Chiropractic Rehabilitation Guide for Adductor Tendinopathy

Explore chiropractic rehabilitation options for adductor tendinopathy to regain leg strength and flexibility.

Abstract

Chronic inner-thigh and groin pain that starts in the adductor complex can limit walking, sport, and ordinary daily movement. Adductor tendinopathy is pain and tenderness along the inner thigh, often worse near the pubic bone and sometimes felt toward the knee. This educational post explains what the adductor muscles do, what changes when their tendons fail to adapt to load, and how chiropractic care can help by restoring pelvic, hip, and lumbar mechanics. As a result, the tendon is no longer asked to do a job it cannot tolerate. A clinical pattern seen in practice, a 35-year-old man with an eight-year history of medial thigh pain and no single remembered injury, is used to show how examination, differential diagnosis, and staged care fit together. At Injury Medical Clinic, chiropractic assessment and treatment are combined with massage therapy, physical therapy loading programs, functional wellness, and medical oversight from Dr. Maria Guadalupe Cardenas, MD. The goal is not a single procedure. It is a coordinated plan that reduces painful overload, rebuilds tendon capacity, and lowers the chance that the same pattern returns.

What the Adductor Muscles Do

The adductors are the inner-thigh muscle group. Their shared job is hip adduction: they draw the thigh toward the midline. That is only part of the work they do in real life. They also help control the pelvis during single-leg stance, assist hip flexion or extension depending on the muscle, and stabilize the hip when a person cuts, kicks, skates, climbs stairs, or shifts weight from one leg to the other.

Five muscles make up the usual adductor group:

• Adductor longus is the long, fan-shaped muscle most often involved in groin pain. It arises from the pubic body and runs to the middle third of the femur.

• Adductor brevis lies deeper and is shorter, also arising from the pubis and inserting on the femur.

• Adductor magnus is the largest. Its adductor portion comes from the inferior pubic ramus and ischial ramus; its hamstring portion comes from the ischial tuberosity and extends the hip.

• Pectineus is a flat muscle at the top of the inner thigh that flexes and adducts the hip.

• Gracilis is the long, thin strap from the pubis that crosses the knee and helps flex and medially rotate the leg.

All of these muscles, except the hamstring portion of the adductor magnus, originate from the pubic region. Their tendons crowd onto a small bony footprint. That shared insertion is a high-stress zone. In the Doha agreement on groin pain in athletes, adductor-related groin pain is a defined clinical entity: pain in the adductor region, tenderness at the adductor insertion, and pain reproduced by resisted adduction (Weir et al., 2015). This post focuses on that pattern.

In the clinic, I describe the adductors as midline stabilizers as much as “pulling” muscles. If the gluteals, deep hip rotators, or abdominal wall are not sharing load, the adductors are recruited as backup stabilizers. They are built for short, powerful work. They are not built to hold a tilted pelvis together for hours.

What Tendinopathy Does to the Adductor Muscles and Tendons

An acute adductor strain is a muscle or musculotendinous tear, often during a strong contraction while the muscle is lengthening. Adductor tendinopathy is different. It is a load-related tendon problem. Pain may build over weeks or years. There may be no pop, no bruise, and no day the person can point to.

In clinic, adductor tendinopathy presents as pain on palpation of the adductor tendons, pain with adduction of the legs, groin stiffness, and sometimes swelling or a lump in the muscle. In the acute irritable phase, the tendon cannot tolerate repeated tensile load, so running, cutting, and even prolonged walking become limited (Jimenez, 2019). Pain is often worst at the pubic insertion and can be felt down the medial thigh toward the knee.

Modern tendon research moved the label from “tendinitis” to “tendinopathy” because chronic tendon pain is not mainly an inflammatory disease. Cook and Purdam (2009) described a continuum: a reactive tendon that has thickened in response to sudden overload, a tendon in disrepair with matrix breakdown, and a degenerative tendon with disorganized collagen, fewer healthy tenocytes, and neovascular ingrowth. Pain is linked to local chemical and nerve changes, not simply to swelling (Scott et al., 2020).

When that process affects the adductors, several things happen at once:

1. The tendon loses its ability to store and release load. The same step, cut, or sit-to-stand that used to be routine now exceeds capacity.

2. The muscle guards. Patients often cannot fully contract or lengthen the adductors without pain, so strength drops and the opposite hip and the lumbar spine compensate (Jimenez, 2019).

