Adductor Thigh Strain
K. Michele Kirk
Brian Lindenmayer
Sebastian Ksionski
BasicsDescription
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Medial thigh/adductor pain and weakness resulting from injury to muscle
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Usually adductor longus muscle, but may include gracilis, iliopsoas, rectus femoris, or sartorius
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Synonym(s): Groin strain; Pulled groin
Epidemiology
Most common cause of groin pain in athletes, but symptoms overlap with a wide differential.
Risk Factors
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Eccentric loading of muscle (muscle is passively being stretched while it is contracting) is usual mechanism of injury.
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Inactive or fatigued muscles have less ability to absorb energy and are more likely to undergo acute strain.
DiagnosisHistory
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Acutely, often a stretch injury with an abrupt cutting motion as in slide tackling in soccer (1), or straddling injury as in gymnastics, cheerleading, or horseback riding
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Also can result from overuse, as in skating or rollerblading
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May have only minor discomfort with walking, but pain and weakness develop with cutting or running
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If symptoms do not respond to initial therapy, need to consider other diagnoses.
Physical Exam
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Classic triad of tenderness to palpation in the muscle and its insertion, pain with passive stretching, and pain with resisted contraction
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Usually acute episode is noted, but symptoms may become chronic after initial injury if undertreated and repeatedly strained.
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Tenderness along proximal 1/3 of medial thigh and tendinous origin in pubic region
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Pain with passive abduction
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Pain with resisted adduction
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Swelling and ecchymosis increase suspicion for tear
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With complete rupture, palpable depression and knot of torn muscle may be present.
Diagnostic Tests & Interpretation
Imaging
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Generally not necessary in straightforward cases, but may be part of workup if appropriate
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Hip and pelvis films recommended to rule out other conditions (1,2)
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Musculoskeletal US to evaluate for tendon fiber discontinuity or hematoma if there is a palpable mass (1,2)
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Bone scan if stress fracture suspected
Differential Diagnosis
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Osteitis pubis
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Stress fracture of femoral neck or pubic ramus
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Iliopsoas bursitis
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Avascular necrosis of femoral head
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Groin disruption (aka, sports hernia, Gilmore's groin, athletic pubalgia)
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Myositis ossificans
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Adductor tendinitis
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Avulsion fracture (especially in an adolescent)
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Slipped capital femoral epiphysis (usually seen in early teens)
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Inguinal hernia
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Lymphadenopathy
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Nerve entrapment, specifically obturator nerve (2)
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Referred pain from spine or genitourinary tract
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Conjoined tendon lesions (2)
Treatment-
OTC analgesics usually are sufficient.
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Some sources recommend avoiding nonsteroidal anti-inflammatory drugs with antiplatelet properties to help prevent bleeding into tissue.
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Topical anesthetics
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Muscle relaxants may provide some benefit.
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Strict immobilization generally is not recommended, and rehabilitation should be initiated early in the 1st few days.
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Limited activity as tolerated for 1–2 wks; longer for more protracted cases
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Gentle compression with compression shorts, Neoprene sleeve, or elastic wrap
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For severe, incomplete tears, crutches for walking while symptomatic with ambulation
P.17
Additional Treatment
Additional Therapies
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Ice for ∼20 min every 2–3 hrs for the 1st 2–3 days.
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Heat may be added after 2–3 days.
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Gentle stretching exercises may be instituted after the 1st few days.
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Gentle (pain-free) stretching and low-intensity isotonic strengthening can be instituted as symptoms subside (3,4)
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Progress to active strength training and stretching (3,4). Balance training/proprioceptive exercises of hip and groin musculature.
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If full flexibility and pain-free, may increase to full loading (2,5)
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Physical therapy modalities, such as US or electrical stimulation, may benefit in more chronic cases.
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Correction of predisposing factors, such as muscle tightness, weakness, or imbalance, should be addressed.
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Adequate stretching and warmup may help prevent reinjury.
Surgery/Other Procedures
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Surgical repair may be required for complete avulsion from the femur.
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Early repair is generally recommended.
Ongoing CareFollow-Up Recommendations
Except for significant tears, referral to a specialist generally is not necessary unless another diagnosis is being considered and requires evaluation.
References
1. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. 1998;17:787–793, vii.
2. Lacroix VJ. A complete approach to groin pain. Physician Sports Med. 2000;28(1):online.
3. Ruane JJ, Rossi TA. When groin pain is more than “just a strain.” Physician Sports Med. 1998;26(4):online.
4. Anderson M, Hall S, Martin M. Foundations of Athletic Training Prevention, Assessment and Management. 2005:475–477.
5. Sim FH, Nicholas JA, Hershman EB. The Lower Extremity and Spine in Sports Medicine. St. Louis: Mosby, 1995.
Additional Reading
Johnson D, Mair S. Adductor strain. Clin Sports Med. 2006:659.
Fry B, Brunner R. Adductor strain. http://emedicine.medscape.com/article/307308-overview. February 21, 2007.
Macleod DA, Gibbon WW. The sportsman's groin. Br J Surg. 1999:86(7):849–850.
Dahan R. Rehabilitation of muscle tendon injuries to the hip, pelvis, and groin. Vol 5. 1997:326–333.
Baha R, Machlum S. Clin Guide Sports Injur. 2004:266–268.
Garrett WE. Muscle strain injuries. Am J Sports Med. 1996;24:S2–S8.
CodesICD9
843.8 Sprain of other specified sites of hip and thigh
Clinical Pearls
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Decision on return to play depends on extent of injury and underlying predisposing factors. Pain is usually a fair measure, so unrestricted play is generally permitted if pain-free, which may take weeks.
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Although initial symptoms may not be debilitating enough to impair performance, pain is a marker for injury. Left untreated condition can become chronic and ultimately take longer to rehabilitate.