Adductor tendinopathy

What is adductor tendinopathy?

Adductor tendinopathy refers to painful changes in the tendon(s) of the adductor muscles in the groin area. The attachment (enthesis) of the adductor longus muscle to the pubic bone is often affected. Contrary to what the term “tendinitis” suggests, the focus is not primarily on inflammation, but rather on micro-injuries, structural remodeling and reduced tendon quality. Acute irritations and partial tears are possible; chronic progressions occur primarily after repeated overload.

• Location: usually attachment of the adductor longus, rarely brevis, gracilis or adductor magnus
• Complaints: load-dependent groin pain, pressure pain on the pubic bone, loss of strength when adducting
• Course: from acute irritation to chronic, recurring symptoms

Anatomy: adductors at a glance

The adductors consist of several muscles on the inside of the thigh: adductor longus, brevis and magnus, as well as gracilis and pectineus. They arise mainly from the pubic bone (os pubis) near the pubic symphysis (symphysis) and extend to the inside of the thigh. Its main function is to pull the leg towards the center of the body and to stabilize the pelvis and hips - especially during quick changes of direction, braking, shooting movements and one-legged stance phases.

• Highest loads at the base of the tendon during abrupt changes of direction and shooting movements
• Close functional interaction with abdominal and hip abductor muscles
• Importance for pelvic stability and groin symmetry

Symptoms

• Stabbing or pulling pain in the groin, often palpable precisely at the base of the tendon
• Pain during adduction against resistance (squeezing of the legs), when sprinting, shooting, changing direction
• Stiffness in the morning, “start-up pain”, improvement after warming up, increasing again after exercise
• Radiating to the inside of the thigh, occasionally towards the symphysis
• Pain provocation during the squeeze test (pressing legs together in 0°, 45° or 90° hip flexion)

Causes and risk factors

In most cases there is overload or incorrect loading: training jumps without adequate adaptation, too little regeneration, technical deficits or muscular imbalances. Restricted hip mobility and pelvic stability also contribute to the symptoms.

• Sudden increase in training, tournament phases, start of the season
• Lots of changes in direction, shooting/passing stress, slippery or hard surfaces
• Weakness of the hip abductors and trunk (core) with increased adductor load
• Limited hip internal rotation, shortening of myofascial structures
• Previous groin pain, incomplete rehabilitation
• Systemic factors: smoking, lack of sleep, stress

Diagnostics in practice

Diagnosis is based on history, clinical examination and, if necessary, imaging. It is important to recognize accompanying causes (e.g. irritation of the symphysis, hip joint impingement) and to distinguish it from other groin syndromes.

• Palpation: tenderness directly at the tendon insertion on the pubic bone
• Strength/pain tests: Squeeze test in 0°, 45° and 90° hip flexion, adduction against resistance
• Function: Pelvic and trunk stability, hip mobility, leg axis control
• Differentiation: hip joint (impingement/labrum), inguinal hernia, irritation of the pubic symphysis, nerve constriction

Imaging: When is it useful?

Imaging complements the clinical examination - especially when the situation is unclear, severe, persistent symptoms or suspected partial tears.

• Ultrasound: tendon thickness, echo changes, possibly increased vessels (neovascularization), exclusion of significant tears
• MRI: assessment of tendon, signs of enthesitis, edema of the pubic bone, assessment of the symphysis and adjacent structures
• X-ray: rarely necessary; If necessary, if bony changes to the symphysis are suspected

Conservative therapy – the standard

The aim is to gradually adjust the load with consistent strengthening of the adductors and pelvic stabilizers. Passive measures can make it easier to get started, but active training is crucial. Individualized planning is carried out according to pain and functional status.

