On ‘Adductor Tendinopathy’: “it’s a real mixed picture. There’s two challenges. Number one is, where is the pain coming from? You have multiple overlapping structures there between the abdominals, the adductors, the adjacent pubic bone, where you can have symptoms coming from one or multiple structures at any given point in time. So that can be difficult from a differential diagnosis point of view. And you have the second thing where when it is the adductor and the presentation isn’t necessarily the way it would be with either anatomically or biomechanically, the way it would be, let’s say with an Achilles ⁓ tendinopathy or elsewhere. And you get a lot of athletes who present with pain in the adductor, but don’t really show tendinopathic changes the way you would see it in other tendons.”
“Often find with the iliopsoas tendon, which can also be a regular source of symptoms, is yes, you do get some acute tears in that tendon, but you also get a lot of irritation of the tendon sheath and fluid in and around the tendon as well. So you can have multiple different sources, but it’s probably ⁓ difficult to identify the exact source of pain because there’s multiple sources of pain.”
“Our pain provocation tests are often very sensitive, but not specific. So if I squeeze my knees together and I don’t really know where the pain is coming from. From that point of view, if I squeeze my knees together and I have no pain, there’s a good chance I don’t have an adductor problem. So they’re good clearance tests, but they’re tricky diagnostic wise.”
“If we think of much the pathomechanics about how you control your pelvic position or your frontal and transverse plane control around the hip, very much it’s the antagonist muscles, in particular, the obliques, the lateral hip, and other aspects like that that are the driver and then the adductor is actually trying to take up the slack.”
For an acute injury, yes, there’s clear avulsion injuries, there’s high grade injuries, especially the proximal muscular tendinous junction, and they need loading. They need to redevelop those pathomechanical positions and then try to identify risk factors. it’s interesting when you look at the acute and the chronic, the acute is it doesn’t cause people a lot of bother. The acute groins do well. They come back. It’s the more chronic ones where diagnosis is difficult, but also then understanding the pathomechanics and what that athlete needs can be often very individualized for a number of athletes who have the same pain ⁓ and presenting with similar radiology but have their pain for different reasons.”
“The acute cases is definitely loading, like you damage any muscle or tendon. The most important thing is to load it loaded early, loaded progressively loaded at length.”
“When you look at the injury mechanism in football for acute, it can be the stance leg or can be the swing leg. So it can be during a push off during change direction, it can be during a jump. So they’re very much stance legs. So the entire kinetic chain is going to influence the adductor load in that regard. Or it can be a swing leg injury, can be in terms of reaching out to tackle or in kicking the ball, which can be either sagittal plane dominant or also with rotation. So the positions, the function of the groin of the adductors and the positions that they get in are really important. So for acute injuries, loading at length is going to be important. Restoring mobility is going to be important and really being able to control hip extension and hip abduction are going to be really, really important in the swing leg side of things and mid stance stability is going to be really important.”
“For the acute, it’s easier because I need to load that tissue and I need to then address whether the stance leg mechanics or the swing leg mechanics, depending on how that injury occurred. And for the more chronic presentations, I think we want to understand why that area has become overloaded. And often that excessive tone in the adductors, that excessive pulling is not because my adductors are not strong enough. Very often it’s because they’re trying to work and compensate for biomechanical deficits everywhere, whether that’s anterior pelvic tilt or controlling hip extension.”
“The guys that when they do their core work, it brings on the groin pain. Well, that’s brilliant because it means the way I’m doing it is contributing to overload my adductors as well, independent of other higher level activities like running mechanics and change direction mechanics.”
“The question is more why has that become overloaded? Of which that may be insufficient strength, but the majority of the time that doesn’t seem to be the case in the more chronic presentations.”
“There’s a huge amount of athletes that are asymptomatic but have posterior wall weakness. So if you go looking for posterior wall weakness in a footballer, you’ll find it four times out of five usually. And so what happens is if that’s what your trip management strategy is and you go looking for it, you find it and therefore you go down a certain management pathway.”
“When you look at motor control around the shoulder, they’re very precise in getting good cuff work and building into compound movements. Whereas in the hip, we just get strong and just load it up. And there’s nothing wrong with that when that’s required of it. But there’s a lot of refined motor control around the hip that often gets neglected compared to the shoulder.”