3. The pubic enthesis becomes a pain generator. Direct pressure on the tendon as it meets the pubic bone reproduces the familiar ache.

4. Nearby structures get blamed. Because the pain sits in the groin and can travel down the thigh, patients and clinicians sometimes treat it as sciatica. Obturator-nerve irritation and lumbar referral can coexist with adductor pain, but they are not the same diagnosis (Jimenez, 2019).

Risk factors I look for match what the literature and clinic both show: a sudden jump in training, repeated change of direction, incomplete warm-up, fatigue, strength imbalance between adductors and abductors, a leg-length difference that changes gait, weak abdominal or thoracic control, age-related tendon change, and higher body mass (Jimenez, 2019; Thorborg, 2023).

A Familiar Clinical Pattern

A 35-year-old man came in with eight years of intermittent aching over the medial right thigh. The pain radiated toward the knee. He could not recall a fall, a tackle, or a single sports injury. That history usually points to accumulated microtrauma rather than one tear.

Palpation told the local story. Tenderness increased as I traced the adductor longus from the muscle belly to the tendon and was sharpest where the tendon anchors on the pubic bone. Pressure on the pubic bone itself made it worse. Resisted adduction, asking him to pull the leg inward against my hand, reproduced the same pain. That combination- adductor-region pain, insertion tenderness, and pain on resisted adduction- is the clinical definition of adductor-related groin pain (Weir et al., 2015).

The exam does not stop at the tendon. I also screen the lumbar spine, sacroiliac joints, hip range, and abdominal wall, because pubic, inguinal, iliopsoas, and hip-joint problems can mimic or travel with adductor pain (Weir et al., 2015). Imaging is added when the history suggests a tear, a bony stress injury, or a hip-joint source. Most long-standing adductor-related pain can be classified at the bedside.

How Chiropractic Care Helps

Chiropractic care does not “heal collagen” by itself. The tendon remodels when it is loaded in a way it can tolerate. Chiropractic care changes the mechanical environment that keeps overloading the tendon, the protective muscle tone that blocks a clean contraction, and the movement options at the hip and pelvis so rehabilitation can actually be performed.

Pelvic and Sacroiliac Mechanics

An asymmetrically rotated or tilted pelvis changes the resting length of the adductors. If one innominate is stuck in a position that lengthens the adductor origin relative to its insertion, the tendon sees a constant low-grade stretch plus every step of gait. Restoring sacroiliac and pubic-region motion, and checking leg-length contribution from the pelvis rather than assuming a true bony discrepancy, removes a driver I see repeatedly in chronic cases (Jimenez, 2019). Adjustments here are specific and comfortable. The goal is symmetrical load, not forcing a painful groin.

Lumbar Motion and Adductor Nerve Supply

The adductor muscles are supplied mainly by the obturator nerve, from the L2, L3, and L4 roots, with pectineus often supplied by the femoral nerve. Restricted lumbar segments and protective paraspinal tone can change how those muscles fire. Patients describe the thigh as “not listening” or as aching after sitting. Lumbar chiropractic adjustment and mobilization restore segmental motion and reduce guarding so the adductors can be trained instead of only stretched. This is also why I do not accept a sciatica label until I complete both the lumbar and adductor exams (Jimenez, 2019).

Hip Mobility Without Compressing the Tendon

Restricted hip rotation makes the adductors compensate during gait and squatting. Mobilization of the hip, when the joint itself is the stiff segment, reduces that compensation. Aggressive adductor stretching is different. In a painful, compressive enthesis, long end-range stretches can irritate the insertion. Early on,n I prefer gentle capsular mobility and later, controlled lengthening under load, rather than hanging in a groin stretch.

Soft-tissue Treatment as Part of Chiropractic Care

Instrument-assisted soft-tissue work, myofascial release, and muscle-energy techniques address the muscle belly and the musculotendinous junction, where strain and guarding concentrate (Jimenez, 2019). The aim is to reduce hypertonicity and improve sliding between the adductor longus, gracilis, and medial hamstrings so a stuck muscle doesn’t yank the tendon. Soft-tissue work is paired with activation. Releasing a muscle and sending the person home without a strength plan tends to fade within days.

