Adductor tendinitis or tendinopathy

Adductor tendinopathy is an irritation of the tendons that attach the groin muscles to the pelvis. This injury causes pain on the inside of the thigh. It often affects athletes who play hockey, soccer, or cross-country skiing. The good news is that physiotherapy allows for complete recovery in most cases.

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 muscle to bone. When a muscle contracts, the force passes through the tendon, which pulls on the bone to create movement. Adductor tendons are particularly stressed in sports that require rapid lateral movements.

What is the difference between tendinitis and tendinopathy?

Recent research shows that most tendon pain is not related to active inflammation. The term tendinopathy (tendon pain) describes pain without necessarily showing signs of inflammation. Tendinitis implies actual inflammation of the tendon.

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 groin tendons experience repetitive stress that exceeds their ability to adapt. The main causes are overloading too quickly 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. Starting a hockey season after the summer without adequate preparation is a classic example. Tendons need time to adapt to new demands.

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 contribute to the development of tendinopathy:

• 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?

Some people are more likely to develop adductor tendinopathy. Men, athletes, and individuals with weak pelvic stabilizing muscles have a higher risk.

Personal Factors

Men are more often affected than women, possibly due to greater participation in high-risk sports. The average age of affected individuals is between 25 and 35 years old.

Sports Factors

The following sports carry a higher risk:

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

Biomechanical factors

Weakness in the core or gluteal muscles can increase the load on the adductors. An imbalance between hip muscles (adductors weaker than abductors) is also a recognized risk factor.

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.

Location of pain

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?

Diagnosis is based on your symptom history and a clinical examination. In most cases, your physiotherapist can identify this condition without the need for imaging.

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 mobility

Role of imaging

Ultrasound or MRI scans are generally not needed to confirm the diagnosis. These tests may be helpful if there is uncertainty or if symptoms do not improve with treatment.

Conditions to differentiate

Several other problems can cause similar groin pain:

• Inguinal hernia
• Pubic stress fracture
• Osteitis pubis (inflammation of the pubic bone)
• Hip problems (labrum, osteoarthritis)
• Referred back pain

Your physiotherapist will rule out these conditions during the assessment.

When should you see a physiotherapist for adductor tendinopathy?

You should see a physiotherapist if you have groin pain that has lasted more than 7 to 10 days or limits your activities. You do not need to see a doctor before consulting a physiotherapist.

Signs that warrant a consultation

Consult if you experience:

• Groin pain during or after sports for more than a week
• 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?

Physiotherapy treatment combines load management, progressive strengthening exercises, and correction of contributing factors. The goal is to restore the tendon's ability to support desired activities.

Comprehensive assessment

Your physiotherapist will assess:

• Your hip joint mobility
• Your nerve gliding (to rule out a nerve component)
• 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)
• Correction of identified muscle imbalances

• 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?

At-home measures aim to reduce pain and promote healing without making the condition worse. Complete rest is not advised, but temporarily adjusting your activities is crucial.

Recommended adjustments

Here are tips for daily management:

• Temporarily avoid movements that significantly increase pain
• Engage in activities that keep you fit without straining your groin (swimming, stationary cycling)
• 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
• Staying completely inactive (complete rest weakens the tendon)

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 after 10 to 14 days of active management, consult a physiotherapist. A professional assessment will help identify factors slowing your recovery and establish a tailored program.

How long does it take for adductor tendinopathy to heal?

Healing from adductor tendinopathy typically takes between 6 and 12 weeks with appropriate treatment. Recovery time varies depending on the severity and how long symptoms have been present before treatment begins.

Factors that Influence Healing Time

Recovery is faster if:

• Treatment starts early (within the first few weeks)
• You regularly follow the exercise program
• You adhere to the gradual progression for returning to sport

Recovery may take longer if:

• Symptoms have been present for several months
• The tendon has undergone degenerative changes
• The underlying cause (weakness, imbalance) is not corrected

Back to sports

Returning to sport is done in stages:

• Resuming low-intensity training (4 to 6 weeks)
• Gradual increase in volume and intensity (2 to 4 weeks)
• Return to competition when strength tests and sports movements are pain-free

How to prevent adductor tendinopathy?

Prevention relies on adequate preparation and a gradual increase in activities. Strengthening hip muscles and listening to your body's signals significantly reduces the risk of injury.

Prevention Strategies

• Increase your training volume by a maximum of 10% per week
• 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
• Maintain a good balance between hip muscle groups

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

Copenhagen Program for Adductors

The Copenhagen exercise is known for its effectiveness in prevention. This exercise involves holding your body in a side plank position, supporting yourself on the inside of your elevated foot on a bench. It effectively strengthens the adductors in a functional position.

Sources

• Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774. doi:10.1136/bjsports-2015-094869

• Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128. doi:10.1177/03635465010290020301

• Harøy J, Thorborg K, Serner A, et al. Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players: A Randomized Controlled Trial. Am J Sports Med. 2017;45(13):3052-3059. doi:10.1177/0363546517720194