Version June 2024
| Phase I (acute): From time of injury to up to five days depending on severity |
| Acute care: |
| RICE (rest, ice, compression, elevation) for first 48 hours; ice can be applied as often as every hour for 10 to 20 minutes for pain relief; Acetaminophen or topical or oral NSAIDs for pain relief if needed. |
| Massage: |
| Gentle soft tissue techniques; avoid deep tissue, cross friction, or other vigorous techniques. |
| Compression: |
| A compression sleeve or elastic wrap may limit swelling and increase comfort during and after exercise. Some athletic trainers prefer adductor taping techniques during activity. |
| Hip passive range of motion in pain-free range: |
| Hip abduction and external rotation are limited by pain. Passive hip movement may be performed gently by PT. PT may recommend easy home exercises. Patient should not extend motion beyond point of mild pain (2/10); excess motion may disrupt healing. Gentle static stretching within a pain-free range once or twice daily - usually a maximum of 3 stretches for 15 to 30 seconds for each stretch - may be performed. |
| Isometric adductor contractions: |
| Begin with submaximal isometric contractions for 15 to 30 seconds with knees bent. Gradually progress to contraction with knees straight, and then to maximal isometric contraction, when this can be done pain free. Performed to relieve pain and allow a flexible scar to form. Not for strengthening at this stage. |
| Light resistance exercises performed in non weight-bearing position without added load (all except abduction/adduction). Exercises should be pain-free. Example: side-lying bridge with physio ball squeezed between knees, 3 sets of 30 second holds on each side. |
| General exercises: |
| Strength exercises for trunk, upper extremities, and contralateral lower extremity that do not cause pain in injured adductors; flexibility exercises as indicated for uninjured muscles; balance board using bilateral stance to improve proprioception - building up to 1 minute with eyes open, and progressing to 1 minute with eyes closed. |
| Ultrasound and electrotherapy: |
| The author uses these modalities with the goal of promoting early healing. No high quality evidence supporting these techniques is available. |
| Progress to Phase II when athlete can perform concentric adduction against gravity without pain, signs of inflammation have decreased, and minimal or no pain present at rest (some pain with adduction, abduction stretch, and palpation will persist). |
| Phase II (subacute): From 72 hours up to 6 weeks post injury depending on severity |
| Mobility and flexibility: |
| Range of hip motion exercises is increased to the point of mild pain only. Motion exercises should not cause significant pain. Specific Soft Tissue Mobilization (SSTM) and Myofascial release performed by an experienced therapist may be added. |
| Adductor stretches: |
| May use static stretch or proprioceptive neuromuscular facilitation (PNF) techniques. Avoid pain and increase range of motion gradually. |
| Continue general flexibility exercises as indicated. |
| Adductor-specific strength exercises: |
| Concentric adduction against gravity - build up to 3 sets of 10 to 12 repetitions. |
| Single leg stance - 3 sets of 30 seconds. |
| When basic strength exercises can be performed without pain, add standing exercises against resistance, Sumo squats, and lunges. Standing concentric/eccentric adductor exercises against resistance (eg, elastic band, weight column); start with light resistance; gradually build to 3 sets of 10 to 12 repetitions. Maintain strength of uninjured adductors. |
| Sumo squats: Start with 1 set of 6 repetitions; gradually build to 3 sets of 12 repetitions. |
| Unilateral lunges: Start with 1 set of 8 to 10 repetitions, and gradually build to 3 sets of 10 to 12 repetitions. |
| When basic adductor strength exercises are performed without pain, introduce sliding board exercises: Unilateral adduction on sliding board moving in frontal plane: perform under control with arms holding stationary object for support; start with 1 set of 6 to 8 repetitions, and gradually build to 3 sets of 10 to 12 repetitions. |
| Bilateral adduction on sliding board moving in frontal plane: Perform under control with arms holding stationary object for support; start with 1 set of 6 to 8 repetitions and gradually build to 3 sets of 10 to 12 repetitions. |
| General conditioning: |
| May begin stationary cycling or swimming. Start with 10 to 15 minutes and build to 30 minutes. Begin cycling with no resistance; may gradually add light resistance, provided no pain. Backstroke, freestyle, and butterfly okay; avoid breaststroke, flip (tumble) turns, and diving. |
| With mild injuries, jogging may be permitted provided it is pain-free. |
| Progress to Phase III when range of motion for injured lower extremity is equal to uninvolved side and strength of injured adductors (tested with hand dynamometer/cuff) at least 75 percent of ipsilateral abductors. Experienced clinicians may determine preparedness for Phase III based on examination, but some objective assessment demonstrating adequate strength in the affected lower extremity should be performed. |
| Phase III (preparation for return to sport): From 6 weeks up to 1 year post injury |
| Continue SSTM in more functional positions. |
| Continue stretching exercises as indicated. |
| Perform select Phase II strength exercises (eg, standing adductor exercises, Sumo squats, slide board) with appropriate but gradual increases in load and volume. |
| Lunges in all planes: Start with 1 set of 10 to 12 repetitions and build to at least 3 sets (volume needed for full rehabilitation varies by sport). |
| Begin sport-specific training: Participants in sports involving change of direction (eg, soccer, rugby, basketball, tennis) perform shuttle runs and cutting exercises involving frequent and sudden changes in direction; participants in sports involving kicking begin kicking exercises. |
| Exercises for skaters: |
| Resisted strides using cable column or elastic band (to simulate skating). |
| On ice, kneeling adductor pull-togethers. |
| Assess sport biomechanics and correct or modify technique (eg, ice skating) as necessary. |
| Progress to full sport when adduction strength at least 90% of ipsilateral abduction strength (tested using dynamometer or cuff) and equal to contralateral adduction strength. Running must be without a limp, even when executing a sharp change of direction, and push-off force should be equal with each extremity. |
| Evaluation of the athlete's kinetic chain and all intrinsic as well as extrinsic factors should be evaluated and addressed to prevent recurrence. |
| Important warning: The pace of each stage of rehabilitation for any injury should be determined according to the injury, the athlete's overall needs and goals, and to the healing response. In particular, although the rehabilitation exercises used may be similar, tendon injuries heal more slowly than isolated muscle injuries, and older athletes heal more slowly than younger ones. |
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