This video will discuss the different training techniques that can be used for the prehabilitation of adductor strains. The exercises selected are either related to muscular strength, core stability, flexibility/mobility or balance/proprioceptive training.
Slide 2= Muscular strength
The Copenhagen adduction exercise was implemented into the FIFA 11+ warm up programme, to investigate the effect on eccentric hip adductor strength (Harøy et al., 2017). This study concluded that the Copenhagen exercise increased eccentric hip adduction strength, while the standard Fifa 11 + warm up did not. However, its preventative effect had not yet been tested until Harøy et al. (2019) investigated the effect of a single exercise approach, based on the Copenhagen adduction exercise, in reducing the prevalence of adductor injuries in male footballers. They found that this programme decreased the prevalence and risk of adductor problems, during the competitive season by 41%; therefore, this exercise could be implemented into prehabilitation programmes to prevent adductor strains.
As you can see from figure 1, there are three different variations of the exercise, ranging from easy to hard. Players were asked to start at level 3 but if pain was provoked (3/10 on VAS) during the movement, they were advised to perform the exercise at a level 2. Similarly, if they experienced pain at level 2, they were instructed to do the movement at a level 1 (Harøy et al., 2019).
It is important for this exercise to be implemented into preseason because participating in an adductor strengthening programme before the competitive season begins, has reduced the incidences of adductor strains (Esteve, Rathleff, Urrútia, & Thorborg, 2015).
During this exercise, the hip adductors (adductor longus, adductor brevis, adductor magnus, pectineus and gracilis (Neumann, 2010)) are specifically activated, whereas previous exercises have had a combined focus on the hip adductors, flexors and abdominals (Harøy et al., 2019). Regarding the adductor muscles, the adductor longus has been shown to produce electromyography (EMG) activity of 108% of a maximal voluntary isometric contraction (Ishøi et al., 2016). It is necessary to include adductor strengthening into an exercise prescription, particularly when preventing adductor strains, because a risk factor for this injury is decreased adductor strength (Whittaker et al., 2015). Furthermore, abduction strength gain has also been observed, which is important to improve, as another risk factor for adductor injuries is imbalances between the hip abductor and adductor muscles, therefore the abductors (gluteus medius, gluteus minimus and TFL (Neumann, 2010)) still need to be activated (Engebretsen et al., 2010). This was demonstrated using surface EMG activity, where there was an activity of 48% maximal voluntary isometric contraction through the hip abductors (Polglass, Burrows, & Wilett, 2019).
Side 3 = Core stability
Okubo et al. (2010) investigated muscle activity during lumbar stabilization exercises. They concluded that the overall activity of the abdominal muscles was greater during the exercises that were performed in a prone position, either using elbow-toe or hand-knee combination for support, during the movements. This is why the specific progressions for the plank have been selected, in order to improve core stability by the activation of the abdominal muscles. Furthermore, the exercise that activated the transverse abdominus muscle the most was elbow-toe plank with contralateral arm and leg lift. This is of great significance and should therefore be included in a prehabilitation programme for an adductor strain, as risk factor for this injury is delayed contraction of the transverse abdominus (Engebretsen et al., 2010). As the advanced plank activated the transverse abdominus the most, it is important to try and reach the end stage of the plank progression, while ensuring it is done gradually to prevent reversibility/injury; However, all of these exercises would be beneficial in the prevention of adductor strains, for the reasons already discussed.
Abdominal hollowing is a movement that consists of drawing in your lower abdomen maximally towards the spine, without any motion from the pelvis and thorax (Hirayama, Akagi, Moniwa, Okada, & Takahashi, 2017). It should be done in all of these exercises because it causes a significant increase in EMG levels of the transverse abdominus(Bjerkefors, Ekblom, Josefsson, & Thorstensson, 2010).
Slide 4= Mobility/flexibility
Stretching should be included in any prehabilitation programme, as it can prevent joint stiffness and allow for both muscles and nerves to move at their optimal length (Sathe, 2017).
Similarly, it is important to include hip abductor stretching, in order to prevent adductor strains. This is because a decrease in opposing muscle length is a risk factor for this injury(Ryan, Mc Creesh, & De Burca, 2014). Furthermore, decreased abduction ROM has been supported as another risk factor for adductor injuries, therefore this abductor stretch can be used to improve ROM as well as length. The recumbent hip external rotator and extensor stretch specifically targets the gluteus medius (when the leg is kept flat on the floor) which is the primary abductor for the hip, as well as the gluteus minimus and the piriformis (Retchford, Crossley, Grimaldi, Kemp, & Cowan, 2013).
The seated groin stretch activates the adductor muscles which includes gracilis, adductor longus, adductor magnus, adductor brevis and pectineus. If the feet are moved further away from the groin area, it increases the stretch on the gluteus medius (abductor), gluteus maximus and erector spinae, therefore places an increased stretch on the origin of the adductor muscles (Nelson & Kokkonen, 2020).
