Adductor Strain Rehab

The purpose of this blog is to provide the reader with a general rehab framework for adductor strains (also known as groin pulls or groin pain). This blog will review groin pain terminology, relevant anatomy and function, and a comprehensive program including specific groin exercises and a return to running protocol.

Looking to improve the strength, range of motion, and control of your hips to enhance your function and performance? Check out our Hip Resilience program!

Quick Disclaimer

This blog is not meant to diagnose you, nor is it meant to be a self-guided rehab program. Each individual will have unique medical histories, goals, desired activities, etc. As always, I recommend you talk to your doctor or find a reliable health care practitioner to help guide you during your recovery.

Terminology

Understanding the appropriate terminology and definitions of groin pain is an important starting place, since if it is not truly adductor related, then this exercise program will not be the most appropriate option for you.

In a 2005 article by Weir et al, the authors developed a classification system for groin pain. These subheadings include defined clinical entities for groin pain, hip-related groin pain, and other causes of groin pain. Within the defined clinical entities for groin pain there is adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain.

The rehabilitation program outlined in the following sections will be focused on adductor related groin pain, which is clinically defined by the presence of adductor tenderness and local pain on resisted adduction testing.

Anatomy and Function

The adductor muscles consist of the pectineus, gracilis, adductor longus, adductor brevis and the adductor magnus.

Expectedly these muscles adduct the hip. However they also contribute to varying degrees of hip flexion, extension and rotation. Understanding the function of the adductors is an important consideration since it influences exercise selection.

Adductor Strain Program Overview

The exercise program reviewed in this blog is adopted from a 2020 article by Serner et al titled “Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes.” Here, the authors developed a rehabilitation program for elite male athletes looking to return to sport following an adductor injury.

The key components of this rehabilitation protocol include a groin exercise program, a running and sports function program, and a sport specific controlled training program, which acts as a prerequisite for return to sport. Since this last program is highly dependent on your sport, position, etc, it will not be reviewed in this blog.

The remainder of this blog will focus on the two major programs of this rehabilitation protocol: groin exercises (4 phases) and running and sports function (4 phases). The phases of these programs are done simultaneously and can be progressed independently of one another. Meaning, you can be in phase 2 of the groin exercises, and phase 4 of the running and sports function, or vice versa. Each phase will have set criteria that should be met prior to progressing to the next phase.

Before reviewing the exercises, there are a couple important notes to discuss. First, depending on your goals, you may not need to complete the running and sports function exercises, or all the phases of the groin strengthening protocol. And second, not everyone will have the same starting place. Depending on time of injury, severity, etc, you may start from the beginning or it may be appropriate to start with the more advanced progressions.

Groin Exercises Program

Phase 1: Active Flexibility

1. Leg Swings (Flexion and Extension)

Holding onto an object at your side, swing your leg forward and backward within a comfortable range of motion and speed, keeping the chest tall.

2. Leg Swings (Abduction and Adduction)

Holding onto in front of you, swing your leg side to side within a comfortable range of motion and speed, keeping your chest tall.

3. Hip Circles

Stand with your hands on your hips and move your hips and pelvis in a circular motion at a comfortable speed.

Parameters: 4 sets of 20 repetitions on each side, 3 times a week.
Progression Criteria (to Phase 2):

• Minimal pain (<2/10) with walking and at rest.

Phase 2: Early Resistance

Continue with the previous exercises (1-3), and add in three resistance exercises:

4. Resisted Hip Adduction

Strap a band or cable around the ankle, and stand far enough away from the anchor so there is tension at the start. Hold onto an object for balance. Start with the leg out, and slowly adduct, or pull your leg toward the standing leg. Slowly control it back to the start and repeat.

5. Resisted Hip Flexion

Strap a band or cable just above the knee, and stand far enough away from the anchor so there is tension at the start. Hold onto an object for balance. Start with the hip extended, and slowly flex your hip to about 45 degrees, keeping your chest tall. Slowly control your leg back to the start and repeat.

