A Real Pain in the... Inguinal

Sat, 10 Jan 2026 13:04:28 GMT

Adductor Related Groin Pain

Late 20's female who complained of 4 month history of intermittent groin pain after increasing her training at CrossFit. Main problems were heavy squats, wall balls and running. She had tried resting and some sports massage but the issue persisted. There was no report of back or hip pain or a history of hip pain, no pins and needles or numbness. On examination she had excellent range of motion in the hip and was able to fully squat - this did reveal excessive hip flexion, all pain free. Isometric hold using her adductors reproduced the pain and there was tenderness at the muscle tendon junction of her adductor magnus. Testing also revealed weakness in control of her trunk and pelvis along with weakness in hip extension and abduction. Pain limited her strength in adduction. There was no muscle tightness. She was suffering with adductor related groin pain (ARGP).

A rehab plan was set up to allow continued training, albeit with some activity modifications to avoid exacerbating her pain. A graded loading programme was put in place to target her adductor complex along with lots of education and reassurance on the nature of the problem.

This nice illustration from @derek_griffin_phd that highlights the factors that can contribute to developing a tendinopathy. It will exist on a continuum from acute to chronic. The tendon continuum model describes how your tendons respond to stress across three overlapping stages: Reactive, Dysrepair, and Degenerative.

The Three Stages of Tendon Health

Reactive Tendinopathy: Think of this as a "flare-up." It usually happens after a sudden burst of unaccustomed activity (like a new workout or a sudden increase in running miles). The tendon thickens slightly to protect itself from the load; it’s painful and swollen, but the structure is still intact and can fully return to normal with a short period of rest and modified activity.

Tendon Dysrepair: If the tendon continues to be overloaded without enough rest, it moves into "failed healing." The internal structure becomes more disorganized, and the body may start growing extra blood vessels and nerves in the area to try to fix it, making the tendon more sensitive.

Degenerative Tendinopathy: This is the chronic stage often seen in older athletes or those with long-term injuries. Large portions of the tendon's fibres are now broken down or "silent," meaning they can no longer handle weight effectively. While these damaged areas may not fully heal, the healthy parts around them can still be strengthened. This summed up nicely here https://bjsm.bmj.com/content/50/19/1187 by Cook et al (2016).

The next challenge is knowing how to address it. In essence the aim is to build resilience and capacity within the tendon to tolerate higher loads through range and with greater rates of force development. The challenge is often finding the appropriate starting point and increasing loading variables but taking account of the tendon response to the new stimulus.

We were able to start with low level isometrics in a comfortable mid range progression along with core strengthening and hip extension and abduction work to address some of the imbalances found on testing. Loading duration and intensity was increased along with more challenging positions in the coming months and exposure to previously problematic movements and actions (depth of squat and a graded running programme with a focus on distance and speed).

The graphic shown opposite is a great starting point from @clinicaledge for tendon loading across the spectrum. Frequency of loading is also important with consistency of work and rest days in a ratio 1:1 or 1:2.

The Dropped Shoulder

Mon, 05 Jan 2026 18:34:02 GMT

A bit out of left field

57 yo male patient presented in their words with a ‘dropped shoulder’ on their dominant side with insidious onset and their main issue was difficulty lifting the arm overhead occurring gradually over several months. They did not report an episode of debilitating pain nor could recall any recent viral infection. Generally fit and well with a history of shoulder stabilisation on the same side many years ago and excellent recovery (able to play badminton/lift weights without issue). The patient had no red flags (night pain, recent weight loss, history of cancer, non smoker)

Examination revealed marked wasting to upper fibres of trapezius and levator scapulae with a depressed and protracted shoulder girdle. They had intact sensation and upper limb motor power along with reflexes. Neck range revealed tightness of upper trapezius and levator scapular but when shoulder position was restored it was full with no reproduction of any arm symptoms. Shoulder joint range of movement was restricted due to reduced scapula mobility, when this was restored he had full shoulder pain free range. Rotator cuff testing was intact once the scapula stabilised. There was no upper limb adverse nerve tension and thoracic outlet testing was negative.

After advising the patient of the suspected diagnosis he was referred for investigation under a shoulder specialist with scans completed of his neck, brachial plexus, axilla (armpit) and shoulder. Management was centred around information provision and prognosis, guidance on movements and support for shoulder musculature, mobility and alternative exercise movements to consider.

What is Brachial Neuritis/Parsonage Turner Syndrome

A rare neurological issue affecting the brachial plexus, the network of nerves originating in the neck and controlling the function (movement and sensation) of the arm and hand. Typically the condition involves sudden onset of shoulder pain and arm in the absence of an injury. This can last for several hours to a few weeks. It is thought to be caused by the immune system, often after a viral illness. As the pain resolves it is replaced by weakness in the affected muscles and wasting will be evident (amyotrophy) on examination, you may notice the shoulder has changed ‘shape’. Each person can be affected differently depending on the specific nerves involved and recovery can vary from person to person, most often occurring over months to years.

Pain in the initial or acute phase is continuous, severe and can be worse at night or in the evening. In some instances it can be excruciating and very debilitating. Moving out of this phase the pain often settled but some movements can be problematic/restricted or painful depending to the extend of the associated weakness. Nerves can remain more sensitised for some time and any stretch or compression can cause pain and discomfort.

Weakness then becomes the predominant issue and can range from slight to pronounced depending on the number of nerves affected. This is accompanied by muscle wasting due to lack of nerve signalling and use. Reflexes can be affected along with experiencing altered sensation (numbness/ tingling/pins and needles or hypersensitivity.

Due to the weakness people can be more prone to shoulder and neck pain, due to overload of other muscles, positional changes or stiffness due to lack of use. Some may experience issues with circulation, changes to hair and nail growth or swelling.

Some individuals recover full strength and function with most regaining 70-90% of their strength and function at the 2 year point with 10-20% being left with some residual pain, decreased exercise tolerance and strength of the affected arm. It is suggested that recurrence can range from 5-25%

Treatment from a physio perspective is aimed at ensuring this is not an alternative diagnosis (cervical radiculopathy/ rotator cuff issue, frozen shoulder, guillain-barre, thoracic outlet syndrome). This will involve referral to a specialist and consideration of imaging of the shoulder, neck and brachial plexus. The focus is then on protecting any affected joints, maintaining range of movement and strength as able, advice and guidance on the course of recovery.

More information is available at https://rarediseases.org/rare-diseases/parsonage-turner-syndrome/

https://pmc.ncbi.nlm.nih.gov/articles/PMC2926354/

Clinical cases and evidence based physio

A Real Pain in the... Inguinal

Adductor Related Groin Pain

The Dropped Shoulder

A bit out of left field