Understand the role of chiropractic rehabilitation in treating adductor tendinopathy and promoting healing.

Abstract

As a clinician with dual qualifications in chiropractic (DC) and advanced practice nursing (APRN, FNP-BC), complemented by extensive certifications in functional and integrative medicine, I have dedicated my career to unraveling the complexities of musculoskeletal pain. In this post, I will guide you through a common yet often mismanaged condition: chronic medial thigh pain, focusing specifically on adductor tendinopathy. We will explore a case study of a 35-year-old male with an eight-year history of this ailment, detailing the diagnostic process, the underlying anatomy and physiology of the adductor muscle complex, and the clinical reasoning behind our targeted treatment strategies. This post will delve into the science of regenerative injections, explaining how they work at a cellular level to promote tissue healing. I’ll also explain the unique, collaborative framework of our practice, Injury Medical Clinic PA, in El Paso, Texas. Here, I work alongside our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD, an experienced internist. This multidisciplinary model lets us seamlessly integrate chiropractic care, advanced medical procedures, functional medicine, and rehabilitation to provide a comprehensive, evidence-based pathway to recovery for our patients. We will showcase how this integrated approach, which combines my expertise in biomechanics and musculoskeletal health with Dr. Cardenas’s medical oversight, offers a powerful solution for complex chronic pain conditions.

Introduction: A Journey into Chronic Medial Thigh Pain

I’m Dr. Alex Jimenez. With a career rooted in both chiropractic and advanced practice nursing, and holding certifications in functional, integrative, and anti-aging medicine, I have always been driven by a single purpose: to find the most effective, evidence-based solutions for my patients’ pain and dysfunction. At our practice, Injury Medical Clinic PA, we amplify this mission through our unique collaborative model. I am honored to work with Dr. Maria Guadalupe Cardenas, MD, a highly respected, board-certified internist with over 40 years of experience. As our Medical Director and Collaborative Physician, Dr. Cardenas provides essential medical oversight, allowing us to create a truly integrative environment where chiropractic science, medical expertise, functional medicine, and rehabilitation converge.

This synergy is particularly vital when we encounter patients with chronic conditions that have resisted conventional treatments. Today, I want to take you on a deep dive into one such case—a condition that can be profoundly disruptive to a person’s quality of life: chronic medial thigh pain, often stemming from what is known as adductor tendinopathy. This isn’t just a simple muscle strain; it’s a persistent, nagging ailment that can affect walking, sports, and even sitting comfortably.

Through a recent patient case, we will explore this condition in detail. We’ll examine the intricate anatomy of the inner thigh, explore why tendons in this area become painful, and walk through a modern, minimally invasive treatment protocol designed to target the root cause. My goal is to demystify this condition and show how a comprehensive, integrative approach—one that respects the body’s biomechanics and leverages its innate healing capabilities—offers a clear, effective path to lasting relief.

Case Presentation: An Eight-Year Battle with Inner Thigh Pain

Recently, a 35-year-old gentleman came to our clinic with a history that is, unfortunately, all too common. For eight years, he had been living with chronic, intermittent pain located on the medial (inner) aspect of his right thigh. He described it not as sharp or acute, but as a deep, persistent ache that often radiated down his inner thigh, sometimes reaching his knee. This classic presentation immediately brought several potential diagnoses to mind, but the location and character of the pain strongly pointed toward the adductor muscle group.

One of the most telling details of his history was the absence of a specific, memorable traumatic event. He couldn’t recall a single incident—a fall, a sports injury, or a sudden overstretch—that initiated the pain. Instead, it had developed insidiously and become a persistent part of his life. This is a crucial clue. Acute injuries are often straightforward, but chronic pain without a clear starting point suggests a process of gradual wear and tear, or cumulative microtrauma, leading to a degenerative condition rather than a simple tear. This is where “tendinopathy” is more accurate than “tendinitis.” “Itis” implies inflammation, which is characteristic of acute injuries. “Opathy” signifies a pathology or disease of the tendon, which in chronic cases is more about disorganized, weakened, and degenerated tissue than active inflammation.

The Physical Examination: Pinpointing the Source

A thorough physical examination is the cornerstone of an accurate diagnosis. In his case, the goal was to locate the source of his pain precisely. My clinical examination focused on palpation—methodically applying pressure to identify tender structures.

