Adductor tendinopathy describes a number of conditions that develop in and around the tendon as a result of chronic overuse At the histopathological level, changes in the molecular structure of the tendon, typically collagen separation and collagen denaturation, and macroscopically Tendon thickening, loss of mechanical properties, and pain levels are often seen . The role of inflammation is still under debate, as research has shown that inflammatory cells are often absent around the lesion  and the term “tendinitis” has become obsolete. The adductors are made up of 5 muscles that can be divided into long and short adductors: the long adductors (gracis and adductor magnus) attach to the pelvis extending to the knee, the short adductors (pubic bone adductor brevis and adductor longus) also attach at the pelvis and extend to the thigh bone. These adductors help stabilize the pelvis and draw the leg toward the midline (adduction). 
Clinically Relevant Anatomy
The adductor muscles run from the lower pelvic bone to the lower femoral region around the knee and lie between the flexor and extensor muscles of the thigh. They are used when we cross our legs and help balance the pelvis when standing and walking.
The adductor magnus is the largest muscle of the group and sits behind the other muscles. The muscle has 2 parts, the adductor part and the hamstring part. The adductor part arises from the inferior pubic rami and ischial ramus, and attaches to the linea cognac and medial side of the femur epicondyle (where its tendon inserts). The hamstring portion extends from the ischial tuberosity to the adductor tuberosity and medial supracondylar line. Its action is adduction, which helps to flex the thigh (adductor part) and extend the thigh (hamstring part).
The adductor longus extends from the superior pubic rami and pubic symphysis, attaching to the linea grana. It is a large, flat, fan-shaped muscle that forms part of the medial border of the femoral triangle. It also forms the aponeurosis at its distal attachment, extending to the femoral muscle inner muscle. It adducts and rotates the thigh inward.
The adductor brevis lies below the longus muscle and runs from the inferior pubic ramus to the posterior aspect of the aspera line. Brevis adducts the thigh.
The gracilis muscle is the only 2-articular muscle of the aneurysm that extends from its insertion at the inferior border of the pubic symphysis to the medial surface of the tibia and inserts between the sartorius and semitendinosus tendons. It is the most superficial of the group and its effect is additive Thigh and bend leg at knee.
The adductor muscles are active in many sports, such as running, soccer, horseback riding, gymnastics, and swimming. The repetitive nature of the movements in some of these exercises and the constant change of direction in others can put a lot of stress on the adductor tendons.  This makes athletes more commonly Adductor tendinopathy and groin injuries. Other causes may be overstretching of the adductor tendon  or a sudden increase in training or training type (eg intensity).
The development of adductor tendinopathy is multifactorial. One of these factors is the significant difference in leg length that affects gait patterns. (although it doesn’t say what’s important). Poor or altered movement patterns during physical activity may also be overstressed Adductor tendon. Muscle length differences, strength imbalances, or muscle weakness in the lower body or abdomen may also affect the development of adductor tendinopathy. Other factors may be; lack of warm up inactivity fatigue obesity age related weakness degeneration or Genetics  However, the exact pathology is unknown.
Adductor tendinopathy is usually felt as groin pain on palpation of the adductor tendon of the leg and/or affected leg. Pain can develop gradually or present as acute severe pain.  Stiff adductor muscles in the groin area may also feel swollen or lumpy or inability to contract or stretch the adductor muscles. In severe cases, physical activity will be limited  as the tendon can no longer withstand repeated tensile loads.
Since osteitis pubis can be difficult to distinguish from adductor tenosynovitis, groin pain can have many causes. Other diagnoses’ can be; sports or inguinal hernia iliopsoas bursitis stress fracture avulsion fracture Nerve compression, snapping hip syndrome, or chronic prostatitis.
A physical therapist can make an objective diagnosis after a thorough evaluation, or further investigations such as ultrasound, MRI or CT scan can be done. 
The outcome measure was return to previous level of motion in the absence of pain.
To prevent the development of adductor tendinopathy, athletes are best served by participating in a strength and conditioning program that addresses the above factors, such as improving muscle strength and coordination, but allowing adequate recovery and adaptation time between workouts Meetings i.e. don’t do too much training too early. 
Athletes must develop muscular strength and stability around the groin and pelvic area by engaging in specific exercises related to their activity/sport requirements, as well as at varying levels of difficulty, such as speed and jump drills. Another important aspect is the muscle flexibility. Regular stretching is recommended. Products such as mobility and muscle support may also help reduce high impact. 
Although NSAIDs may be ineffective due to the non-inflammatory nature of the injury, pain relief is recommended first. Steroid injections are not always necessary due to the risk of rupture of the tendon if injected directly into the tendon.
Physical Therapy Management
Physical therapy is recommended for the treatment of adductor tendinopathy, and although there is no gold standard for tendon rehabilitation, active treatment through an exercise program is preferable to more passive approaches. recovery varies from person to person The condition may be degenerative or the load has failed to heal. Individuals may respond well to a rehabilitation program, or in some cases, tendons may be unresponsive to a range of treatments. It is also recommended to strengthen the abdominal core muscles to support the adductor muscles during activity because and hip flexor exercises. Exercises should then be tailored to the athlete’s specific sport to avoid relapse. In acute cases, normal function can be restored within a few weeks, but in more chronic cases, recovery may take months before normal pain returns free event. 
