As we eluded to in our previous post, appropriate rehabilitation of the adductor group is imperative for successful outcomes which include: significantly decreasing the risk for subsequent injuries, restoring appropriate synergistic balance between the hip abductors and adductors, improving control of lower limb positioning during dynamic tasks, and addressing any flexibility deficits in multiple degrees of hip flexion and extension.
With these things in mind our rehab guidelines should include the following:
1. Improving proximal stability, core strength/endurance, and pelvic positioning during dynamic activities.
2. Isolated strengthening and stretching of the adductors.
3. A hip adductor to abductor strength ratio close to 1. Even more so in our frontal plane dominant athletes.
4. Training the adductors in eccentric fashion due to injury mechanisms discussed in part 2.
5. Training the adductors in multiple planes of motion.Their relevance in sagittal and rotational plane movement might be understated.
6. Training at mid range and end range of adductor muscles lengths.
In 2010, Tyler et al. published rehabilitation goals based on tissue healing times, passive range of motion, and adductor/abductor strength ratios. These can be used for the clinician looking for more concrete phasing of their rehab program and are listed as such:
Acute phase - Pain free concentric adduction against gravity.
Sub acute phase - Lower extremity passive range of motion equal to that of the uninvolved side and involved adductor strength at least 75% that of the ipsilateral abductors.
Return to play/discharge criteria - Adduction strength at least 90-100% of the abduction strength and involved muscle strength equal to that of the contralateral side.
Exercise Selection and Progressions
**The thing to remember is that the principles of anatomy, kinesiology, physiology, and specificity make up the construct of the rehab program; it's the why, when, and how of the exercises that really matter, not the exercises themselves. There is no right or wrong exercise as long as your application is appropriate. With that being said, these are some of the exercises we like to use.
Bent Knee Fall Outs - for lumbopelvic control, isometric contraction of adductors on stable leg, and eccentric/concentric contraction of adductors on leg that is moving.
Supine Marches - for core endurance during hip flexion. EMG studies show the pectineus may be more active as a hip flexor/adductor around 90 degrees of hip flexion.
Narrow Bridge: decreased hip abduction/external rotation limits the passive tension placed on the adductors.
Adductor isometrics at varying hip widths and degrees of hip flexion: See part 1 for more information on the EMG studies performed in varying degrees of hip flexion.
Hip internal rotation with adduction: A good exercise if there is range of motion deficits into hip flexion or internal rotation.
Supine bent knee adductor stretch: making sure pelvic position isn't lost is important with this stretch
Dynamic adductor stretch in quadruped: hip width can vary to tolerance of stretch.
Sub Acute Phase:
Side-lying hip adduction against gravity: As noted in the Tyler et al study, pain free hip abduction against gravity is a good indicator for progress to the "sub-acute" phase.
Tall kneeling hip hinge: with increasing hip widths to influence the demands of the adductors as hip extensors.
Single leg balance: For progression to more dynamic based activities and re-education of appropriate limb control during single leg exercises.
Standing cable hip adduction: pelvic position and eccentric control are important.
Wide Stance Squats: Remember, squat width influences the demands of the adductors/abductors - quads and hammies, not so much.
Lunge matrix: Both limbs for adductor strength and length during dynamic activities.
Worlds greatest stretch: dynamic stretching of adductors
Dynamic stretching of hip adductors in flexion and extension
Return to Sport/Discharge
Understanding the functional anatomy, injury mechanisms, and the protective benefits of the adductors on the hip and knee joint should not be undervalued in the rehabilitation and performance settings. Appropriate exercise selections and progressions are based on a multitude of factors and no one exercise is inherently better than another. Programs that include a heavy eccentric component, address core deficits, and promote mobility of the adductors should be considered when discussing the adductors.