The adductors are incredibly important muscles and it seems that with all the "sports hernia" injuries happening today, clinicians and strength coaches seem to be paying more attention to them. This is especially true after some of the articles Mike Boyle has written over the past few months regarding adductor strains ("groin pulls"), strength and conditioning for hockey and sports hernia.
For most clinicians (physical therapists, chiropractors, etc) or massage therapists this can be a very "touchy" area to get into when attempting soft tissue work. I'd put it up there with anterior neck work - due to the fact that you need to displace the hyoid and thyroid cartilage with one hand while you work on the longus coli and longus capitis with the other hand -- as being a pretty uncomfortable area to work. However, no matter how uncomfortable it is, there are times when this work needs to be done.
But, what if you don't have access to a therapist? What if you are a strength coach and can't provide hands on soft tissue treatments to your athletes? What if you are a clinician or a massage therapist and don't feel comfortable working this area with your own hands (in my opinion, you need to get over it)?
Below are some strategies that you can use for yourself or teach your athletes/clients so that they can perform their own soft tissue work on their adductors.
Adductor Anatomy
Action
The adductor group is made up of five muscles, all of which attach at various locations along the base of the pelvis. When talking about the function of the adductor muscles, things can get hairy. This is because the adductors approach the hip from many different angles and orientations, creating various lines of force. Therefore, the adductors can produce movement in all planes of motion at the hip.
In the frontal plane, the adductor muscles contribute to adduction of the hip. In the transverse plane, the adductor muscles produce internal rotation of the femur in the transverse plane. Finally, in the sagital plane, the position of the hip will dictate what the adductors do -- either hip flexion or extension. When the hip is near full flexion, the adductors are in a greater position to contribute to hip extension and when the hip is near full extension, the adductors are in a greater position to contribute to hip flexion. However, regardless of hip position, the posterior fibers of the adductor magnus, along with the gluteus maximus and the hamstring musculature, are always powerful hip extensors.
Attachments
Pectineus -- From the superior pubic ramus to the pectineal line of the femur
Adductor Brevis -- From the inferior pubic ramus to the pectineal line and medial lip of the linea aspera of the femur
Gracilis -- From the inferior pubic ramus and the ramus of the ischium to the pes anserine tendon on the proximal/medial shaft of the tibia
Adductor Longus -- From the pubic tubercle to the medial lip of the linea aspera
Adductor Magnus -- From the inferior pubic ramus, the ramus of the iscium (anterior fibers) and the ischial tuberosity (posterior fibers) to the entire medial lip of the linea aspera of the femur and the adductor tubercle -- the gap between the two insertion points on the femur is called the adductor hiatus.
Self Treatment of The Adductors
Before you go pressing around on the adductors, you need to understand that this is not only a very sensitive area (most people can not tolerate a ton of pressure in this area) but it is also an area which houses some extremely important structures that you do not want to go jabbing into and pressing on. The femoral triangle is made up of the inguinal ligament, the Sartorius and the Adductor Longus.
Within this triangle lie the femoral artery, femoral vein, femoral nerve and the inguinal lymph nodes. Obviously this is not an area you want to be jabbing your fingers into!
To get a sense of where this structure is, so that you can approach the area with caution, start by contacting your ASIS. The inguinal ligament runs from the ASIS to the pubic tubercle. Once you have found your ASIS, simply slide medially about 1 inch and just inferior and you should be able to feel the femoral pulse. The important structures are going to be around the pulse, so if you can locate the femoral pulse, you will have an idea of where not to work. In addition, if at any time you start to feel a pulse during your soft tissue work, just back out of the area, and reposition yourself. Also, it is important to note that you should try and locate your femoral pulse with any finger except your thumb. Since the thumb has a relatively strong pulse of its own, it will throw off your ability to feel the true femoral pulse
Now that we know where not to work, it is time to get down to the nitty gritty.
The individual adductor muscles may be difficult to isolate, however with patience and practice you should be able to locate the tender, ropey and congested areas and work them out.
To start, lie on your back and flex the knee of the hip you want to work on. Allow the leg to fall out to the side, externally rotating. Placing the leg in flexion and external rotation will help you palpate some muscles, which can landmark your position and let you know what you are working. For the palpation and treatment you will be using the ipsi-lateral hand (the hand on the same side of the leg you are working). This will leave your contra-lateral hand to perform resisted movements so that you know which muscle you are on.
With the leg flexed and externally rotated, use the ipsi-lateral hand to locate the ASIS. Place your opposite hand on top of your thigh for resistance and perform gentle hip flexion into the hand (it doesn't have to be forceful). This will cause the sartorius to pop up and will give you the lateral landmark of the femoral triangle. If you slide down off the ASIS and just medial to the sartorius, you will drop into the femoral triangle (remember to stay off anything that has a pulse!). With your hand gently palpating the area medial to the sartorius, use the opposite hand and place it on the medial aspect of the thigh for resistance and perform adduction into your hand. This will cause the adductor longus -- the medial border of the femoral triangle -- to jump up. You can use this muscle as a landmark to find the other adductor muscles. You can start by treating the belly of this muscle with compressions and you can work superiorly and slide up onto the pubic tubercle and treat the attachment site with friction. As you slide up the belly of the muscle, once you get to the attachment site, you can perform resisted adduction again to confirm your position -- you will feel the attachment of the muscle tense up under your fingers. The attachment of the adductor longus will be very prominent.