Treatment consists of rest from the aggravating activity of the acute injury within the first 48 hours. Use RICE treatment 3 times a day for 10-20 minutes to help reduce swelling and inflammation from any sudden trauma.  When swelling decreases, blood flow stimulation therapy can be started Increases the healing process. Aggressive treatment is then indicated to maximize recovery. The goal of rehabilitation is to restore muscle and tendon properties, where strength training benefits tendon matrix structure, muscle properties and limb biomechanics  Recent evidence suggests Eccentric-based exercise programs are most effective, as well as heavy slow eccentric and concentric exercises, to improve tendon pain and function, but Cook et al. proposed a new three-stage model of tendinopathy in which exercise therapy varies in different phases. different. them It is suggested that eccentric loading regimens currently used for stages 2 and 3 may be detrimental for stage 1 tendinopathy. Determining the stage of tendinopathy is critical for effective treatment.
Loading provides active stimulation to both the tendon and musculature, but there is no single effective method of tendon rehabilitation, and the repetition set and applied load depend on the rehabilitation stage and the patient’s muscular tendon response to the exercise. Exercises designed to address neuromuscular and tendon changes (strength and ability) in tendinopathy. .
These stages proposed by Cook et al. are: reactive tendinopathy tendon disrepair (failure to heal) and degenerative tendinopathy. During the early reaction phase, it is critical to adjust the load to a bearable level so that the tendon can recover and heal. However Cook suggested that the tendons could have a About 24 hours of latent response. This means that a feeling of unresponsiveness immediately following activity may flare up 24 hours later. The use of NSAIDS is inconclusive at this stage, but it is suggested that their use may be beneficial. Always consult your GP before taking any medicines. 
Stretching is also not suitable for the reaction phase, as it puts stress on the affected tendon, which can aggravate symptoms. One option is massage to maintain muscle length. In this acute phase, the recommended treatment is isometric rather than eccentric exercise (resisting load but not exercise) and rest from strenuous activity, where rest is relative to the individual. i.e. rest from aggravating activities that may be speed distance intensity and be alert to any pain that may develop after 24 hours. Must be guided by symptoms and pain response, Cross training is recommended to maintain fitness and function. During this stage, the changes within the tendon may reverse.
Stage 2 tendinopathy is usually characterized by persistent discomfort, localized thickening of the tendon due to chronic overloading, and may be seen in patients of varying ages depending on: how long the loading occurs the frequency and intensity of the loading. stage 2 May be clinically indistinguishable and some reversal may occur, but load management to stimulate load structures is recommended for long-term tendon health. 
With stage 3 degenerative tendinopathy, stromal and cellular changes have progressed to irreversible levels, so treatment and management are aimed long-term, including eccentric loading strengthening and stabilization exercises. Degenerative tendons are often seen in older adults Athletes, and occasionally in young adults, depending on the degree of chronic overload. There may be areas of thickening and acute pain onset may indicate areas of stage 1 tendinopathy within the tendon. Severely degenerated tendons are also at risk of rupture.  treatment Symptoms therefore need to be mirrored; follow Phase 1 until the acute pain subsides, then proceed with the long-term exercise program described above.
However, Malliarus et al.  showed that there is little evidence for separating the eccentric portion in tendinopathy rehabilitation of the Achilles and patellar tendons, conversely, the eccentric concentric and isometric contraction schemes had the best results.
There is no one cure for tendinopathy, so it is advisable to work with a physical therapist to manage symptoms and how to use rest  and graded return to activity. Once any symptoms have resolved, a gradual return to normal stretching activities can also begin.
However, stretching should never be a painful activity.
A few examples of adductor stretches:
- The short adductors:
- Sit in the following positions. Sit as high as you can to avoid collapsing your lower back.
- Gently press your elbows into your knees until you feel a stretch
- Hold for 20-30 seconds Repeat 3-4 times
2. The long adductors:
- Stand up and spread your legs to form a wide pose.
- Bend the opposite knee that is tilted to this side until you feel a stretch
- Hold for 20-30 seconds . Repeat 3-4 times 
An example of an isometric exercise: Sit in a chair with a resistance band above your knees and hold your leg in an adducted position against the resistance of the band. As long as you feel comfortable, you can stick to it. Resistance can be adjusted by increasing or decreasing the elastic bands.
Example exercise to strengthen the adductor muscles: Stand near a table and place a resistance band around the ankle of the affected leg. Stand on a block with the unaffected leg so that the affected leg can swing freely. Keeping your back and knees straight, slowly move your leg away from the midline. Then Add legs. 
Clinical Bottom Line
Knowing the stages of tendinopathy is key to effective treatment and long-term management of symptoms. Reversal of early symptoms is possible, but degenerative tendons require a long-term management plan to avoid rupture or require complete cessation Activity. There is no single approach to the treatment and management of tendinopathy, and everyone responds differently. When exercise therapy is not effective for immediate pain relief, medication may be used, but steroids must be used with caution.
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