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CASE REPORT
Year : 2017  |  Volume : 17  |  Issue : 2  |  Page : 118-120

Assessment and management of adductor strain


Department of Physiotherapy, Rajeev Gandhi College, Bhopal, Madhya Pradesh, India

Date of Web Publication6-Jun-2017

Correspondence Address:
Prachi Khandekar
Department of Physiotherapy, Rajeev Gandhi College, E-8, Trilanga Colony, Shahpura, Bhopal, Madhya Pradesh
India
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DOI: 10.4103/1319-6308.207576

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  Abstract 

Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, adductor muscle strain is one of these most common injuries in athletes who are involved in sports requiring sudden change of direction. High forces occur in the adductor tendons when the athlete must shift direction suddenly in the opposite direction. As a result, the adductor muscles contract to generate opposing forces. An adductor strain that is treated improperly can become chronic and career threatening. Despite the identification of risk factors and strengthening intervention for athletes, adductor strains continue to occur throughout sport. The prevention and management of groin injury remains a substantial issue. The purpose of this article is to let the readers know regarding the conservative treatment options for adductor strain and provide recommendations for sports medicine clinicians for improved treatment and patient outcomes.

Keywords: Adductor muscle strain, shift direction, Taekwondo


How to cite this article:
Khandekar P. Assessment and management of adductor strain. Saudi J Sports Med 2017;17:118-20

How to cite this URL:
Khandekar P. Assessment and management of adductor strain. Saudi J Sports Med [serial online] 2017 [cited 2021 Oct 24];17:118-20. Available from: https://www.sjosm.org/text.asp?2017/17/2/118/207576


  Introduction Top


Adductor muscle strain is a tear or rupture to any one of the five adductor muscles (pectineus, adductor brevis and adductor longus, gracilis and adductor magnus). The most common sports that put athletes at risk for adductor strains are football, soccer, hockey, basketball, tennis, figure skating, baseball, horseback riding, karate, softball, and cricket.[1],[2]


  Pathophysiology Top


In general, groin injuries make up 2%–5% of all sport-induced injuries, of which adductor strain is the usual musculoskeletal etiology of the pain.[3] The arrangement and fusion of adductor muscles, their fibrocartilaginous entheses and differences in vascularity of their proximal tendons may be important anatomical considerations in the pathogenesis and pattern of adductor-related groin pain.[4] The adductor longus is a commonly injured muscle in sport activities.[5],[6],[7],[8],[9] The adductor tendons have a small insertion area that attaches to the periosteum-free bone. This transitional zone is characterized by a poor blood supply and rich nerve supply, which is the cause of high level of perceived pain and poor healing in adductor strains.

Potential risk factors of adductor related strains are different forms of sports, high level of play, age and core stability.[10],[11],[12] Other Risk factors for adductor strain include adductor tightness, previous adductor injury,[13] and hip adductor-toabductor strength imbalance.[14] Common mechanism of the injury is sudden change of direction [15] or violent external rotation with abduction at hip joint while the foot is planted on ground.[16] Strains are usually easily diagnosed on physical examination with pain on palpation of the involved muscle and pain on adduction against resistance.[17] When the muscle is activated, muscle strain injury occurs, most often during eccentric contraction. Pre-season hip strength testing of professional players can identify players at risk of developing adductor muscle strains.[3]


  Discussion Top


In this case, a 20-year-old female, flyweight category, Taekwondo player was assessed who had a complaint of pain in the groin region on the right side which started during stretching. She had difficulty in performing kicking activities since then. The patient came to the center with the complaint of pain in the groin region on right side, which started while performing stretching exercise during warm-up period. As reported by the patient, she had an incidence of medial meniscus tear 1-month back and took physiotherapy for that. Her pain recovered and she again started her training schedule gradually. She had no history of diabetes, asthma, hypertension, gynecological abnormalities, visceral pain, or any history of hernias. Moreover, as reported, she was a nonsmoker, nonalcoholic, and nonvegetarian. When her occupational history was taken, she was a university level player with 2 years of experience. She was training on irregular surface since 7 months with a high intensity, and duration of training was long (approximately 2:30 h/two times a day). She performed warm-up and cool-down activity as per the session.

The pain history was onset - sudden, duration - since 2 days, type - dull aching, localized, site - in groin region on the right side with severity on visual analog scale - 5 on activity and 2 at rest. There was no radiation of pain. It was aggravated by stretching exercises of hip adductors during warm-up and cool-down period and kicking activities. Pain was relieved by rest and icing. Predisposing factors were practicing on rough terrain. There were no sleep disturbances due to pain. On palpation, there was local tenderness of Grade 1.

On general examination, the built was found to be ectomorphic. Posture evaluation in antero-posterior view showed normal alignment with no significant deviations, in lateral view there was normal alignment with no significant deviations, in posterior view also normal alignment with no significant deviations was observed. Gait evaluation revealed no significant deviations. On local examination there was no swelling, scar, and wound. Shoes were examined which showed no corrective insole and no wear–tear. The range of motion and end feel was checked which was found to be about normal and the manual muscle testing done according to the Oxford grading was found to be above average.

The test for flexibility reviled normal length of iliopsoas bilaterally through Thomas test, normal length of rectus femoris bilaterally through Ely's test, normal length of tensor fascia latae bilaterally through Ober's test, and normal length of piriformis bilaterally through piriformis test. Hamstring muscle was tight on the right side assessed through active knee extension test.

The special test done for checking involvement of adductor muscles was Squeeze test which came out to be positive. Resisted isometric testing of right-sided adductor muscles also came out to be positive. Other tests done to rule out other hip joint, pelvis, or sacroiliac joint pathology were Faber's test, hip quadrant test, Trendelenburg test, cough impulse test, Gaenslen's test, and Craig's test, which were all negative. There was no leg length discrepancy. In addition, the femoral nerve involvement came out to be negative. A digital X-ray was also performed which did not reveal any chance of stress fracture.


