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Adductor Strain
From WikiSM
Contents
Other Names
- Groin strain
- Pulled groin
- Medial Thigh Pain
- Adductor Muscle Strain
- Adductor Tear
Background
- This pain refers to acute strains and injuries of the Adductor Muscles
- This generally refers to the adductor muscle complex: Adductor Brevis, Adductor Longus, Adductor Magnus
- Chronic tendinopathies are discussed separately: Adductor Tendonitis
History
Epidemiology
- General
- Most common cause of groin pain in athletes but is difficult to differentiate between other causes (need citation)
- Incidence
- Among European soccer players, adductor muscle injuries were the second most commonly injured muscle group behind hamstrings (need citation)
- Another study of soccer players estimated adductor pain or strain accounted for 9% - 18% of all injuries (need citation)
- In sub-elite male soccer players, adductor strain accounted for 51% of all groin pain (need citation)
- Among Swedish hockey players, groin strains accounted for 10% of all injuries[1]
- In elite Finish ice hockey players, 43% of muscle injuries were groin strains[2]
- Among NHL players, estimated to be 3.2 per 1000 player-game exposures[3] and the incidence is increasing[4]
- Among Scandinavia soccer players, the incidence of groin strain is estimated to be between 10 and 18 injuries per 100 soccer players[5]
Pathophysiology
- Groin strain
- Defined as pain on palpation of the adductor tendons or the insertion on the pubic bone, or both, and groin pain during adduction against resistance[6]
- General
- Most commonly due to eccentric loading with a concentric contraction
- Most tension is when leg is externally rotated, abducted
- Often a stretch injury associated with abrupt cutting motion, straddling injury, or overuse
- Dominant leg most commonly injured
- Musculotendinous junction
- Most commonly injured site
- This area is characterized by rich nerve supply, low blood supply which causes high level of perceived pain, poor healing
- Adductor Longus
- Area of injury in 62-90% of cases[7]
- Thought to occur due to low tendon:muscle ratio
Etiology
- Biomechanical contributions
- Sudden acceleration is the most common mechanism of injury (need citation)
- Sudden changing in direction can cause rapid eccentric hip adduction against an abducting limb, exaggerating stress on tendon
- Jumping is another cause
- Overstretching the adductor tendon is less common
- Kicking a ball with externally rotated leg using inside of foot
Pathoanatomy
- Adductor Complex
- Primary adductor muscle group
- Includes: Adductor Brevis, Adductor Longus, Adductor Magnus
- Responsible for majority of adduction of the thigh
- Closed chain activation: stabilize pelvis, lower extremity during gait
- Adductor magnus can provide some internal rotation; adductor longus can help extend the hip
- Muscles with some adduction activity
Risk Factors
- Common Sports
- Other
Differential Diagnosis
Differential Diagnosis Thigh Pain
- Fractures
- Muscle and Tendon
- Neurological
- Other
Differential Diagnosis Groin Pain
- Muscle And Tendon
- Adductor Tendonitis
- Adductor Strain
- Hip Flexor Tendonitis
- Snapping Hip Syndrome
- Rectus Femoris Strain
- Rectus Abdominus Strain
- Myositis Ossificans
- Sports Hernia
- Hip Etiology
- Acetabular Labrum Tear
- Femoral Acetabular Impingement
- Avulsion Fractures
- Avascular Necrosis of the Hip
- Acetabular Labrum Tear
- Ligamentum Teres Injury
- Osteochondritis Dissecans
- Pelvic Stress Fracture
- Neuropathies
- Ilioinguinal Nerve Injury
- Genitofemoral Nerve Injury
- Iliohypogastric Nerve Injury
- Obturator Nerve Injury
- Meralgia Paresthetica (Lateral Femoral Cutaneous Nerve)
- Spine
- Pelvis
- Athletica Pubalgia
- Osteitis Pubis
- Inguinal Hernia
- Femoral Hernia
- Sports Hernia
- Pediatric Considerations
- Genitourinary & Reproductive
- Ovarian or testicular torsion
- Nephrolithiasis
- Epididymo Orchitis
- Ovarian Cyst
- Pelvic Inflammatory Disease
- Urinary Tract Infection
- Endometriosis
- Prostatitis
- Gastrointestinal
- Appendicitis
- Diverticulitis
- Lymphadenitis
- Inflammatory Bowel Disease
Clinical Features
- History
- Typically sudden onset of pain
- Medial thigh, groin and adductor pain and weakness
- Worse with activity
- May have minor discomfort with walking
- Symptoms can become chronic if undertreated and repeatedly strained
- Physical Exam: Physical Exam Hip
- May see swelling, ecchymosis, and/or palpable depression if tear or rupture present
- Pain with passive stretching/abduction or resisted contraction/adduction
- Tenderness along proximal 1/3 of medial thigh and adductor tendon origin in pubic region
- Special Tests
Evaluation
Radiographs
- Standard Radiographs Pelvis, consider Standard Radiographs Hip
- Need AP view, frog leg view
- Typically normal, rarely will demonstrate bony avulsion
- Useful to exclude other pathology
MRI
- Findings
- Edema, hemorrhage at site of injury
Ultrasound
- Can visualize majority of structures
- Identify area, extend of injury
- Serial examinations during recovery phase
Classification
- First degree: Pain without significant loss of strength or range of motion
- Second degree: Pain with loss of strength
