Adductor Related Groin Pain Flashcards
Public complex pathology ( 5 pathologies)
- Pubic Bone Stress Response
- Pubic Apophysitis
- Adductor Tendinopathy
- Adductor Enthesopathy
- Acute Adductor Lesions
PUBIC BONE STRESS RESPONSE
• “Normal finding” in the athletic population that shows an increase with training load
• Higher grade of pubic BMO is associated with groin pain
• Consistent with a bone stress injury - no evidence of inflammatory cells or
osteonecrosis
• Stress response / fracture
• Associated with acuity
PUBIC BONE STRESS RESPONSE : SUMMARY
• Unilateral or bilateral pubic body pain +/- lower abdominal &/or upper
adductor discomfort
• Younger male or first time athlete
• Gradual onset of symptoms that worsen with progressive loading
• Better after warm-up, deteriorate after rest periods & worse towards the end of the game
• Reduction in acceleration, agility & kicking penetration
• Sore that night and stiff / sore upon rising the next morning
• Clinical diagnosis : palpation, squeeze test & MRI
TREATMENT & PREVENTION
• Ensure adequate “pre” pre-season
• Load management of younger & older players
• Recovery
• Address running biomechanics – overstriding
• Address shock absorption capacity
• Bone cells respond to load but quickly lose mechanosensivity - less osteogenic
with repeated loading
• Longer recovery between repetitions during a loading cycle (15 seconds) & between loading bouts (alternate days) - results in restoration of full mechanosensitivity & higher relative bone formation rate
PUBIC BONE STRESS RESPONSE
• Pre-puberty & peri-puberty - utilise exercise to enhance growth-related
gains in bone mass & geometry
• In late puberty, the growth-related periosteal expansion persists but the
exercise-induced periosteal gains tend to plateau from Tanner stage 3 (Ducher et al 2009)
• Testosterone may enhance the osteogenic response to loading by directly acting on bone tissue but also by increasing muscle mass
• Cortical BMD is greater & endosteal circumference lower in peri-puberty
females (Tanner 3-5) than males (Leonard et al 2010)
• Oestrogen lowers the bone remodelling threshold - greater gain in bone mass during puberty
PUBIC APOPHYSITIS
• Pubis is the last part of the human skeleton to reach maturation - epiphyseal
closure is not complete until 35-40 years of age
• Pubic apophysis maturation begins at 16, finishing around 21 years of age
• Late maturation of the apophysis & high training loads in the younger athlete likely contributors
• Incidence of groin injury shows a significant rise though adolescence
• Osteochondral disorders occur in younger subjects who are late maturers
• Groin strains occur in earlier maturers
PUBIC APOPHYSITIS : SUMMARY
- Unilateral or bilateral pubic body pain +/- upper adductor discomfort
- Younger male athlete (16-21yo)
- Gradual onset of symptoms that worsen with progressive loading - running, agility & kicking (Sailly et al 2015)
- Better after warm-up, deteriorate after rest periods & worse towards the end of the game
- Reduction in acceleration, agility & kicking penetration
- Sore that night and stiff / sore upon rising the next morning
PUBIC APOPHYSITIS clinical Dx, Rx and prevention
• Clinical diagnosis : palpation, squeeze test, RSC Adduction in full Abduction, passive stretch & MRI
TREATMENT & PREVENTION
• Monitor “growth spurts” – increased myofascial tone
• Load management of younger players
• Monitor kicking loads v ball size / weight (Sailly et al 2015)
• Recovery
• Address running biomechanics – overstriding
• Address shock absorption capacity
• Multi-intervention neuromuscular training
• Address muscular endurance
• Ground hardness
• Optimize Hip rotation
• Monitor Squeeze test
• Myofascial release of adductors
• No aggressive stretching!!!!