  Differential Diagnosis Top


A digital X-ray was also performed which did not reveal any chance of stress fracture. The findings reviled and hence it was confirmed that it is not a visceral pain (pain was localized), nerve irritation (no burning or radiation of pain), hernia (pain was not positive with cough impulse), osteitis pubis, and pubic stress symphysis (normal radiographic appearances).


  Treatment Options Top


A physiotherapy management program was planned with short-term goals such as to reduce pain, reduce tenderness, maintain the cardiovascular fitness, improve the strength, improve proprioception and balance and long-term goals such as maintain proprioception and balance, maintain the strength and improve sport-specific skills, and return to sport.

In the initial phase rest, ice massage: 3–4 times a day for 10 min, active pain-free exercises such as hip flexion and extension in different positions were given. Adductor isometrics were advised. Strengthening was gradually progressed through active adduction–abduction, resisted flexion and adduction with resistance band, wall squat exercises, one-leg squat exercises, and muscle energy techniques.

To maintain flexibility around the hip-knee joints and lumbar spine joint, hamstring stretching, supine gluteus stretching, hip flexor stretching, gentle adductor stretching, and iliotibial band stretching were done. Functional strengthening was done with static bicycling, jogging, abdominal stabilization exercises, drop squats, and eccentric adductor strengthening exercises 3–4 times a week. For proprioceptive training, sand walking, one-leg standing, tandem walking, and wobble board exercises were given 3–4 times on alternate days of the week. Sports-specific skills were improved with exercises such as running straight line, running figure of 8, and kicking with weight balls.

Moreover, a home exercise program included icing, exercises and stretching regimes, proper rest, and proper warm-up and cool-down session. A caution was given to not practice on hard surfaces, wear proper guards as required, and maintain a balanced diet and adequate hydration.


  Prognosis Top


A systematic approach was followed in management as a result of which she willingly returned to practice. On examination, the pain on the visual analog scale was found to be 1/10 on rest and 3/10 on activity. Her range of motion and muscle strength was improved. There was a marked decrease in tenderness. There was a positive feedback regarding the exercise as well as training session.


  Conclusion Top


Adductor muscle strain is the most common cause of groin pain among athletes, especially in sports that require kicking, quick accelerations/decelerations, and sudden direction changes, such as soccer and football. These injuries are overlooked most of the times. Hence, a well-defined early assessment is necessary as it does not hinder the athlete's sporting activity and shall not convert into a career-threatening injury.

Designing a strengthening program to address which muscles are weak and which muscles are tight is of great essence. This should generally include strengthening of the muscles around pelvis and core strength. This should be incorporated with stretches to be completed following all training sessions. This will prevent any joint stiffness and allow your muscles and nerves to move at their optimal length.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Maffey L, Emery C. What are the risk factors for groin strain injury in sport? A systematic review of the literature. Sports Med 2007;37:881-94.  Back to cited text no. 1
    
2.
Inklaar H, Bol E, Schmikli SL, Mosterd WL. Injuries in male soccer players: Team risk analysis. Int J Sports Med 1996;17:229-34.  Back to cited text no. 2
    
3.
Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. The American Journal of Sports Medicine 2001;29:124-8.  Back to cited text no. 3
    
4.
Davis JA, Stringer MD, Woodley SJ. New insights into the proximal tendons of adductor longus, adductor brevis and gracilis, British Journal of Sports Medicine 2012;46:871-6.  Back to cited text no. 4
    
5.
Hoelmich P. Adductor-related groin pain in athletes. Sports Med Arthroscopy 1997;5:285-91.  Back to cited text no. 5
    
6.
Morelli V, Smith V. Groin injuries in athletes, Am Fam Physician 2001;64:1405-14.  Back to cited text no. 6
    
7.
Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med 1980;14:30-6.  Back to cited text no. 7
    
8.
Fu FH, Stone DA, editors. Sports injuries: Mechanisms, prevention, treatment. Baltimore: Williams & Wilkins; 1994.  Back to cited text no. 8
    
9.
Inklaar H, Bol E, Schmikli SL, Mosterd WL. Injuries in male soccer players: Team risk analysis. Int J Sports Med 1996;17:229-234  Back to cited text no. 9
    
10.
Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc 2001;33:1423-33.  Back to cited text no. 10
    
11.
Cowan SM, Schache AG, Brukner P, Bennell KL, Hodges PW, Coburn P, et al. Delayed onset of transversus abdominus in long-standing groin pain. Med Sci Sports Exerc 2004;36:2040-5.  Back to cited text no. 11
    
12.
Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004;36:926-34.  Back to cited text no. 12
    
13.
Tyler TF, Silvers HJ, Gerhardt MB, Nicholas SJ. Groin Injuries in Sports Medicine, Sports Physical Therapy 2010;2:231-6.  Back to cited text no. 13
    
14.
Ibrahim A, Murrell GA, Knapman P. Adductor strain and hip range of movement in male professional soccer players. Journal of Orthopaedic Surgery 2007:15:46-9.  Back to cited text no. 14
    
15.
Brukner P. Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill; 2012.  Back to cited text no. 15
    
16.
Zuluaga M. Sports physiotherapy: Applied science and practice. Melbourne: Churchill Livingstone; 1995.  Back to cited text no. 16
    
17.
Hoelmich P. Adductor-related groin pain in athletes. Sports Med Arthroscopy 1997;5:285-91.  Back to cited text no. 17
    




 

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  In this article
Abstract
Introduction
Pathophysiology
Discussion
Differential Dia...
Treatment Options
Prognosis
Conclusion
References

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