Some cases labeled "adductor strain" actually involve the connective-tissue complex linking the rectus abdominis, pubic plate and adductor longus origin. The rectus abdominis runs down the front of the abdomen and the adductor longus runs up the inner thigh, and at the front of the pubic bone their attachments blend into a shared connective-tissue region. Injury there can feel like an adductor problem, an abdominal problem or both, and it is one reason persistent athletic groin pain deserves a precise anatomical diagnosis.
The anatomy: one connective-tissue complex
The adductor longus tendon arises from the front of the pubic bone. Just above it, the rectus abdominis attaches to the pubic crest. Their fibers do not simply stop at bone. They blend with each other, with the fibrous tissue covering the front of the pubic bone and with the capsule of the pubic symphysis. Radiologists and surgeons describe this region with terms such as the rectus-abdominis/adductor aponeurosis, the common aponeurosis or the aponeurotic plate.
Because these structures are mechanically linked, forceful kicking, twisting or sudden changes of direction can load them together. An injury can therefore involve:
- the adductor longus origin and its enthesis
- the aponeurotic plate that bridges the rectus abdominis and adductor longus
- the rectus abdominis insertion
- adjacent pubic bone or the symphysis capsule
A 2019 imaging review noted that recent consensus work emphasized the adductor/rectus aponeurosis and the pubic symphysis capsule as key areas in athletic groin injury, and recommended anatomical descriptions over loosely used terms such as cleft, enthesitis, plate injury or defect (Madani, 2019).
Sports hernia, athletic pubalgia and core muscle injury
Terms such as athletic pubalgia, sports hernia and core muscle injury are often used inconsistently. Whenever possible, Novo describes the actual anatomical structure involved.
"Sports hernia" is the least precise of these labels. It has been applied to inguinal-related groin pain, to rectus-adductor aponeurosis injuries and to other problems, and it is easily confused with a true inguinal hernia, which is a different diagnosis. The Doha agreement on groin pain terminology classifies athletic groin pain by clinical entity, such as adductor-related, inguinal-related or pubic-related pain, rather than by these umbrella terms (Weir, 2015). An aponeurotic injury can produce symptoms that overlap several of those entities. The abdominal side of this spectrum is covered in core muscle injury and the rectus-adductor aponeurosis.
How these injuries present
Aponeurotic injuries often present as activity-related pain near the pubic bone that may spread into the inner thigh, the lower abdomen or both. Typical aggravating activities include kicking, sprinting, cutting, sit-ups and sometimes coughing or sneezing. Tenderness may be found where the rectus abdominis and adductor longus meet, and both resisted adduction and resisted sit-up testing may reproduce the pain.
These features overlap with adductor-related, inguinal-related and pubic-related groin pain, and with hip problems. Multiple sources are common: in a multidisciplinary assessment of 100 athletes, 44% had more than one clinical entity contributing to their groin pain (Taylor, 2018). The clinical overlap is explained in adductor groin pain vs. hip, iliopsoas and pubic pain.
Why these injuries are easy to mislabel
An injury at the junction of two muscle groups does not respect the boundaries of a single diagnosis. Pain may be reported along the inner thigh, at the pubic bone or in the lower abdomen, and the dominant site can shift from day to day. Resisted adduction may hurt, but so may a sit-up. A quick examination can therefore label the problem an adductor strain, an abdominal strain or a sports hernia, depending on which test happened to be most painful. Repeated "strains" that never fully settle, or groin pain that responds poorly to adductor loading alone, are reasons to consider the aponeurosis.
Questions the examination tries to answer
- Is the pain centered on the adductor longus origin, the rectus insertion, the pubic symphysis or the inguinal canal?
- Does resisted adduction, a resisted sit-up or both reproduce the familiar pain?
- Is there a palpable hernia or another reason for surgical referral?
- Does the hip joint contribute, through restricted or painful rotation or mechanical symptoms?
- How much adductor and trunk load can the athlete currently tolerate?
- Would MRI change management?
Why MRI is often the key test
MRI is particularly useful when symptoms suggest an aponeurotic or pubic injury rather than isolated adductor tendinopathy. A review of MRI in athletic pubalgia and core muscle injury described MRI as the standard-of-care imaging modality for this spectrum of injury. With a dedicated noncontrast protocol, MRI can characterize osteitis pubis, midline pubic plate lesions and rectus-abdominis/adductor aponeurosis injury, while also identifying confounders such as hip joint derangement and unexpected visceral or musculoskeletal lesions (Coker, 2015).
A 470-athlete MRI series illustrates how heterogeneous groin pain can be, with abnormalities involving the rectus-adductor origin, short adductors, pubic bone, symphysis and hip. The series reviewed pelvic MRI performed for groin pain in athletes of all levels and classified findings as injury to the common rectus-abdominis/adductor-longus origin, injury to the short adductor muscles, pubic bone edema, pubic symphysis degenerative change, hip joint injury and other findings. Only 46 of the 470 athletes were female, and patterns differed by sex: female athletes were less likely to have rectus-adductor, short-adductor or hip injuries and much more likely to have pubic degenerative changes (Hynes, 2023).
Those findings describe what MRI shows in symptomatic athletes. They do not mean every abnormality caused the pain. Reactive changes around the pubic symphysis are also common in athletes without symptoms, so imaging has to be read alongside the examination (Madani, 2019).
