Immediate icing of direct muscle tears of the groin and especially adductor attachment tears is beneficial and necessary in the 24-hour period after the injury. Unlike hamstring injuries, however, movement while icing is not necessary and may in fact be detrimental to the turn-around time of adductor injuries. This will be expanded further in the section on stretching.
The reader is referred to issue 26 of SIB, page 6, regarding the dangers of over-zealous use of non-steroidal anti-inflammatories in muscle injuries.
Any therapy that reduces muscle tone in the adductor muscles will be a useful adjunct in the treatment of this injury. This may be any soft-tissue massage (ischaemic pressure and longitudinal flush) in the area below the tear or 'trigger point' injection therapy into the adductor muscle belly.
It is common practice in Australia (particularly the Rugby League haven of New South Wales) to use groin straps in the management of adductor lesions. However, they are almost unheard of in the United Kingdom (this author needs to import them from Australia).
The rationale behind the adductor (groin) strap is similar to the Chopart or patella tendon strap. The application of the strap directs force on to the strap and away from the injured tissue. In relation to the adductors, the strap is usually applied high up around the thigh as close to the adductor tubercle as possible. It is placed on quite tight to be supportive but not occlusive to the femoral artery, vein and nerves. This then takes stress away from the adductor tubercle. It will result in an immediate decrease (not abolition) in pain on functional movement and adductor squeeze testing.
The athlete is instructed to keep the strap in situ 24/7, except for showering and sleeping (however, there is no reason why it needs to be removed during sleep). The athlete can continue to wear the strap during rehabilitation and return to sport.
For some bizarre reason, the adductor muscles (and TFL for that matter â€“ this will be discussed in the next article in this series series, on quadriceps) are the only muscles that respond POORLY to stretching in the initial post-injury period. There is no plausible explanation for this phenomenon. One possible reason (and this reason does have its flaws) is that the adductor muscle does not operate through a large range of motion during the execution of most sporting manoeuvres. Therefore, stretching of the muscle into end-of-range positions in the initial period may in fact place the muscle in a position it is not used to and comfortable with. This may lead to an adverse tissue reaction that further adds to the stress of the muscle and results in further increases in muscle tone.
The alternative to stretching the adductor muscle group is to use 'isometric stretching'. This is done by squeezing a football, rugby ball or netball. The ball is placed between the knees in the three testing positions mentioned on page 11 of the last issue of SIB. The ball is then squeezed to the point of discomfort but not pain. The contraction is held for 10 seconds and the legs are then moved up to the next position, 45-degrees knee flexion. Again, this is held for 10 seconds and the legs are then lifted to the 90-degree hip flexion position and contraction repeated for 10 seconds. Back down to legs straight and start again. This can be done five times in each position.
Why it works
The theory behind isometric stretching of the adductors is as follows. As the muscle isometrically contracts against a stationary and non-deformable object (the ball), the muscle tissue will undergo a degree of shortening. As a consequence, the tendon attached proximally to the muscle will be required to elongate slightly to keep the entire muscle-tendon complex at the same length. The amount of stretch and elongation we are talking is tiny; however, it is enough to cause a slight elongation in the tendon and tenoperiosteal junction. No other muscle in and around the pelvis responds in the same way to this technique as the adductor muscles.
Another way to isometrically stretch is to have the therapist control the weight of the leg, which is in knee extension. The leg is then lifted into progressive degrees of hip flexion, abduction and internal or external rotation. The patient is then instructed to gently pull into the opposite direction (adduction, flexion and the other rotation). This is very similar to a PNF contract-relax stretch. The leg can then be lifted and placed into more progressive positions based on the feeling of movement blocks (a term those trained in 'muscle energy' will be familiar with). This can be continued into the extreme end-of-range positions of hip flexion, with moderate amounts of rotation and minimal range of abduction.
Initial strength retraining may take the form of 'adductor squeezing' as described above. This can be started almost at day one. The act of performing the adductor squeeze thus serves two functions; isometric stretch and strength retraining. This can be progressed from supine lying positions to wall squat positions. The protocol is the same: aim for 10-second holds and attempt five repetitions in each position.
