Adductor tendinopathy is typically the result of noncontact injuries. Its onset is usually atraumatic, although acute groin strains can become recalcitrant to treatment, resulting in symptoms lingering greater than 12 weeks. Symptoms are gradually progressive and are aggravated by sprinting, lunging, and pivoting. Pain is consistently located below the inguinal ligament, over the pubic origin of the adductor longus. Systematic history and review of symptoms must be conducted to rule out other potential causes of groin pain.

The correct diagnosis of adductor strain relies heavily on an accurate physical exam [3]. Examination of the athlete with an isolated adductor injury reveals full range of motion of the hip. Tenderness is elicited with palpation of the pubis at the pelvic origin of the adductor longus. The athlete will experience pain at the adductor longus musculotendinous junction with resisted adduction. Importantly, both symptoms of pain and findings of tenderness are elicited below the inguinal ligament. These physical examination maneuvers have been shown to have good intra- and inter-observer reliability [25]. Systematic examination must be performed and referral to other specialties may be considered, as there can be several processes occurring concomitantly [26].

Plain radiographs that include anteroposterior (AP) pelvis as well as AP and lateral views of the involved hip should be performed to investigate for potential important findings such as femoral acetabular impingement, hip arthrosis, and stress fractures. Radiographs are typically unremarkable; however, changes may be seen in long-standing cases of adductor tendinopathy [27]. Ultrasound is an imaging modality that can be useful [28]; however, it is typically not necessary for diagnosis. Magnetic resonance imaging (MRI) is also not routinely ordered unless there is suspicion of concomitant intra-articular hip pathology (e.g., labral tear) and/or a rectus abdominis injury. MRI has been found by some authors to be useful in diagnosing adductor longus enthesis edema [29]. If MRI is obtained, increased T2 signal may be present within the adductor longus tendon [30–33].

An injection test can be performed using lidocaine in order to confirm the diagnosis of adductor tendinopathy. An athlete with chronic adductor pathology should respond with a decrease in tenderness on palpation and a decrease in pain with resisted adduction. Some authors have used injection of local anesthetic and steroid for both diagnosis and treatment [33, 34]. Schilders et al. found that competitive athletes with adductor tendinopathy in the setting of normal MRI findings commonly have at least 1 year of pain relief following injection [33]. For recreational athletes, these authors found that steroid injection provided less predictable results, and results did not correlate with MRI findings [34]. It is essential to be cognizant that athletes sometimes experience symptoms only after competition, so an injection test may not be reliable in this setting.

The patient is placed in the supine position with both hips flexed and maximally abducted (Fig. 15.1). The knees are flexed, and the plantar aspects of the feet are placed in contact with each other. The affected limb is draped free to allow movement as needed during the procedure.

The incision is made at least 1 cm distal to the inguinal crease to prevent postoperative wound maceration from moisture and to allow better healing with less chance of wound breakdown (Fig. 15.2). After dissection through the skin and subcutaneous tissue, the superficial fascia over the adductor longus is incised and elevated as a distinct layer for subsequent closure. A right-angle clamp is placed under the origin of the adductor longus tendon (Fig. 15.3). It is important to watch for and to take care in protecting the obturator nerve during this maneuver.

After isolation of the adductor longus tendon, the tendon is fully released as close as possible to its origin on the pubis using electrocautery (Fig. 15.4). Use of electrocautery signals if the release is too close to the obturator nerve. It is essential to note that some adductor longus muscle fibers attach directly to the pubis, and these fibers must be addressed to perform a complete release. Finally, it is important to digitally displace the tendon distally into the thigh to prevent reattachment (Fig. 15.5).

The wound is irrigated and meticulous hemostasis is ensured to prevent hematoma formation and wound drainage. A multilayer water-tight closure is performed to prevent seroma formation and drainage.

Following adductor release, an abduction pillow is utilized. Patients are discharged home on the day of the procedure and are allowed to weight bearing as tolerated with crutches.

The treatment of sports hernias will be addressed in more detail elsewhere in this book. However, it is important to note that sports hernia frequently coexists with adductor tendinopathy [5, 41, 42]. Examination is notable for tenderness along the inguinal canal, tenderness over the distal rectus abdominis attachment, and pain with resisted sit-up [41].

The procedure is performed after induction of general anesthesia. We prefer the technique developed by Dr. David Berger. An incision is made and carried down through Scarpa’s fascia to the external oblique. The external oblique is incised to the external ring. The spermatic cord is mobilized. A direct inguinal hernia is typically visualized, and the hernia is dissected free. The aponeurosis of the internal oblique and transversus abdominis muscle is relaxed by performing a short fasciotomy to the muscle fascia. A prolene hernia system (Ethicon, Bridgewater, NJ) is placed through the defect and sutured in place with interrupted zero Ethibond sutures (Ethicon, Bridgewater, NJ). Hemostasis is ensured, and a layered closure is performed. Interrupted 3–0 silk is used to close the external oblique, a running 3–0 chromic is utilized to close Scarpa’s fascia, and a running 4–0 Monocryl (Ethicon, Bridgewater, NJ) is used to close skin in subcuticular fashion.

A recent systematic review found that surgical treatment of sports hernia resulted in better outcomes as compared to nonoperative treatment [43]. Successful outcomes have been demonstrated following both open and endoscopic treatment [41, 44–47].

Physical therapy plays an important role in the patient’s postoperative recovery following adductor release. It is generally divided into three phases. Phase I is performed during the first week after surgery. The goals are to enable wound healing and to prevent reattachment of the adductor longus tendon. The athlete’s leg(s) are kept abducted as much as possible for the first 3 days. Repeated abduction stretching is performed throughout the day.

Phase II occurs during postop weeks 2–5. The goals of this phase are to keep the adductor muscles stretched, prevent excess scarring, and improve flexibility. Stretching exercises consist of (1) progressively abducting the legs while standing, (2) shifting weight to one side over a flexed knee while keeping the opposite knee straight, (3) placing one foot on a table with the knee in extension and reaching toward the toes, and (4) lying face down and grabbing one ankle at a time and trying to pull the heel to the buttocks. Strengthening is performed by standing single-leg abduction exercises, supine single-leg leg lifts, standing single-leg circumduction maneuvers, and straight leg sit-ups.

Phase III begins at 6 weeks post-op. It entails a gradual return to running and sport-specific training. Return to sport is only allowed when wound healing is complete, the athlete has full hip range of motion, there is painless adductor muscle function, and preoperative groin pain has resolved.

Patients often feel a “pop” or “tear” at around 8 weeks after they return to running. This is typically due to tearing of adhesions and, in fact, advances recovery and alleviates any residual postoperative soreness or symptoms.