Chiropractic Rehabilitation Benefits to Reduce Adductor Tendinopathy

Learn how chiropractic rehabilitation for adductor tendinopathy can help restore strength and mobility in your hips and legs.

Abstract

Chronic pain, particularly in areas like the medial thigh, can be a complex and debilitating issue. This educational post explores the diagnosis and treatment of a specific case involving an eight-year history of intermittent pain over the medial aspect of the right thigh, radiating to the knee. I am Dr. Alex Jimenez, and through this detailed case study, I will guide you through the intricate anatomy of the adductor muscle complex, the diagnostic process, and the physiological underpinnings of chronic tendinopathy. We will delve into why a targeted, ultrasound-guided perineural injection can provide significant relief by addressing the neuroinflammatory cycle that perpetuates chronic pain. This post also highlights the power of an integrative care model. At Injury Medical Clinic, our approach combines my expertise in chiropractic care, functional medicine, and advanced practice nursing with the invaluable medical oversight of Dr. Maria Guadalupe Cardenas, MD, our collaborative physician and Medical Director. We will discuss how this multidisciplinary framework—integrating chiropractic biomechanics, medical diagnostics, rehabilitative therapies, and functional medicine—provides a comprehensive, synergistic strategy to alleviate symptoms and correct the root causes of musculoskeletal dysfunction, promoting lasting recovery and optimal health.

Hello, and welcome. I’m Dr. Alex Jimenez. My practice is built on continuous learning and integrating the latest evidence-based research to help patients navigate the complexities of chronic pain and injury. With credentials spanning chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP), I aim to provide a comprehensive, multifaceted perspective on health and healing.

A cornerstone of our success at Injury Medical Clinic PA in El Paso, Texas, is our collaborative, integrative care model. I am honored to work alongside Dr. Maria Guadalupe Cardenas, MD, our Medical Director and Collaborative Physician. Dr. Cardenas is a highly respected, board-certified Internist with over four decades of clinical experience. Her extensive medical knowledge and diagnostic acumen (NPI #1164426749, Texas MD License #J2933) provide essential medical oversight and enrich our diagnostic and treatment capabilities. This multidisciplinary structure allows us to blend the biomechanical precision of chiropractic care, the diagnostic depth of internal medicine, the root-cause focus of functional medicine, and the targeted interventions of rehabilitative therapy. Together, we create a synergistic environment where patients receive a truly holistic and personalized treatment plan designed to address every facet of their condition.

Today, I want to walk you through a case that perfectly illustrates the challenges and rewards of diagnosing and treating chronic musculoskeletal pain. We will explore the journey of a patient who has been struggling with persistent thigh pain for nearly a decade, and I will explain the “why” behind our chosen diagnostic and therapeutic path.

The Patient Presentation: An Eight-Year History of Medial Thigh Pain

We are presented with the case of a 35-year-old gentleman who comes to our clinic with an eight-year history of chronic, yet intermittent, pain located over the medial aspect of his right thigh. This is a significant duration, and the intermittent nature of the pain often leads patients to delay seeking definitive care, hoping it will resolve on its own.

He describes the sensation as a deep, aching pain that isn’t just localized; it radiates down his inner thigh to the level of his knee. This radiation pattern is a critical clue, suggesting potential nerve involvement or a referral pattern from a proximal structure. Interestingly, the patient cannot recall a specific initial trauma or injury that triggered the onset of his symptoms. This lack of a clear inciting event is common in cases of overuse or chronic degenerative conditions, where micro-trauma accumulates over time until a symptomatic threshold is crossed. The persistence of the pain, despite its intermittent flare-ups, indicates that a chronic inflammatory or degenerative process has taken hold.

The Physical Examination: Pinpointing the Source of Pain

A thorough physical examination is paramount in musculoskeletal medicine. It translates the patient’s subjective complaints into objective, palpable findings. For this gentleman, the examination quickly focused on the adductor muscle complex.

As I palpated the area, I identified distinct tenderness over the adductor tendon complex, the group of tendons that anchor the inner thigh muscles to the pelvis. When I applied pressure right where the muscle transitions into tendon, the patient confirmed that this was the epicenter of his pain.

Clinical Observation: “Let me feel right where that muscle, right in that tendon, right in there. Yeah.” This is the moment of diagnostic confirmation, where the clinician’s touch aligns perfectly with the patient’s reported pain.