• Palpation of the Adductor Complex: As I carefully felt along the muscles of his inner thigh, it became immediately clear where the problem was. He had distinct tenderness over the adductor muscle complex. Specifically, the pain was most pronounced at the proximal adductor tendon, the thick, cord-like structure where these muscles converge before attaching to the pubic bone.
• Provocative Maneuvers: To confirm that this was the problematic structure, I used a simple provocative test. I asked him to actively engage these muscles by adducting his leg (pulling it inward) against my resistance. I then passively stretched the muscles by adducting his leg (moving it inward and downward). Both maneuvers replicated his familiar aching pain, confirming that the adductor mechanism was the pain generator.
• Locating the Epicenter: The tenderness was exquisitely localized. As he described, “Let me feel right where that muscle, right in that tendon, right in there. Yeah.” The pain was most intense at the point where the tendon attaches to the bone, an area known as the enthesis. When I applied gentle pressure directly on the pubic bone at this insertion point, the pain intensified significantly. This finding strongly suggests adductor insertional tendinopathy, where the primary pathology lies at the tendon-bone junction.

So, my physical examination confirmed that the pain originated from the common tendon of the adductor muscles at its insertion onto the pubic symphysis. This pinpoint accuracy is critical because it dictates the precise target for our treatment. We weren’t dealing with a generalized muscle ache; we were dealing with a very specific point of structural failure.

Anatomy and Physiology of the Adductor Muscle Complex: The “Groin” Muscles

To truly understand this patient’s condition and the rationale behind our treatment, we need to explore the anatomy and function of the adductor muscle group. These muscles are often collectively, and somewhat imprecisely, referred to as the “groin” muscles. They make up most of the medial compartment of the thigh and play a crucial role in stabilizing the pelvis and moving the leg.

The Key Players: A Group of Five Muscles

The adductor complex includes five primary muscles, each with slightly different origins, insertions, and functions, but all contributing to adduction—pulling the thigh inward toward the midline of the body.

• Pectineus: A short, flat muscle located at the top of the inner thigh. It originates from the superior ramus of the pubis and inserts onto the pectineal line of the femur. It primarily adducts and flexes the thigh.
• Adductor Brevis: As its name implies (“brevis” meaning short), this is a relatively short muscle. It lies deep to the pectineus and adductor longus. It originates from the body and inferior ramus of the pubis and inserts onto the linea aspera of the femur.
• Adductor Longus: This is a long, fan-shaped muscle and one of the most commonly injured adductors. It originates from the front of the pubic bone and inserts along the middle third of the linea aspera. It is a powerful thigh adductor.
• Adductor Magnus: This is the largest and most powerful muscle of the group. It’s a massive, triangular muscle with two distinct parts: an adductor part and a hamstring part. The adductor part originates from the inferior ramus of the pubis and inserts along the linea aspera. In contrast, the hamstring part originates from the ischial tuberosity (the “sit bone”) and inserts onto the adductor tubercle of the femur. This dual nature means it can both adduct the thigh and help extend it.
• Gracilis: This is the most superficial muscle of the group, a long, thin, strap-like muscle that runs down the entire length of the medial thigh. It originates from the pubic symphysis and inserts on the medial surface of the tibia, just below the knee, as part of the pes anserinus. Because it crosses both the hip and knee joints, it can adduct the thigh, flex the leg, and help medially rotate the tibia.

All of these muscles (except the hamstring portion of the adductor magnus) are primarily innervated by the obturator nerve, which explains why pain from adductor tendinopathy can sometimes feel like it refers down the inner thigh, following the nerve’s distribution.

The Common Adductor Tendon and the Enthesis: The Point of Failure

The pectineus, adductor brevis, and adductor longus converge at the top of the thigh, blending into a common tendon that inserts onto the pubic bone. The gracilis has its own distinct origin nearby. This common insertion point bears immense mechanical stress. Every time we walk, run, pivot, or kick, tremendous tensile forces are transmitted through this tendon to the pubic bone.

The enthesis, as mentioned earlier, is the specialized transitional tissue where the tendon inserts into the bone. This isn’t a simple “gluing” of one tissue to another. It’s a highly sophisticated, graduated structure that transitions from fibrous tendon to unmineralized fibrocartilage, then to mineralized fibrocartilage, and finally to bone. This gradual change in stiffness helps to dissipate stress and prevent force from concentrating at a single point.

However, with chronic overuse, this elegant system can break down. Repetitive strain leads to micro-tears within the tendon fibers. In a healthy individual with adequate recovery time, the body repairs these micro-tears. But when the rate of damage exceeds the rate of repair, failed healing ensues. This is the essence of tendinopathy.

