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Clinical Edge > Adductor Related Groin Pain > Flashcards

Adductor Related Groin Pain Flashcards

1
Q

Public complex pathology ( 5 pathologies)

A
  • Pubic Bone Stress Response
  • Pubic Apophysitis
  • Adductor Tendinopathy
  • Adductor Enthesopathy
  • Acute Adductor Lesions
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2
Q

PUBIC BONE STRESS RESPONSE

A

• “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

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3
Q

PUBIC BONE STRESS RESPONSE : SUMMARY

A

• 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

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4
Q

PUBIC BONE STRESS RESPONSE

A

• 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

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5
Q

PUBIC APOPHYSITIS

A

• 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

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6
Q

PUBIC APOPHYSITIS : SUMMARY

A
  • 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
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7
Q

PUBIC APOPHYSITIS clinical Dx, Rx and prevention

A

• 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!!!!

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8
Q

Adductor Tendinopathy

A

• 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

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9
Q

ADDUCTOR TENDINOPATHY

A

• MRI -> Immediately after
kicking the % change in mean signal intensity in the kicking leg was:
- Gracilis 49%
- Adductor Longus 31%

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10
Q

ADDUCTOR TENDINOPATHY : SUMMARY

A
  • 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
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11
Q

ADDUCTOR TENDINOPATHY Clinical Dx, Rx and prevention

A

• 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

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12
Q

ADDUCTOR ENTHESOPATHY

A

• 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)

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13
Q

ADDUCTOR ENTHESOPATHY: SUMMARY

A
  • 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
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14
Q

ADDUCTOR ENTHESOPATHY Clinical Dx, Rx and Prevention

A

• 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
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15
Q

ACUTE ADDUCTOR LESIONS

A

• 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)
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16
Q

ACUTE ADDUCTOR STRAIN RISK FACTORS

A

•Recent systematic review of risk factors for groin injury in sport (Whittaker et al 2015) found level 1 & 2 evidence for

  • previous groin injury
  • higher level of play
  • reduced hip adductor strength (absolute & relative to hip abductors)
  • lower levels of sport specific training
    Virtually no investigation of the relationship to exposure / athletic load
    (Weir et al 2015)
17
Q

O/E

A
  • Observation – asymmetry, sway etc.
  • Lx spine APM’s – F, E, LF, Rotation, Quadrant
  • Pelvic motion – APT, PPT, Lateral slide, Rotation
  • Dynamic SIJ – Stork, Squat, Lx E
  • Weight transfer tasks – Lx E, SL stance, stepping
  • Dynamic loading – SL squat, hopping etc.
•
PSST +/- compression or contraction - Hip E
- RSC Hip F
- RSC Hip Adduction in neutral
- RSC Hip Adduction in 30' Abduction
  • Leg length
  • Pelvic alignment
  • Passive SIJ
  • Neural mobility
  • Hip ROM & special tests
  • Sit-up

• Squeeze +/- compression or contraction : sensitive but poor specificity (Falvey et al 2016)

  • 45’ optimal for recruitment of AL - sEMG & sphygmomanometer
    (Delahunt et al 2011, Lovell et al 2011)
  • BUT 0’ showed greater force output using a load cell (Lovell et al 2011)
  • Normative pre-season data in non-injured professional rugby players 200-220mmHg (Hodgson et al 2014)

•
RSC Adduction
- “break” test reveals that dominant leg is 14% stronger than non-dominant leg regarding eccentric strength in players (Thorborg et al 2011a)
- “make” test bilaterally equal dominant v non-dominant and adduction / abduction isometric strength ratio is 1.05 (Thorborg et al 2011b)

  • RSC in to E/Adduction from FAbER
  • Hip Abduction Stretch
  • FAbER stretch
  • ASLR +/- compression or contraction
  • MMT - abduction, IR & ER (Hoggan micro FET2)
  • Core stability - Pelvic Floor (Barber et al 2002, Ashton-Miller & DeLancey 2007, Wallner et al 2008)
  • Palpation is the most important assessment tool - especially for RA & AL origin (Falvey et al 2016, Serner et al 2016)

• Palpation

  • Abdominal complex - Pubic bone
  • Adductor complex
  • Pubic bone
  • SPL
  • PS
  • Arcuate ligament
  • Adductor Longus rupture - evidence of RTP at 13 weeks supported operatively (Tansey et al 2015) & non-operatively (Ueblacker et al 2016)
  • Managed non-operatively missed a mean of 6 weeks v operatively missed 12 weeks (Schlegel et al 2009)
  • Non-operative management will provide a more rapid return (statistically significant) & avoids surgical complications
  • All reported complete resolution of symptoms & returned to full strength on manual examination
18
Q

Treatment

A
  • Tx & Lx spine mobility & stability
  • Pelvic alignment & stability
  • MFR of Adductor complex
  • Neural mobility - slider
  • Stretching +/- MFR
  • Load management
  • Optimise shock absorption - shoewear, training surface, running & landing technique etc.
  • Offload taping / belt
  • Adductor strengthening (Serner et al 2013, Delmore et al 2014)

Clinical Edge (6 decks)

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