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Tuesday, June 6, 2023

Adductors: Release and Lengthening

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

Adductor Flexibility:

Lumbo Pelvic Hip Complex Dysfunction (LPHCD) , Sacroiliac Joint Dysfunction (LSD) and Lower Leg Dysfunction (LED)

by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

For a complete review of origin, insertion, innervation, action, integrated function, arthrokinematics, motor behavior, subsystem involvement, and trigger points, please check out the Functional Anatomy & Human Movement Science of the:

For an introduction to release techniques, joint mobilizations and lengthening techniques, including a list of commonly over-active muscles, the intent of mobility techniques, progression, acute variables, order of mobility techniques and a PDF of the Integrated Warm-up Template and Integrated Rehab Templates, check out:

Signs of over-activity and adaptive Shortening:

Carefully assess dysfunction in every individual before suggesting corrective techniques.

Optimizing Motion (Best Practice):

Maintaining optimal length and activity of the adductors is likely dependent on not only optimal soft tissue extensibility, but optimal arthrokinematic motion and activity of functional antagonists.

Research Corner:

Several texts have noted the propensity of the adductors to become over-active and short, reducing hip mobility (1-5). Further, many of these texts recommend techniques similar to those described in this article. Recently, more research has been done to investigate the relative activity of the adductors as it relates to movement impairment, specifically knee valgus. In two separate studies functional knee valgus (knees bow in), was found to be an indicator of relative over-activity of the adductor muscles when compared to the activity of the abductors (gluteus medius ) (6, 7), and in a study by Bell et al., an exercise intervention including release and lengthening of the adductors was effective in reducing functional knee valgus (8).

Although, there have not been studies on self-administered release that specifically addressed the adductor muscles, research has shown that self-administered release is effective for increasing range of motion, without reducing force output (9, 10). Further, self-administered release followed by stretching has shown to be more effective for increasing ROM than either technique alone, and the combination of both technique may be more effective for the treatment of injuries (11-13).

Techniques and Progressions:

  • Anterior Adductor Release
  • Posterior Adductor Release
    • No practical self-administered dynamic release techniques for these muscles have been developed
  • Anterior Adductor Static --> Active --> Dynamic Stretching
  • Posterior Adductor Static --> Dynamic Stretching
    • No practical self administered active stretch for the posterior adductors have been developed
  • Anterior and Posterior Adductor Manual Stretch
  • Thomas Test Stretch for short Anterior Adductors (Pectineus and Brevis)

Self-administered Static Release for the Anterior Adductors:

  1. Instruct your patient/client to assume a prone position.
  2. Ask them to abduct and flex their hip to about 90°, or as far as they can (knee flexed).
  3. Place a foam roll, softball, or trigger point tool under the inner thigh of the flexed/abducted hip.
  4. This is important! Ensure that they are trying to maintain a "flat" pelvis, maintaining both anterior superior iliac spine (ASIS) as close to the ground as possible.
  5. Have your patient/client slide side-to-side, using the release tool to scan the entire adductor complex for tender points (groin to knee).
  6. Once, the most tender point is located (generally about 4 inches from the the knee, or in proximity to the groin) have your patient hold still on that spot and relax.
  7. Wait for the discomfort to subside or for a "release" (generally 30 - 120 seconds).
  8. Move on to another tender point or the next muscle to be released.
    • Common mistakes:
      • Rolling on one's side rather than maintaining a "flat" pelvis while searching for a tender point
      • Not finding the right release tool for the individual (i.e. softball versus foam roll)
    • Caution:
      • If it pulses, get off it. This technique can result in compression of the femoral artery. Arteries are not very wide. If a pulse is felt, moving a 1/2 inch will usually move the foam roll of the artery.

Self-administered Static Release for the Posterior Fibers of Adductor Magnus:

  1. This muscle is easiest to release sitting on a bench, table or platform, with the legs "hanging".
  2. Have your client or patient place a softball or similar release tool under the "mass" of their inner thigh.
  3. Have your patient/client slide back and forth, using the release tool to scan the entire adductor complex for tender points (gluteal fold to knee).
  4. Once, the most tender point is located (generally in the center of the mass of the adductors) have your patient hold still on that spot and relax.
  5. Wait for the discomfort to subside or for a "release" (generally 30 - 120 seconds).
  6. Move on to another tender point or the next muscle to be released.
    • Quick Tip:
      • Your adductor magnus is a hip extensor: Your patient or client can reduce or increase tension in the muscle by leaning back or bending forward over the knees (hip flexion and extension). This may aid in providing the optimal amount of tension for release.