As adductor squeeze and function improves, the following exercises may be added to strengthen the adductor muscle:
Theraband adductions (crook lying): lying supine with knees and hips bent to 45 degrees. Place theraband around knee and attach to leg of table. Let the leg fall out to position of abduction and contract back to knees together position. This can be progressed into greater range, greater speed and greater resistance.
Theraband adductions (standing): standing with theraband around heel, hold on to chair for support, allow band to pull leg into abduction, contract back to adduction. Perform with the foot in front of the stance leg and foot behind the stance leg. And very important, do both legs. The adductor needs to retrain its movement function as well as its stabilising function.
Lunging (around the clock): feet together, step out in front (12 o'clock) and take weight via a lunge action. Push back to start position. Step out to the side (3 or 9 o'clock position) and back, then step backwards (6 o'clock) and back. Again, do BOTH legs.
Lateral step ups: place a knee-height box or chair about three feet at your side. Step up on to the box sideways and down again. Again do both legs. Progress by increasing speed.
Swiss ball squats: on a Swiss ball, either stand (for the vertically challenged) or perform a partial squat. This is a great isometric-adductor strength exercise.
Weights: this is not the time or the place to discuss weight-training routines, but a few key principles regarding leg weights need to be laid down. First, perform and be happy with two-legged bilateral exercises before progressing to one-leg unilateral exercises. For example, do two-legged leg press before attempting one-legged leg press. Second, be careful with the progression of load and speed. Adductors tend to work exponentially harder as one approaches the one-repetition maximums. Respect this before progressing loads. Furthermore, ballistic movements such as power cleans and snatches tend to recruit more adductor activity. Exercises where the feet do not leave the floor are generally safer initially.
Functional strengthening: field activities such as side-stepping and cariocas.
This stage has similar progressions to the fitness testing mentioned below. In order to retrain the adductors for functional use, activities need to be presented in a logical and progressive order.
The stages can be progressed from one day to the next, or progressed within the same session depending on presentation of symptoms. The progressions are as follows:
Straight line running: distances can be progressed in pyramid fashion. That is, 10m, 20m, 30m, 40m and so on. Overall maximum distance will depend on the individual athlete's requirements (sport and position). Speed needs to be progressed sensibly and always on the basis of presenting symptoms (pain) and clinical signs (adductor squeeze and palpation). Aim to reach full top-end speed before reaching flat-out acceleration and deceleration.
Weave running: progressed as above but instead of in a straight line, the athlete runs curves.
Sideways shuttles: stand on a line. Side-step five times to the right and then sprint forward 10 metres. Rapidly stop and then side-step five times to the left. Sprint 10 metres again and repeat the process to the right. This can continue for as many 10-metre segments as desired.
Sprint and cut: sprint forward 20 metres and step rapidly to the left at a 45-degree angle. Walk back and repeat to the right.
Cone drills: place five cones out in a random order over a 10-x-10- metre square. The idea of this drill is for the athlete to sprint to one cone, rapidly stop and reach down to touch the cone, look up at the tester who points at another cone for the athlete to sprint towards. This continues for 20 seconds and can be repeated as many times as desired.
Functional skills: depending on the sport played, this would include (if relevant) kicking, scrums, tackling, jumping etc..
Those involved with the management of groin injuries (physiotherapists, sports medicine physicians, orthopods and athletic trainers) all have their favourite ways of assessing fitness for competition. Outlined below is a very direct and accurate method of assessing the functional ability to perform in competition and avoid risk of re-injury following an adductor-muscle strain.
The premise of the following fitness testing protocol is that two criteria must be satisfied; first, that the athlete can perform the testing procedure pain-free and without functional limitation, and second, that the adductor muscle does not 'tone up' two to three hours following fitness testing. This is assessed by palpation of the muscle. It is common for athletes to able to complete such a fitness testing session, and then have all sorts of problems in the few hours following.
As far as timing goes, this type of testing can be done the day before competition or even on the morning of an afternoon competition. This is in contrast to hamstring muscle injuries that ideally should be fitness tested 48 hours prior to competition.
