Groin Strain/Adductor Tendinopathy

What is a groin strain?

A groin strain is when one of the muscles or the tendon of the inner thigh muscles (the adductors) gets stretched, ‘pulled’, torn or overused.

A groin strain is used as a term to describe an injury to the groin area. However, there are two types of injury in this area; one is to the muscle itself, the other is to the tendon (the tendon attaches the muscle to the bone). They can both present in similar ways and are often caused by a similar mechanism of injury.

1. A muscle strain or tear – this might be mild if the muscle is only slightly overloaded, or severe if there is a significant muscle tear.
2. Tendinopathy – if there has been no sudden, specific incident or trauma but you are getting groin pain, it might be that you have developed an overuse injury, known as an adductor tendinopathy.

Muscle tear or strain

Muscle tears occur within the muscle tissue. They are graded with numbers 1 to 3, depending on how serious the injury is:

• Grade 1 – Mild pain and tenderness, with only minor loss of strength and movement. Often described as a muscle strain, or pulled muscle.
• Grade 2 – Moderate damage to muscle fibres, causing pain, tenderness, weakness, and sometimes bruising.
• Grade 3 – Severe/complete tear of the muscle, causing significant pain, bruising, and loss of strength and function.

Adductor tears or strains can occur anywhere along the length of the muscle. Tears to the mid-belly of the muscle are more straightforward to rehabilitate, but the most problematic tears are towards the tendon at the top of the muscle where it inserts to the pelvis. Injuries here are far slower to recover, and may become chronic, and can sometimes cause secondary adductor tendinopathy.

Adductor Tendinopathy

Hip adductor tendinopathy is a condition that is caused by the inflammation or degeneration of the tendons that attach the hip adductor muscles to the pelvis or thigh bone. This condition is a common source of groin pain and can result from repetitive stress and overuse of the adductor muscles. As mentioned previously, it can also develop following a previous muscle tear, especially if that injury was not treated and rehabilitated properly.

During the contraction of the groin muscles (adductors), a tremendous amount of tension is placed through the tendon where it attaches to the pelvis. When the tension becomes too much because of an excessive amount of force and repetition, damage to the tendon can occur. Adductor tendinopathy is diagnosed when there is damage to the tendon accompanied by inflammation and/or tissue degeneration.

Anatomy of the groin muscles

There are five groin (adductor) muscles, three short (pectineus, adductor brevis, adductor longus), and two longer muscles (adductor magnus and gracilis). They originate from the pubic bone, and apart from gracilis attach above the knee on the inside of the femur (thigh bone), while gracilis inserts just below the knee on the tibia (shin bone).

The adductor tendons attach the muscles onto the bone.
The most common muscle to be involved in a groin strain is the adductor longus – this is one of the muscles that attach above the knee.

The main function of the adductor muscle group is to pull the leg inwards, towards the midline and across the body (adduction). Adductor magnus is also an important hip extensor.

The groin muscles also stabilise your pelvis and help control pelvic movement when you are walking and running. They are especially important in any sport which requires rapid changes in direction such as football, rugby, netball, hockey and tennis.

What causes a muscle strain/tear?

A groin strain or tear results from putting too much stress on the muscles in your groin and inner thigh. If these muscles are contracted too forcefully or too suddenly, they can get overstretched or torn. The most common causes are:

• If the muscle gets stretched too far (overstretched).
• If the muscle has to work too hard i.e. sudden, excessive, heavy resistance.
• If the muscle gets worked frequently i.e. lots of repeated movements.
• A direct injury or a blow to the area.

Muscle strains generally occur in high speed sports that involve sprinting, twisting, turning, changing direction. They are also very common in sports that involve kicking a ball, or martial arts. However, they can also occur more slowly over time due to repetitive overuse and overloading during sports. This is when it is more likely to develop into an adductor tendinopathy.

Risk factors for muscle strain​​ or tendinopathy

Although groin strains can occur randomly there are factors that can increase the likelihood of you sustaining a groin strain.
These include:

• Not warming up properly
• Weak adductor muscles
• Poor pelvic stability
• Tight adductor muscles
• Poor fitness
• Previous groin or lower limb injury
• Lower back pain/previous back injury
• Biomechanical factors – adverse lower limb movement patterns
• Poor technique
• Sudden increase or change in training/activity

What causes Adductor Tendinopathy?