Ultrasound has a role, with limits
Ultrasound is widely available and allows real-time assessment of superficial tendons and the inguinal region. For the deeper common aponeurosis, it can miss injuries. In one study of professional soccer players, ultrasound was highly specific but only 44.4% sensitive for common rectus-abdominis/adductor-longus aponeurosis lesions, reinforcing the value of MRI when this deeper injury is suspected.
That study included 39 professional soccer players, 15 with pubalgia and 24 without. Aponeurosis lesions were more frequent in players with pain, and ultrasound detected them with 100% specificity but 44.4% sensitivity. Pubic degenerative changes were frequent in both groups, including players without pain (Todeschini, 2019). The figure applies to this specific lesion in this small group, not to every groin ultrasound examination.
Is this a real structural injury?
Yes. Surgical series further confirm that rectus-adductor aponeurotic plate injuries represent a distinct structural diagnosis, but surgery is generally reserved for selected refractory cases after appropriate conservative management.
In one level 4 case series of 100 competitive athletes with rectus-abdominis/adductor-longus aponeurotic plate injury, the diagnosis was confirmed by history, physical examination and MRI, and surgery was offered only after 6 to 12 weeks of appropriate conservative treatment had failed (Emblom, 2018). That series shows that the lesion is recognized and treatable. Because it was an uncontrolled surgical series from a single surgeon, its return-to-play figures should not be used to argue that surgery is a first-line treatment.
How the adductor origin fits in
Not every proximal adductor problem involves the aponeurosis. The adductor longus origin itself can be the main source of pain. Early MRI case series in competitive and recreational athletes with adductor-related groin pain found that some had MRI-visible enthesopathy at the adductor longus origin and others did not (Schilders, 2007; Schilders, 2009). Those series also tested pubic cleft steroid injections. They describe the anatomy and its imaging appearance, but they do not establish injection as a routine treatment.
The practical question is therefore not simply whether the adductor is injured, but which part of the adductor-rectus-pubic complex is involved and how it behaves under load. The answer shapes both the rehabilitation plan and the decision about imaging.
Management principles
Most aponeurotic and adductor-origin injuries are managed without surgery at first. Treatment generally includes:
- Clear communication about the diagnosis: naming the structure involved helps set realistic expectations for recovery and explains why a generic groin-strain program may not be enough
- Load management: temporarily reducing kicking, sprinting, cutting or abdominal loading that provokes symptoms, without prolonged rest
- Progressive strengthening: adductor loading progressed from isometric to eccentric work, combined with trunk and pelvic control, then running, cutting and sport-specific loading. Active strengthening has the strongest randomized evidence for long-standing adductor-related groin pain (Hölmich, 1999).
- Adjuncts where appropriate: manual treatment for clinically relevant soft-tissue restriction, and shockwave for selected chronic presentations once the pain source has been localized. The evidence is reviewed in shockwave therapy for adductor tendinopathy and groin pain.
- Referral: for a significant aponeurotic or tendon disruption, a suspected hernia, significant hip pathology, a suspected stress fracture or symptoms that do not respond to appropriate conservative care
How Novo approaches suspected aponeurotic injury
We examine the adductor origin, the rectus abdominis insertion, the pubic symphysis, the inguinal region and the hip, and test how each responds to load. When the pattern suggests an aponeurotic or pubic injury rather than isolated adductor tendinopathy, MRI is usually the next step. See how we approach adductor tendinopathy and groin pain.
References
- Madani H, Robinson P. Top-ten tips for imaging groin injury in athletes. Seminars in Musculoskeletal Radiology. 2019;23(4):361-375. PMID 31509865. (link)
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine. 2015;49(12):768-774. PMID 26031643. (link)
- Taylor R, Vuckovic Z, Mosler A, et al. Multidisciplinary assessment of 100 athletes with groin pain using the Doha agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clinical Journal of Sport Medicine. 2018;28(4):364-369. PMID 28654441. (link)
- Coker DJ, Zoga AC. The role of magnetic resonance imaging in athletic pubalgia and core muscle injury. Topics in Magnetic Resonance Imaging. 2015;24(4):183-191. PMID 26244616. (link)
- Hynes JP, O'Flaherty M, Glynn D, Eustace S, Kavanagh EC. Imaging of groin pain in athletes: patterns of injury at MRI and gender differences therein. Irish Journal of Medical Science. 2023;192(3):1411-1418. PMID 35971036. (link)
- Todeschini K, Daruge P, Bordalo-Rodrigues M, Pedrinelli A, Busetto AM. Imaging assessment of the pubis in soccer players. Revista Brasileira de Ortopedia. 2019;54(2):118-127. PMID 31363256. (link)
- Emblom BA, Mathis T, Aune K. Athletic pubalgia secondary to rectus abdominis-adductor longus aponeurotic plate injury: diagnosis, management, and operative treatment of 100 competitive athletes. Orthopaedic Journal of Sports Medicine. 2018;6(9):2325967118798333. PMID 30263900. (link)
- Schilders E, Bismil Q, Robinson P, O'Connor PJ, Gibbon WW, Talbot JC. Adductor-related groin pain in competitive athletes: role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. Journal of Bone and Joint Surgery (American). 2007;89(10):2173-2178. PMID 17908893. (link)
- Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A, Gibbon WW, Bismil Q. Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. Journal of Bone and Joint Surgery (American). 2009;91(10):2455-2460. PMID 19797582. (link)
- Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. The Lancet. 1999;353(9151):439-443. PMID 9989713. (link)
