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Athletes With Adductor-Related Groin Pain: A Narrative Review

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Abstract

Adductor-related groin pain is extremely common among athletes, and despite its high prevalence and impact, there is no consensus regarding taxonomy, anatomy, physiopathology, or treatment. We performed a comprehensive literature review and tried to demystify this pathology and its treatment. The Doha agreement classification and its impact are scrutinized as well as the complexity of the proximal adductor longus (AL) insertion and its relationship with the pyramidalis-anterior pubic ligament-AL complex. The stress-shielding and compression theories for the origin of AL tendon pathology are exploited along with how this knowledge translates into injury prevention protocols and surgical techniques. The importance of active rehabilitation protocols and intersegmental control-focused programs is highlighted. The role of an enthesis injection in the treatment algorithm is discussed along with when to perform a tenotomy. The differences between selective and complete tenotomy are highlighted.
Review began 08/26/2024
Review ended 09/01/2024
Published 09/04/2024
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Dinis et al. This is an open access article
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DOI: 10.7759/cureus.68625
Athletes With Adductor-Related Groin Pain: A
Narrative Review
João Dinis , José Ricardo Oliveira , Bárbara Choupina , Pedro Seabra Marques , David Sá ,
Andre Sarmento
1. Orthopaedics and Traumatology, Unidade Local de Saúde de Gaia/Espinho, Vila Nova de Gaia, PRT
Corresponding author: João Dinis, joao.dinis@ulsge.min-saude.pt
Abstract
Adductor-related groin pain is extremely common among athletes, and despite its high prevalence and
impact, there is no consensus regarding taxonomy, anatomy, physiopathology, or treatment. We performed
a comprehensive literature review and tried to demystify this pathology and its treatment. The Doha
agreement classification and its impact are scrutinized as well as the complexity of the proximal adductor
longus (AL) insertion and its relationship with the pyramidalis-anterior pubic ligament-AL complex. The
stress-shielding and compression theories for the origin of AL tendon pathology are exploited along with
how this knowledge translates into injury prevention protocols and surgical techniques. The importance of
active rehabilitation protocols and intersegmental control-focused programs is highlighted. The role of an
enthesis injection in the treatment algorithm is discussed along with when to perform a tenotomy. The
differences between selective and complete tenotomy are highlighted.
Categories: Orthopedics, Sports Medicine
Keywords: groin tendon injury, adductor tendinopathy, core muscle injury, pubalgia, adductor-related groin pain
Introduction And Background
Chronic groin pain is a common complaint among athletes, accounting for up to 15% of all injuries [1].
Among dozens of causes for groin pain, adductor-related pain is the most frequent, being the culprit for up to
two-thirds of the cases [2]. In a large cohort of professional soccer players [3], adductor injuries represented
23% of all muscle injuries and were responsible for an average of 14 days of absence from sports.
Although adductor pathology and related groin pain have a high prevalence and impact, they are poorly
understood. There is discussion and contradictions in the literature regarding taxonomy, relevant anatomy,
pathophysiology, and treatment. The inconsistencies in the taxonomy and the questions surrounding the
pathophysiology and anatomy translate not only to the difficulty encountered by the surgeon in identifying
the source of pain in the athlete but also the complex anatomy of the region and multiple interactions,
including the rectus abdominis insertion, the pyramidalis, the adductor longus (AL) tendon, the gracilis
tendon, the anterior pubic ligament, the inguinal canal with its contents, the pubic symphysis, the internal
and external oblique, the iliopsoas, and the hip joint. All these structures belong to the same kinetic chain
and are under stress when a soccer player kicks a ball, for example. Therefore the same aggression can lead
to different injuries, with the involvement of more than one muscle in the pathological process being
frequent [2]. One-third of the patients have more than one clinical entity.
Although there are several published systematic reviews [4-9], the discrepancies in diagnostic terms and
criteria are so profound that it is nearly impossible to reach a significant conclusion. In this article, we
reviewed the available literature in the major databases and tried to identify the controversies surrounding
adductor-related groin pain and shed some light on this matter.
