Groin Pull, Pain with L Hip Flexion / Adduction. 3+ months of modified activity

Medical Q&A [Moderated]
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Little background about myself: 26 year old male. Started training for strength about 2 years ago, and my best lifts have been a 365lb squat, 275lb bench, and 475lb deadlift at 180 lbs. Obviously room for improvement, but I wouldn’t consider myself a novice.

I did my first meet in February 2018 and it was an amazing experience. Afterwards, I went into an offseason mode and went full retard. I started doing sets of 10 on squats and then my gym picked up a belt squat machine, so of course the natural reaction to that would be to do sets of 20 on that as well right? Because of that one Matt Wenning video? And you’re basically an elite powerlifter at this point? Well anyway, I paid for my stupidity because in April my inner hip/groin really started bothering me. Squats and then later deadlifts became really painful in the area, especially the day after the exercises. For the initial month, I tried alternative exercises that didn’t bother it as much like moderate stanced box squats. For the past 3 months, I have stopped doing lower body movements, other than occasional bridges, glute ham raises, and step ups just to try to keep something alive down there. I work at a desk in a physical therapy office, so I worry about going 100% inactive. I also kept in upper body movements and was focused on benching with feet on the bench. The leg drive bugged my injury and feet up helped.

I had my third MD follow up on 7-23-2018 after 3 months of not squatting, deadlifting, or doing activities that directly agitate it. No change in status. Pain with resisted hip flexion and adduction. Mostly located on top inside-to-front-ish area of my left thigh. I have had an ultrasound and MRI that have not revealed anything. MD has ruled out hernias/sports hernias because of lack of adominal pain on certain tests and doesn’t believe this to be the issue. Range is good and based on imaging, MD does not believe it to be labrum or FAI related. The diagnosis on the reports is “adductor strain.”

On that most recent visit, I also got to talk to our Director of Sports Medicine. He believed it to be possible micro tears around the muscular-tendon junctures of the area. This MD’s belief was that by doing activities like bridges or heavy upper body movements like benching, I may not be necessarily making things worse, but it may be preventing/delaying the healing process. He wanted me to abstain from all forms of exercise for 3-4 weeks, then if the problem persists (which based on my experience, I am confident it will) then he will give me the number to a big shot sports ortho in Orlando (an hour away) for a second opinion. Surgery should try to be avoided, but if it does come down to that, he mentioned one where they essentially scrape the micro tears to create one larger tear to promote bloodflow and healing, but the success rate on that is not very high (I may have butchered his paraphrasing).

Anywho, feel pretty hopeless. Excercise has been a huge part of my life for over 10 years, and lifting/powerlifting means a great deal to me. I don’t know whether I should keep waiting, listen to these doctors, find new doctors, or continue letting my body atrophy. Allot of these MD’s give me the vibe akin to “What you did isn’t even a sport lol heavy weights are bad for you”. Depression has been rough. Anyway, sorry for the paragraphs of word vomit, but any advice would be appreciated. I would be happy to provide any additional information if needed. Thank you for your time.

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Hi Mike. Sorry to hear about your difficult course here.

Where are you located?

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Hey Austin,

I am currently living in Daytona Beach, Florida.

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Hey Mike, I’m sorry to hear about your adductor issues. Unfortunately I do not know of any clinicians in the Daytona area but, if you do not mind, I would like to lend some advice to your case. If we are 4+ months into this and you are still having issues, we are beyond our normal “wait it out” time frame and need to be looking to first, get you back into lower extremity activity, then get you back into training, then start talking about platforms. Without doing an exam it is difficult to attempt to pinpoint exactly what is going on at the tissue level, but likely the heuristic for starting to work back towards lifting is the same.