• Load control: Reduction of pain-causing stress (sprints, changes of direction, series of shots), maintenance of basic fitness
• Pain management: short-term cooling/anti-inflammatory measures, analgesic measures as needed; NSAIDs – if tolerated and only for a short time
• Physiotherapy: progressive strengthening (isometric → concentric/eccentric), neuromuscular control, pelvic/trunk stability
• Optimize technique and running style, check footwear/surface
• Manual therapy/soft tissue techniques as a supplement, not a replacement for training
• Shock wave therapy (ESWT): Option for chronic courses after unsuccessful basic therapy
• Infiltrations: diagnostic local anesthesia possible; Withhold cortisone at the enthesis due to tendon risk; PRP only selectively after informed consent

Returning to sports activities takes place gradually: first pain-free walking and cycling, then easy running, change of pace, change of direction, sport-specific drills, finally full competition - each pain and function-led.

Exercises and rehabilitation

The following principles serve as guidance. Intensity and progression should be dosed individually and ideally accompanied by physiotherapy.

• Dosage: It is better to use frequent, moderately intense stimuli rather than infrequent maximum loads
• Aim for adductor-to-abductor strength balance; Train the gluteus medius/minimus in a targeted manner
• Stretching carefully dosed; no aggressive final position stretches in the acute phase

Acute management of recent irritation

• Relative relief 48–72 hours: avoid pain-causing movements, maintain everyday activity
• Cool briefly (10-15 minutes) several times a day, pay attention to skin protection
• Test gentle isometric adduction tolerance; Pain as a guiding signal
• Early, pain-adapted mobility and cycling with low loads are often possible

Interventions: What makes sense and when?

Interventions complement active therapy, but do not replace it. The decision is made individually based on the course, imaging and goals.

• Shock wave therapy (ESWT): can reduce pain in chronic tendinopathy; several sessions necessary
• Ultrasound targeted injection: local anesthesia diagnostic; Cortisone on the enthesis only in exceptional cases (tendon risk) and after informed consent
• PRP (platelet-rich plasma): Option for treatment-resistant cases after months of structured rehabilitation; Evidence mixed

Surgery – rarely necessary

Surgical procedures (e.g. partial adductor longus tenotomy, enthesis debridement) are exceptions for selected cases with a long, frustrating course and significant functional limitations. Possible disadvantages include loss of strength and altered pelvic mechanics. Before each surgical step, consistent conservative therapy lasting several months should be exhausted.

Course and prognosis

Many patients achieve good symptom control and a return to sport with structured, active therapy. In the case of acute irritation, this can often be achieved within weeks; chronic and recurring symptoms tend to take a few months. Relapses are possible - especially if the load is increased too early or if strength is not built up sufficiently. Realistic goals, patience and consistent training are crucial.

Prevention of groin pain

• Integrate regular adductor strengthening (e.g. Copenhagen exercises) into your training routine
• Balanced core and hip abductor strength for pelvic stability
• Slowly increase volume and intensity, plan breaks and regeneration
• Warm up with dynamic movements; Training sport-specific technique
• Appropriate footwear and suitable surface; Avoid slippery or extremely hard surfaces

When should I seek medical advice?

• Suddenly shooting pain with a “cracking sound”, pronounced loss of strength or hematoma – suspected partial tear
• Persistent groin pain >2–3 weeks despite relief and basic exercises
• Pain at rest at night, fever, general feeling of illness
• New-onset numbness, burning, or radiating sensation that is not exercise related
• Uncertainty about continuing training or returning to sport

Differential diagnoses

• Inflammation of the pubic bone (osteitis pubis), problems with the symphysis
• Hip joint impingement (FAI), labral lesion
• Iliopsoas tendon irritation or snapping
• Hamstring attachment problems at the sciatic tuberosity
• Nerve constriction (obturator nerve), inguinal hernia, urological/gynecological causes

Common mistakes and how to avoid them

• Only treat passively (massages/stretching) without actively building up strength
• Returning too quickly to sprints/shooting series without a step-by-step plan
• Ignore pain instead of adjusting load and technique
• Unilateral training of the adductors without hip abductors and core
• No root cause analysis: surface, shoes, training jumps, everyday stress

Your orthopedic contact point in Hamburg

As a practice for conservative orthopedics in Hamburg-Winterhude (Dorotheenstrasse 48, 22301 Hamburg), we value thorough clarification, transparent information and everyday and sports-oriented therapy planning. You can easily request appointments online or by email.