Tendinopathy is a progressive condition that occurs when the tendon fails to cope with the load resulting in small micro-tears. This causes mild swelling and inflammation which often quickly heals if it is managed properly with rest. However, repeated overloading or overstrain to your tendon causes increased microtrauma; when this exceeds the rate of repair, it results in an incomplete, sub-optimal healing response. At first, the injury may only be minor and not cause any problem, but will progressively become worse, causing the tendon to become more inflamed and thickened, which can result in significant pain and dysfunction. This process can occur over many months or can happen quite rapidly with one bout of intense exercise. There are usually two main causes of tendinopathy:

1. Problems with tendon loading

A sudden change in tendon loading, such as starting to train at the beginning of a sports season after a period of rest, or increasing your training too quickly. This type of tendinopathy is more common in patients aged 15-30. Men are also more likely to be affected.

2. Problems with the health of the tendon

This usually affects adults over 35, as their tendons slowly begin to degenerate. This is part of the normal ageing process due to wear and tear. Genetics, smoking and some medical conditions can also affect the health of tendons.

What are the symptoms of a groin strain/tendinopathy?

The main indication of a groin strain/tear is a sudden, sharp pain in that area. If it is a more severe injury, then pain might also be experienced down the inside of the thigh. You may or may not be able to continue playing/training, depending on the severity. There may also be swelling in the injured area, and in some cases bruising. This usually occurs two or three days after the incident. Bruising is especially prominent when the muscle is completely ruptured.

With adductor tendinopathy the onset of pain may be more gradual, but the description of symptoms are likely to be similar.

The most common symptoms include:

• Pain and tenderness in the groin area and inside your thigh.
• Pain when you bring your legs together against resistance (i.e., when you contract the adductor muscles), or perform a kicking movement.
• Pain when you raise your knee or bring your leg forwards.
• Your groin may be warm to touch.
• Bruising or swelling in the groin area or inside the thigh.
• Increased pain when stretching the inside of your thigh.
• Limping when walking/running.

If you are suffering from any of the above symptoms and would like to book an appointment with one of our Physiotherapists please contact us on 0207 4823875 or email info@complete-physio.co.uk.

How is a groin strain/tendinopathy diagnosed?

Clinical Assessment

A diagnosis will be made by your physiotherapist by carrying out a comprehensive, subjective and objective clinical assessment. Making sure you get an accurate diagnosis is essential, as it allows your clinician to select the most effective treatment plan for you.

Initially you will be asked questions about how you sustained your injury, your progression of symptoms, and what aggravates and eases them. Your physio will also discuss your normal daily activities, and exercise routine as well as your past medical history. These questions help to build a picture of your likely diagnosis and underlying causes.

Following these detailed questions, your specialist physiotherapist will complete a series of physical tests to confirm your diagnosis. This may include:

• Assessing your range of movement and muscle strength.
• Assess muscle length and flexibility.
• Watching you perform activities such as squatting, hopping, jumping or running.
• Checking other regions of the body as needed, such as knees, feet and lower back.
• Gently, but skilfully, palpating (feeling) around your groin and adductor muscles to determine the exact structures involved in your injury.

The clinical assessment is normally sufficient to diagnose a groin strain. However, it is limited in providing detailed information about the severity of the strain, and the tissue damage and swelling that might have occurred. MRI and ultrasound investigations can identify the location and extent of a groin injury accurately.

MRI

Magnetic resonance imaging is an extremely powerful radiological investigation using magnetic resonance to obtain detailed images of the groin and pelvis which will identify any muscle or tendon tears in the adductors. It can also be useful to help to differentiate between other causes of groin pain, such stress fractures, hernias, or the hip joint.

Diagnostic Ultrasound scan

Diagnostic ultrasound is very good for looking at muscles and tendons in the groin region. It provides inexpensive, non-invasive, radiation-free imaging with excellent resolution of soft-tissue. Real-time images and interaction with the patient allows dynamic assessment of tissues, to locate the source of pain. The procedure offers comparison with the unaffected side when required.

Complete Physio offers a unique diagnostic ultrasound service that is led by our team of expert Clinical Specialist Physiotherapists, who can perform a diagnostic ultrasound as part of your initial assessment. There is no extra cost for this service, however you must book in to see one of our clinical specialists.

Complete Physio has gained an exceptional reputation amongst patients and peers for providing a highly specialised clinic for those suffering with tendon pain, particularly tendinopathy which is not improving with conservative care.

We would recommend that if your pain is not improving, or you have previously been diagnosed with a groin strain, but the pain is still present, that you should book in for an initial assessment with one of our Clinical Specialists. You will need to make this clear at the time of booking.

What is the treatment for groin strain/tendinopathy?