Also, it sounds like they have done a full work up to rule out athletic pubalgia so that shouldn’t get in our way. There is a good bit of research on chronic strains as it relates to hamstrings so I am going to make some inferences in what I would recommend from that. What often happens is a cycle develops where there will be a little relief in symptoms and then a new activity is attempted and it is welcomed with a new exacerbation. What we need to do initially is start to build some capacity in that tendon/tissue. For hamstrings, the normal recommendation is the Nordic Hamstring Curl, for adductors however, it is normally the lateral lunge. This is an instance where tempo is your friend and I cannot overemphasize the word SLOW enough. In the beginning I would start with bodyweight and go down to where you start to feel a stretch/tension in the groin area. Your affected leg should be the one remaining straight in the beginning. Once you can obtain full range on that side, then start introducing bilaterally. You are not out to break records the first few times, but rather to start gaining some increased, pain free ROM. I would start with 3x10, slow (I’m going to keep saying this). What you will likely notice is the symptoms remain the same or improve some, but you will start to go deeper. There is no contraindication to you doing glute bridges, glut ham raises, or step ups but I would reiterate that tempo is your friends in the beginning. Once we can start getting 3x10 to full ROM with no weight, it is time to start looking to introduce weight to the movement. Right now we gotta start getting some wins for you to get back under the bar (way better euphemism than back on the horse).

Back to my hamstring comparison earlier, the normal retear rate for hamstring strains is about 30% and there is good evidence of big time strength deficits persisting when athletes return to sport feeling perfectly fine. If it is an adductor strain (which is certainly how this subjectively presents) you are likely in this same deficit right now and we need to start, slowly, working it back to strength. I would stay off of any surgical intervention as long as you can and start developing a base plan to get you built back up.

I do have a few questions that will give me a better idea of where we need to start/how fast we can progress. Do you feel it at all when you are sitting/walking/bodyweight squatting? When you said you were trying to work around it in the beginning, could you elaborate a little more on what your programming was? It sounds like right now this situation has been approached with a shotgun when we may be better off with a rifle.

Derek

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Thank you both! I appreciate the well thought out input.
Tempo control was an interesting concept I hadn’t thought about before.

For the lateral lunges, would you recommend resetting my stance to shoulder width each rep or maintaining the wider stance throughout the set? Would a 5-1-5 tempo or something similar be sufficient? Frequency through the week?

In addition, I had a few other questions. Would compression around the site be of any use? I have a compression cuff (Big Hammy Band from SuperTraining) and some old knee wraps. Also, I work in a PT clinic as a tech / front desk and some guys at my gym are chiropractors. Would manual therapy or ART (not too familiar with it) be of any use? Or is that going into the shotgun territory, when I should be refining my focus to the lunges?

For that initial month, I subbed out regular squats. I had a day of moderate stanced box squats and conventional deadlifts (70-80%, 8x3) and a day of trap bar deadlifts and cambered good mornings (70-75%, 5x5) roughly. I stopped this after about a month. I wasn’t getting worse or improving, but once I hit close to 80%, the injury would become aggravated. I stopped lower movements as per M.D. orders and wanting to let the area heal.

On the third month, I had introduced a rehab protocol of essentially bridges, sidelying hip abduction, paused hip flexion, donkey kicks along with my 3-4 days of upper body work at the gym. I would do step ups to a 12 inch box /glute ham raises(3x10) there as well. Nothing aggravated it, but I had to be cautious about the paused hip flexion movement.

The pain is more of a constant discomfort, and allot of times it is delayed to a few minutes after the activity. Whether I feel it sitting or walking depends on whether I am having a good or bad day with it. In the gait cycle, it is usually during the end of hip extension and I am bringing my leg forward. I don’t seem to have any tolerance for free squatting, bodyweight or otherwise. Usually I’ll deal with the reprecussions a day or so later. I have been experiencing a rough week because pain had been mild for a few weeks and I attempted squatting 3x5 with an empty bar. Apparently, that was a mistake. I do tend to try to move explosively, so I guess that tempo suggestion will remain a key aspect to adhere to for a while. Pain level usually ranges from a mild 1 to a 4, but is constant.