Review
Taxonomy
The terminology for pain in athletes around the groin has been a matter of debate [10]. A systematic review
found 33 different diagnostic terms to characterize groin pain [4]. The most frequently used diagnoses were
sportsman’s hernia (31%), chronic groin pain (10%), osteitis pubis (10%), adductor-related groin pain (10%),
and iliopsoas-related pain (3%, diagnosed as iliopsoas syndrome or iliopsoas tendinitis). Core muscle injury,
athletic pubalgia, inguinal disruption, hockey-goalie syndrome, and Gilmore’s groin are also commonly
found terms in the literature.
In an attempt to solve this problem, 24 experts from different backgrounds reunited in Doha, Qatar, at the
First World Conference on Groin Pain in Athletes in November 2014. Following a Delphi process to achieve
agreement, a clinically-based classification was developed [11]. The classification subdivides groin pain into
the following three subgroups: the first includes four defined clinical entities for groin pain (adductor-
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Open Access Review Article
How to cite this article
Dinis J, Oliveira J, Choupina B, et al. (September 04, 2024) Athletes With Adductor-Related Groin Pain: A Narrative Review. Cureus 16(9): e68625.
DOI 10.7759/cureus.68625
related, iliopsoas-related, inguinal-related, and pubic-related groin pain); the second comprises hip-related
groin pain; and the third encompasses other causes of groin pain in athletes.
It is solely based on history and physical examination. During history, the patient should describe pain in
the affected region that worsens with exercise. Palpation is the main tool for examination and should be
complemented with resistance testing and stretching of the affected muscle groups. Palpation should be
precise given the proximity of different structures and is rendered positive if the athlete feels tenderness
over the affected area that mimics the usual injury pain. By not adding radiologic criteria, this classification
circumvents the uncertainty due to the high prevalence of findings in asymptomatic athletes. In a study by
Dallaudiere et al., AL tendon ultrasound abnormalities were found in 45 out of 45 (100%) asymptomatic
patients [12]. Loss of normal echogenicity and the fibrillar structure were present in more than 90% of the
patients. Further, in a recent Delphi study, experts agreed that clinical evaluation and sport-specific tests
should be used to support the return to play (RTP) and not imaging [13].
According to the Doha classification, adductor-related groin pain is defined by a history of pain in the region,
adductor tenderness, and pain on resisted adduction testing. This classification has been shown to have
excellent interexaminer reliability when the patients presented only one clinical entity but a lower
agreement when more than one diagnosis is present [13]. Palpation examination has been found to have a
slight to moderate interexaminer reliability while adductor stretch and resisted tests have a moderate-to-
substantial correlation [14]. Even though the development of this classification has allowed clearer
communication, publications since 2015 have continued to use variable taxonomy, as reported in a
systematic review [5].
Relevant anatomy
The proximal insertion of the AL tendon is complex and has been a matter of debate. It was historically
considered to be the existence of a continuity of the rectus abdominis (RA) fascia at the pubic insertion with
the origin of the AL tendon via an aponeurotic plate [15]. Therefore, these two muscles were considered to
act as a pair, counterbalancing each other with the pubis at the center, in a fashion similar to the Copernican
theory of the sun [10].
Schilders et al. showed there is no continuity between RA fascia or tendon and AL tendon [16]. AL
posteriorly inserts in the pubic bone through a fibrocartilage (1.5 cm × 1.9-2.5 cm) [17,18], and, anteriorly, it
is connected to the anterior pubic ligament (APL). This ligament is also the distal insertion of the
pyramidalis muscle. The authors named this complex the pyramidalis-anterior pubic ligament-adductor
longus complex (PLAC).
A systematic review comprising 76 anatomical cadavers reported similar conclusions [6]. The concept of the
aponeurotic plate has become outdated and surgeons should now consider the PLAC. Mathieu et al. recently
showed that the gracilis and adductor brevis also have their proximal insertions in the APL and only gracilis
and adductor brevis may have an insertion in the inferior pubic ligament [19]. Furthermore, conjoint tendons
between these three muscles can be found. The association between gracilis and adductor brevis tendons
was the most common (90.9%). Its exact role in the pathophysiology of adductor tendon injuries remains to
be elucidated.
The existence of intramuscular tendons in the AL and adductor brevis [17] muscles and the decreasing ratio
in the cross-sectional area between the AL tendon and muscle should also be accounted for. Proximally, the
ratio of tendon/muscle tissue is approximately 38% to 62%. At 2 cm from the origin, the muscle area
comprises approximately 73% [20]. These details help us understand the stress-shielding theory and the role
of the selective surgical partial release of the AL tendon.
