SCI Sports Combine Institute
Rehabilitation Protocol // SCI-RP-002

Adductor-Related Athletic Groin Pain: A Criterion-Based Rehabilitation Protocol for the Basketball Athlete

A five-phase, evidence-based framework built on active, adductor-focused loading, the Copenhagen exercise progression, and clinically pain-free criteria to guide the basketball athlete from acute symptom management through unrestricted return to competition.

Protocol Type
Soft Tissue // Adductor
Sport Focus
Basketball // Multi-Plane
Typical Duration
3 wk – 3+ Months
Progression Model
Criterion-Based // 5 Phases
// Phase Progression Map
I
ACUTE
Pain Control & Load Protection
II
EARLY
Strengthening & Lumbopelvic Control
III
PROGRESSIVE
Running & Linear COD
IV
LATE
Multi-Directional Loading
V
RTP
Return to Sport
01
Phase I // Acute Stage

Acute Pain Control & Load Protection

The earliest stage manages symptoms, protects healing tissue, and re-introduces low-level adductor loading without provocation. Passive treatments alone are insufficient — active, adductor-focused rehab is significantly more effective than passive care for returning athletes to symptom-free sport.1,2

// Primary Goals
  • Control pain and calm reactive tissue
  • Restore symptom-free gait
  • Re-introduce adductor isometric loading
  • Maintain general aerobic and upper-body capacity
  • Educate athlete on load management
  • Establish baseline strength asymmetry
Key Interventions
Active
  • Low-load adductor isometrics (squeeze tests at long and short lever)
  • Pain-monitored hip ROM in pain-free range
  • Glute and core activation without frontal-plane stress
  • Soft tissue work to adductors, hip flexors, and adjacent musculature
  • Stationary cycling for aerobic preservation
  • Activity modification education and load tracking
Assessment Focus
Clinical
  • Pain on palpation of adductor longus origin
  • Pain with resisted adduction at multiple angles
  • Pain with passive adductor stretch
  • Squeeze test at 0°, 45°, and 90° hip flexion
  • Baseline handheld dynamometry of adduction and abduction

Document baseline adductor/abductor ratio. A ratio below 0.80 is a known risk factor warranting aggressive correction.4,6

Medical Team Takeaway
Hip adductor strength below 80% of ipsilateral abductor strength has been associated with up to a 17-fold increased risk of future groin injury in athletes.4,6 The adductor/abductor ratio is the central risk metric in this protocol — it must be measured at intake and tracked through every subsequent phase.
Basketball-Specific Integration
Phase I

No cutting, slides, or wide-stance loading. Maintain skill engagement through seated and supported drills that bypass frontal-plane stress on the adductors.

  • Seated ball handling: stationary crossovers, in-and-outs, figure-8 patterns
  • Seated or supported chest and bounce passes to wall or partner
  • Form shooting from a seated or symmetric, narrow stance
  • Film study, opponent scouting, and tactical review
02
Phase II // Early Strengthening

Progressive Adductor Strengthening & Lumbopelvic Control

This phase introduces the foundational strength stimulus that drives recovery and reduces reinjury risk. The Copenhagen adduction exercise and its regressions form the backbone of programming — backed by the strongest evidence for improving adductor strength and reducing groin injury rates.2,7,8

// Primary Goals
  • Progress from isometric to short-lever isotonic loading
  • Introduce Copenhagen adductor exercise regressions
  • Build abductor, gluteal, and trunk strength
  • Normalize gait and basic single-leg stance control
  • Tolerate low-amplitude lateral loading
  • Improve adductor/abductor strength ratio
Adductor Loading
Primary
  • Short-lever Copenhagen (knee on bench)
  • Side-lying hip adduction with progressive load
  • Supine adduction squeeze at 0°, 45°, 90°
  • Standing cable hip adduction
  • Slider lunges in shallow range
Posterior & Lateral Chain
Supportive
  • Side plank progressions with hip abduction
  • Side-lying clams and lateral band walks
  • Glute bridges and single-leg bridges
  • Romanian deadlifts and split squats
  • Forward and lateral step-ups
Lumbopelvic Control
Coordination
  • Dead bug and bird dog progressions
  • Pallof press and anti-rotation work
  • Single-leg stance with perturbations
  • Multi-plane hip and trunk integration
  • Single-leg balance under cognitive load
Basketball-Specific Integration
Phase II

Reintroduce basketball positions and stationary skill work. Avoid wide stances, hard plants, and lateral displacement.