“The diagnosis really matters because you want to decide is it for rehab or is it for something else? So that’s where it really matters. So if it’s a stress fracture of the neck, a femur or some underlying inflammatory, that’s not going to do well with rehab… So yes, the diagnosis matters, but it matters more in is this for rehab or is it for something else? ⁓ Once you decide it’s for rehab, then it doesn’t really matter where you say the pain is coming from because you’re going to use your pain provocation test to dictate your improvement and your transition to running.”
“Some get better and some don’t get better. And then we blame the anatomy. So therefore, I go chasing a new procedure or a new injection rather than taking the step back.”
“Usually when you have a bit of discomfort doing your groin exercise, it’s a reflection that you’re doing it wrong, that you’re either your recruitment strategy is wrong or your loading is wrong or your positioning is wrong. And as I said, you’d find that often when guys and girls are doing their abdominal work and it brings on the groin pain. Well, your strategy is clearly reinforcing the overload rather than addressing the individual deficit with it.”
“Pain is your best friend because pain is a good indication of, am I doing the right stuff? And it’s good indication tomorrow morning as to how today went.”
“The acutes, when they’re loaded progressively, they do really well… we should try and strengthen the adductors in the frontal and the sagittal plane. They have a good moment arm into hip flexion and that’s often neglected ⁓ in that regard. The second thing is that we should be strengthening them into length. So really getting into outer range sometimes with our cable work or our side lying early exercises… We want to get strong in that abducted position because when it comes to change direction and it comes to tackling where you’re kind of sticking out the leg, that’s the provocative position. And also, know for all muscle and tendon injuries, eccentrics and eccentrics into a lengthened position where you’re going to get the most potent stimulus. So that’s very important. ⁓ The last bit then is certainly that pelvic position is really important. ⁓ when you with the chronic groin, but even with the acute, when you see them trying to do a Copenhagen or a side plank or something, they can’t maintain a neutral pelvis. They tend to go into anterior tilt to try and stabilize. Very often they’re the guys and girls that’ll tell you, I feel that up into my insertion or I feel that right. And so being able to load in that neutral pelvic position is really important. And that can be, you see people doing eccentric adductor work or eccentric Copenhagen work, which is a very potent stimulus, but not really doing it in way. It’s like doing a Nordic and feeling it in your back. You know, you’re not really getting the adaptation, the stimulus where you want to get it.”
“If you have a lot of tone in your adductor, doing more adductor work is going to increase the tone in your adductor.”
“The contradiction here is that when you get a chronic groin, it can be very hard to settle down and take the time to get back. But often there’s more time loss injuries in the acute groin injuries. And therefore, you know, being strong for your adductors… And so, having sufficient preparation through the offseason for that is very important. So acute is where you lose your time more so than chronic. But when when you start losing time with chronic, then you’re in trouble because it takes time to settle it down.”
“In the chronic ones, if I take the abdominals as an example… most of the exercise is through the rectus abdominis, which in and of itself is probably overloaded or over dominant when in fact it’s the obliques, in particular the external oblique you’re looking to get. So that’s not a great exercise because A, it’s bilateral when the majority of our groins will have unilateral deficits, especially in the obliques. And number two is it’s being executed in a way that’s overloading the area that’s already symptomatic rather than targeting the muscle group where you want to get. So you’re looking for a nice burn through the obliques more laterally.”
“Pain is very useful because for most of us, we don’t know when we’re not doing it right… if you ever have pain, you’re clearly reinforcing the overload rather than reducing it.”
“Now having seen a lot of groins, my coaching in around the hip and the trunk has actually got far better because you have a feedback loop to tell you whether you’re making profit or not. Whereas in an asymptomatic athlete, you get away with murder because you just load it and it is what it is.”
“You want good, strong adductors. That goes without saying. You just want to make sure that your adductor work is not aggravating your symptoms and also that whatever you’re doing is improving your symptoms. That’s kind of the two keys we’re looking for.”
I think when you look at contributors to overload in that region, so let’s say put them all together again, recab, pubic bone, a doctor, those three, you can put them into buckets. So as I said, the trunk can be one. ⁓
Thoracic rotation: “You see it lot in American football, contact sports like rugby’s. Guys and girls break a rib, they get stiff, they get sore, they have shoulder surgery. Next thing that that rotational coordination and range gets compromised and the abdominal function is compromised and then someone has to pay for that. And you’ll see it in or around the front of the hip… So sufficient rectus femoris strength, sufficient iliopsoas strength. If not, then the adductors are our prime candidate to make up that extra work. Not only in terms of their ability to produce force, but their ability to control extension. So you’ll see many athletes that don’t have good hip extension range or are unable to control extension into toe off. That’ll cause increased stress around all the structures in the front of the hip. And then the lateral hip in particular.”