Adductor Tendinopathy
• First description of adductor tendinopathy - ultrasound, surgical & histopathological study by Kalebo et al (1992)
• Anatomy - anterior surface of Adductor Longus is flat and tendinous whilst the posterior surface being muscular (Tuite et al 1998, Strauss et al 2007, Norton-Old et al 2012)
• Vascularity of Adductor Longus & Adductor Brevis decreased significantly toward the enthesis
• Adductor Longus active at all speeds during “toe off” & remaining active during
follow through & early forward swing (Mann et al 1986)
• AL may be the conduit between resisting hip extension & recruitment of the
prime hip flexor
• Also a short burst of activity when foot descent begins during sprinting, to bring the foot toward the midline
ADDUCTOR TENDINOPATHY
• MRI -> Immediately after
kicking the % change in mean signal intensity in the kicking leg was:
- Gracilis 49%
- Adductor Longus 31%
ADDUCTOR TENDINOPATHY : SUMMARY
- Unilateral upper adductor pain
- Sudden onset related closely to altered loading
- Sore during warm-up but good throughout game except immediately after rest period
- Symptomatic with running, kicking, agility, sit-ups, coughing, sneezing
ADDUCTOR TENDINOPATHY Clinical Dx, Rx and prevention
• Clinical diagnosis : stretch, RSC Hip adduction, RSC Hip flexion & palpation
TREATMENT & PREVENTION
• Load management
• Strengthen Hip flexors
• Condition Hip adductors (Delahaye et al 2003, Thorborg et al 2014)
• Balance Hip abductors & adductors (Merrifield & Cowan 1973, Tyler et al 2001, Tyler et al 2002, O’Connor 2004)
• MFR of Adductors
ADDUCTOR ENTHESOPATHY
• Abnormal anterior pubis & enthesis enhancement on post-gadolinium MRI
correlated with clinical side (Robinson et al 2004)
• AL & RA have bilateral attachments to PS capsular tissue, fibrocartilagenous
disc & hyaline cartilage (Robinson et al 2007)
• All entheses are fibrocartilagenous (Davis et al 2011)
• Primary cleft is an oval shaped cavity located within the postero-superior
aspect of the disc & occupying half the disc height (Becker et al 2010)
• Repetitive tractional loading of the anterior aponeurosis may result in formation
of a “secondary cleft” (Putschar 1976)
• Potentially just an extension of adductor or abdominal enthesopathy - anterior aponeurotic plate lesion
• Secondary cleft sign - 100% correlation with side of groin pain
• Associated with a tear of gracilis, adductor brevis & pectineus (Brennan et al 2005, Cunningham et al 2007)
• Strong correlation between side of lower abdominal discomfort & side of superior
cleft - suggestive of rectus abdominis / adductor longus tearing (Murphy et al 2013)
ADDUCTOR ENTHESOPATHY: SUMMARY
- Unilateral pubic body pain +/- upper adductor (lower abdominal) discomfort
- Gradual onset that may or may not be related to altered loading
- Deteriorate with progressive loading
- Take longer to “warm up” than a tendinopathy
- Symptomatic with running, kicking, agility, sit-ups, coughing, sneezing
ADDUCTOR ENTHESOPATHY Clinical Dx, Rx and Prevention
• Clinical diagnosis : stretch, RSC Hip adduction, RSC Hip flexion, palpation, MRI
TREATMENT & PREVENTION • Load management • Optimize Hip extension • Minimize resistance to Hip flexion • Strengthen Hip flexors • Condition Hip adductors • Balance Hip abductors & adductors • MFR of Adductors - don’t stretch
ACUTE ADDUCTOR LESIONS
• Very little literature on acute groin pathology
• Groin pathology inclusive of many anatomical locations – AL > Iliopsoas > Rectus
Femoris > Pectineus (Serner et al 2015)
• Adductor Longus is primarily injured (Schlegel et al 2009, Serner et al 2015 & 2018)
• Remember pectineus, AB, AM, gracilis & even obturator externus (Gudena et al 2015, Wong-On et al 2017)
• Haematoma dependent on involvement of the posterior muscular portion of the muscle (Dimitrakopoulou et al 2008)
• Injury occur at 3 locations (Serner et al 2018) :
- proximal insertion
- MTJ of proximal tendon - MTJ of the distal tendon
- Often occur in pre-season (Ekstrand & Hilding 1999)
- Kicking in kicking sports (Serner et al 2015 & 2018) – kicking leg was injured 80% of the time : mechanism is likely to be non-contact deceleration of the Extended/Abducted/IR limb (Dimitrakopoulou et al 2008)
- Change of direction – eccentric loading (Schlegel et al 2009, Serner et al 2015 & 2018)
- Stretching insult (Schlegel et al 2009, Serner et al 2015 & 2018)
- Sprinting / Running (Serner et al 2015 & 2018)
- Jumping (Serner et al 2018)
- Tackling (Serner et al 2018)
- Previous injury (Ekstrand & Hilding 1999, Schlegel et al 2009, Serner et al 2015)