Anterior Adductor Static Stretch:

  1. Have your patient/client assume a standing position with feet about double the width of their shoulders.
  2. Ask them to move the foot of the leg you wish to stretch back a few inches, so that the toes of that leg are now inline with the heel of the other.
  3. Have them posteriorly tilt their pelvis (this alone is often enough to impart a good stretch).
  4. If necessary, have the patient/client place the web space of the hand on the greater trochanter of the side you wish to stretch.
  5. Have them imagine they are pressing that hip toward the opposite foot. As they do this, they can descend into a miniature lateral lunge to a point of mild discomfort (make sure that the patient does not lose their posterior tilt during this step).
  6. Wait for the discomfort to subside or for a "release" (generally 30 - 120 seconds).
  7. Move deeper into the stretch or move on to the next muscle to be stretched.
    • Common Mistakes:
      • The most common mistakes are leaning forward and losing the posterior pelvic tilt, essentially trying to stretch around the anterior adductors by incorporating hip flexion.

Posterior Adductors and Inferior Capsule Static Stretch:

Commando Crawl Stretch

  1. Instruct your patient/client to assume a prone position.
  2. Ask them to abduct and flex their hip about 90°, or as far as they can (knee flexed).
  3. Instruct them to try and attain a "flat" pelvis, with both anterior superior iliac spine (ASIS) as close to the ground as possible.
  4. Wait for the discomfort to subside or for a "release" (generally 30 - 120 seconds)
  5. Move deeper into the stretch or move on to the next muscle to be stretched.
    • Common Mistakes:
      • Not flexing the hip enough before trying to attain a "flat" pelvis

"Captain Morgan Stretch"

  1. Instruct your patient/client to place the foot of the leg to be stretched on the highest bench, plyo-box, table or platform they can step on to, while maintaining the other foot flat on the ground and pointing straight ahead.
  2. Pay careful attention to posture. Ensure that the patient/client is not turning the feet out, adopting an anterior pelvic tilt, leaning forward, leaning to either side, or rounding the shoulders to maintain position.
  3. Have your patient/client horizontally abduct the leg on the box (stretching leg); they may use their hand or arm to assist.
  4. If the patient/client feels it is necessary, hip flexion (leaning forward at the hips) may be added to this stretch to further lengthen the posterior fibers of adductor magnus.
  5. Wait for the discomfort to subside or for a "release" (generally 30 - 120 seconds)
  6. Move deeper into the stretch or move on to the next muscle to be stretched.
    • Common Mistakes:
      • Using a platform that is either too low or too high. Be prepared to adjust to the size and flexibility of the patient/client you are working with.

Anterior Adductor Active Stretch:

Note: As with many of our active stretching techniques, the position used is identical to the position used for static stretching. The only difference is activation of the functional antagonist.

  1. Have your patient/client assume a standing position with feet about double the width of their shoulders.
  2. Ask them to move the foot of the leg you wish to stretch back a few inches, so that the toes of that leg are now inline with the heel of the other.
  3. Have them posteriorly tilt their pelvis (this alone is often enough to impart a good stretch).
  4. If necessary, have the patient/client place the web space of the hand on the greater trochanter of the side you wish to stretch.
  5. Have them imagine they are pressing that hip toward the opposite foot. As they do this, they can descend into a miniature lateral lunge to a point of mild discomfort (make sure that the patient does not lose their posterior tilt during this step).
  6. Once they have "found" their end range, have them relax (move slightly out of the stretched position).
  7. To activate the functional antagonists (glutues maximus and gluteus medius ) you may use a posterior pelvic tilt and/or pushing out and back with the leg to be stretched, i.e. extension and abduction of the hip (like "skating" with a posterior tilt). Note: these movement can be broken down into steps, or you may find success using only one action (for example, a posterior pelvic tilt is enough, or just abduction or just extension.)
  8. Perform 10 - 15 repetitions with a 2 - 4 second hold at the end range of each rep.
  9. Move on to the next muscle to be stretched.
    • Common Mistakes:
      • The most common mistakes are leaning forward and losing the posterior pelvic tilt, essentially trying to stretch around the anterior adductors by incorporating hip flexion.

Anterior Adductor Dynamic Stretch (Side-stepping):

Note: The cuing used for dynamic stretching is similar to those used during the active stretching technique; however the new range and cues are integrated into a functional movement pattern.

