Michael is experiencing mild pain in his right groin region. He is 28 years old and has a desk job that keeps him sedentary for most of his day. He played hockey in college and started playing again about a year ago. The pain in his groin started about four to six weeks ago, and he associates it with his hockey playing. He has continued to play through the pain, trying to be conscious of stretching and other preventive measures, but the pain persists.
A week ago, he went downhill skiing and had a bad fall. He felt immediate pain in his hip and groin, but was able to continue skiing for the rest of the day. His hip and groin pain has continued to be a problem for the last week and is painful with certain movements, as well as when he gets up after sitting for long periods. He also notes that it seems like the pain in the area has grown or now includes something else he can’t quite identify.
The first place to start in any evaluation is to gather as much detail as possible about the mechanics of the injury. Michael experienced a mild level of pain prior to the ski accident. However, the accident exacerbated the injury and pain. Determining the biomechanical forces his body was subjected to at the time of the accident helps identify the specific tissues most likely involved.
Michael described the injury in which his body was moving downhill, not at a great speed due to the terrain, and his right ski became caught by a branch. His leg was forcefully pulled into extension and abduction. Because his body was moving forward while his leg was pulled back and away from him, there would be a high eccentric load on the hip adductors and hip flexors.
Groin pain is very common in hockey players and is often associated with injury/dysfunction in one of the adductor muscles. Michael’s history indicates further injury to this region from the accident.

Physical Exam/Evaluation
Michael says his primary pain is in the upper medial thigh region. He can press on this region and reproduce the pain, so a local tissue dysfunction is most likely.
A brief review of the key structures in this region reveals that most of the adductor muscles have attachment sites in the upper medial thigh region. Image 1 shows the location of the deepest group of adductor muscles. The adductor longus is the muscle most commonly strained, especially in many sporting activities like hockey, and this strain is usually referred to as a groin pull.
Each of the adductor muscles also has a musculotendinous junction in the area. Michael indicated pain here. The musculotendinous junction is the most common location for strain and musculotendinous injury.
During range-of-motion testing, Michael reported pain with active adduction but no pain with passive adduction. There was also groin pain with resisted adduction. This pattern of pain would indicate a primary pathology in one of the contractile tissues (muscle or tendon) that produces adduction, so a proximal adductor injury is the most likely cause of his problem.
Reflecting on his initial history, Michael reported a mild aching sensation in this area prior to the ski accident, so it is quite possible he had a moderate muscle/tendon dysfunction or minor strain prior to the fall. Prior existing injury in the muscle/tendon unit is the most common characteristic leading to muscle strain.
Because the proximal tendons of the adductor group are so close together, it can be difficult to isolate the specific muscle injured. There may also be more than one muscle involved. Consequently, treatment should address all the muscles in the medial thigh region.
Palpating superficial tissues in the upper medial thigh reproduces Michael’s pain, and the pain pattern is reproduced with range-of-motion testing. This scenario validates the likelihood of upper adductor muscle pathology. However, he also reports pain that feels related to, but deeper than, the adductor pathology. Additional examination is needed to explore the cause of this secondary pain.
During physical evaluation, Michael reported the secondary pain as feeling closer to his hip than the groin area, but also deeper as well. He was unable to press on anything that reproduced this pain, so a superficial tissue is likely not the cause. The pain is reproduced with active hip flexion from a standing position. Passive hip flexion did not cause discomfort, but resisted hip flexion did. Again, this is the same pattern present with the adductor muscles (pain with active and resisted movement in the same direction, but not with passive movement in that direction) and would indicate pathology in a contractile tissue (muscle or tendon).
The most likely culprit in this secondary pain is the distal tendon of the iliopsoas muscle, which is the strongest hip flexor. Image 2 shows the location of the distal iliopsoas tendon. Recalling Michael’s initial history, he mentioned that his leg was pulled back (extension) and away (abduction) when the branch caught his leg. The forceful abduction put a high eccentric load on the adductors and the forceful extension put a high eccentric load on the hip flexors, both likely leading to musculotendinous injury.