Slide 5= Balance / proprioceptive training
Balance training can be used for the prevention of lower extremity sports injuries including adductor strains(Lesinski, Hortoba, Muehlbauer, Gollhofer, & Granacher, 2015). Furthermore, specific balance exercises for the adductors and the muscles around the pelvis, such as a lunge or squat on a balance board, have been shown to be effective for prehabilitation of this injury (Esteve, Rathleff, Urrútia, & Thorborg, 2015). These types of movements should also be included in a prevention programme for adductor injuries because another risk factor is reduced proprioception and these exercises can help to address this problem (Ryan, Mc Creesh, & De Burca, 2014).
A squat on a balance board activates the synergistic muscles for the hip adductors such as the gluteus maximus. It also targets the stabilising muscles of the hip and pelvis (gluteus minimus, quadratus femoris, gemili, obturator externus and internus) which have been effective in the prevention of adductor strains (Retchford, Crossley, Grimaldi, Kemp, & Cowan, 2013).
Similarly, a lunge on a balance board also activates the hip stabilisers, as well as the bicep femoris (synergist for adduction) and the glutes (Neumann, 2010).
On the next slide is a list of references used, thanks for listening
Bjerkefors, A., Ekblom, M. M., Josefsson, K., & Thorstensson, A. (2010). Deep and superficial abdominal muscle activation during trunk stabilization exercises with and without instruction to hollow. Manual Therapy, 15(5), 502–507.
de Baranda, P. S., & Ayala, F. (2010). Chronic Flexibility Improvement After 12 Week of Stretching Program Utilizing the ACSM Recommendations : Hamstring Flexibility. International Journal of Sports Medicine, 31(6), 389–396.
Engebretsen, A. H., Myklebust, G., Holme, I., Engebretsen, L., & Bahr, R. (2010). Intrinsic Risk Factors for Groin Injuries Among Male Soccer Players A Prospective Cohort Study. The American Journal of Sports Medicine, 38(10), 2051–2057.
Esteve, E., Rathleff, M. S., Urrútia, G., & Thorborg, K. (2015). Prevention of groin injuries in sports : a systematic review with meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 49(12), 785–791.
Harøy, J., Clarsen, B., Wiger, E. G., Øyen, M. G., Serner, A., Thorborg, K., … Bahr, R. (2019). The Adductor Strengthening Programme prevents groin problems among male football players : a cluster-randomised controlled trial. British Journal of Sports Medicine,53(3), 145–152.
Harøy, J., Thorborg, K., Serner, A., Bjørkheim, Rolstad, L. E., Holmich, P., … Andersen, T. E. (2017). Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players. The American Journal of Sports Medicine, 45(13), 3052–3059.
Hirayama, K., Akagi, R., Moniwa, Y., Okada, J., & Takahashi, H. (2017). Transversus abdominis elasticity during various exercises: A shear wave ultrasound elastography study. The International Journal of Sports Physical Therapy, 12(4), 601–606.
Ishøi, L., Sørensen, C. N., Kaae, N. M., Jørgensen, L. B., Hölmich, P., & Serner, A. (2016). Large eccentric strength increase using the Copenhagen Adduction exercise in football- A randomized controlled trial. Scandinavian Journal of Medicine & Science in Sports, 26(11), 1134–1342.
Lesinski, M., Hortoba, T., Muehlbauer, T., Gollhofer, A., & Granacher, U. (2015). Dose-Response Relationships of Balance Training in Healthy Young Adults : A Systematic Review and Meta-Analysis. Journal of Sports Medicine, 45(4), 557–576.
Nelson, A.G., & Kokkonen, J. (2020). Stretching anatomy. Champaign, IL: Human Kinetics.
Neumann, D. A. (2010). Kinesiology of the Hip: A Focus on Muscular Actions. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 82–94.
Okubo, Y., Kaneoka, K., Imai, A., Shiina, I., Tatsumura, M., Izumi, S., & Miyakawa, S. (2010). Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. Journal of Orthopaedic & Sports Physical Therapy, 40(11), 743–749.
Polglass, G., Burrows, A., & Wilett, M. (2019). Impact of a modified progressive Copenhagen adduction exercise programme on hip adduction strength and postexercise muscle soreness in professional footballers. British Journal of Sports Medicine, 5(1), 1–7.
Retchford, T. H., Crossley, K. M., Grimaldi, A., Kemp, J. L., & Cowan, S. M. (2013). Can local muscles augment stability in the hip ? A narrative literature review. Journal of Musculoskeletal and Neuronal Interactions, 13(1), 1–12.
Ryan, J., Mc Creesh, K., & De Burca, N. (2014). Risk Factors for Groin/ Hip Injuries in Field Based Sports: A Systematic Review. British Journal of Sports Medicine, 48(14), 1089–1096.
Sathe, P. K. (2017). Assessment and management of adductor strain. Saudi Journal of Sports Medicine, 17(2), 118–120.
Whittaker, J. L., Small, C., Maffey, L., & Emery, C. A. (2015). Risk factors for groin injury in sport : an updated systematic review. British Journal of Sports Medicine, 49(12), 803–809.