Treating groin pain can be quite challenging. Our physiotherapists at Complete Physio are highly skilled in diagnosing and treating traumatic and biomechanical related groin strain injuries. With accurate assessment and early treatment, most groin strains respond exceptionally well to physiotherapy allowing you to resume pain-free sport and normal activities of daily living.

Treatment will often follow 3 different phases:

1. Rest and pain relief

• Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These may include ice, acupuncture, off-loading taping techniques, soft tissue massage, and temporary mobility aid (e.g. a stick or crutch) to off-load the affected side.
• You will likely need to rest (relatively) for a period of time to allow your pain to settle and your muscle tear or tendon to heal. Your physiotherapist will discuss modifying your normal activities and training.
• You can often start strength training of other muscles early, as long as it doesn’t cause any pain or discomfort to the injured area.
• It is important to remain patient and careful in the beginning. If you ignore the pain, there is a significant risk that the injury will develop into a persistent, painful condition that is hard to treat.
• You may also want to maintain fitness following a groin strain. This can usually be achieved by cycling or swimming, although breaststroke should be avoided as the movements involved place stress on the groin area. Running on a treadmill or along flat paths may also work well. Your physiotherapist will guide you on this.
• You will also be given a detailed explanation of your diagnosis and how you can help aid your own recovery.

2. Restoring range of movement and strength

• As your pain and inflammation settle, your physiotherapist will continue work to restore your normal range of motion, muscle length and flexibility of your hip and groin.
• Muscle strengthening and endurance, proprioception, balance, and gait (walking/running pattern) re-education will follow once movement has been regained. Your physiotherapist will monitor this closely, as progressing too quickly can cause new ruptures in the scar tissue within the muscle, and the problem can become long-term.

• Core stability is a key part of your rehab. Pilates based exercises can be performed to strengthen your abdominals and gluteal muscles which, along with the adductors, are very important to help stabilise and control the pelvis.

3. Returning to Full Function and Activity

• The final stage of your rehabilitation aims at returning you to your desired level of activity and sport. Your physiotherapist will work on more functional rehabilitation and activity/sports specific exercises.
• They will ensure that you are put through your paces so that you feel confident to return to higher level, more demanding activities.

• Everyone has different demands and levels of function that will determine their own specific goals. For some people, it may only be to walk around the block, while others may wish to get back to playing professional football or tennis, or running a marathon. Your physiotherapist will tailor your rehabilitation to help you achieve these goals. At Complete Physio, we treat everyone, from all walks of life, ages and fitness.
• There is a large variation in the rehabilitation time needed following a groin strain. The length of time will depend on how severe the injury is, and what level of activity you are returning to.

Throughout your treatment sessions at Complete Physio, we will ensure that you feel involved and supported in your recovery process. We will continually monitor your progress, and reassess your objective measurements to make sure that you are on track with your treatment and goals.

What if my groin strain isn’t improving?

If your pain doesn’t settle following non-invasive physiotherapy treatment, then you may want to consider having an Ultrasound Guided Injection. Guided procedures are reserved for adductor tendinopathy, rather than a tear. Tendons don’t heal as well as muscles so can be a cause of persistent pain.

Ultrasound-guided corticosteroid injection is a highly effective, evidence-based treatment option, and can be particularly beneficial if your pain is affecting your sleep, is limiting your ability to participate in normal daily life and activities, or if you are unable to partake in your physiotherapy rehab due to severe symptoms.

You should always resume your physiotherapy within 2 weeks of having an injection; it should not be a stand alone treatment, but rather an adjunct, to facilitate your rehabilitation when your pain is very severe.

An ultrasound-guided injection should provide you with at least 3 months of pain relief, which will give you a good window of opportunity to undergo an extensive physiotherapy rehabilitation programme.

Complete Physio offers a unique ‘one stop’ injection service. You do not require a GP referral to see one of our Clinical Specialists, who are all fully qualified Extended Scope Practitioners (ESP), musculoskeletal sonographers, independent prescribers, and injection therapists.

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email info@complete-physio.co.uk.

Will I require surgery for a groin strain?

Surgery is rarely necessary in the case of groin strains, but if a groin muscle fully tears, in some cases it may require surgical repair. At Complete we work closely with an exceptional team of orthopaedic surgeons. Your physiotherapist will make sure that you are referred to someone who is trusted and highly experienced for a surgical opinion.

If you do go on to have surgery, then we will make sure that we continue your post-operative care once you have been discharged from hospital, ensuring a full, seamless and speedy recovery.

If you would like more information or would like to book an appointment please contact us on 020 7482 3875 or email info@complete-physio.co.uk.