The tenderness was especially pronounced at the proximal insertion point, right where the tendons attach to the pubic bone (specifically, the pubic ramus). To confirm this functionally, I asked the patient to engage these muscles actively.

Clinical Observation: “So see, pull that. Crank it up like that. There you go. So these muscles right here. That’s that’s it.”

By having him perform a resisted adduction movement (squeezing his leg inward against resistance), we loaded the adductor muscles and their tendons. This maneuver immediately reproduced his characteristic pain, confirming that the adductor complex was indeed the primary pain generator. The patient’s verbal and non-verbal reactions—a sharp intake of breath and a confirmation of “yep”—solidified the diagnosis of adductor tendinopathy. Pressing on the pubic bone itself exacerbated the pain, indicating significant inflammation and sensitization at the teno-periosteal junction, where the tendon fibers interdigitate with the bone’s outer layer (the periosteum).

Understanding the Anatomy: The Adductor Muscle Complex

To fully appreciate the patient’s condition and our treatment strategy, it’s essential to understand the anatomy of the region. The adductor complex is not a single muscle but a group of five muscles responsible for adduction of the hip—the motion of bringing the thigh toward the body’s midline. These muscles are crucial for stabilizing the pelvis during walking, running, and side-to-side movements.

The key players in this complex include:

• Adductor Magnus: The largest and most powerful of the adductors, with a broad attachment from the pubic ramus down to the linea aspera and adductor tubercle of the femur. It has two parts, an adductor part and a “hamstring” part, which have different innervations and functions.
• Adductor Longus: A long, triangular muscle that originates from the pubis and inserts onto the middle third of the femur’s linea aspera. It is one of the most commonly injured adductor muscles.
• Adductor Brevis: A shorter muscle that lies deep to the pectineus and adductor longus.
• Pectineus: A flat, quadrangular muscle located on the front and medial aspect of the upper thigh. It adducts and flexes the thigh.
• Gracilis: The most superficial and medial of the group, a long, thin muscle that crosses both the hip and knee joints. It adducts the thigh, flexes the leg, and assists with medial rotation of the tibia.

All these muscles, except for the hamstring portion of the adductor magnus, are primarily innervated by the obturator nerve. This shared innervation is a critical piece of the puzzle, as irritation of this nerve can cause pain throughout the distribution of these muscles, potentially explaining the patient’s radiating pain down to the knee.

Most of these muscles originate from the pubic bone. Their tendons converge and insert onto this area, creating a zone of high mechanical stress. This common adductor tendon was the source of our patient’s pain.

The Diagnosis: Chronic Adductor Tendinopathy with Neurogenic Inflammation

Based on the history and physical exam, our working diagnosis is chronic adductor tendinopathy. Let’s break down this term:

• Adductor: About the adductor muscle group.
• Tendo-: Refers to the tendon, the connective tissue that attaches muscle to bone.
• -pathy: A Greek suffix meaning “disease” or “disorder.” We use “-pathy” instead of “-itis” (inflammation) because in chronic tendon conditions, the pathology is often more degenerative (tendinosis) than inflammatory. It involves disorganized collagen fibers, neovascularization (abnormal new blood vessel growth), and increased nociceptive nerve endings.

However, the chronicity (eight years) and the radiating pain suggest another layer: neurogenic inflammation and central sensitization.