  1. Wrap a resista-band or mini band loop just above both knees.
  2. Have your patient/client assume a standing position with feet about double the width of their shoulders.
  3. Ask them to move the foot of the leg you wish to stretch back a few inches, so that the toes of that leg are now inline with the heel of the other.
  4. Have your patient squeeze their glutes, pushing out and back with the leg to be stretched, i.e. extension and abduction of the hip. Note: these movements can be broken down into steps.
  5. Once your patient understands what their end range is, and what the end position should be for each step, have your patient return to a standing position with feet together.
  6. Now, have your patient try to step into that end position, inducing a mild stretching sensation.
  7. You can take consecutive steps for one leg by side-stepping with a slight forward angle (for 10 - 15 steps), or you can combine reps for both legs by making a zig-zag pattern from side-to-side and forward (20 - 30 reps).
  8. Move on to the next muscle to be stretched.
    • Common Mistakes:
      • Not taking big enough steps
      • Reaching with the front leg, rather than pushing with the back leg (the leg you are trying to stretch)

Posterior Adductor Dynamic Stretch (Lateral Lunge):

Note: The lateral lunge is a commonly prescribed exercise in fitness programs; it is also a wonderful posterior adductor magnus stretch when done without additional load, and a reach is added.

  1. Have your patient or client assume a position with feet about twice shoulder width, and 2nd toe pointing straight ahead.
  2. Instruct your client/patient to sit behind one foot, while cuing them to keep the opposite knee in extension (leg straight).
  3. At the bottom position, the leg they sat behind should be aligned in the sagittal plane (ASIS, hip, knee and 2nd toe inline). Adjust their stance width to achieve this position.
  4. Have your patient or client return to the starting position (feet do not move).
  5. Have your patient attempt the same movement pattern on the other side.
  6. Perform 10 - 15 reps on each side
    • Note: The client may experience a stretching sensation on both legs simultaneously. The adductor magnus is both an extensor and adductor, so as one side is pulled into maximal abduction, the other side descends into maximal extension.
    • Progressions
      1. Reach for the toe of the side your patient lunged into with the contralateral hand.
      2. Reach for the heel of the side your patient lunged into with the contralateral hand.
      3. Make the lunge more dynamic by returning to a full standing position (feet together) between each rep.
      4. Add the reach to the more dynamic lunge.
    • Common Mistakes:
      • Too much, too soon: This stretch involves the adductor magnus resisting most of the body's mass… a significant amount of weight for a single muscle. Try to impress on your clients that "deeper" is not necessarily better, and be careful with volume. 1 set of 10 reps on each side is a great place to start. You can always add reps or sets at a later date.

Manual Adductor Stretches:

Anterior Adductors:

  1. With your patient/client laying on a treatment/massage table, assume a position on the side you wish to stretch, perpendicular to their knee.
  2. Abduct your patient/client's leg, and allow the lower leg to hang off the table
  3. Have your patient/client adjust their position on the table so the knee just extends past the table. This may range from your client centered on the table to your client assuming a position closer to the far side of the table.
  4. Use the hand closest to your client to stabilize the pelvis by depressing the contralateral anterior superior iliac spine (ASIS) with the palm of your hand.
  5. Using your other hand or your hip/thigh to push the knee hanging off the table cranially (toward the head) until you reach the first resistance barrier.
  6. Hold this position for 30-120 seconds or until a reduction in tension/release is felt.
  7. Move deeper into the stretch, or move on to the next muscle in your corrective intervention.
    • Common Mistakes:
      • More is not better: A mild sensation of stretch is plenty. Increasing tension to a point of moderate discomfort or pain will only result in muscle guarding, an increased risk of injury, and/or a less effective stretch.

Posterior Adductors

  1. With your patient/client laying on the center of a treatment/massage table, assume a position on the side you wish to stretch, perpendicular to their knee.
  2. Place the bottom of the foot of the leg you wish to stretch on your ASIS or torso, by flexing, abducting and externally rotating the leg.
  3. Use the hand closest to your client to stabilize the pelvis by depressing the contralateral anterior superior iliac spine (ASIS) with the palm of your hand.
  4. Use your other hand to gently block adduction, and or push further into abduction, and lean or step forward to push the clients leg further into flexion until you reach the first resistance barrier.
  5. Hold this position for 30-120 seconds or until a reduction in tension/release is felt.
  6. Move deeper into the stretch, or move on to the next muscle in your corrective intervention.
    • Common Mistakes:
      • More is not better: A mild sensation of stretch is plenty. Increasing tension to a point of moderate discomfort or pain will only result in muscle guarding, an increased risk of injury, and/or a less effective stretch.