“When we’re stabilizing on one leg, it’s always going to be a balancing act between the muscles on the medial side and on the lateral side, that co-contraction coordination. But if you’ve lost strength or coordination on the lateral side, the medial side will take up the slack for it.”
“In the acute groin, half the injuries are on the stance leg, half the injuries are on the swing leg. So in your chronic presentations, my pain might be on my right side. But is that a swing leg problem or is it a stance leg problem? And if it’s a swing leg problem, how much of the stance leg and the contralateral side is contributing to the work that you’re doing when you’re swinging through as you kick or as you sprint or as you accelerate on that side? So I think they’re there to dump it all in one go. But I think you need to look at the shoulder and trunk. I think you need to look at the hip. You need to look at the foot and ankle and then you need to look at how they work together in movements.”
“Frontal plane control at the foot and ankle is really important. Whether that’s on the medial side, let’s say your intrinsics and your tib post, so if you can’t control that pronation, obviously it’ll influence motor control at the hip. ⁓ Similarly, if I can’t control the lateral side, so my FHL and my peroneals, I’ll either externally rotate my foot or I’ll collapse as well when I’m doing it.”
“You’ll see athletes with maybe a lateral ankle sprain. So they’re going to be weak laterally. They’ll probably have lost some plyometric ability or stiffness at that ankle. And so you watch them running and they’ll have a pelvic drop and then they’ll spill into toe off.”
Addressing the foot and ankle: “Most of these athletes will have weakness in abduction, external rotation, I would say, almost 80 % of them. But I can’t either build or retain strength in that area if I have a hole in my bucket. So there’s no point in putting water into the hip and it’s leaking out down below. It’s not like everyone has it, but you need to look for it and identify the ones that do have it and give them the individualized care they need.”
Addressing all the functional deficits: “80 percent are going to get better easily anyway, but for the 20 % that are causing trouble, that level of precision is probably going to be important especially for your higher level athletes where the playing and training loads are unforgiving.”
“The vast majority of groin pain tends to be in field and court sports… So it’s about that ability to control in multiple planes, control flexion, extension, and control single leg, they’re the ones that seem to get the most.”
“Like the way they say that, f you didn’t get patellar tendon pain or Osgood-Schlatter’s as a child, you obviously weren’t a very good athlete because you weren’t playing enough sport. If you haven’t developed cam morphology, you obviously weren’t that good in adolescence because you weren’t playing enough… Cam morphology or the osseous bump on the head neck junction of the femur that will develop throughout adolescence… that generally is strongly related to playing and training load… That kind of abducted externally rotated hip position is the area that seems to overload that area the most.”
“The three legs of the stool of groin pain in that, you’re playing and your training load is most important. If you don’t play in training, you generally don’t get groin pain. Your biomechanics, your motor control will influence where that playing and training load goes. And your anatomy will influence how much room for error you have. And so your hip morphology is a big part of that.”
“You get a kid with quite marked loss of range and a very angry groin at 17, 18, you think, it’s going to be a big job for this athlete to have a long career or they’re going to have to work long adult career without groin pain. So you’re going to have to work really hard to optimize everything else for it. I think those that, again, there’s not a, your mythology can’t predict who will get groin pain and who won’t, but it does influence your room for error. And therefore we try and optimize the other side of it, which would be your function and your resilience and obviously your biomechanics.”
“I think we don’t overstate hip mobility, but we understate thoracic mobility. And it is every bit as important in terms of those presenting with groin pain.”
Hip mobility: “What I would often see is athletes would do loads of stretching, loads of foam rolling, little bit of dry needling, plenty of massage and they’re getting by, it’s not addressing the why, and that only lasts so long. And so to the most point where I would actually do very, very little soft tissue work as part of my rehab for two reasons. Number one is I want them to be able to see that when you do that exercise, that immediately changes your range and or your symptoms. And number two is there’s nothing wrong with doing the soft tissue work first and then doing the exercise, but I want to use the loss of range as an indicator. So we talked about pain being an indicator about whether I’m doing the exercise right or wrong or not. Well, then my change in range and my change in function is my secondary safety net as to whether I’m doing the right exercise or not.”