6. Resisted Trunk Rotation

Stand with feet just wider than your hips, the band or cable at about chest height, and arms straight- with the hands just in front of your inside hip so your trunk is rotated toward the anchor. Keeping hips and pelvis facing forward, rotate through your trunk until the hands move to or just past your outside hip. Control your trunk rotation back to the starting position and then repeat.

Parameters: 2 sets of at least 20 repetitions on each side at a tempo of 3 seconds concentric and 3 seconds eccentric, at an appropriate intensity, 3 times a week.

Progression Criteria (to Phase 3):

• No resting pain (0/10)
• Perform the resisted hip adduction exercise for at least 1 set of 20 PRM with less than or equal to 2/10 pain.

Phase 3: Load Progression

For this phase, you will continue with the previous exercises (1-6) but increase volume and intensity, as well as add in:

7. Single Leg Coordination

While standing on one leg, swing the opposite through hip extension and flexion, with the arms following a reciprocal pattern, as shown. This exercise will mimic running while challenging single leg balance.

Parameters: 3 sets of 15-20 repetitions on each side at a tempo of 3 seconds concentric and 3 seconds eccentric, at an appropriate intensity, 3 times a week.

Progression Criteria (to Phase 4):

Perform the resisted hip adduction exercise for at least 1 set of 15 PRM with less than or equal to 2/10 pain.
Full range of motion during the active leg swings at a high velocity with less than or equal to 2/10 pain.

Phase 4: High Load, High Speed

You will continue the previous exercises (1-7), but with more volume, higher intensity and faster speeds, as well as add in two exercises:

8. Copenhagen Adduction Exercise

Start on your side with the forearm on the ground, bottom leg straight and a partner holding the top leg at either ankle or knee. Lift the body and bottom leg up, until the feet touch and the body is in a straight line. Slowly lower back down, so the foot just gently touches the floor, and repeat.

Alternatively, you can perform this same exercise with the top leg on a bench or another stable surface.

9. Kicking Exercise/Tension Arc

Place a strap of a cable or band around one ankle, while holding another cable or band in the opposite hand overhead. While standing on one leg, quickly move forward in a kicking and throwing motion, and then slowly, take about 3 seconds to return back to the starting position.

Parameters: 4 sets of 10-15 repetitions on each side at a slightly faster tempo of 1 second concentric and 3 seconds eccentric, at an appropriate intensity, 3 times a week.

Clinically Pain Free Criteria (progress to on-field or on-court sport specific training):

• Pain free palpation.
• Pain free maximal isometric testing at outer range.
• Pain free maximal passive adductor stretch.
• Pain free resisted hip adduction exercise at a 10 repetition maximum.
• Pain free Copenhagen Adduction exercise for 10 repetitions.
• Pain free T-test at 100% self-reported intensity

T Test

Set up cones in a T shape pattern as shown in the picture below.

From the starting cone, run forward to the middle cone. Then shuffle to one side and touch the cone with one hand and then shuffle toward the opposite side and touch the other cone. Shuffle back to the middle cone, touch, and then run backward toward the starting cone.

T-test. Ref: Serner et al. Appendix 2

Non Groin Exercises

In addition to the groin exercises, it is recommended to add in non-specific groin exercises on alternate days (Note: these should be completed without any residual pain in the adductor region).

These exercises should focus on hip extension, hip abduction and targeting the hamstrings and calves. An example workout session would be deadlifts, lateral band walks, nordic hamstring curls, and calf raises.

Running and Sports Function Program

Phase 1: Running Movements

You will start with some steps in place and then progress to slow running as tolerated. A ladder may be helpful for cueing step placement. For example, start with alternating steps in place. If tolerated, progress to moving forward, stepping two feet in each box. And finally, you can progress to one foot in each box.

Progression Criteria (to Phase 2):

Running movements performed pain free at 30% intensity.

