Current Concepts in the Management of Adductor Strain and Athletic Pubalgia

High-Yield Summary

• Adductor strain and athletic pubalgia often coexist in athletes presenting with groin pain; precise differentiation guides management.
• Key anatomic structures include the adductor longus origin at the pubic body and the rectus abdominis-adductor aponeurotic complex; injury here dictates surgical approach.
• Non-operative management is first-line for isolated adductor strains; surgical intervention is reserved for refractory cases or confirmed athletic pubalgia with aponeurotic disruption.
• Surgical repair targets the rectus abdominis-adductor aponeurosis or adductor tendon reattachment, with minimally invasive techniques gaining traction.
• Recent evidence supports early diagnosis with MRI and tailored rehabilitation protocols to optimize return-to-play timelines and reduce recurrence.

Clinical Fundamentals

The adductor muscle group, primarily the adductor longus, originates from the pubic body and inserts along the femoral shaft, functioning to stabilize the pelvis during dynamic lower extremity movements. The rectus abdominis shares a common aponeurotic insertion with the adductor longus at the pubic symphysis, forming the rectus abdominis-adductor aponeurotic complex (RAAC). This complex is critical in force transmission during kicking and cutting maneuvers.

Biomechanically, eccentric loading during rapid hip extension and abduction predisposes the adductor longus tendon and RAAC to microtrauma and partial tears. Epidemiologically, adductor strains are prevalent in sports requiring sudden directional changes, with a higher incidence in male athletes aged 20-35. Athletic pubalgia, often termed “sports hernia,” involves chronic groin pain due to RAAC disruption without true herniation, frequently coexisting with adductor pathology.

Classification & Diagnosis

Diagnostic pearls include the necessity of high-resolution MRI with dedicated pubic symphysis sequences to detect subtle aponeurotic disruptions. Common pitfalls involve misdiagnosing adductor tendinopathy as hip joint pathology or overlooking concomitant RAAC injury, which delays appropriate treatment.

Decision-Making Algorithm

Non-operative management is indicated for:

• Grade I and II adductor strains without RAAC involvement.
• Acute injuries with minimal functional deficit.
• Patients responding to structured physical therapy emphasizing eccentric strengthening and core stabilization.

Operative management is reserved for:

• Persistent groin pain >6 weeks despite optimized conservative care.
• MRI-confirmed RAAC disruption or complete adductor tendon avulsion.
• High-level athletes requiring expedited return to sport.

Surgical approach selection depends on injury location:

• RAAC repair via open or minimally invasive techniques for aponeurotic tears.
• Adductor tendon reattachment using suture anchors or transosseous fixation for avulsions.
• Combined repairs when both structures are involved.

Implant choice favors bioabsorbable anchors to minimize hardware complications and facilitate early mobilization.

Surgical Mastery & Pearls

Conceptual surgical steps for RAAC repair:

1. Patient positioning supine with slight Trendelenburg to optimize pubic exposure.
2. A transverse or Pfannenstiel incision centered over the pubic symphysis.
3. Identification and careful dissection of the RAAC and adductor longus origin.
4. Debridement of scar tissue and mobilization of torn edges.
5. Reapproximation of the aponeurotic complex using nonabsorbable sutures in a tension-free manner.
6. Reinforcement with suture anchors placed in the pubic body if tendon avulsion is present.
7. Layered closure with attention to preserving neurovascular structures, particularly the ilioinguinal nerve.

Intraoperative red flags include excessive bleeding from the corona mortis vessel and inadvertent injury to the spermatic cord or femoral neurovascular bundle. Technical tips emphasize meticulous soft tissue handling and avoidance of overtensioning repairs to prevent postoperative stiffness.

Evidence-Based Synthesis

Landmark studies have shifted the paradigm from prolonged conservative treatment to earlier surgical intervention in cases of confirmed RAAC disruption. Randomized trials demonstrate superior pain relief and faster return to play with surgical repair compared to extended rehabilitation alone. Recent meta-analyses underscore the importance of MRI in stratifying patients and tailoring treatment.

Controversy persists regarding the optimal surgical technique, with emerging data favoring minimally invasive approaches for reduced morbidity but lacking long-term outcome equivalence. Rehabilitation protocols incorporating core strengthening and neuromuscular control have been validated to reduce recurrence rates.

Current consensus advocates a multidisciplinary approach integrating precise imaging, individualized rehabilitation, and timely surgical intervention for refractory cases.

Master Class Pro-Tip

Mastery in managing adductor strain and athletic pubalgia hinges on recognizing the subtle interplay between the RAAC and adductor tendon pathology. Intraoperative assessment should include dynamic testing of the repair under gentle traction to confirm restoration of pelvic stability. Employing a layered closure that respects the native anatomy and preserves proprioceptive fibers optimizes functional recovery and minimizes chronic groin pain syndromes.

Last Updated on June 9, 2026 by OrthoNet AI