Training and playing loads: “The goal is find the most aggravating activities and then can I continue doing as much as possible while I’m keeping my symptoms settled down. And so those with groin pain might say look at repetitive kicking or long shots or free kicks is what aggravates me. Lovely. Keep training and just take them out for a couple of weeks or minimize them monthly on to get your pain settled down… You want to try and avoid stopping because it’s difficult to build them back up again. And also then there’s all the other tissues like hamstring, Achilles, you know, so you want to keep a strong stimulus to the rest of the kinetic chain as well.”
“If you’ve pain in a crossover test, so we’re in a Thomas test position, left hip flexion is bringing on right-sided pain, that’s an angry grind. And so any kind of running and acceleration is probably going to continue to poke the bear there. So I probably want to clear my crossover test before I progress on to increase my running volume and sprint speed. So trying to tie in your KPI that say, when I’ve achieved this, there’s a good chance I can go back to this exercise and be fine.”
“You might’ve done outstanding rehab, but come back too quick or come back in too high. If you think of it like a bruise, if I have a bruise on my shin, it doesn’t take much of another kick to annoy it. Whereas, if I have no bruise on my shin, even a small kick, even a moderate kick won’t cause me any pain. So it’s the same with your groin. If your groin is irritable, it takes far less to piss it off than it would when you’re healthy. So making good decisions or having clear KPI that did I do what I said I was going to do and were they settled enough to go into the next level of intensity? That’s an area we commonly, assuming our rehab is good, that’s often spoiled the good work that we’ve already done.”
“Those with stance leg groin pain, when you video them running, you can see increased trunk side flexion and increased pelvic drop on that side. So obviously trying to compensate for the lateral hip and therefore doing more work to the adductor.”
“In running, what you’ll often find is that they rotate, I wouldn’t call it excessively, but they rotate more to one side than the other. OK, so again, I wouldn’t call it poor trunk control, but the asymmetrical trunk control. And therefore, with that extra rotation, the swing leg is having to work harder, especially to the adductors. Or you’ll find during the change direction where they plant and they don’t have good trunk control, so they tend to rotate towards that stance leg. And we talked about the role of that, not only overloading the adductors, but dynamically impinging the hip joint and then causing that stress and shear to come across the symphisis pubis.”
“What you find is that in healthy athletes, during change direction, they tend to sway and rotate less, less frequently than those with groin pain.”
“If I don’t have sufficient strength and sufficient motor control, those higher level activities (e.g., sporting tasks) can be improved, but there’ll be a threshold or ceiling to what I can do with them.”
“I think the first thing in injury-prevention is to stratify risks. So who’s our high risk athletes? The highest risk are those that had groin pain last year. Okay, so half of them are gonna go on to have groin pain again this year. That’s your primary cohort. And your secondary cohort are those that are stepping up in load and intensity. So they’re your youth athletes coming into your senior teams, or maybe your other athletes are coming back from long-term injury to full performance. So they’re the ones you got to look at.”
“If you’re a gym program in the off season is all bilateral work, you’re not going to address simple things, the single leg squat, single leg hip thrust, oblique work that’s bias is rotational and biasing unilateral deficits are really important. I think being long and strong, very important in the frontal and sagittal plane.”
“If you’re a court and a field sport athlete, yes, the weight on the bar matters, but the strategy used to move that weight, I would argue is as important, if not more important, than the weight itself. Your best core exercises are your compound lifts, chin-ups, bench press, squats. Your ability to maintain a neutral lumbopelvic position through those exercises can be a real challenge. So why would I waste the opportunity in the gym to not make the most of that? Or, conversely, I can be doing all this lovely core work. And then I just arch my back and throw it into a deadlift or throw it into a squat. What’s really the point.”
“If me and you were to assess the same athlete, would we identify the deficits the same? If you see it and I don’t see it, you address it and I don’t, sometimes that might not matter because it’s my groin or there’s enough wiggle room or there’s enough capacity in the rest of the system to accommodate that. But that’s not the cases I see. The cases I see are the ones that wiggle room has been exhausted.”
“The assessment and identifying those deficits, that’s the single most important thing because when you hear people have failed rehab, your groin really doesn’t give a shit what you do, it only gives a shit what you change.”
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