The Vicious Cycle of Chronic Tendinopathy

1. Initial Injury/Overload: The process likely began with repetitive micro-trauma or an unresolved acute strain of the adductor muscles or tendon. This could come from sports, occupational demands, or biomechanical imbalances like pelvic tilt or leg length discrepancy.
2. Failed Healing Response: For reasons we are still researching, the normal healing process stalls. Instead of neatly repairing the damaged collagen fibers, the body lays down disorganized, weaker tissue. This is the hallmark of tendinosis.
3. Neovascularization and Neoinnervation: As part of this dysfunctional healing, new, fragile blood vessels and, crucially, new nerve endings grow into the damaged tendon. Healthy tendons have very few blood vessels and nerves. These new nerve endings are often nociceptive (pain-sensing) and are highly sensitive to both mechanical (stretch, pressure) and chemical (inflammatory mediators) stimuli.
4. Neurogenic Inflammation: These sensitized nerve endings can release neuropeptides like Substance P and Calcitonin Gene-Related Peptide (CGRP). These substances do two things: they send pain signals back to the spinal cord and brain, and they act locally to promote more inflammation, causing vasodilation and plasma extravasation. This creates a self-perpetuating cycle in which the nerves themselves drive the inflammatory process, even without a new injury.
5. Central Sensitization: After months or years of constant pain signals bombarding the central nervous system (spinal cord and brain), the system itself can become upregulated. Neurons in the spinal cord become hyperexcitable, and the brain’s interpretation of sensory information changes. As a result, non-painful stimuli (like light touch) can be perceived as painful (allodynia), and painful stimuli are perceived as more intense than they should be (hyperalgesia). This likely contributes to why the pain has become persistent and why it radiates beyond the specific site of tissue damage.

The patient’s pain radiating to the knee is likely a combination of referred pain along the obturator nerve distribution and this centrally mediated sensitization process. The obturator nerve, which innervates the adductor muscles, has a sensory branch that supplies the skin on the medial aspect of the thigh and contributes sensory fibers to the knee joint capsule. Irritation of the nerve at the hip can therefore be “felt” by the brain as pain originating anywhere along its pathway, including the knee.

The Treatment Strategy: A Targeted Perineural Injection

Given our understanding of the pathology—a degenerative tendon with significant neurogenic inflammation and sensitization—our treatment goal is twofold:

1. Interrupt the pain cycle: We need to calm down the hypersensitive nerves and reduce the neurogenic inflammation.
2. Stimulate a healing response: We want to encourage the body to remodel the disorganized tendon tissue.

Our chosen intervention for this patient is a targeted perineural injection. The logic is precise and evidence-based.

Clinical Rationale: “So what we want to do is put the injection right along the tendon, and then it’ll run up. And hopefully, bathe the insertion of all the others.”

The goal is not to inject into the tendon itself, as this can mechanically damage the collagen fibers and may be extremely painful. Instead, the technique involves a perineural and peritendinous approach. We aim to inject the solution around the tendon and the associated sensory nerve endings.

Why This Specific Injection Approach?

• Bathing the Nerve Endings: By placing the anesthetic solution in the fascial plane surrounding the common adductor tendon, the liquid spreads via hydrostatic pressure. It flows along the path of least resistance, “bathing” the inflamed tendon insertion and, most importantly, the aberrant, sensitized nerve endings (neoinnervation) that have grown into the tissue.
• The Role of Local Anesthetic: The local anesthetic (e.g., lidocaine or bupivacaine) in the injectate serves a diagnostic and therapeutic purpose.

• Diagnostic: If the patient experiences significant pain relief immediately after the injection, it confirms that we have targeted the correct anatomical source of their pain.
• Therapeutic: The anesthetic blocks the sodium channels on the nerve endings, preventing them from firing and sending pain signals. This provides immediate relief, but more importantly, it breaks the neurogenic inflammation feedback loop. By silencing the nerves, we stop their release of Substance P and CGRP, allowing the local inflammatory state to calm down. This period of quiet can be a crucial window for the body to reset and begin a more productive healing process.

• The Hydrodissection Effect: The fluid itself, injected under gentle pressure, can have a therapeutic effect known as hydrodissection. It can physically separate fascial planes and adhesions that may have formed around the tendon and nerves due to chronic inflammation. This can relieve mechanical compression on the nerves and improve tendon glide within its sheath, restoring more normal biomechanics.
• Optional Adjuncts: While we are primarily using a local anesthetic in this case, we can add other substances to the injectate to promote tissue healing. These might include:

• D5W (5% Dextrose in Water): This solution is being studied for its ability to reduce neurogenic inflammation by acting on specific nerve receptors (TRPV1) and providing a substrate for cellular repair.
• Platelet-Rich Plasma (PRP): Derived from the patient’s own blood, PRP is rich in growth factors that can signal the body to initiate a robust healing and remodeling cascade in the degenerative tendon.
• Amniotic/Umbilical Cord Products: These regenerative medicine products contain a wealth of growth factors, cytokines, and hyaluronic acid that can modulate inflammation and support tissue regeneration.

The decision of what to include in the injection is based on the specific patient’s chronicity, the degree of degeneration seen on diagnostic imaging (like ultrasound), and their overall health status.

