Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Groin Injuries

Overuse of the adductor muscle-tendon unit

The muscles that draw the leg inwards (adduct at the hip joint) are primarily the adductor longus, the adductor magnus, the adductor brevis, and the pectineus muscles. The gracilis muscle and the lower fibers of the gluteus maximus also work as adductors. However, it is usually the adductor longus that is damaged during sporting activity.

The adductor longus muscle tendon arises from the pubic bone and is inserted into the back of the midshaft of the femur. Overloading can be caused by sideways kicks in soccer, hard track training, and drawing the free leg inwards when skating. It is also common in team handball and ice hockey players, skiers, weightlifters, hurdlers, and high-jumpers. The symptoms may begin insidiously, perhaps at a
training camp or during other intensive training periods.

Symptoms and diagnosis

– Pain can often be located in the origin or at the junction of the muscle-tendon unit and may radiate downwards into the groin. The pain often decreases after initial exertion and can disappear completely, only to return after training with even greater intensity. There is a risk that athletes will enter a cycle of pain in which case the condition is difficult to treat.
– Tenderness is felt at one particular point on the pubic bone over the origin of the muscle. This tenderness is distinct.
– The pain can be triggered by pressing the legs towards each other against resistance.
– Functional impairment is common. Sometimes the athlete cannot run but can manage to cycle. The athlete should not participate in explosive sports.
– An X-ray examination may show calcification around the origin of the muscle on the pubic bone.
– An MRI or ultrasound can be helpful.
The distance between the origins of the adductor longus and the rectus abdominis muscles is small, and inflammatory changes probably affect both muscles simultaneously.

Preventive measures

Preventive training with specially designed strength and flexibility exercises is essential and should be included in every training program as an integral part of the warm-up and cool-down. The coach should
be aware of the training levels of the different athletes and should, if possible, vary the training individually with this in mind. Athletes who undergo good basic fitness training are injured less often than others, and this is especially true of muscle injuries.

Treatment

The athlete should:
– rest from painful activities as soon as pain in the groin is felt; the condition will then resolve relatively quickly without any other treatment (this is based on the assumption that the injured athlete does not return to training and competition until there is no tenderness or pain when making movements with the leg under load);
– use general heat treatment in the form of hot baths;
– maintain basic fitness by cycling (preferably on an exercise bicycle) or swimming, using a crawl stroke, but only if these activities are pain-free;
– apply local heat and use a heat retainer in chronic conditions.

The doctor may:
– prescribe anti-inflammatory medication;
– prescribe a special program of muscle training, preferably under the supervision of a physical therapist or athletic trainer;
– administer a steroid injection around the muscle attachment or tendon attachment in question, and also prescribe 1–2 weeks’ rest from excessive exercise after the injection (the injection should only be given when there is distinct tenderness over the attachment into the bone);
– prescribe local heat or other treatment;
– operate in cases of delayed resolution. Surgery often consists of tendon release and/or local removal of damaged tendon tissue.

The following training and rehabilitation program is suitable for anyone who has injured the adductor longus muscle.

1. Warm-up: a light dynamic training program, such as using an exercise bicycle, for 5–10 minutes.

2. Isometric training without loading the adductor muscle, at different joint angles up to the pain threshold.

3. Dynamic training without resistance.

4. Isometric training, gradually increasing the external load.

5. Stretching.

6. Dynamic training with gradually increasing load.

7. Technique-specific coordination or proprioceptive training.

8. Sport-specific training.

Healing and complications

The exercises and movements that caused the inflammatory condition in the adductor muscle should not be resumed until the pain and tenderness have disappeared. If the affected athlete rests immediately pain begins, the condition will heal in 1–2 weeks, but if training is resumed too early treatment can be much more difficult. If the condition is not managed properly there is a risk that it will become prolonged or chronic. Return to sport is often possible within 1–3 months but chronic cases may take a long time if not handled properly after surgery; a return to sport may be possible after 3–5 months.

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