Groin issues make up about 2-5% of all athletic injuries. Groin pain can become challenging because it has a high recurrence and has lingering symptoms. The most common groin injury is a strain to the adductor muscles.
What is it
The adductor muscles function to approximate the thigh in open chain motions and they stabilize the pelvis during closed chain activities. The adductor group is also used to generate substantial force during complex athletic movements.
Injuries most often occur during explosive actions that require the adductors to contract eccentrically.
Chronic adductor issues are caused from repetitive stress to the area during activity and leads to more proximal hip irritation. Acute injuries occur most commonly at the musculotendinous junction and rarely occur at the muscle belly. Complete ruptures are rare.
There is a grading system for groin strains that range from grade 1 to grade 3. Grade 1 is when there is some pain in the area but has minimal loss of mobility or strength. Grade 2 includes pain along with loss of strength and function. Finally, a grade 3 is when there is a complete tear of the muscle/tendon which is accompanied by no function.
Some predisposing factors for groin strains include a history of prior injury or inadequate physical conditioning. Injuries are seen more commonly in sports requiring forceful eccentric adductor contraction, such as kicking, sprinting, forceful trunk rotation, and side-to-side cutting.
The chief complaint of an adductor strain includes pain on the proximal inner thigh that radiates distally and is provoked through movement. Symptoms are exacerbated when the muscle involved is stretched or when contracted eccentrically during a sports movement.
While grade 1 strain produces minimal pain and disability, more severe strains/ grade three can lead to intense pain and complete loss of function. Acute tears often cause an immediate functional deficit, whereas chronic stress injuries lead to a more gradual reduction in function.
During a clinician evaluation of a groin strain there will be tenderness when palpating over the proximal inner thigh. In addition, there will be pain with passive abduction and/or resisted adduction.
Also, during the clinician evaluation there should be an assessment of the lumbar spine, sacroiliac joints, and hips to identify concurrent or alternate pathology. There may be some functional deficits that compromise hip stability and contribute to groin pain which include hyperpronation, lower cross syndrome, and gluteus medius weakness.
A clinical evaluation is the gold standard for diagnosing an adductor strain. However, if the clinician believes there is any tendon avulsion or bony pathology, a radiography may be ordered. If bony pathology is not suspected, an ultrasound may be a better option for imagery. If necessary, an MRI may be appropriate to find a lesion and rule out alternative diagnoses.
A timely management of adductor strains is crucial, as lingering injuries can progress into athletic career threatening problems. The longer a patient goes without treatment the more muscular imbalances will lead to secondary problems.
Acute injuries may benefit from a 48-hour RICE protocol. Active treatment of bone-tendon injuries may need a delay until acute symptoms improve. However, tears can usually tolerate an earlier and more aggressive rehab approach. Chronic strains demonstrate an earlier return to activity with an active rehab program versus a passive approach with manipulation and modalities only.
Patients should go through a progressive treatment where the goals include pain-free adduction against gravity, full range of motion, restore adductor strength, and balancing strength with abductors.
The ultimate goal of rehab would be to restore adduction strength so that the involved side is equal to or close to the uninvolved side. There also needs to be a close correlation between the strength of the adductor muscles and the abductor muscles.
Chiropractic manual therapy typically includes a focus on the lumbopelvic manipulation, soft tissue manipulation, and myofascial release. IASTM (instrument assisted soft tissue mobilization) may be helpful to release adhesions and stimulate healing. Acupuncture may be considered to help assist the rehab program of a groin strain.
Clinicians will help the patient long term by addressing biomechanical issues such as hip abductor weakness, lower crossed syndrome, and foot hyperpronation.
Patients may need to consider that their footwear could be contributing to the problem. They should also avoid running excessively on hard or soft surfaces during their recovery.
Preventative programs that focus on building adductor strength have been shown to help prevent groin strains.
NSAIDs and steroid injections are used for the management of adductor strain, however their efficacy and appropriateness is questionable compared to conservative care.
Surgery is generally reserved for injuries to the bone-tendon attachment or musculotendinous injuries that are unresponsive to a prolonged trial of care.
The majority of groin strains permit return to activity for about four weeks. Moderate acute strains typically recover within four to eight weeks with the correct care routine. Chronic strains may persist as long as six months. Discomfort following return to activity is not uncommon.