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Adductor Strain

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Other Names

  • Groin strain
  • Pulled groin
  • Medial Thigh Pain
  • Adductor Muscle Strain
  • Adductor Tear

Background

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


Risk Factors

  • Common Sports
    • Hockey
    • Soccer
    • Football
    • Basketball
    • Tennis
    • Figure skating
    • Baseball
    • Horseback riding
    • Karate
    • Softball
    • Taekwondo[8]
    • Cricket[9]
  • Other
    • History of previous hip or groin injury
    • Increased age
    • Fatigued/weakened adductors [3]
    • Inflexible adductor muscles
    • Excessive foot pronation
    • Leg-length discrepency
    • Adductor-abductor strength ratio < 80% are at 17x increased risk[7]
    • Decreased hip abduction range of motion

Differential Diagnosis

Differential Diagnosis Thigh Pain

Differential Diagnosis Groin Pain


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

Strain of the Adductor Magnus

Radiographs

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

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


References

  1. 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
  2. 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. 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
  4. Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med 1999; 9: 151–6
  5. Sim FH, Simonet WT, Malton JM, et al. Ice hockey injuries. Am J Sports Med 1987; 15 (1): 30–40
  6. Lynch SA, Renström PA. Groin injuries in sport: treatment strategies. Sports Med 1999; 28 (2): 137–44
  7. 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
  8. Khandekar, Prachi. "Assessment and management of adductor strain." Saudi Journal of Sports Medicine 17.2 (2017): 118.
  9. Inklaar H, Bol E, Schmikli SL, Mosterd WL. Injuries in male soccer players: Team risk analysis. Int J Sports Med 1996;17:229-34
  10. 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. 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)
  12. Ruana JJ, Rossi TA. When groin pain is more than "just a strain." Physician Sports Med. 1998;26(4):online.
  13. Anderson M, Hall S, Martin M. Foundations of Athletic Training Prevention, Assessment and Management. 2005:475-477.
  14. Lacroix VJ. A complete approach to groin pain. Physician Sports Med. 2000;28(1):online.
  15. 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
Authors:
Last edited:
21 October 2022 15:54:47
Categories:
Lower Extremity | Groin | Hip | Thigh | Sprains And Strains | Acute