The Pathophysiology of Tendinopathy: From Inflammation to Degeneration

In the past, chronic tendon pain was thought to be due to chronic inflammation (“tendinitis”). However, modern research, using tissue biopsies from patients with chronic tendinopathy, has painted a very different picture. Instead of inflammatory cells, researchers found a disorganized, degenerative state characterized by:

• Collagen Disorganization: Healthy tendons are composed of tightly packed, parallel bundles of Type I collagen fibers, giving them incredible tensile strength. In tendinopathy, these fibers become haphazard, thinned, and separated. There is also an increase in the weaker Type III collagen.
• Angiofibroblastic Hyperplasia: The body attempts to heal the area, but it does so in a dysfunctional way. New, abnormal blood vessels proliferate (neo-angiogenesis), and activated fibroblasts (the cells that produce collagen) increase. However, these new vessels are often leaky and accompanied by a disorganized web of nerve endings (neo-innervation), which is thought to contribute significantly to the chronic pain of tendinopathy.
• Increased Ground Substance: The matrix between the collagen fibers becomes swollen with water-binding molecules called glycosaminoglycans, leading to a thickened, boggy, and structurally weak tendon.

This degenerative process explains why the patient’s pain has persisted for eight years. His tendon is not inflamed; it is sick. It has lost its normal architecture and its ability to withstand mechanical loads. Simple rest and anti-inflammatory medications (like NSAIDs) often fail because they don’t address the underlying structural problem. Our treatment goal must be to reverse this degenerative state and stimulate a true, regenerative healing response.

Our Integrative Treatment Strategy: Regenerative Injection Therapy

Given the diagnosis of chronic adductor insertional tendinopathy, the treatment plan needed to be precise and targeted directly at the site of tissue degeneration. My clinical judgment, supported by extensive evidence-based research, pointed toward a regenerative injection procedure. The objective was not to mask the pain with a corticosteroid (which can actually weaken tendon tissue over time), but to stimulate a natural healing cascade right where it’s needed most.

The patient’s own words confirmed our target: “And when I press on the pubic bone up in there, it makes it even worse.” This tells us the enthesis is the hot spot. Therefore, the plan was clear: “put the injection right along the tendon, and then it’ll run up. And hopefully, bathe the insertion of all the others.” This strategy ensures that the healing solution is delivered not just to one spot on the tendon, but permeates the entire insertional area where the different muscle tendons converge.

Procedural Preparation: A Commitment to Safety and Comfort

Any invasive procedure, no matter how minor, requires meticulous preparation to ensure patient safety, comfort, and sterility. This is a non-negotiable standard of care in our clinic, overseen by the rigorous medical protocols established with Dr. Cardenas.

1. Marking the Injection Site: The first step is precision. Based on my palpatory findings, I identified the exact point of maximal tenderness along the proximal adductor tendon. To ensure I didn’t lose this spot, I marked it using a simple but effective technique: pressing the retracted tip of a ballpoint pen into the skin. This leaves a small, temporary indentation that is perfectly visible and sterile. As I noted, “I’m going to just mark it with the retracted tip of the ballpoint pen.”
2. Aseptic Technique: Preventing infection is paramount. The skin is a natural barrier, but it’s also home to bacteria. A needle puncture can introduce these bacteria into deeper tissues. To mitigate this risk, we employ a standard, multi-step sterile preparation.

• Alcohol Prep: First, we thoroughly cleanse the area with an alcohol swab. Alcohol is an effective disinfectant that degreases the skin and kills a broad spectrum of surface bacteria.
• Betadine Application: Following the alcohol, we apply Betadine (povidone-iodine). Betadine is a more powerful, broad-spectrum antiseptic with a longer-lasting effect. We apply it in an expanding circular motion, starting from the center and moving outward, to avoid re-contaminating the injection site. This two-step process—“prep it with alcohol, and then betadine”—is a cornerstone of sterile procedure. “So that we can keep this a sterile procedure.”

• Minimizing Procedural Pain: The Role of Vapo-Coolant Spray: Patient comfort is essential for a successful procedure. A relaxed patient is easier to treat, and the experience is far less daunting. While the injection itself involves a fine needle, the initial skin puncture can be uncomfortable. To eliminate this, I use a vapo-coolant spray.