From the adductor longus, if you slide just laterally to the belly, you will be working the bellies of the pectineus and the adductor brevis. If you notice the picture above, these two muscles lie inside the femoral triangle, so use caution and remember to stay clear of anything that has a pulse. Again, you can work up onto the pubic bone and hit the attachment sites of the muscles. For those with a history of groin pulls, this area may be particularly tender, so go easy at first. The muscles may feel very ropey or taut.
Again, using the adductor longus as our guide, if we locate the attachment site on the pubic bone, we can slide just medial to the muscle and work onto the gracilis. Friction can be applied to the attachment site and compressions can be used over the belly of the muscle. Like the adductor longus, the gracilis attachment will be prominent. The belly of the gracilis will be more medial than the adductor longus and it will run down the entire medial aspect of the thigh and attach below the knee, onto the tibia with the sartorius and semitendanosus at the pes anserine tendon.
The attachments of the adductor magnus can be worked by locating the prominent attachments of the adductor longus and gracillis. Once they are located, you can slide off of them in a posterior direction toward the adductor magnus. Again, friction can be applied to the attachment site -- posterior to the more prominent adductor attachments and under onto the ischial tuberosity. A second alternative for treating the adductor magnus is to sit on a tennis ball and work the medial aspect of the ischial tuberosity -- where you may also be getting some of the attachment of the semimembranosus.
Positional Release
If any of the adductor muscles are particularly tender, you may find it beneficial to use a technique called positional release or sometimes referred to as strain-counterstrain. In order to make this technique work, you simply need to know what the muscle does and then place it into that position passively.
First, start by locating the tender spot within one of the adductor muscles. The spot should register about an 8-10 on a ten-point pain scale. Maintaining contact on the tender spot, use the opposite hand to passively flex and adduct hip until the pain registers less than a 3, and in most cases it will be pain free when the position of release has been reached. Hold this position for about 90 seconds. With the hand that is contacting the tender spot (which should no longer be tender), you may either hold compression or apply gentle circular friction to the tissue, but never leaving that spot. After 90 seconds, passively place the hip back into the start position and re-test the spot to see if the pain/tenderness has decreased (it may be totally pain free after applying this technique). If the pain has subsided, continue your palpation until the next area of congestion has been reached.
Trigger Points and the Adductor Muscles
Trigger point referral patterns for the adductor muscles are relatively localized to the groin area. The pain may feel like a dull ache, but can be sharp, especially with extreme extension of the hip. Clients may complain of pain deep in the hip joint, the groin, and pain inside the pelvis, pubic bone, vagina, rectum and bladder (adductor magnus referral sites). In addition, the adductor longus and brevis have trigger point referral patterns that are not only located in the groin area, but also can go down the medial aspect of the leg to just above the foot. Adductor longus trigger points may cause the hip to stiffen up and limit hip ranges of motion in all directions, with pain occurring during any hard contraction of the inner thigh muscles.
Conclusion
Adductor strains can be a real pain (no pun intended). Some self-care may be helpful in working out myofascial pain or tightness in these muscles that may have developed from training and competition. Be sure to seek medical advice if you are injured or believe there is something more going on than just muscle strain. If you are having a hard time locating these structures on yourself, be patient! As always, seek out a qualified soft tissue professional that not only feels comfortable performing this kind of work on you, but can also teach you how to perform this work on yourself to help re-enforce the work he/she is doing in the treatment room and enhance your therapeutic gain.
Before teaching these techniques to your clients/athletes be sure to practice them on yourself several times to get an idea of what it feels like and an understanding of what the muscles feel like when you are treating them -- remember, you can't palpate an anatomy book! You have to get a feel for the structures before you can explain it to someone else.
References
Beil, Andrew. Trail Guide To The Body: How to Locate Muscles, Bones and More. Books of Discovery Publishing. 3rd ed. 2005.
Neumann, Donald. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. 2002.
Davies, Clair. The Trigger Point Therapy Workbook. New Harbinger Publications Inc. 2nd ed. 2004.
Chaitow, Leon. Delany, Judith. Clinical Applications of Neuromuscular Techniques - Volume 2: The Lower Body. Elsevier. 2002.
About the Author
Patrick Ward is the owner of Optimum Sports Performance LLC. He holds a Masters Degree in Exercise Science and several professional certifications (CSCS, PES, NASM-CPT, USAW). In addition, Patrick holds a diploma in massage therapy. He specializes in clinical, therapeutic and sports massage and is certified in Active Release Techniques (ART) for the Upper Extremity. He has worked with athletes and general population clients of all ages and abilities on both exercise programs and soft tissue therapies. He can be reached at Patrick@optimumsportsperformance.com. © Optimum Sports Performance LLC. 2009