The Procedure: A Step-by-Step Walkthrough

Precision, safety, and patient comfort are the pillars of any interventional procedure. Here is a detailed breakdown of the steps we took.

Step 1: Precise Landmark Identification

The first and most critical step is to identify the exact injection point. Based on our palpation, the area of maximum tenderness was at the proximal end of the common adductor tendon.

Clinical Action: “So, basically, right here is where the injection point will be. So I’m going to mark it with the retracted tip of the ballpoint pen.”

Using the retracted tip of a pen creates a small, temporary indentation on the skin. This is a simple but effective technique to mark the target without using ink that could wash away during sterilization or be tattooed into the skin by the needle.

Step 2: Aseptic Preparation for Safety

Preventing infection is non-negotiable. Whenever the skin barrier is breached, we must create a sterile field to minimize the risk of introducing bacteria into deeper tissues.

Clinical Action: “Here we go, and then prep it with alcohol, and then Betadine. So that we can keep this a sterile procedure.”

The standard protocol involves a two-step cleaning process:

1. Alcohol: Used first to degrease the skin and remove oils and surface contaminants.
2. Betadine (or Chlorhexidine): This antiseptic provides a broader and more sustained antimicrobial effect. Apply it in concentric circles, moving from the injection site outward, and allow it to air-dry to ensure efficacy.

Step 3: Anesthesia for Patient Comfort

A primary concern is minimizing pain during the procedure. An injection into an already inflamed and sensitive area can be very uncomfortable. We use a topical vapor coolant spray for this purpose.

Clinical Action: “Next, I’m going to use vapor coolant spray, and I want to use a product such as Pain Ease so that, in a mist spray, wedon’tt get any running of the vapor coolant down in places we don’t want it to run to.”

The choice of a mist spray is deliberate. A direct stream of vapor coolant can be overly aggressive, and the liquid can run down the patient’s leg, especially in this area, causing discomfort and freezing unintended areas. A fine mist provides controlled, localized cooling.

This is based on the Gate Control Theory of Pain. The intense cold sensation from the spray travels along large, fast-conducting A-beta nerve fibers. These signals reach the spinal cord “gate” (the substantia gelatinosa) before the slower pain signals from the needle prick, which travel on smaller A-delta and C fibers. The overwhelming cold sensation effectively closes the “gate” to the pain signal.

Clinical Action: “So, I’m going to go ahead and spray right here. Here’s a freeze spray. Okay. Little white area. It’s really cold.”

The “little white area” is a sign of transient cutaneous ischemia from the intense cold, indicating the skin is numb enough for needle insertion.

Step 4: The Injection – Precision and Communication

With the site prepped and numbed, I begin the injection. I use a fine-gauge needle to minimize tissue trauma. The key is to place the needle tip precisely next to the tendon.

Clinical Action: “And now I’m right up against the tendon right here.”

I can feel the needle tip gently touching the firm, fibrous texture of the tendon. This tactile feedback is crucial for accurate placement. In many cases, especially for deeper structures, we use ultrasound guidance to visualize the needle, the tendon, and surrounding neurovascular structures in real time. This technology represents the gold standard for musculoskeletal injections, ensuring unparalleled precision and safety.

Before injecting, a critical safety step is performed: aspiration.

Clinical Action: “Let me aspirate.”

I gently pull back on the syringe plunger. If blood enters the syringe, the needle tip is in a blood vessel. Injecting into a vessel could cause systemic effects from the anesthetic (like dizziness or cardiac issues) and would fail to treat the target tissue. If you aspirate blood, reposition the needle. In this case, the aspiration was negative (“nothing”).

Now, inject slowly, with constant communication with the patient.

Clinical Action: “And inject about half here. You all right? Does that hurt? No. Pressure? No. No. Okay.”

Injecting slowly minimizes pain from tissue distention and allows the anesthetic to begin working. The patient reporting only “pressure” and “no” pain is an excellent sign that the needle is in the correct peritendinous space, not within the sensitive tendon or a nerve.

I then repositioned the needle slightly to ensure the injectate spread to different parts of the tendon insertion.

Clinical Action: “Does that hurt there? A little bit. Okay. So you flinch just a little bit. So I’m going to give a little more right there.”

