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