Manual Hip Flexor Stretch/Thomas Test Position (Pectineus and Adductor Stretch):

  1. Have your client assume a position at the bottom of the table with their legs completely hanging off, but the sacrum supported by the table.
  2. It is easiest to achieve this position by having your patient stand-up, walk to the bottom end of the table, sit their sacrum on the edge of the table, pull the knee opposite the side you wish to stretch to their chest, and then gently assist them rolling back onto their back.
  3. You will position yourself in front of the flexed leg with the hanging leg against your hip/thigh. You may use your chest to block the flexed leg so that your patient may relax. You can use the flexed leg to control the amount of pelvic tilt and or adjust pelvic alignment in the frontal plane.
  4. Using your palm or web space of the hand closest to the hanging leg; gently press the leg down into extension until you reach the first resistance barrier.
  5. You can then use your hand or hip to gently take up any "slack" into abduction and preferentially stretch the shorter muscles of the anterior adductors.
  6. Hold this position for 30-120 seconds or until a reduction in tension/release is felt.
  7. Move deeper into the stretch, or move on to the next muscle in your corrective intervention.
    • Common Mistakes:
      • More is not better: A mild sensation of stretch is plenty. Increasing tension to a point of moderate discomfort or pain will only result in muscle guarding, an increased risk of injury, and/or a less effective stretch.

Lower Leg Dynamic Stretching Series (Dynamic Anterior Adductor Stretch Included):

The sample circuit includes dynamic stretches for commonly over-active muscles in those exhibiting Lower Leg Dysfunction (LLD) . This includes the dynamic stretch for the anterior adductors discussed above.

Sample Flexibility Program and Progression:

Perform each technique with accuracy (ex. hold until release for static techniques, 10-15 repetitions for active techniques a 2-4 second hold at end range, etc.). Progress the flexibility routine as trigger points are reduced, techniques are mastered, and optimal flexibility is attained (generally over the course of weeks). Progressions may include adding additional release techniques, and/or replacing static techniques with active and/or dynamic techniques.

  1. Anterior Adductor Static Release (No active release technique available)
  2. Hip Mobilization
  3. Anterior Adductor Static Stretch (Progress to Active Stretch )

Bibliography:

  1. Phillip Page, Clare Frank , Robert Lardner , Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  2. Dr. Mike Clark & Scott Lucette, “NASM Essentials of Corrective Exercise Training” © 2011 Lippincott Williams & Wilkins
  3. Leon Chaitow, Muscle Energy Techniques: Third Edition, © Pearson Professional Limited 2007
  4. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
  5. Cynthia C. Norkin, D. Joyce White, Measurement of Joint Motion: A Guide to Goniometry – Third Edition. © 2003 by F.A. Davis Company
  6. Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association, 27(7), 1813-1823.
  7. Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training, 47(5), 525.
  8. Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. Journal of athletic training,48(4), 442-449.
  9. Sullivan, K.M., Silvey, D.B.J., Button, D.C., Behm, D.G. (2013). Roller-massager application to the hamstrings increases sit-and-reach range of motion within five to ten seconds without performance impairments. International Journal of Sports Physical Therapy 8(3) 228-236.
  10. Halperin, I., Aboodarda, S.J., Button, D.C., Andersen, L.L., Behm, D.G. (2014). Roller massager improves range of motion of plantar flexor muscles without subsequent decreases in force parameters. The International Journal of Sports Physical Therapy. 9(1): 92 -102
  11. Mohr, A. R., Long, B. C., & Goad, C. L. (forthcoming 2014). Foam Rolling and Static Stretching on Passive Hip Flexion Range of Motion. Journal of sport rehabilitation. Currently in press.
  12. Skarabot, J., Beardsley, B., Stim, I. (2015). Comparing the effects of self-myofascial release with static stretching on ankle range of motion in adolescent athletes. International Journal of Sports Phyiscal Therapy. 10(2): 203-212
  13. Renan-Ordine, R., Alburquerque-Sedin, F., De Souza, E.P.R., Cleland, J.A., Fernandez-De-La-Penas, C. (2011) Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: A randomized controlled trial. Journal of Orthopaedic & Sports Medicine

© 2016 Brent Brookbush

Questions, comments, and criticisms are welcome and encouraged.

Related Articles:

Guidelines for Self-Administered Release Techniques

Joint Mobilizations: Introduction

Introduction to Mobility Techniques

Refined Static Stretching Protocol

What Can We Learn From Static Stretching Research?

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