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 physical therapy allows for a full recovery in most cases.

What is adductor tendinopathy?

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

The adductor muscles form a group of five muscles on the inner side of the thigh. The long adductor, short adductor, large adductor, pectineus, and gracilis all attach to the pubis. They then descend toward 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. The 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 any signs of inflammation. Tendinitis involves actual inflammation of the tendon.

In practice, the distinction is irrelevant for treatment. Treatment remains similar, whether there is 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 are subjected to repetitive stress that exceeds their capacity to adapt. The main causes are excessive strain too quickly or repetitive movements with a wide range of motion.

Training overload

Increasing the intensity or volume of activity too quickly often exceeds the tolerance of the tendons. Returning to 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 place significant strain on the adductors. Skating movements, soccer kicks, and sprints with changes of direction place significant stress on these tendons.

Typical examples of development

The following situations promote the onset of tendinopathy:

• Getting back into hockey after several months off
• Suddenly increasing the volume of cross-country skiing
• Starting a new soccer season without preparation
• Switching 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 people with weak pelvic stabilizing muscles are at higher risk.

Personal factors

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

Sports factors

The following sports carry a higher risk:

• Ice hockey (repeated skating movements)
• Soccer (kicking the ball, changing direction)
• Cross-country skiing (classic and skating techniques)
• Running (sprint and trail)
• Racquet sports (sideways movements)

Biomechanical factors

Weakness in the core or gluteal muscles can increase the load on the adductors. An imbalance between the 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. It increases with certain movements and decreases with rest.

Location of pain

The pain is usually located:

• In the groin, near the pubic bone
• Inside the 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 your leg to put on stockings or pants
• Walk with long strides
• Climb the stairs by skipping steps
• Go ice skating or cross-country skiing
• Kicking a soccer ball
• Squeeze your thighs together

Typical progression

The pain often begins during or after sports activities. At first, it disappears quickly with rest. Without treatment, it can become persistent and limit daily activities.

How to diagnose adductor tendinopathy?

The diagnosis is based on the history of symptoms and clinical examination. Your physical therapist can identify this condition without the need for imaging in most cases.

Clinical evaluation

The exam 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)
• Hip mobility assessment

Place of imaging

Ultrasound or MRI scans are not usually necessary to confirm the diagnosis. These tests may be useful in cases of doubt or if symptoms do not improve with treatment.

Conditions to differentiate

Several other problems can cause similar pain in the groin:

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

Your physical therapist will rule out these conditions during the evaluation.

When should you see a physiotherapist for adductor tendinopathy?

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

Signs that warrant a consultation

Consult if you have:

• Groin pain during or after exercise for more than a week
• Pain that recurs every time you resume the activity
• Pain that limits your daily movements
• Inability to resume your sport at the usual level

Direct access to physical therapy

In Quebec, you can consult a physical therapist directly without a doctor's prescription. If your condition requires medical evaluation, your physical therapist will refer you to the appropriate professional.

What are the physical therapy 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 physical therapist will assess:

• Your hip joint mobility
• Sliding your nerves (to remove a nerve component)
• The quality of your functional movements
• Your muscle strength and pelvic stability

Rehabilitation program

Treatment generally consists of three phases:

• Temporary modification of activities that cause pain
• Isometric exercises for the adductors (contraction without movement)
• Hip mobilization if necessary

• Adductor strengthening exercises with progressive load
• Work on the stabilizing muscles of the pelvis (glutes, abdominals)
• Correction of identified muscle imbalances

• Exercises specific to the sport practiced
• Gradual resumption of training
• Recidivism prevention program

Complementary techniques

Depending on your needs, your physical therapist may also use:

• Manual therapy to improve hip mobility
• Muscle relaxation techniques
• Temporary support taping

What can you do at home for adductor tendinopathy?

Home measures aim to reduce pain and promote healing without aggravating the condition. Complete rest is not recommended, but a temporary change in activities is essential.

Recommended adjustments

Here are some tips for daily management:

• Temporarily avoid movements that significantly increase pain.
• Engage in activities that keep you fit without straining your groin (swimming, stationary bike).
• 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:

• Stretching the groin aggressively
• Resume exercise as soon as the pain subsides slightly.
• Ignore the pain and continue the activity as if nothing had happened.
• Remaining completely inactive (complete rest weakens the tendon)

Signs of improvement

You are on the right track if:

• The pain gradually subsides over several weeks.
• You can resume light activities without aggravating the condition.
• Morning pain decreases or disappears

When to seek medical advice if there is no improvement

If you see no improvement after 10 to 14 days of active management, consult a physical therapist. A professional evaluation will identify the factors that are slowing down your recovery and establish an appropriate program.

How long does it take for adductor tendinopathy to heal?

Adductor tendinopathy usually takes between 6 and 12 weeks to heal with appropriate treatment. Recovery time varies depending on the severity and duration of symptoms prior to treatment.

Factors that influence healing time

Recovery is faster if:

• Treatment begins early (in the first few weeks).
• You follow the exercise program regularly
• You respect the gradual progression of returning to sport

Recovery may take longer if:

• The 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 sports is done in stages:

• Resumption of low-intensity training (4 to 6 weeks)
• Gradual increase in volume and intensity (2 to 4 weeks)
• Return to competition when strength tests and athletic movements are painless

How can adductor tendinopathy be prevented?

Prevention relies on adequate preparation and gradual progression of activities. Strengthening the hip muscles and listening to your body significantly reduces the risk of injury.

Prevention strategies

• Increase your training volume by a maximum of 10% per week.
• Allow yourself time to prepare before the sports seasons begin.
• Alternate between intense training days and recovery days.

• Include adductor exercises in your routine
• Strengthen your glutes and core muscles too.
• Maintain a good balance between the muscle groups in the hip.

• Specifically prepare the groin muscles before activity.
• Include dynamic movements that engage the adductors.
• Avoid prolonged static stretching before exercise.

Copenhagen Program for Adductors

The Copenhagen exercise is recognized for its effectiveness in prevention. This exercise involves holding the body in a side plank position while resting on the inside of the foot raised 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