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Adductor Pain |
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| This injury is one many
try and put off seeing an injury specialist for because of where it
is. The adductor muscle group is one of the most sensitive (I find)
but can have a simple cause and treatment. Some adductor problems
have nothing to do with the adductors but is referred from tightness
and weakness of the hip
structures or the back. However the adductor muscle group can get
injured and cause considerable pain when walking and anything to do
with lifting the leg. A chronic groin problem can cause a challenge
to the therapist as there are a number of tendons and bursa (13 in
the hip) that can
cause symptoms.
It is vital to localise the area of abnormality. This can be as simple as an acute onset of pain strongly suggestive of a muscle strain. However pain can be vague and felt in different areas simultaneously. It is important to establish the time course of pain. Pain that is worse after exercise, especially the following morning and gradually lessens during exercise is indicative of an inflammatory condition like tendinopathy. Pain that becomes progressively worse with exercise may suggest a stress fracture, bursitis or muscle strain. The movements which cause pain need to be established as many muscles cross the hip joint. Pain on kicking may involve the hip flexors illiopsoas or rectus femoris, a twisting injury would lead to an adductor strain, sit-ups may indicate a problem with rectus Abdominis or a hernia. The most common bursa to cause groin pain is the iliopsoas. It's also important to look at the back and hip if previous injuries have occurred in these areas. I have had a few cases now where the main complaint was groin pain but treatment consisted of one simple treatment to relax the external rotators of the hips. Chronic groin pain - Muscle imbalance Groin injuries are often of the overuse type and typically the athlete will have had pain for a considerable period of time. The "holy trinity" of chronic groin injuries are the sports hernia (disruption to the inguinal canal without an apparent hernia), osteitis pubis (inflammation or degeneration of the pubic symphysis) and chronic adductor tendinosis (degeneration or wear at the origin of the adductor tendons of the inner thigh). Athletes may develop one, two or all three of the above. All of these conditions are thought to be caused by repetitive shearing forces acting across the pubic symphysis (the joint at the front of the pelvis where the two pubic bones meet).
What the unfortunate sufferers often have in common is poor
pelvic stability. They are unable to stabilise the lower abdomen and
pelvis whilst performing the twisting and turning movements needed
for their sport. When this group of muscles are examined for muscle
imbalances we invariably find that their mobilisers' the hamstrings,
adductors (inner thigh), hip flexors (kicking forward) and rectus
abdominus (six pack muscle), have become shortened and their
principal stabilisers: the transverse abdominals (deep abdominal)
and posterior gluteus medius have become long, weak and inhibited.
The mobilisers are attempting to stabilise as well as mobilise and
perform neither role particularly well. To help correct this imbalance we would typically involve shortening and stabilising the transverse abdominals (abdominal hollowing), multifidus (low back push down) and gluteals (squats, leg extension, one leg balance etc) and lengthening the tensor fascia latae/ iliotibial band, rectus femoris and psoas (hip flexors) and invariably the hamstrings (see stretches below). Weakness in the core muscles can place added stress onto the adductors and cause an acute strain.
Adductor/Groin muscle strain - Video This injury usually occurs with sudden changes in direction. It is acute in nature but can develop into chronic tendinopathy. Pain is localised tenderness with pain on passive abduction (leg out to side) and pain on resisted adduction (squeezing legs together (may need to be combined with hip flexion). Varying the degree of rotation of the leg whilst performing resisted adduction can give some idea of which adductor muscle is injured (neutral-add longus, int rot-pectineus, ext rot-add mag). The types of activities affected will be sitting and then lifting your leg to get up and lifting your leg out to the side as in getting out of the car. The forward swing of the walking gait may also be painful particularly going up stairs. If torn you may not be able to walk due to pain. Treatment involves initial rest using RICE principle. Early stretching is usually not advised you usually give it 4 days after the injury before commencing any stretching or strengthening. This does not mean you cannot try gentle range of motion exercises (but within your pain free range only). As pain subsides the athlete can commence early isometric exercises. As there may be a loss of core stability, low load exercise is essential to reduce overload on the adductor group and enhance force closure. This should be started as soon after injury as possible. Regaining full, pain-free hip range of movement must be an early objective in the management of this patient. For an optimal return to sport and prevention of recurrence of groin injury, strengthening of the adductor group is dependent on full hip range of movement being present. When it has been determined that bleeding has stopped in the muscle and there is no risk of haematoma, calcification and myositis ossificans, the following treatment modalities could be introduced; Hydrotherapy - to regain hip range of movement and early muscle conditioning Manual techniques such as;
Strengthening Muscle strengthening regimes vary among therapists. The progression of the strengthening exercises for adductor muscle injury follows the same principle as any muscle rehabilitation. it is essential to address the core muscles as weakness in these may stop the injury from healing and becoming chronic in nature (muscle imbalance). Rehabilitation tips The following exercises are only suggestions which may be included in the rehabilitation programme. Bridging is an excellent exercise and can be introduced as early as pain allows. Management of an adductor strain is complicated by the strong desire for early return to sport by both players and coaches. When a player returns to sport too soon there is a danger that the muscle sustains repetitive micro trauma leading to scar tissue and ongoing inflammation resulting in recurrence of injury. It is essential to discuss timescales with the patient and explain the injury fully so that they understand the consequence of returning too soon to sport. References used
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Anatomy
There are five adductor muscles which help to pull the leg back towards the midline. The Pectineus, adductor brevis and adductor longus which originate from the pelvis and insert on to the thigh bone. The adductor magnus and gracilis are longer and insert onto the inside of the knee (bi-articular). During walking the muscles are used to keep the leg towards the middle to maintain balance. They are used extensively in sprinting, horse riding and hurdling. This may explain why when injured it can be difficult to move the leg forward as in walking. If weakness is present in the hip flexors the adductors will take over and this can be a cause of injury.