Making the Rehabilitation Load Possible

The strongest evidence in adductor-related groin pain favors active exercise over passive treatment alone. In a randomized trial, active training with adductor and abdominal strengthening and coordination produced better outcomes than conventional passive physical therapy (Hölmich et al., 1999). A later review found moderate evidence that active exercise improves success compared with passive modalities, and that multimodal care which includes a manual-therapy technique can shorten return to sport compared with exercise alone (Serner et al., 2015). This supports combining adjustment and manual care with a loading plan, not substituting one for the other.

Thorborg (2023) summarizes the practical progression: measure pain, strength, and function; build hip-adductor, gluteal, and trunk strength; progress time under tension; then return to sport-specific load. In our clinic, that sequence looks like this:

• Isometric adduction, such as a ball or fist squeeze, when the tendon is irritable. Short holds can settle pain and start a muscle contraction without repetitive tendon strain.

• Heavy, slow concentric-eccentric adduction as irritability falls. I have long emphasized eccentric, heavy, slow work to restore adductor structure and symptoms (Jimenez, 2019).

• Copenhagen-style adduction progressions in athletes who need eccentric hip-adduction strength. Adding the Copenhagen adduction exercise to rehabilitation improved eccentric strength, pain, and hip-and-groin scores in soccer players with adductor-related groin pain (Alsirhani et al., 2024).

• Gluteus medius and maximus work, trunk control, and balance, because weak lateral hip and abdominal muscles shift stabilizing duty onto the adductors (Thorborg, 2023).

Chiropractic visits are scheduled around that progression. If the pelvis or lumbar spine locks up between sessions, an exercise that was tolerable on Tuesday can become sharp on Thursday. Keeping the joints moving is what lets the tendon program continue.

Beyond Adjustments: Chiropractic and Integrative Healthcare- Video

Combining Chiropractic Care With Other Nonsurgical Treatment

Lasting change usually comes from stacking treatments that do different jobs. At Injury Medical Clinic, our medical director, Dr. Maria Guadalupe Cardenas, MD, coordinates this so medical decisions stay within a physician-supervised plan.

Medical Evaluation and, When Appropriate, Injection

Dr. Cardenas’s internal-medicine oversight matters because groin pain isn’t always tendon-related.Before a local procedure, consider hip joint disease, inguinal disruption, urinary or pelvic sources, and lumbar referral. If you use a diagnostic injection, the goal is confirmation and a short window for rehabilitation, not a cure. Local anesthetic can test whether the tendon region is the source. If you choose a corticosteroid, do not place it in the body of the tendon. Direct intratendinous steroid has a known association with later rupture, which is why I do not recommend injecting into the tendon itself (Jimenez, 2019). After aspiration, place any injection around the tendon sheath and enthesis, under sterile prep. Use the 3 days of reduced pain to start isometrics and correct mechanics, not to return immediately to the activity that caused the overload.

Physical Therapy and Supervised Loading

Physical therapy carries the tendon-remodeling work: staged adduction strength, gluteal and trunk strength, and return-to-run or return-to-lift criteria. Chiropractic care and physical therapy are scheduled so manual treatment does not replace loading and loading is not pushed through a locked pelvis. Serner and colleagues (2015) noted that study quality in groin-pain treatment is still limited, so we do not promise a protocol. We match the tendo stagen, as Cook and Purdam (2009) argued, and we track squeeze strength and the Copenhagen Hip and Groin Outcome Score domains when we need numbers, not guesses.

Massage Therapy

Massage and clinical soft-tissue therapy reduce protective tone in the adductor longus, gracilis, and medial hamstring, and they improve tolerance for the next exercise session. Massage does not replace eccentric loading. It makes the loading tolerable. Athletes often need the muscle belly treated on the same day the tendon program progresses, or the belly stays tight,t and the insertion keeps taking the strain.

Functional Wellness

Tendon recovery is slower when sleep, protein intake, and overall load are poor. Functional medicine in this setting is practical. We look at training spikes, daily step load, body composition, and whether the person is eating enough protein and vitamin C to support collagen turnover. Vitamin C is a cofactor for collagen cross-link formation; it is not a substitute for mechanical loading. If pain has been present for years, we also look for systemic contributors, including low activity, higher body mass, and metabolic inflammation, that keep tissues from adapting (Jimenez, 2019). Use laboratory testing when the history suggests it, not as a routine panel for every groin ache.

Shockwave and Other Adjuncts

Extracorporeal shockwave is sometimes used as an adjunct for chronic tendon pain when exercise has stalled. It is an add-on to loading and biomechanical correction, not a standalone fix. The same rule applies to dry needling or instrument-assisted work.

