Anterior - groin - adductor

Can be acute onset, after episode of eccentric contraction of adductors or gradual onset due to cumulative stress.

Mainly incomplete tears close to the musculo-tendinous junction (Weir et al, 2011). Adductor longus is the most affected accounting for 62% of strains (Weir et al, 2011, Tyler et al, 2014).

Risk factors: Level 2 evidence to suggest that previous injury, higher level of play, and relative hip add/ abd strength (Tyler 2001 suggests adductor strength should be > 90% of abductors) and lower level of sports specific training (Whittaker et al, 2015,Weir et al, 2015) can all lead to increased risk of developing groin pain.

Pain is located normally medial groin, medial thigh and scrotum.

Aggravating factors: kicking, turning/twisting, running, end-range hip abduction/ extension.

Prevalence

Mainly young sporting males with an increased incidence in soccer, Aussie rules, rugby and ice hockey. Thought to be the most common cause of groin pain. Werner et al (2009) quotes 65% all football injuries are adductor related.

For a test to be positive it should reproduce the patient's reported pain. Some of these tests have shown reliability and validity in the diagnosis of groin pain.

Squeeze test (Video Link)

Shown to be reliable and valid (Malliaris et al (2009), Verall et al, 2005).

Position patient in supine, resist abduction at medial aspect of knees with hips at 45° flexion and knees flexed to 90° (Verrall et al, 2005).

Bent knee fall out (Video Link)

Shown to be reliable and valid (Malliaras et al, 2009).

Performed in supine, let knees fall out bilaterally to the side. Measure distance from fibular head to floor or bed. Felt to assess adductor flexibility/ guarding. May also be limited by other structures e.g. anterior capsule.

Palpation (Holmich et al, 2004 and Weir et al, 2015).

With patient in supine with knees in unilateral bent knee fall out. Tendon of adductor longus can be palpated below the pubic tubercle.

Resisted adduction

In varying degrees of flexion (0, 90°) (Holmich et al, 2004, and Lovell et al, 2012).

Hip Joint screening tests

Many different tests are available to assess the hip joint. These are a few of the most commonly used tests:

• Hip flexion looking for limitation and/ or pain
• Hip internal rotation looking for limitations and/or pain
• Impingement test (Video Link)
  
  Flex hip to 90 ° then adduct and internally rotate thigh. A positive test produces groin pain.
• FABER (Video Link)
  
  The hip is placed in flexion, abduction, and external rotation (a figure 4).The examiner applies a posterior directed force against the medial knee of the bent leg towards the table top whist fixing the opposite ASIS. A positive test occurs when groin pain or buttock pain is produced.

MRI used for diagnosis of exclusion and to confirm adductor tendon or pubic symphysis pathology.

• Optimise pain management
• Minimise tendon compression (hip abduction and hip extension) e.g. reduce stride length
• Optimise muscle function + tendon loading
• Muscle re-training (isometrics → functional exercise)
  • All advice and treatment should not ‘flare’ symptoms watch for 24 hour pattern
  • Load modification and reduction in activity levels (running/sports) may be required
  • Restore patient's normal range (Verrall et al, 2005).

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment, based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Conservative management efficacy not well documented.

Moderate (Grade 2) evidence to suggest :

Supervised Exercise

An active supervised physical training programme has a higher success rate and percentage of players returning to sport than passive modalities alone (Holmich et al, 1999).

Multimodal Treatment

A systematic review (Serner et al 2015) suggested moderate evidence that:

• an active physical training programme (adductor and abdominal strengthening and coordination exercises) is superior to passive physical therapy (consisting of laser, transverse frictions, adductor stretching and electric nerve stimulation) for long standing groin pain.
• Multimodal treatment (consisting of adductor warming, a specific manual adductor stretch, static adductor stretches and a return to running programme) enables a quicker return to sport than the physical training programme (consisting of adductor and abdominal strengthening, coordination exercises and a running training programme) for longstanding groin pain.

Adductor strengthening (consider concentric and eccentric)

• Isometrics if very sore +/ weak

Lumbo-pelvic Region

May need to incorporate exercises for other muscles around lumbo-pelvic region (Holmich et al, 1999 and Weir et al, 2015).  Progress as symptoms allow

Hip ROM (Verrall et al, 2005 and Verrall et al, 2007)

Improve / restore

Non evidence based strategies

Physiotherapy interventions commonly used in treatment of musculo- skeletal conditions with insufficient evidence:

• Relative rest
• Hot/cold
• Electrotherapy
• Transverse friction massage
• Manual therapy

Adductor stretching

Only indicated if found to be short on muscle length testing, shortening may be muscle guarding. Holmich et al (1999) advises against stretching.

Generally 3 – 4 months to see significant improvement but may take up to 6 months (Morelli and Smith, 2001).

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

• Discuss with senior member of staff
• Consider onward referral to Orthopaedics or General Surgeons for imaging and surgical decision
• Surgery is rare, but partial release of adductor longus has been shown to be effective for return to sport over time

Holmich, P., Holmich, L.R. and Bjerg, A.M. 2004. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. British Journal Sports Medicine: 38: 446-51. Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Holmich, P., Uhrskou, P and Ulnits, L., Kanstrup, I.L., Nielsen, M.B., Bjerg, A.M. and Krogsgaard, K. 1999. Effectiveness of active physical training for long standing adductor- related groin pain in athletes: ramdomised trial. The Lancet: 353 (9151) : 439-443 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Lovelle, G.A., Blanch, P.D. and Barnes, C.J. 2012. EMG of the hip adductors muscles in clinical examination tests: Physical Therapy in Sport:13; 134-140 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Malliaras, P., Hogan, A., Nawrocki, A., Crossley, K. and Schache, A. 2009. Hip flexibility and strength measures: reliability and association with athletic groin pain, British Journal of Sports Medicine 43: 739 -744 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Morelli, V. and Smith, V. 2001. Groin injuries in athletes. American Family Physician; 64 (8): 1405-14 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Verrall, G.M., Hamilton, I.A., Slavotinek, J.P., Oakeshott, R.D., Spriggins, A.J., Barnes, P.G. and Fon, G.T. 2005. Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. Journal of Science and Medicine in Sport 8(1):77–84 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A.G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., Tyler, T., Verrall, G., de Vos, R.J., Vuckovic, Z. and Holmich, P. 2015. Doha agreement meeting on terminology and definitions of groin pain in althletes. British Journal of Sports Medicine 49 (12): 768-774 Link Here (link correct as of 22/01/22). NHS Scotland Athens username and password may be required.

Weir, A., Jansen, J.A., van de Port, I.G., Van de Sande, H.B., Tol, J.L. and Backx, F.J. 2011. Manual or exercise therapy for longstanding adductor-related groin pain: a randomised controlled clinical trial. Manual Therapy 16(2): 148–54 Link Here(link correct as of 22/01/21 ). NHS Scotland Athens username and password may be required.

Werner, J., Hagglund, M., Walden, M. and Ekstrand, J. 2009. UEFA injury study: a prospective study of hip and groin pain in injuries in professional football over seven consecutive seasons. British Journal of Sports Medicine 43(13): 1036-40 Link Here(link correct as of 22/01/22). NHS Scotland Athens username and password may be required.

Musculoskeletal (MSK) Physiotherapy - NHSGGC - hip self help and information

NHS Inform - Hip Problems