Thanks again!

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Mike,

I would recommend trying to keep the wider stance throughout the set to keep tension on the tendon/proximal belly. I think either 3-1-3 or 5-1-5 would be sufficient as there may be some adjustments according to tolerance. I would also recommend starting every day, to tolerance. If this has been going on for four months now the main goal is to start building more capacity for activity before we start integrating in intensity.

Compression does not have any evidence for utility with strains and is contraindicated for tendinopathies so either way I would not use compression at this time. As for manual therapy, I tend to fall in the same camp as Jordan and Austin and not see much use for manual therapy and even less for ART specifically as it lacks any evidence and tends to be delivered from a “something is wrong with you, let me fix it” slant. At this point we would be best introducing one variable at a time so we can account for the effects of each.

As for the MD’s advice to stop lower body training, I would have politely disagreed. This gets into the concept of loading having multiple variables and tissue responds to the dosage of those variables best. If we had a true strain (once again, I have not performed an examination or seen any imaging so I am speaking of the highest probability) then your prior 70-80% would not have been your true 70-80% at the time as a strain implies some tearing of the muscle belly (I will caveat this by saying according to the current strain consensus DOMS is considered a grade 1 muscle strain so it’s not all that bad. It also helps to explain why you can’t come back at max percentages when you are sore). Austin, try not to stroke out a that run on sentence. Areas heal with the right amount of stress applied and “none” is rarely the right amount. Strains and tendinopathies both respond best to the controlled variable of tempo so often starting with basic tempo specific to that area will help facilitate the healing process.

As for the pain you are currently experiencing with daily activities, our biggest priority right now is getting you to where that is not a thing and starting to chain together rows of “good” days with a lesser frequency of “bad.” If we can get there, then it is time to start reintroducing the bar but, as mentioned earlier, both strains and tendinopathies are slow healing and often come with a strength deficit that needs worked out. Even once we start back under the bar some dedicated work to continue to build up the capacity of your adductor will likely be warranted.

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Understood. This gives me essentially a framework to begin building around. I am extremely grateful as your suggestions has given me some much needed hope.

Brainstorming on a plan of care for myself, to complement some form of training. I was thinking something along the lines of Sunday (Bench focus), Wednesday (lighter Bench/OHP focus), Friday (OHP focus), with some back/accessories thrown in. The goal being to not go nuts and aggravate it. Meanwhile, I would be working up to performing tempo lateral lunges daily, beginning with partial range of motion / keeping the injured leg straight. I would progress to bilateral, full ROM and eventually add weight.

In the future, when weight is added based on tolerance and the recommended exercise dosage being daily, would doing 3-4 days weighted and the remaining unweighted at home be acceptable? Otherwise, I would need stop by my gym daily. I assume this would be appropriate, but just wanted to confirm.

Also, you mentioned some dedicated adductor work. Should I wait until I am once again under the bar to add these in, or add them in gradually after other things begin to progress? Would exercises like banded adductions be of any use? Things like these come to mind: https://www.youtube.com/watch?v=oPSBlqHfAg8 or https://www.youtube.com/watch?v=qjUnE74wV78
Would seeking out a hip abduction/adduction machine at a commercial gym be of any benefit?

Finally, mildly worried that illiopsoas/deep hip flexors are an additional component in this equation. Would this also be covered by the tempo controlled lateral lunges? Or after a few weeks could I include some sort of tempo hip flexion type movement? Part of my reasoning for this was that gentle hip flexion stretches bother me much more than gentle adductor stretches, and I know the symptoms both adductor and illiopsoas are supposedly quite similar. I may be reading too much into things and if I am, I don’t mind being told so.

Once again, thank you for your help. I just about have a plan forumulated. If I wanted to touch base with you maybe once a month or so, just with updates / inquiries, would that be appropriate? I just do not want to take advantage as I know you are a working clinician with a case load and I am not a paying patient.