Of note, in men, the medial RA tendon continues distally with the tendon of the gracilis and fascia lata,
while in women, it inserts directly in the anterosuperior aspect of the pubis. The existence of the recto-
gracilis tendon in men has gained relevance as it may be one of the reasons behind the increased prevalence
of groin pathology in males compared to females [21].
Pathophysiology and prevention
AL tendon injury most commonly affects athletes involved in sports that demand kicking and pivoting
frequently, e.g., soccer, hockey, football, and rugby. For instance, in soccer, the AL is under maximal stress
when the ipsilateral limb is kicking a ball. Specifically, it is at the greatest risk of injury between 30% and
45% of the swing phase because at this point it is stretching most rapidly while also being eccentrically most
active [22]. In these sports, adductor-related groin pain is most commonly caused by an overuse insult. In a
cohort study encompassing 2,299 soccer players, adductor-related groin pain most commonly presented a
gradual onset (42%) when compared to hamstring (30%), quadriceps (26%), or calf muscle (28%) injuries [3].
Anatomically, the overuse aggression to the AL tendon is considered an insertional tendinopathy. It has
been proposed that insertional tendinopathies may have two different pathological mechanisms with the
same result: it may be caused by compression or stress-shielding [23,24]. Both mechanisms affect
2024 Dinis et al. Cureus 16(9): e68625. DOI 10.7759/cureus.68625 2 of 7
predominantly the deeper part of the tendon. Historically, most surgeons address the AL tendinopathy as an
excess of pulling force, i.e., compression mechanism, and therefore perform a complete release of the
tendon to decrease this force vector [25,26].
Stress-shielding of the deeper part of the tendon ensues as a consequence of load distribution in the tendon.
As the superficial tendon is more distant to the axis of the joint, it is subjected to a higher load while the
deeper part is “shielded” from the mechanical stimulus. Having the stress-shielding theory in mind
associated with the knowledge of the existence of intramuscular tendons in the AL we have an explanation
for the clinical improvement seen with partial release of the AL tendon as only the superficial tendon is cut
[27]. The stress-shielding theory also helps us understand the benefit of adductor strengthening in injury
prevention. We may hypothesize that strengthening will effectively load the inner part of the tendon.
MRI findings are also consistent with an overuse etiology [28]. Furthermore, enhancement of the anterior
pubic region and AL enthesis after gadolinium correlate with the athletes’ symptoms [29]. However,
gadolinium-enhanced MRI is not commonly used, and the findings in non-enhanced MRI are also frequently
found in asymptomatic individuals.
Assuming its overuse etiology, efforts have been made to identify the risk factors for this injury that could be
prevented. Lack of flexibility is considered to be one of the main culprits for suffering an adductor injury.
However, in ice hockey players, tight adductors have been shown not to be a risk factor [30]. These findings
are aligned with the less successful outcome of stretching and massage rehabilitation programs in chronic
adductor injuries when compared with strengthening programs.
A systematic review identified reduced hip abductor and adductor strength, a higher level of play, a previous
groin injury, and lower levels of sport-specific training as risk factors for sustaining a groin injury [7].
Regarding specifically adductor injuries, an imbalance between adductor and abductor strength has been
recognized as one of the main risk factors. Elite ice hockey players have 17 times higher risk of suffering
adductor injury if their adductor strength is 80% or less of the abductor strength [31]. The muscular
imbalance between abductor and adductor muscles associated with a decreased adductor strength results in
decreased muscle capacity and imbalances during movements in which synergistic function of these groups
is necessary as are side-to-side cutting, quick acceleration/deceleration, striding, and sudden direction
changes [32,33]. A higher level of play seems to play a role as a risk factor mainly due to the higher intensity
of sporting activity and volume [34].
Soccer players who suffer a groin injury have a two times higher risk of suffering a new injury [32], and more
than one-third of adductor injuries are recurrent [35]. It is believed previous injury plays a role as a risk
factor mainly due to inadequate rehabilitation and healing and specific individual characteristics that place
players at greater risk (e.g., anatomical variants, style of play) [36].
Pre-season conditioning and strengthening have been proven to reduce adductor injury rate during the
following season [31,37]. The combination of the Copenhagen adduction exercise [38] with other specific
exercises has shown the highest efficiency in preventing injuries [37]. The correction of muscle imbalances,
the optimization of muscle recruitment, and, therefore, the reduction in muscle fatigue are believed to be the
reasons behind its protective role [39].