- Third degree: Complete disruption of muscle or tendon fibers with loss of strength
Management
Prognosis
- Favorable prognosis
- Most athletes return to play with minimal pain, normal function after appropriate therapy
- Akermark et al surgical tenotomy
- They found 16/16 patients improved but only 10/16 (63%) were able to return to previous level of activity[10]
- 5 athletes were able to return to sports at a lower level
Prevention
- Directed at strengthening adductors
- Maintaining adductor strength at a minimum of 80% of abductor strength has been shown to reduce adductor injuries (need citation)
- NHL prevention program
- Tyler et al: players identified as having weak abductors participated in a 6-week preseason strengthening program which reduced adductor strains from 3.2 injuries per 1000 player-game exposures to 0.71[11]
- See study for program including warm up, strengthening and sport specific protocols
Nonoperative
- Modality of choice in most cases
- Analgesics: NSAIDS, Acetaminophen
- Ice
- Consider compression
- If severe pain, may need Crutches with ambulation
- Activity restriction/ relative rest
- Corticosteroid Injection
- Needle Tenotomy
- US or electrical stimulation may have benefit in chronic cases
Operative
- Indications
- Surgical repair may be required for complete avulsion
- Lack of response to conservative therapy in full thickness tears
- Greater than 6 months of refractory conservative therapy
- Technique
- Adductor tenotomy has been suggested
Rehab and Return to Play
Rehabilitation
- General
- Limited activity as tolerated for 1-2 weeks
- Gentle stretching in first few days followed by gentle stretching and low-intensity isotonic strengthening as symptoms subside [12][13]
- Progress to active strength training and stretching, may increase to full loading if flexibility is full and pain-free[14][15]
Program from Tyler et al[11]
- Phase 1 (acute)
- See study for specific protocol
- RICE for first 48 hours, NSAIDS, massage therapy, TENS, ultrasound
- Multiple pain free excercises and stretching limited by pain
- Clinical milestone: concentric adduction (against gravity without pain)
- Phase II (subacute)
- Increasing pain free activity
- Clinical milestones: lower extremity PROM equal to unaffected side, ipsilateral adductor strength at least 75% of contralateral abductors
- Phase III (sport specific)
- Examples include slide board, lunges, correcting technique
- Clinical milestones: adduction strength 90-100% of abduction strength, ipsilateral adduction strength equal to contralateral adduction strength
Return to Play
- Unrestricted play is allowed if completely pain-free and predisposing factors are corrected, which may take weeks
Complications
- Can become chronic, evolve into Adductor Tendinopathy
- Complete rupture
- Avulsion injury
- Missed playing time
- Inability to return to sport
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Lorentzon R, Wedren H, Pietila T. Incidences, nature, and causes of ice hockey injuries: a three year prospective study of a Swedish elite ice hockey team. Am J Sports Med 1988; 16: 392–6
- ↑ Molsa J, Airaksinen O, Nasman O, et al. Ice hockey injuries in Finland: a prospective epidemiologic study. Am J Sports Med 1997; 25 (4): 495–9
- ↑ 3.0 3.1 Tyler TF, Nicholas SJ, Campbell RJ, et al. The association of hip strength and flexibility on the incidence of groin strains in professional ice hockey players. Am J Sports Med 2001; 29 (2): 124–8
- ↑ Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med 1999; 9: 151–6
- ↑ Sim FH, Simonet WT, Malton JM, et al. Ice hockey injuries. Am J Sports Med 1987; 15 (1): 30–40
- ↑ Lynch SA, Renström PA. Groin injuries in sport: treatment strategies. Sports Med 1999; 28 (2): 137–44
- ↑ 7.0 7.1 Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of Hip Flexor and Hip Adductor Strains in National Collegiate Athletic Association Athletes, 2009/2010-2014/2015. Am J Sports Med. 2017 Oct;45(12):2713-2722
- ↑ Khandekar, Prachi. "Assessment and management of adductor strain." Saudi Journal of Sports Medicine 17.2 (2017): 118.
- ↑ Inklaar H, Bol E, Schmikli SL, Mosterd WL. Injuries in male soccer players: Team risk analysis. Int J Sports Med 1996;17:229-34
- ↑ Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med 1992; 20 (6): 640–3
- ↑ 11.0 11.1 yler TF, Nicholas SJ, Campbell R, et al. The effectiveness of a preseason exercise program on the prevention of adductor strains in professional ice hockey players [abstract]. Presented at the 27th Annual Meeting of the American Orthopaedic Society for Sports Medicine (AOSSM); 2001 Jun 28-Jul 1, Keystone (CO)
- ↑ Ruana JJ, Rossi TA. When groin pain is more than "just a strain." Physician Sports Med. 1998;26(4):online.
- ↑ Anderson M, Hall S, Martin M. Foundations of Athletic Training Prevention, Assessment and Management. 2005:475-477.
- ↑ Lacroix VJ. A complete approach to groin pain. Physician Sports Med. 2000;28(1):online.
- ↑ Sim FH, Nicholas JA, Hershman EB. The Lower Extremity and Spine in Sports Medicine. St. Louis: Mosby, 1995.
Created by:
John Kiel on 5 July 2019 08:47:47
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Last edited:
22 January 2023 16:47:54
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