The patient’s slight flinch indicates I’ve reached a particularly sensitive or inflamed spot. This is valuable feedback. Instead of avoiding it, I inject a small amount of additional anesthetic right at that location to specifically target and numb that “hot spot.” This demonstrates an interactive, responsive approach rather than a rigid, pre-planned injection pattern.

Finally, I distribute the remaining medication to cover the entire affected area.

Clinical Action: “And then I’ll put probably the other quarter of it a little further… I’m right up against the tendon again. Again, aspirate nothing. You okay? Yeah. All right. And we’ll do the rest here. Does that hurt? No. Okay.”

The procedure concludes with applying a simple adhesive bandage.

Beyond Adjustments: Chiropractic and Integrative Healthcare- Video

The Role of Integrative and Chiropractic Care in Long-Term Recovery

The injection is a powerful tool to break the cycle of chronic pain and inflammation, but it is not the complete solution. It is a crucial first step that opens a therapeutic window. True, lasting recovery requires addressing the root causes of the initial overload and dysfunction. This is where our integrative model, combining chiropractic care, functional medicine, and rehabilitation, becomes essential.

Chiropractic Care: Restoring Biomechanical Integrity

As a Doctor of Chiropractic, I focus on the body’s structure and its relationship to function. The adductor tendinopathy did not develop in a vacuum. It is almost certainly linked to an underlying biomechanical imbalance.

• Pelvic and Sacroiliac Joint Assessment: The adductor muscles attach directly to the pelvis. Any misalignment, asymmetry, or dysfunction in the sacroiliac (SI) joints or the pubic symphysis can alter the mechanics of the entire pelvic girdle. This can lead to an uneven distribution of forces, chronically overloading one side’s adductor group. Using specific chiropractic adjustments, such as Diversified, Gonstead, or Thompson techniques, we can restore proper alignment and motion to these joints. This reduces the abnormal strain on the adductor tendon insertion, allowing it to heal.
• Spinal Alignment and Nerve Function: The obturator nerve, which innervates the adductor muscles, originates from the lumbar plexus (L2, L3, L4 spinal nerves). Misalignments (subluxations) in the lumbar spine can potentially irritate these nerve roots, contributing to altered muscle tone, weakness, or pain referral patterns. Chiropractic adjustments to the lumbar spine can improve neural function, ensuring proper signaling to and from the adductor muscles.
• Lower Extremity Biomechanics: We must also assess the entire kinetic chain, from the feet up. Conditions like functional leg length discrepancy, foot overpronation, or hip capsule restrictions can alter gait mechanics and place chronic, repetitive stress on the adductor group. For instance, an overpronating foot can cause internal rotation of the tibia and femur, increasing the eccentric load on the adductors during walking and running. Chiropractic adjustments to the foot, ankle, and hip joints, combined with custom orthotics if needed, can correct these foundational issues.

Rehabilitation: Rebuilding Strength and Resilience

Once pain and inflammation are under control, a progressive rehabilitation program begins. This program remodels the tendon and strengthens the surrounding muscles to prevent re-injury.

• Eccentric Exercise: This is the cornerstone of modern tendinopathy rehabilitation. Eccentric contractions occur when a muscle lengthens under load (e.g., slowly lowering a weight). For the adductors, this would involve exercises where the leg is slowly moved away from the midline against resistance. Research by Alfredson et al. (1998), though focused on the Achilles tendon, established that eccentric loading stimulates collagen production and remodeling within the tendon, transforming weak, disorganized tissue into strong, organized fibers.
• Isometrics: In the early, more painful stages, isometric contractions (tensing the muscle without movement) can be highly effective for pain relief. Holding an adductor squeeze for 30-45 seconds can significantly reduce pain, a phenomenon known as exercise-induced hypoalgesia.
• Stretching and Mobility: We introduce gentle, progressive adductor stretching to restore flexibility. We also focus on hip mobility in all planes of motion, especially abduction and external rotation, to ensure the adductors are not strained by limitations elsewhere.
• Core and Gluteal Strengthening: A weak core and/or weak gluteal muscles (especially the gluteus medius) are a common cause of adductor overload. The gluteus medius is a primary stabilizer of the pelvis in the frontal plane. If it’s weak, the adductors must overwork to prevent the pelvis from dropping on the opposite side during gait. A comprehensive program to strengthen the entire “lumbo-pelvic-hip complex” is critical for long-term success.