Conservative treatment
Conservative treatment for longstanding adductor-related groin pain syndrome has not shown reliable and
consistent results. A systematic review found only moderate evidence in favor of compression clothing
therapy, manual therapy together with strengthening exercise, and prolotherapy. Corticoid injection,
platelet-rich plasma therapy, intra-tissue percutaneous electrolysis, and pulse-dose radiofrequency showed
conflicting evidence and a lower grade of recommendation [8].
Regarding rehabilitation after injury, the outcome of programs focused on strengthening adductors and
pelvic-stabilizing muscles is similar to the findings in pre-season conditioning, being more effective than
stretching or local therapy [40]. In a randomized control study of 68 athletes with chronic adductor-related
pain, 79% of the patients submitted to active training returned to sports at a median time of 18.5 weeks
compared with 14% of the patients who received passive physiotherapy (transcutaneous electrical nerve
stimulation, laser treatment, stretching, transverse friction massage). The positive effect of exercise
rehabilitation had a long-lasting effect that was still present at 8-12 years after the initial study. The impact
was even greater in the subgroup of soccer players [41]. Weir et al. compared a multimodal approach
encompassing manual and exercise therapy with isolated exercise therapy and found similar return rates of
50-55%. However, the multimodal group had a shorter time to return [42].
Movement analysis have shown that athletes may present one of three patterns during a 110-degree cutting
task: hip, knee, or ankle-dominant [43,44]. Although no association has been reported between a certain
pattern and a specific anatomic injury, rehabilitation programs focused on intersegmental control have
proven to be superior to programs focused on isolated muscle strength, presenting RTP rates of 73% at a
2024 Dinis et al. Cureus 16(9): e68625. DOI 10.7759/cureus.68625 3 of 7
mean time of 9.9 weeks [45].
Overall, it is expected that 20% of the patients will not improve with active rehabilitation. It is essential to
promptly recognize these patients to avoid the loss of an extended period of the season by the athlete.
Schilders et al. proposed a staging system based on the practice level of the athlete and the presence of
enthesopathy in MRI. High-level athletes without abnormal findings on MRI could expect a year free of pain
after injection with corticosteroid and topic anesthetic in the AL enthesis; patients of the same level of
activity with MRI evidence of enthesopathy could only expect five weeks of relief [46]; in recreational
athletes, the infiltration had a 75% success rate, independent of the MRI findings [47]. In all cases, patients
were submitted to an active training rehabilitation protocol after the procedure.
Surgical treatment
A systematic review reported that surgical treatment of athletes with groin pain may differ based on the
specialty of the surgeon (general surgery or orthopedics), with orthopedic surgeons performing AL tendon
tenotomy more frequently [5]. The same study showed that the trend has evolved from performing surgical
procedures based on asymptomatic findings to a more tailored approach based on clinical findings. Some
surgeons previously advocated for bilateral tenotomy [26] or for an “all-round” approach with abdominal
wall repair, neurectomy, and AL tenotomy [48]. In recent studies, more AL tenotomies have been performed.
The evolution in the treatment of these athletes is explained by the increased knowledge of anatomy, and
epidemiology and by the experience attained with previous approaches. The importance of the Doha
agreement must also be accounted for as it proposed a simple classification to a complex entity, thus
providing precise targets to the surgeons.
Regarding patients with adductor-related groin pain, the presence of two theories for tendinopathy, i.e.,
compression and stress-shielding, gave rise to two surgical approaches and philosophies.
Some studies have advocated for the complete release of the AL tendon at the pubic insertion complemented
with a rehabilitation protocol focused on stretching and avoiding reinsertion of the muscle [49,50]. Schilders
et al. recommended selective partial adductor release and a rehabilitation protocol focused on adductor
muscular strengthening [51].
Gill et al. performed a complete release of the adductor longus tendon in 32 athletes, including 16 National
Football League players [49]. Surgery was performed if the patient complained of groin plain below the
inguinal ligament, located at the proximal origin of the AL tendon. The pain must have had a duration of
more than 10 weeks and must have limited their ability to compete. Schilders et al. performed partial release
in 43 professional athletes who complained of AL dysfunction for more than three months and showed no
improvement with non-operative treatment. The clinical tests for AL pathology were similar, namely,
tenderness over AL insertion and pain with resisted hip adduction. Schilders et al. also considered pain with
passive stretch and only considered patients with isolated AL pathology.