• How It Works: These sprays, such as Pain Ease, contain a volatile liquid (like ethyl chloride) that evaporates almost instantly upon contact with the skin. This rapid evaporation draws heat away from the skin so quickly that it creates an intense, temporary cooling effect, effectively numbing the superficial nerve endings.
• Technique: The key is to use a product that delivers a mist spray rather than a stream. A stream can cause the liquid to run, potentially freezing unintended areas, especially in a sensitive location like the groin. As I explained, “I want to use a product such as Pain Ease so that, in a mist spray, we don’t get any running of the vapor coolant down in places we don’t want it to run to.” I sprayed the marked area until a “little white area” appeared, indicating the skin was sufficiently chilled and anesthetized for the needle insertion. “Here’s a freeze spray. Okay. Little white area. It’s really cold.”

The Injection Technique: Precision and Patient Feedback

With the site prepped and numbed, the injection itself can proceed. In this case, the injection was a combination of local anesthetic (like lidocaine or bupivacaine) and a regenerative substance (such as a dextrose solution for prolotherapprolotherapyet-Rich Plasm[[PRPRPlasma ePRP]thetic provides immediate pain relief and serves a diagnostic purpose: if the pain disappears, it confirms we’ve targeted the correct structure. The regenerative substance is the long-term player, designed to stimulate healing

My technique involves several key steps:

1. Placement and Aspiration: The needle is inserted at the marked spot, and I use my tactile senses to guide it right up against the tendon. I can feel the change in tissue resistance as the needle tip touches the dense, fibrous tendon. “And now I’m right up against the tendon right here.” Before injecting any solution, I perform a critical safety check: aspiration. I pull back on the syringe plunger to create negative pressure. If blood enters the syringe, it means the needle tip is inside a blood vessel. Injecting into a vessel can cause systemic side effects from the anesthetic and renders the treatment ineffective. By aspirating and seeing no blood return (“Let me aspirate.”), I can proceed with confidence.
2. Staged Injection and Patient Communication: I don’t inject the entire volume in one spot. I deliver it in stages, repositioning the needle slightly to “pepper” the solution throughout the affected area. This ensures a wider distribution of the regenerative formula. Throughout this process, continuous communication with the patient is vital.

• After the first deposit, I checked in: “You all right? Does that hurt? No. Pressure? No. Okay.” The lack of pain confirmed the vapo-coolant’s effectiveness and the gentleness of the technique.
• As I moved the needle to a new spot, I continued the dialogue: “Does that hurt there? A little bit.” He flinched slightly, which is valuable feedback. That flinch tells me I’ve hit a particularly sensitive or pathologic spot. My response was to “give a little more right there,” delivering the healing solution precisely where the body is signaling the most distress.
• I continued this process, placing the solution a little further along the tendon, always aspirating first (“Again, aspirate nothing.”), and checking in with the patient (“You okay? Yeah.”). This interactive approach not only improves patient comfort but also improves treatment precision.

After delivering the full dose, the procedure is complete. The final step is to apply a simple adhesive bandage to protect the injection site. “So, let me go ahead and put a bandage on that.”

Beyond Adjustments: Chiropractic and Integrative Healthcare- Video

The Role of Chiropractic Care and Integrated Rehabilitation

The regenerative injection is a powerful catalyst for healing, but it is not a standalone cure. It initiates a biological process, but to ensure the new tissue matures into a strong, functional, and resilient tendon, a comprehensive rehabilitation program is essential. This is where integrating chiropractic care and physical rehabilitation becomes critical to long-term success. Our philosophy at Injury Medical Clinic PA is that we must not only repair the damaged tissue but also correct the underlying biomechanical faults that led to the injury in the first place.

Chiropractic Care: Restoring Pelvic and Spinal Biomechanics

As a Doctor of Chiropractic, my primary focus is on the structure and function of the musculoskeletal system, particularly the spine and pelvis. The adductor muscles do not work in isolation; they are a key component of the lumbo-pelvic-hip complex. Their function is intimately linked to the alignment and stability of the pelvis and lumbar spine.