Treatment Strategy
It appeared that the primary issues for Michael involved muscle/tendon pathology (likely a strain injury) to one or more of the proximal adductor muscles, and also to the distal iliopsoas muscle. Treatment would therefore focus primarily on these areas, although other areas such as the anterior and posterior thigh region, gluteal region, and low back should also be addressed because of their close biomechanical relationships. Treating these other regions helps maintain biomechanical balance and proper muscle pattern coordination.
The first treatment goal in any soft-tissue injury is to normalize the soft-tissue dysfunction. In a muscle strain, this means reducing tightness in the injured muscle and working on the injury site to help encourage the development of a functional scar. Michael’s ski accident was over a week old when he came in for treatment, so it was not in the acute phase. He still had significant movement capability and the pain during range-of-motion testing was at a level indicating the strain was not severe. Consequently, massage therapy would be safe and appropriate.
The entire adductor muscle group of the medial thigh should be treated, because there is frequently hypertonicity in a muscle group as a result of strain injury. Reducing tightness throughout the muscle group also helps restore proper biomechanical balance and encourages faster healing of the injury.
Broad cross-fiber and deep stripping techniques are applied to the long adductors (gracilis and adductor magnus) from the knee to their attachment on the pelvis. The same approach should be used with the short adductors (adductor longus, pectineus, and adductor brevis) from the medial thigh region to their pelvic attachments. Stripping techniques can begin with a broad contact surface such as the palm or back side of a fist. The broad contact surface spreads the pressure and prepares the tissues for deeper and more specific treatment.
After initial treatment of the adductor group with a broad-contact stripping technique, more specific work can be applied to the adductors with a small-contact surface stripping method (Image 3). This technique can be applied with the thumb, fingertip, or a pressure tool. Keep in mind the adductors are frequently tight and don’t get worked very often. As a result, they can be quite tender when deep stripping techniques are applied. Maintain clear communication with your client about the appropriate pressure level.
Once the muscles are treated with long stripping techniques to help encourage relaxation and elasticity, deep friction massage can be applied to the primary site of tissue injury (Image 4). The purpose of deep friction is to reduce excess fibrous adhesions at the injury site and encourage the development of a functional scar.
In Michael’s case, there is also apparent injury to the distal iliopsoas tendon. Consequently, a similar strategy used on the adductor muscle group could be employed for the iliopsoas muscle. Treatment should begin with reducing tightness in the iliopsoas muscle belly. In fact, that will become our primary strategy of treatment, because the distal musculotendinous junction is difficult to access because of its depth in the hip region and the great number of superficial tissues lying over it.
There are potential contraindications to the most common treatment method for the iliopsoas muscle, which is to access it in the abdominal region by pressing through the abdominal organs. Applying pressure to the iliopsoas in the abdomen means you are pinning organs, such as the small intestine, between your fingers and the muscle. These tissues are usually resilient, but they are not designed to have that type of pressure applied to them.
A more serious concern is the proximity of the iliopsoas to the external iliac artery, which branches directly from the aorta (Image 5). Applying pressure in this region could put pressure on the external iliac artery and decrease blood flow through that artery. Pressure on this artery could cause a serious adverse event. It is not a common occurrence, but if it happened, it could be a serious injury.
An alternative for reducing tightness in the iliopsoas muscle is to perform a facilitated stretching technique (also called proprioceptive neuromuscular facilitation or PNF, muscle energy technique, or active isolated stretching) such as that shown in Image 6. The client drops the leg off the side or end of the table so there is a full range of motion for the hip. The client attempts to flex the hip against resistance, and the resistance is held for about four to five seconds. The client is instructed to relax the contraction while the practitioner pushes the hip further into extension, stretching the hip flexors. This technique is surprisingly effective without the adverse effects of pressure on the abdominal structures.

Conclusion
Michael’s case illustrates a common situation with many clients in which there is an underlying soft-tissue dysfunction present for some time but it doesn’t seem bad enough to warrant treatment. However, once additional stressors are added, a more serious injury results. Another key issue to remember from our work with Michael is that in many cases the tissue injury may include more than one area, so the evaluation needs to be comprehensive enough to account for all the existing symptoms as much as possible.

Draping for Groin Work
One of the more challenging issues in treating the upper medial thigh region is appropriate draping. The client’s physical and emotional privacy must be maintained. It is absolutely essential this work be performed with the ultimate level of professionalism in order to maintain a sense of comfort and safety for the client.
A good draping option when working the upper adductor attachments on the pelvis is to have the client hold
the drape in position with his or her own hand. Have the client place a hand over the drape between the genital region and thigh. This way the client’s hand is always between the genital region and the therapist’s hand and will prevent unintended contact.
It is also helpful to maintain periodic eye contact and a dialogue with the client about what is being treated and exactly how the treatment is being performed. Maintaining eye contact and watching facial expressions may help you determine if the client is apprehensive or uncomfortable with the treatment, but isn’t saying so.

Whitney Lowe’s texts and programs have benefited massage professionals and schools for more than 25 years. Learn about Lowe’s innovative and engaging online courses and products at www.academyofclinicalmassage.com.