  • Standing stationary crossovers and between-the-legs dribbling in narrow stance
  • Set shots from close range with comfortable, symmetric stance
  • Short-duration defensive stance holds with trunk and pelvic focus
  • Mikan-style finishing at low intensity with neutral foot positions
  • Stationary pivoting in triple-threat without wide step displacement
03
Phase III // Progressive Loading

Running, Linear COD & Low-Amplitude Lateral Loading

With adductors tolerating higher loads in strength tasks, the focus shifts to linear running, controlled small-range lateral work, and tissue tolerance under increasing demand. Symptom monitoring during and 24 hours after each session drives progression decisions.2,3,11

// Primary Goals
  • Progress to long-lever and loaded Copenhagen variants
  • Complete a graded linear running progression
  • Tolerate short-range lateral shuffles symptom-free
  • Introduce planned linear change-of-direction
  • Maintain pain ≤1/10 during and after sessions
  • Track adductor/abductor ratio toward parity
Strength Progression
High Load
  • Long-lever Copenhagen with full leg extension
  • Sliding lateral lunges through progressive range
  • Loaded standing cable adduction in multiple angles
  • Side plank with top-leg adduction
  • Eccentric-emphasis adductor loading
Running Progression
Linear
  • Walk-jog intervals on level surface
  • Continuous jogging at conversational pace
  • Progressive accelerations to 70–80% effort
  • Straight-line dribble jogs baseline to baseline
  • Linear deceleration drills with controlled stops
Performance Team Takeaway
The Copenhagen adduction exercise has the strongest evidence base for both prevention and rehabilitation of adductor-related groin pain.7,8 Progressing from short-lever to long-lever variants — not adding sets or reps at the same lever — is the primary loading variable. The exercise should be programmed in every session from Phase II onward.
Basketball-Specific Integration
Phase III

Add controlled linear and low-amplitude lateral basketball patterns. Symptom monitoring is mandatory during and 24 hours after every session.

  • Straight-line dribble patterns baseline to baseline at jog pace
  • Short-range defensive shuffles, 1–2 slide steps each direction at 50–60% effort
  • Close-range jump shots with controlled, symmetric landings
  • Front and reverse pivots in triple-threat with compact step size
  • Catch-and-shoot from stationary positions with light footwork
04
Phase IV // Late-Stage Loading

Multi-Directional Loading & Sport-Specific Integration

High-load adductor training is paired with multi-directional running, planned change-of-direction, and basketball-specific movement under progressive intensity. This is where frontal-plane and rotational adductor demand is systematically reintroduced.2,3,11,14

// Primary Goals
  • Achieve high-level adductor strength and capacity
  • Restore adductor/abductor ratio to ≥0.90
  • Tolerate planned multi-directional change-of-direction
  • Integrate full-range lateral and rotational loading
  • Build frontal-plane deceleration capacity
  • Maintain symptom-free status through high-intensity work
// Adductor LSI
≥90%
Within 10% of contralateral limb on dynamometry5
// Add:Abd Ratio
≥0.90
Adductor strength within 10% of ipsilateral abductors4,6
// Pain Threshold
≤1/10
During and 24 hours after high-intensity sessions2,11
// COD Intensity
80%
Planned 45° and 90° cuts at progressively higher effort
High-Load Adductor Work
Maximal

3–4 sets of 6–12 reps at high intensity. Eccentric capacity is prioritized because eccentric adductor strength deficits predict future groin injury.5,6