What This Looks Like Over Time

For the eight-year pattern described above, care moves in three overlapping phases.

Phase 1 is classification and calm. Confirm adductor-related pain, rule out hip-joint and inguinal sources, settle the irritable tendon with isometrics and temporary load reduction, and begin pelvic and lumbar chiropractic care so the next phase is not fighting a twisted pelvis.

Phase 2 is capacity. Massage and soft-tissue treatment quiet the muscle belly. Physical therapy progresses heavy, slow adduction and gluteal-trunk strength. Chiropractic care maintains pelvic and lumbar motion. If a peritendinous injection was used, this is the window it was meant to open.

Phase 3 is return and prevention. Add sport-specific or work-specific cuts, kicks, and lifts. Adductor strength is kept in proportion to abductor strength. Training spikes are planned, not accidental. Recurrence is common when the person feels better and drops the strength work. The tendon adapted to the program. It will de-adapt if the program disappears.

Clinical Observations From Practice

These observations are drawn from published clinical discussions on adductor strain and tendinopathy and from daily practice at Injury Medical Clinic (Jimenez, 2019; dralexjimenez.com).

• Groin pain that patients call “sciatica” is often adductor until the resisted-adduction test and the lumbar exam say otherwise. Treating the wrong structure wastes months.

• Tenderness that peaks at the pubic insertion and worsens when you press the pubic bone points to the enthesis rather than a mid-belly strain.

• A missing injury story is common. Cumulative load, a gait asymmetry, or a pelvic torsion explains more eight-year cases than a forgotten fall.

• Leg-length difference, weak abdominal control, and a sudden change in training show up together more often than any single “tight groin.”

• NSAIDs often disappoint, which fits a tendon problem that is not primarily inflammatory (Jimenez, 2019).

• Eccentric and heavy-slow strength work changes function more reliably than rest followed by stretching.

• Adjustments and soft-tissue care hold their benefit when the exercise dose continues. They fade when they are the only treatment.

Conclusion

Adductor tendinopathy is a capacity problem at the pubic insertion of the inner-thigh muscles, often kept alive by pelvic asymmetry, lumbar and hip restriction, and a load program the tendon cannot meet. Chiropractic care helps by restoring the mechanics and muscle coordination that rehabilitation needs, and by treating the tendon region directly with soft-tissue methods. It works best combined with physical therapy loading, massage, functional wellness, and medical oversight from Dr. Maria Guadalupe Cardenas, MD. The 35-year-old with eight years of medial thigh pain is not unusual. The useful shift is to stop hunting for one forgotten injury and start rebuilding how the adductors, pelvis, and trunk share load.

This article is educational. It is not a diagnosis or a personal plan of care. Groin pain has several causes, some of which need imaging or surgical opinion. Make decisions about injections, medications, and return to sport with the treating clinicians.

References

• Alsirhani, A. A., et al. (2024). The effectiveness of the Copenhagen adduction exercise on improving eccentric hip adduction strength among soccer players with groin injury: A randomized controlled trial. The Physician and Sportsmedicine, 52(5), 497–506.
• Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416.
• Hölmich, P., Uhrskou, P., Ulnits, L., Kanstrup, I.-L., Nielsen, M. B., Bjerg, A. M., & Krogsgaard, K. (1999). Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: Randomized trial. The Lancet, 353(9151), 439–443.
• Jimenez, A. (2019, June 17). Adductor strain, tendinopathy, and sciatica. Injury Medical Clinic PA. https://dralexjimenez.com/adductor-strain-tendinopathy-and-sciatica/
• Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R.-J., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S. P., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical terminology. British Journal of Sports Medicine, 54(5), 260–262.
• Serner, A., van Eijck, C. H., Beumer, B. R., Hölmich, P., Weir, A., & de Vos, R.-J. (2015). Study quality on groin injury management remains low: A systematic review on treatment of groin pain in athletes. British Journal of Sports Medicine, 49(12), 813.
• Thorborg, K. (2023). Current clinical concepts: Exercise and load management of adductor strains, adductor ruptures, and long-standing adductor-related groin pain. Journal of Athletic Training, 58(7–8), 589–601.
• Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K. M., Lovell, G., Meyers, W. C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A. G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., … Hölmich, P. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 49(12), 768–774.

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