The surgical techniques are similar: an incision is made 2 cm below the inguinal crease to avoid maceration,
the AL fascia is longitudinally divided, and then the tendon is completely released from the pubic bone
(complete tenotomy) or only the superficial part of the tendon is cut 2-4 cm distal to the origin. The
rehabilitation protocol follows the surgery. After partial release, the goal is to strengthen the remaining
tendon, while after complete release, the goal is to avoid reattachment; hence, strengthening exercises are
begun three weeks postoperatively. Both approaches have shown excellent results in high-level athletes
with a return rate to the previous level of above 90%. Athletes submitted to partial release took an average of
nine weeks to return [51], while athletes in whom complete release was performed needed an average of 12
weeks [49].
Both endoscopic [52] and percutaneous approaches to the tenotomy have been described but have not
gained popularity. Endoscopic surgery presents a high level of difficulty and sparse benefits when compared
to the 2 cm incision needed for the open approach, and the percutaneous release has shown lower return
rates when compared to the open approaches [53].
Conclusions
Managing an athlete with groin pain is challenging due to the complex anatomy, overlapping clinical
presentations, and redundant radiological findings. However, recent advancements have provided valuable
tools for surgeons. The Doha agreement offers a straightforward classification based on symptoms and
physical examination. Anatomical studies have introduced the PLAC concept, highlighting the attachment of
the AL to the APL. Recognizing that AL tendinopathy is an overuse injury associated with stress shielding
helps us understand the success of strengthening exercises in prevention, and why a multimodal approach
combining manual and exercise therapy is the most effective conservative treatment.
For high-level athletes, MRI can offer prognostic value, with abnormal findings often indicating the need for
2024 Dinis et al. Cureus 16(9): e68625. DOI 10.7759/cureus.68625 4 of 7
early surgery. Recreational athletes may experience long-term symptom relief with local infiltrations,
regardless of MRI results. Surgery is recommended for athletes with persistent symptoms or high-level
athletes with positive MRI findings. AL tenotomy, whether complete or partial, offers similar outcomes,
though partial release combined with active rehabilitation may expedite a return to sport. Continued
research is essential to standardize diagnostic criteria and management strategies, enabling clearer
recommendations.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: João Dinis, Bárbara Choupina, David Sá, Pedro Seabra Marques
Acquisition, analysis, or interpretation of data: João Dinis, José Ricardo Oliveira, Andre Sarmento
Drafting of the manuscript: João Dinis, Bárbara Choupina, Andre Sarmento, Pedro Seabra Marques
Critical review of the manuscript for important intellectual content: João Dinis, José Ricardo Oliveira,
David Sá
Supervision: Andre Sarmento
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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Article
Objectives: The potential contribution of ultrasound (US) to diagnose adductor longus (AL) tendinopathy in athletic pubalgia requires clarification. We investigate US findings from AL tendons of asymptomatic participants to identify the range and prevalence of common US features not associated with groin pain. Methods: We consecutively enrolled 45 volunteers physically active participants with no history of groin pain. US features of bilateral AL tendons were investigated and recorded by two experienced musculoskeletal radiologists (MSKR) in accordance with a defined ultrasound protocol. Two other MSKRs retrospectively and independently analyzed all US images. Results: Ninety AL tendons from 45 participants (4/45 women) were imaged (average age: 35 years ±14.6; dominant side: 37/45 (82.2%) right, 8/45 (17.8%) left). Abnormalities on US were found in all 45 (100%) AL tendons, including: abnormal echogenicity (98.9%/100% respectively according to reader), loss of fibrillar structure (92.2%/97.8%), irregularities of the superficial paratendon (23.3%/30%), calcifications (22.2%/25.5%), and cortical erosion (52%/55.5%), with excellent inter-observer assessment. No AL tears or hyperemia at color Doppler were detectable. Conclusions: AL tendon abnormalities were identified via US in 100% of our asymptomatic athletes. The significance of these US findings should be interpreted cautiously with respect to clinical presentation. On the other hand, there is a need for supplemental investigation into the clinical relevance of US AL tendon tears not present in the present asymptomatic athlete population.