• Pelvic Misalignment and Sacroiliac Dysfunction: Patients with chronic adductor tendinopathy often have underlying biomechanical imbalances. For example, a subtle pelvic misalignment (e.g., an anteriorly rotated ilium on one side) can alter leg length and change the mechanical forces acting on the hip adductors. This can chronically overload one side, predisposing the adductor tendon to injury. Similarly, dysfunction in the sacroiliac (SI) joints can create a cascade of muscular imbalances throughout the pelvis, forcing the adductors to work harder to provide stability.
• Chiropractic Adjustments: Through specific, targeted chiropractic adjustments, I can restore normal joint motion and alignment in the pelvis and lumbar spine. A sacroiliac joint adjustment, for instance, can help level the pelvic girdle, normalizing the tension on the adductor muscles. Adjusting a restricted lumbar vertebra can improve nerve flow from the obturator nerve, which innervates the adductors, potentially improving muscle function and reducing referred pain patterns.
• Addressing the Kinetic Chain: The body functions as a kinetic chain, where movement (or lack thereof) in one joint affects joints above and below it. A problem like foot overpronation (flat feet) can cause the knee to collapse inward (valgus stress), which increases strain on the adductor muscles as they try to control this motion. As part of my chiropractic assessment, I evaluate the entire lower kinetic chain—from the feet and ankles up to the hips and spine—to identify and correct any contributing factors. This might involve recommending custom orthotics or specific foot-strengthening exercises.

By addressing these foundational biomechanical issues, chiropractic care helps offload the healing adductor tendon, creating an optimal environment for regeneration and, most importantly, preventing recurrence.

Integrated Rehabilitation: Rebuilding a Stronger Tendon

Following the injection, the body initiates an inflammatory and proliferative healing phase. This is the time to protect the area and allow the initial healing to occur. However, after a short period of relative rest, a carefully structured rehabilitation program must begin. Our team of rehabilitation specialists supervises this, working in concert with my chiropractic plan and under the medical direction of Dr. Cardenas.

The principle guiding tendon rehabilitation is mechanotransduction: the process by which cells convert mechanical stimuli (i.e., exercise) into a biochemical response. Controlled loading signals tendon cells (tenocytes) to produce strong, organized Type I collagen.

Our rehabilitation protocol is typically phased:

1. Phase 1: Isometric Loading (Days 3-7 post-injection): Isometrics involve contracting the muscle without moving the joint. For the adductors, this could be as simple as squeezing a small ball or pillow between the knees. Research shows that isometric contractions have a significant analgesic (pain-relieving) effect and can begin mechanotransduction without stressing healing tissue. This is a gentle “wake-up call” for the tendon.
2. Phase 2: Isotonic Loading (Weeks 2-6): Once pain-free with isometrics, we introduce isotonic exercises, which involve movement through a range of motion. Start with light resistance, such as resistance bands for adduction movements. The goal is to gradually increase the load, stimulating collagen synthesis and fiber alignment. Examples include standing or side-lying hip adduction.
3. Phase 3: Eccentric and Heavy Slow Resistance Training (Weeks 6-12): This is the crucial phase for remodeling the tendon into a robust structure.

• Eccentric exercises involve lengthening the muscle under load (e.g., slowly controlling the leg as it moves outward against gravity or a band). Eccentric loading is particularly effective for promoting tendon remodeling and strength.
• Heavy Slow Resistance (HSR) training is a newer, evidence-based protocol that involves performing exercises (like a Copenhagen plank or a weighted adduction machine) with a heavy load but at a very slow, controlled tempo. This maximizes the time under tension, providing a powerful stimulus for tendon hypertrophy and increased stiffness.

• Phase 4: Sport-Specific and Plyometric Training (Week 12+): The final phase involves reintroducing movements that are specific to the patient’s functional goals, whether that’s returning to running, soccer, or simply being able to play with their children without pain. This includes plyometric exercises (jumping, cutting, pivoting) to retrain the tendon’s ability to store and release energy, preparing it for the dynamic demands of daily life and sport.

Throughout this process, our team continuously monitors the patient’s progress and adjusts the program based on their pain and functional capacity. This combination of stimulating healing with an injection and then guiding that healing with a progressive loading program is the most reliable way to achieve a full and lasting recovery from chronic tendinopathy.

The Power of an Integrated, Multidisciplinary Practice

This case beautifully illustrates the philosophy that drives our practice. Treating complex chronic pain is rarely a one-size-fits-all endeavor. It requires a multifaceted approach that draws on expertise from different disciplines. At Injury Medical Clinic PA, our structure is intentionally designed to facilitate this.