Assess adductor squeeze (pain and weakness) at three testing positions and feel muscle tone to gain an initial baseline. These should feel good if you have progressed to fitness testing.
Ten minutes of general running and stretching
Straight line running: 5 x 40 metre run-throughs progressed from warm-up speed to full speed. The rate of acceleration is not important at this point; the focus is on reaching full speed before 40 metres. Walk return after each repetition.
Straight line acceleration: (over 20 metres): 1 x 20 metre flying start (jog in before flat-out acceleration); 1 x 20 metre upright start (off the mark); 1 x 20 metre 3-point stance start; 1 x 20 metre starting on stomach.
Weave running: 4 x 40m: running in a 5-10 metre channel, the athlete sprints whilst weaving between two parallel lines (the in- goal area of a Rugby pitch is ideal). This is a pure weave (similar to running around a curve) and no side-stepping is involved. For example, the athlete may be instructed to touch the right line and then left line twice each on the first run, three times on the second, and so on. By increasing the number of touches on each line, the angles involved in the weave will become more acute and more challenging for the groin muscles.
Cutting manoeuvres: sprint 20 metres straight line and cut (stepping off) 45 degrees to the left or right (at full speed) and continue to sprint for another 10 metres before decelerating. Complete two to the left and two to the right.
Cone drills: place five cones out in a random order over a 10-x-10-metre square. The idea of this drill is for the athlete to sprint to one cone, rapidly stop and reach down to touch the cone, look up at the tester who points at another cone for the athlete to sprint towards. This continues for 20 seconds. The athlete repeats this for a total of four repetitions with one-minutes rest between efforts.
The final two efforts are modified in the following way. Instead of bending down to touch the cones, the athlete falls to the ground on his/her front. Before the athlete gets back to their feet, the assessor places some pressure on the athletes back so that they need to fight their way back on to their feet before continuing. This continues for 20 seconds (in this time expect the athlete to hit the ground 3-4 times). As a word of caution, this is very fatiguing to do at full speed for a full 20 seconds (if you disagree, try it yourself). Therefore, if testing on the morning of a game the time period may need to be modified depending on the individual fitness characteristics of the athlete/player.
Kicking: if this is a common skill component encountered in the game. Start with short-distance kicking and progress to long kicking and kicking across the body and kicking on the run. Warm down and stretch for 10 minutes.
Re-assess adductor squeeze and muscle tone: immediately after warm down, then again 2-3 hours following fitness testing. It is important that the adductor muscle is not treated in this time period.
The above testing procedure will assess the ability to perform all physical components required for competition whether the sport is football, rugby, basketball or Australian Rules Football. The distances can be modified for court sports such as tennis, basketball and netball, and the need to assess the ability to spring off the ground is not essential for these sorts of sports.
As I mentioned earlier, the above test should be performed pain-free and without functional limitation. Examples of functional limitation would be the inability or reluctance to turn away from the injured side, holding back on the acceleration component and obvious limping (hopefully the assessor would be wise enough to not even bother fitness testing in this situation).
The re-assessment of muscle tone is also of critical importance. If muscle tone is to increase following such an intense and involved testing session, then it will do so within the first two to three hours following the testing. From a pathological perspective, an increase in muscle tone is an indication that the original source of pathology (whether it be muscle or tenoperiosteal junction) has been irritated and has 'driven' the tone in the involved muscle belly. This is an important indication that the muscle is subject to possible further damage (in the form of a strain) especially under fatigue. The increase in tone will be quite obvious when you palpate if you have been assessing tone on a regular basis during preceding treatment days.
* Groin/Pelvic Pathologies
* Adductor muscle tears (Grade 1-3) (Add Brevis, Add Longus, Gracilis)
* Adductor Tendonitis/
* Osteitis Pubis (Pubic Symphysitis)
* Inguinal/Sportsman's Hernia
* Posterior wall insufficiency
* Conjoined tendon tear
* Ilioinguinal nerve irritation
* Iliopsoas strain/bursitis
* Stress fracture (pubic ramus)
* Referred pain (lumbar spine and sacroiliac joint)
* Obturator nerve neuropathy
* Sinister pathologies such as prostatitis, UTIs, testicular tumour, infection.