In addition to their role in adducting the hip, the adductor muscles can also flex the extended hip and can extend the flexed hip. For example in activities such as climbing up hill when the hip is flexed, the adductor muscles are forceful hip extensors. The adductor muscles also have the ability to assist in hip rotation. When the hip is flexed the adductor muscles rotate the hip in and when the hip is extended, the adductors rotate the hip out. Adductor magnus is the main adductor muscle which assists in hip rotation. other groin muscles to take into consideration
Case Study A recreational runner sought out help at my clinic when groin pain was stopping her from running. The main complaint was right sided groin pain which was occasionally felt in the left. Initially pain would be felt early on in running then would ease off before turning into an ache and gradually developed into a sharp pain. It was more present on incline running and getting out of a car. This problem has been on and off for 2 years, the last episode she rested for 1 month before trying running again. The pain returned so she sought out help. What was of interest before the examination started was the patient had had inserts put into her shoes to help with a severe foot problem, the inserts were put in two years ago! Pain was felt halfway between the symphysis pubis and ASIS (hip bone). Some pain was also felt more inferior to the symphysis pubis. Almost every hip movement caused pain somewhere in and around the hip joint. Internal rotation caused pain in the piriformis region and also showed a little weakness. There was also increased range on motion on the fabers test which was negative for SI joint irritation. Adduction and internal rotation were the most painful and restricted. Hip extension was slightly limited with weakness. Palpation revealed a small tenderness and mal-alignment of the pubic symphysis. The patient had prior to the assessment an x-ray which came back clear from any degenerative changes. Also of interest; there was also some pelvic instability present when testing a forward bend with the right leg slightly forward (right side). There was also a positive trendelenberg on the right side. It was found that this patient had poor muscle control around her pelvis and trunk especially between the hip rotators, the gluteus medius being long and weak and the piriformis being very tight. This caused decreased hamstring flexibility. When running it was suggested that there was an inability to recruit the deep abdominals because of the muscle tightness in an around the hip joint. The diagnosis was anterior-medial impingement and capsulitis (due to a positive hip quadrant) related to muscle imbalance. Treatment Massage was implemented to reduce tightness in the piriformis, and hamstring. Hip mobilisations were performed to gain full hip range of movement. Even after 1 treatment the groin pain had reduced and light running could be commenced. It was also suggested that the insoles were to be taken out and slowly introduced whilst strengthening was performed. Taking out the insoles permanently would just cause the foot pain to come back. Strengthening was given for gluteus maximus/gluteus medius and core muscles. A hamstring stretching programme was also issued with hip flexor and piriformis stretches. 5 months on and full running has commenced with no reoccurrence of symptoms, a full stretching programme is still in place and will be continued as part of her training routine. To help with keeping the muscles strong a core balance training programme was introduced as part of a cool down routine. Many people do not have time to place strengthening programmes in there training so implementing them into a warm-up and cool down can be very helpful. How much the insoles played in the development of this injury is unknown. The old foot posture may have been caused by the hip biomechanics so correcting the feet isolated the hip muscle imbalance. It can be difficult finding the true cause when the condition is chronic in nature. Iliolumbar ligament The iliolumbar ligament can refer pain into the groin and adductor region. The iliolumbar ligament extends from the transverse process of the fifth lumbar vertebrae to the posterior part of the iliac crest. It links together the sacrum and fifth lumbar vertebrae preventing L5 moving forward in respect to S1. This ligament is thought to be a frequent source of groin pain and is worth considering in sports which involve rotation of the spine such as racket sports and golf. Adductor magnus or biceps femoris? Getting a correct diagnosis is essential for the rehabilitation process. Two muscles which can be confusing are the hamstrings and adductor magnus. The insertions of these muscles are very close and cause similar symptoms. Many people will self diagnose themselves with a hamstring injury when it the adductor magnus. this is because the adductor magnus helps the hamstrings with extension as in squats and lunges (playing squash). Neural tension? Altered neuro dynamics describes the inability of the nervous system to move concurrently with changes in body position. The spinal cord and peripheral nerves are a mobile elastic structures which are designed to move and adapt to any changes taking place in body position. However physiological and mechanical dysfunction can occur which affects the nervous system resulting in pain and decreased range of movement. The nerve may be affected by extra neural or intraneural factors. Extra neural dysfunction describes an alteration in the mobility of a nerve within the tissue it runs through. This is known as an interface problem and can be caused by scar tissue, trauma, poor posture, surgery, adductor brevis/psoas tightness, compression between muscles. Intraneural pathology describes abnormalities within the nerve itself such as an increase in nerve sensitivity. This may be caused by inflammation, scar tissue, stiffness of the lumbar spine (causing a stretching of the nerve). Minor alterations in posture around the pelvis can cause a neural element to the injury. Tests used are straight leg raise and slump.
modified slump test to diagnoses and treat Chronic Groin injuries When a groin injury becomes chronic it can be a great challenge to the therapist. It takes a lot of history taking as the injury will have more than one cause. |
The
pubis symphysis has a poor blood supply making healing a slow
process.
Hamstrings
Hip flexors