  • Full long-lever Copenhagen with hold variations
  • Slideboard lateral lunges through full range
  • Heavy cable adduction across multiple angles
  • Lateral bounds with controlled landings
  • Eccentric-emphasis hip adduction protocols
Multi-Directional COD
Planned

Planned change-of-direction at increasing speeds, progressing from shallow to sharper angles before any reactive work is introduced.3,11

  • Planned 45° cuts at 60–80% speed
  • Progression to 90° cuts under control
  • Shuttle runs and lateral T-test patterns
  • Jump-stop into controlled lateral outlet
  • Crossover and step-back mechanics drills
Basketball-Specific Integration
Phase IV

Full-range basketball patterns return under planned, controlled conditions. Reactive and game-speed work is reserved for Phase V.

Defensive and lateral work:

  • Extended defensive slides over 3–5 steps, progressing to half-court at 60–80% effort
  • Closeouts with sharp deceleration and controlled stance landing
  • Single-leg lateral bounds with soft, symmetric landings

Offensive cuts and crossovers:

  • Planned 45° and 90° cuts out of dribble at moderate speed
  • Controlled push-off from inside leg with strong lumbopelvic alignment
  • Catch-and-shoot off V-cuts and L-cuts at short distances

Jump-stop combinations:

  • Jump-stop from slow approach into controlled lateral or diagonal step
  • Rebound simulations with immediate lateral outlet at moderate speed
05
Phase V // Return to Play

Return to Sport & Performance Optimization

Return-to-play decisions integrate clinically pain-free status, restored adductor strength and ratio, and successful completion of generic and sport-specific functional tests. The Aspetar criteria-based framework demonstrated low reinjury rates (~8%) when athletes passed structured controlled sports training before unrestricted competition.3,11,14

RTP Criteria

Integrated Return-to-Play Clearance

Clearance requires meeting all clinically pain-free criteria, restored strength symmetry, and demonstrated capacity in both generic and sport-specific functional testing. No single criterion clears an athlete.

Domain Threshold Notes
Palpation Pain-free No tenderness at adductor origin or muscle belly11,14
Isometric Adduction Pain-free, maximal At outer range and across all test angles (0°, 45°, 90°)11,14
Passive Adductor Stretch Pain-free Through full available range11,14
Resisted Adduction Pain-free at 10RM Meaningful resistance loads without symptom provocation11
Adductor LSI ≥90% Within 10% of contralateral limb on dynamometry5
Adductor/Abductor Ratio ≥0.90 Adductor strength within 10% of ipsilateral abductors4,6
Generic Agility Tests 100% effort, pain-free T-test or Illinois agility test at competitive performance level13
Sport-Specific Testing Symptom-free at match intensity Basketball-specific cuts, slides, and small-sided games11,13,14
Controlled Training Block Completed without flare Several sessions of on-court team training before full clearance11,14
Non-Negotiable
Returning to full competition without completing a controlled sports training block substantially raises reinjury risk.3,11,14 Clearance from clinic testing does not equal clearance for full minutes. Several sessions of structured, on-court team training must be completed symptom-free before unrestricted play.
High-Speed Basketball Integration
Phase V

Final-stage basketball work culminates in high-speed, reactive, open-skill basketball that mirrors competitive demand. Adductors must absorb and produce force pain-free across all directions.

High-speed movement and COD:

  • Full-speed defensive slides baseline to baseline and sideline to sideline
  • Closeouts from paint to three-point line with sharp deceleration
  • Dribble-to-crossover and dribble-to-step-back at game speed
  • Reactive cuts at 45–135° with coach or visual cues

Jump-land-change sequences:

  • Rebound simulations with immediate lateral or diagonal outlet at full speed
  • Jump-stop into lateral jab, cross-step, drive, or pull-up combinations

Open-skill and scrimmage exposure:

  • 1-on-1 and 2-on-2 in constrained spaces with time and rep limits
  • 5-on-0 transition sets progressing to 5-on-5 controlled scrimmage
  • Monitored full-court scrimmage with load tracking and symptom check