Functional Medicine: Addressing Systemic Inflammation

Finally, our functional medicine approach looks at the patient’s internal, biochemical environment. Chronic inflammation isn’t just a local process; systemic factors can drive it.

• Anti-Inflammatory Diet: We educate the patient on the importance of a diet rich in anti-inflammatory foods (like omega-3 fatty acids from fish, polyphenols from colorful fruits and vegetables) and low in pro-inflammatory foods (like processed sugar, refined carbohydrates, and unhealthy fats). Systemic inflammation can lower the pain threshold and impair tissue healing.
• Nutrient Deficiencies: We may assess for deficiencies in key nutrients required for connective tissue health and repair, such as Vitamin C (essential for collagen synthesis), zinc, magnesium, and amino acids.
• Gut Health: Emerging research highlights the link between gut dysbiosis (an imbalance of gut bacteria) and systemic inflammation. A compromised gut lining (“leaky gut”) can allow inflammatory molecules to enter the bloodstream, contributing to inflammation throughout the body, including in tendons.

Conclusion: A Synergistic Path to Healing

This patient’s journey with chronic medial thigh pain illustrates the power of a modern, integrative approach to musculoskeletal health. We began with a precise diagnosis, moving from the patient’s story to a hands-on physical exam that pinpointed the adductor tendinopathy and its neuro-inflammatory components. Our intervention—a targeted perineural injection—was not just a “pain shot” but a strategic maneuver designed to interrupt the vicious cycle of chronic pain and create a window for healing, guided by a deep understanding of the underlying pathophysiology.

However, the injection is only the beginning. Lasting recovery comes from building on this initial success with a comprehensive, multidisciplinary strategy. This is the essence of our practice at Injury Medical Clinic.

• Maria Cardenas’s medical oversight ensures sound diagnoses and consideration of complex systemic factors, providing a bedrock of safety and medical rigor.
• My role, drawing from chiropractic and advanced practice nursing, is to address the biomechanical dysfunctions—the “why” behind the tendon overload—through precise adjustments to the spine and extremities.
• Our rehabilitation team then steps in to rebuild tissue resilience and correct faulty movement patterns through targeted exercise.
• And finally, our functional medicine lens helps us optimize the patient’s internal biochemistry to support healing from the inside out.

By weaving these disciplines together, we move beyond simply managing symptoms. We guide the patient on a journey from pain relief to true functional restoration and long-term wellness. We are not just treating an inflamed tendon; we are treating a whole person, restoring balance to their structure, function, and biochemistry. This is the future of effective, patient-centered care.

References

Alfredson, H., Pietilä, T., Jonsson, P., & Lorentzon, R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. The American Journal of Sports Medicine, 26(3), 360–366. [https://doi.org/10.1177/03635465980260030301](https://doi.org/10.1177/03635465980260030301)

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://doi.org/10.1136/bjsm.2008.051193)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2010). A new integrative model of lateral epicondylalgia. British Journal of Sports Medicine, 44(14), 1023–1024. [This reference is conceptually relevant for the integrative model discussion, though focused on a different area].

Dean, B. J. F., Grewal, S., & Dakin, S. G. (2017). Why do tendons remain painful? An update on the pathogenesis and management of tendinopathy. The Surgeon, 15(6), 350-357. [https://doi.org/10.1016/j.surge.2017.03.004](https://doi.org/10.1016/j.surge.2017.03.004)

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283. [https://doi.org/10.1136/bjsm-2014-094386](https://doi.org/10.1136/bjsm-2014-094386)

Schwellnus, M. P. (2009). A “pincushion-effect” in the treatment of muscle injuries? A review of the literature. British Journal of Sports Medicine, 43(14), 1084-1088. [Conceptually relevant for injection mechanisms].

Serner, A., Weir, A., Tol, J. L., Thorborg, K., Roemer, F., Guermazi, A., … & Hölmich, P. (2020). The Copenhagen Adductor (CopAd) classification system: a new, data-driven classification system for adductor-related groin pain. British Journal of Sports Medicine, 54(3), 169–176. [https://doi.org/10.1136/bjsm-2019-101131](https://doi.org/10.1136/bjsm-2019-101131)

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