• Medical Oversight and Advanced Procedures: As a Family Nurse Practitioner, I am qualified to perform procedures like the regenerative injection described. However,I   do so under the collaborative agreement and medical direction of Aria Guadalupe Cardenas, MD. Her extensive experience as an internist provides essential medical oversight, ensuring all treatments meet the highest standards of safety and care. She is integral to our team, reviewing complex cases and providing medical consultation that enriches our diagnostic and therapeutic capabilities. This MD/DC/APRN collaboration allows us to offer services that a standalone chiropractic or medical clinic might not.
• Chiropractic and Biomechanical Expertise: My background as a chiropractor provides the crucial framework for understanding and correcting the underlying biomechanical faults. I look at the patient not just as a painful tendon, but as a whole, integrated system. By addressing spinal and pelvic alignment, we can correct the root causes of mechanical overload.
• Functional Medicine Perspective: My functional medicine certifications (CFMP, IFMCP) add another dimension. We also consider the systemic factors that can impair healing. Does the patient have nutritional deficiencies (e.g., Vitamin C, zinc) that are essential for collagen synthesis? Is systemic inflammation driven by diet or gut health issues hindering recovery? A functional medicine approach allows us to optimize the patient’s internal “soil,” making the body more receptive to healing.
• Comprehensive Rehabilitation: Our dedicated rehabilitation team delivers the physical therapy protocols essential for long-term success. They work hand in hand with me to ensure the exercise program aligns with the patient’s stage of healing and biomechanical needs.

This integrated model means patients receive seamless, coordinated care under one roof. The chiropractor, nurse practitioner, medical doctor, and rehab specialist are all on the same team, communicating about the patient’s progress and working toward the same goal. It breaks down the silos that so often exist in healthcare, providing a patient-centered journey from diagnosis to full recovery. For conditions like chronic adductor tendinopathy, this comprehensive, team-based approach is not just beneficial—it is essential.

Conclusion: A New Paradigm for Chronic Pain

The journey of the 35-year-old gentleman with an eight-year history of thigh pain powerfully illustrates the principles of modern, integrative musculoskeletal care. His story demonstrates that chronic pain, even pain that has persisted for nearly a decade, is not something one has to “live with.” By combining a precise diagnosis based on a thorough understanding of anatomy and pathology, a targeted regenerative treatment to stimulate the body’s own healing mechanisms, and a comprehensive rehabilitation program rooted in chiropractic and biomechanical principles, we can offer real, lasting solutions.

His case highlights that effective treatment goes beyond just addressing the site of pain. It requires us to look at the patient as a whole—correcting underlying structural imbalances, optimizing their biology for healing, and empowering them with the tools to rebuild a stronger, more resilient body. This is the future of pain management, and it is the standard of care we are proud to provide every day at Injury Medical Clinic PA, thanks to the powerful synergy of our multidisciplinary team led by Dr. Maria Cardenas and me.

References

The information in this educational post is based on established medical and scientific principles, as well as the latest evidence-based research in musculoskeletal medicine, sports medicine, and regenerative orthopedics.

1. Brukner, P., & Khan, K. (2017). Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1 (5th ed.). McGraw-Hill Education.

• This foundational sports medicine text provides comprehensive details on the diagnosis, pathophysiology, and management of tendon injuries, including adductor tendinopathy. It supports the shift from the “tendinitis” model to the “tendinopathy” model, emphasizing degeneration over inflammation.

• [Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409–416. https://doi.org/10.1136/bjsm.2008.051193](https://bjsm.bmj.com/content/43/6/409)

• This seminal paper introduces the “continuum model” of tendinopathy, which describes the progression from a reactive tendinopathy to tendon disrepair and finally to degenerative tendinopathy. This model is crucial for understanding why chronic cases like the one presented do not respond to anti-inflammatory treatments and require a regenerative approach.

• [Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopedic & Sports Physical Therapy, 45(11), 887–898. https://doi.org/10.2519/jospt.2015.5987](https://www.jospt.org/doi/10.2519/jospt.2015.5987)

• Although focused on the patellar tendon, this article provides an excellent overview of modern tendon rehabilitation principles, including the evidence for isometric exercises for pain relief and the efficacy of heavy slow resistance training for promoting tendon remodeling. These principles are directly applicable to adductor tendinopathy.

• [Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K. M., Lovell, G., Meyers, W. C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A. G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., … Hölmich, P. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 49(12), 768–774. https://doi.org/10.1136/bjsm-2015-094869](https://bjsm.bmj.com/content/49/12/768)

• This consensus statement from leading global experts provides a standardized terminology for groin pain, defining adductor-related groin pain as a specific clinical entity. It reinforces the diagnostic approach used in the case study, focusing on palpation and provocative testing.

 

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