Phase 2: Slow Running and Side Steps

Running

You will continue to run in a linear fashion, and slowly build speed and duration.

Lateral Shuffles

Using a ladder, start with small steps, so each foot touches the same box. To progress, increase speed, or distance, by skipping a box.

Side to Side Steps

Also known as the ickey shuffle ladder drill, this exercise incorporates forward and lateral movement.

Step one foot, then the other in the first box. As the second foot moves into the box, the other foot will step forward and outside. The second foot then moves forward one box, and the first foot enters the same box. This is then repeated in an alternating fashion moving your way down the ladder.

Zig Zag Shuffles

Using cones as a guide, shuffle sideways at a diagonal angle toward one cone, and then change directions shuffling toward the next one. Start at a comfortable pace, and to progress, you can increase speed and quickness of turns.

Progression Criteria (to Phase 3):

• Run pain free for 15 minutes up to a 60% intensity.
• Perform side steps and zig-zag turns pain free at a 60% intensity.

Phase 3: Progressive Running and Change of Direction

Running

You will now increase the intensity of running by focusing on shorter distances and faster speed. Start with 30 meter distances and build up speed as tolerated.

Lateral Shuffles and Side to Side Steps

Same as the previous phase, but you will increase speed and the step width by skipping one or two boxes.

Zig Zag Shuffles

Same as the previous phase, but you can progress by incorporating shorter distances and more turns, faster speed, or even implementing a ball, if appropriate.

Zig Zag Turns

Same cone set up as the previous drill, but you will now run forward, and then perform a sharp turn at the cone, and then run toward the next cone. Repeating at a tolerable speed.

Acceleration and Deceleration

Set up cones at 0 meters, 5 meters, 10 meters and 15 meters. Start at the first cone and accelerate forward toward the second cone. Decelerate and then run backward to the start. Repeat to the third cone and back, and then to the fourth cone and back.

Acceleration and Deceleration. Ref: Serner et al. Appendix 2

Progression Criteria (to Phase 4):

• 10 straight 30 meter sprints pain free at 80% intensity.
• T-Test pain free at 80% intensity.

Phase 4: High Speed Running and Change of Direction

Running

Continue with the 30 meter linear running intervals but build up to maximum effort sprints.

Lateral Shuffles and Side to Side Steps

Progress these to maximum width and maximum speed.

Zig Zag Shuffles and Turns

Progress these to maximum speed with and without a ball, if appropriate.

Acceleration and Deceleration

Progress these to maximum speed.

Change of Direction and Cutting (Star Drill)

The goal of this phase is to expose you to cutting and change of direction at various angles, better preparing you for return to sport.

The Star Drill is a good example. Set up cones as shown in the picture. Start at the first cone and run to the middle cone, then cut and accelerate to one of the other cones on either side. Jog back to the first cone and repeat. To start, choosing a designated cone prior to each run. To progress, you can make the drill more reactive. Start the drill, and just before you reach the middle cone, have someone call out your target cone. This makes the drill less predictable and more similar to sport.

Star Drill. Ref: Serner et al. Appendix 2

Clinically Pain Free Criteria (progress to on-field or on-court sport specific training):

• 10 straight 30 meter sprints pain free at 100% intensity.
• Pain free T-test at 100% intensity.

Summary

Understanding the terminology and definitions of groin pain, as well as the anatomy and function of the adductors allows us to develop an appropriate rehabilitation program for adductor strains.

If you are looking to return to running and or sport, then completing both the groin exercises and the running and sport function program outlined above is highly recommended. However, depending on your goals and desired activity, the groin exercise program might be sufficient by itself.

After the completion of both the groin and running and sports function program and you are deemed clinically pain-free, you may progress to controlled sports training. This is the final stage prior to return to sport, or full team training. Since this phase is highly dependent on your sport, position, etc, it is advisable to find a reliable healthcare practitioner to help you with your individual needs.