Protocol Principles

// 06 Core Principles
01
Active rehab outperforms passive treatment. Active, adductor-focused exercise programs are significantly more effective than passive modalities for returning athletes to symptom-free sport.1,2 Passive treatments alone are not a rehabilitation strategy.
02
The adductor/abductor ratio is the central risk metric. Adductor strength below 80% of ipsilateral abductor strength has been associated with up to a 17-fold increase in groin injury risk.4,6 This ratio must be measured at intake and tracked through every phase.
03
The Copenhagen exercise is non-negotiable. The Copenhagen adduction exercise has the strongest evidence base for improving adductor strength and reducing injury risk.7,8 Progression is through lever length, not volume.
04
Clinically pain-free status drives progression. Pain-free palpation, isometric testing at outer range, passive stretch, and resisted adduction at meaningful load are the Aspetar criteria gating advancement.11,14
05
Lumbopelvic control protects the adductor. Frontal-plane pelvic and trunk control under load reduces adductor strain in lateral and rotational tasks.2,3 Trunk and gluteal strengthening must run parallel to adductor work in every phase.
06
Controlled training exposure is part of clearance. The Aspetar protocol demonstrated low reinjury rates (~8%) when athletes completed structured controlled sports training before full team training.3,11,14 Clinic clearance is not full clearance.
// References & Primary Literature
  1. Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):439-443.
  2. Harøy J, Thorborg K, Serner A, et al. Current clinical concepts: exercise and load management of adductor-related groin pain in sport. Sports Med. 2023;53(2):215-233.
  3. Serner A, Mosler AB, Tol JL, Bahr R, Weir A. Return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes. Am J Sports Med. 2020;48(3):746-755.
  4. Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. Am J Sports Med. 2010;38(10):2051-2057.
  5. Thorborg K, Branci S, Nielsen MP, et al. Eccentric and isometric hip adduction strength in male soccer players with and without adductor-related groin pain: an assessor-blinded comparison. Orthop J Sports Med. 2014;2(2):2325967114521778.
  6. Engebretsen AH, Bahr R. The association between eccentric hip adduction strength and future groin injuries in male elite soccer players. Am J Sports Med. 2010;38(2):346-352.
  7. Ishøi L, Hölmich P, Aagaard P, Thorborg K. Effects of the Copenhagen adduction exercise on hip adduction strength and groin injury risk in subelite soccer players. Am J Sports Med. 2016;44(4):1155-1163.
  8. Esteve E, Rathleff MS, Vicens-Bordas J, et al. Effects of an 8-week Copenhagen adductor exercise programme on hip adduction strength and groin problems in sub-elite soccer players: randomized controlled trial. Br J Sports Med. 2015;49(22):1465-1470.
  9. Serner A, Jakobsen MD, Andersen LL, et al. EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. J Strength Cond Res. 2014;28(4):1045-1054.
  10. Hölmich P, Holmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med. 2004;38(4):446-451.
  11. Serner A, Tol JL, Jomaah N, et al. Sport after criteria-based rehabilitation of acute adductor injuries in male athletes: a prospective cohort study. Am J Sports Med. 2020;48(3):736-745.
  12. Mosler AB, Weir A, Serner A, et al. Hip and groin problems in elite players: prevalence, MRI findings and return to sport. Br J Sports Med. 2015;49(22):1464-1470.
  13. Falvey EC, King E, Franklyn-Miller A, et al. Adductor strains in athletes. Int J Sports Phys Ther. 2023;18(2):203-220.
  14. Tol JL, Serner A, Mosler AB, et al. Acute adductor injuries: Aspetar clinical practice guideline for treatment and return to sport. Aspetar Sports Med J. 2020;9:48-63.
  15. Safran MR, Benedetti RS, Bartolozzi AR, Mandelbaum BR. Lateral ankle sprains: a comprehensive review part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc. 1999;31(7 Suppl):S429-S437.