Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

29. Adductor Longus–Related Groin Pain

Robert T Sullivan and William E. Garrett

DEFINITION

images Groin injuries are common among athletes, accounting for 2% to 5% of all athletic injuries.12

images A broad spectrum of pathology can cause groin pain in the athlete, and the differential diagnosis is critical.

images Adductor longus–related pain is the most common entity, particularly in athletes participating in kicking sports, such as soccer, and in sports requiring rapid directional changes such as ice hockey and American football.6,7,12,13

images Most acute adductor-related groin pain represents strain at the muscle–tendon junction. Although rare, complete avulsions of the adductor longus origin from the pubis can occur.

images Chronic adductor pain typically occurs as an isolated enthesopathy or in concert with athletic pubalgia or pre-hernia complex.

ANATOMY

images The adductor longus is a large, fan-shaped muscle that originates from the anteromedial aspect of the superior pubic ramus just inferior to the pubic tubercle and inserts on the linea aspera of the femur.

images Innervated by the anterior division of the obturator nerve, the origin of the adductor longus consists of direct attachment of both muscle fibers and tendon to the pubis. The proximal tendon has a narrow cross-sectional area.12

images The proximal tendon is readily identified on the anterior surface of the muscle with an oblique muscle–tendon junction. The proximal posterior surface usually is entirely muscular in origin.13

images A common anomaly is muscle fibers forming the lateral 5 to 11 mm of the anterior origin (FIG 1).13

images In maturity, the fibrocartilage of the symphysis pubis develops a small, central fluid-filled cavity or cleft.This cleft manifests as a central focus of high signal intensity at T2weighted and fat-suppressed short T1 inversion recovery (STIR) imaging.3

images

FIG 1  Muscle fibers forming the most lateral aspect of the adductor longus origin.

PATHOGENESIS

images The pathogenesis of chronic adductor strains and frequently associated sports hernias or athletic pubalgia is poorly understood.

images The problem usually is seen in athletes using powerful and ballistic muscle action involving a rapid change from a trunk rotated posteriorly to the plant foot with simultaneous hip extension and abduction followed by a sudden anterior trunk rotation with hip flexion and adduction.

images Examples are an in-step kick in soccer or a fast gait in hockey when the trailing leg is pulled forward, where these actions create strong muscle activity around the lower abdominal muscles and hip adductors and flexors.

images Many of these conditions are chronic or acute on chronic.

images The possibility of a subtle degree of pelvic instability has been considered, but it is difficult to prove.24

images Hip adductor involvement is more likely an abnormality at the insertion than a chronic tendinitis or tendinosis.24

NATURAL HISTORY

images Acute adductor strains at the musculotendinous junction, like other muscle strain injuries, vary considerably in time to recovery based on the severity of the injury. These are almost always managed without surgery.

images Prior adductor strain has been shown to be a significant risk factor for injury.14

images An adductor-to-abductor muscle strength ratio of less than 80% is predictive for a future adductor strain as well. Preseason hip strengthening regimens can lower the incidence of adductor strains.14,15

images In the rare instance of a complete adductor longus avulsion, nonoperative management is preferred.11

images Chronic adductor pain presenting as an enthesopathy may occur simultaneously with athletic pubalgia or may follow an acute strain. Enthesopathy can lead to resistant, chronic groin pain, warranting operative intervention.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The diagnosis of an acute adductor strain is relatively straightforward, because the athlete typically presents with a sudden injury to the groin incurred during athletic competition.

images There is tenderness to palpation at the muscle tendon junction. This pain is exacerbated with resisted adduction and passive abduction. Imaging rarely is required for acute strains, but is more commonly obtained for professional athletes.

images In the setting of a more severe acute injury or avulsion, edema and ecchymosis are present and a defect may be palpated.

images The diagnosis of chronic groin pain is not as straightforward because of the broad spectrum of clinical entities that can cause pain in this region and their similar presentations.

images There is no current diagnostic gold standard for chronic groin pain.

images The differential diagnosis is critical owing to the possibility of other serious disorders; thus, a comprehensive history and physical is warranted in the patient with chronic groin pain.

images The physical findings of chronic adductor pain are similar findings to those of an acute strain, but the examiner is more likely to elicit pain with palpation of the pubic symphysis and is more reliant on imaging, coupled with the examination, for a definitive diagnosis.

images Involvement of the symphysis pubis detected by physical and even radiographic examination is common.

images Chronic adductor-related pain often occurs in conjunction with athletic pubalgia. Sports hernias can present with complaints of vague and migratory lower abdominal pain radiating to the medial thigh.

images Sports hernia findings are pain with a sit-up maneuver or resisted internal rotation of a flexed hip. Tenderness to palpation is found above the inguinal ligament and superior to the pubic tubercle. Tenderness may be more focal, involving the external inguinal ring without a palpable hernia or in the vicinity of the conjoint tendon.

images Physical examination should include.

images Palpation of the adductor longus. Focal tenderness suggests adductor-realated groin pain. A palpable defect implies adductor avulsion.

images Squeeze test. The presence or absence of pain is noted. Strength is graded as follows: mild—minimal loss of strength; moderate—clear loss of strength; severe—complete loss of strength. Pain with or without a strength deficit implies adductor-related groin pain.

images Passive stretch of adductors. Pain localized to the adductor implies adductor-related groin pain.

images Palpation of external inguinal ring. Pain in the absence of a palpable hernia implies a sports hernia.

images Sit-up against resistance. Adductor pain implies a concomitant or isolated sports hernia.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Imaging studies are most effective when selected on the basis of a thorough history and physical examination.

images MRI is the imaging modality of choice to evaluate chronic adductor-related pain.

images Muscle strains have high T2 signal at the muscle–tendon junction, which can extend along the epimysium.

images Enthesopathy, an overuse inury, reveals signal change within the adductor origin and, often, the pubic marrow.

images We believe that osteitis pubis, ie, marrow changes within the pubis, is a radiologic sign rather than a diagnosis, because these changes are most often present in the setting of adductor-related symptoms.

images Robinson demonstrated that patient symptoms and MRI abnormalities within the pubis correlated significantly and reproducibly with symptomatic adductor enthesopathy or chronic myotendinous strain.2,10Thus, pubic marrow changes should alert the clinician to consider an adductor or lower abdominal wall injury.9,10

images Additionally, Cunningham4 demonstrated pubic marrow changes are frequently associated with adductor injury, but adductor enthesopathy is also commonly identified in the absence of pubic marrow changes. This suggests adductor dysfunction most likely precedes pubic marrrow changes.

images

FIG 2  Secondary cleft sign seen on T2-weighted coronal MRI, suggesting a partial avulsion of the adductor longus on the right.

images In addition to signal changes within the adductor origin, muscle tendon junction, or pubis, a secondary cleft sign may be present.

images Brennan et al3 defined the abnormal secondary cleft as an extension of the normal hyperintense signal seen within the central symphyseal cleft to a location lateral to the midline or inferior to the joint.

images The secondary cleft is best visualized on a coronal STIR image (FIG 2). This secondary cleft, like pubic marrow changes, is thought to be a consequence of prolonged traction on the pubic rami and common aponeurosis anterior to the symphysis.

images Chronic injury leads to a communication between the central and secondary clefts owing to a microtear or partial avulsion of the adductor longus from the pubis.3,4

DIFFERENTIAL DIAGNOSIS

images Athletic pubalgia (sports hernia)

images Inguinal hernia

images Acetabular labral tear

images Hip arthritis

images Femoral neck stress fracture

images Hip synovitis

images Referred testicular pain

images Gynecologic pathology

images Coxa saltans

images Iliopsoas strain

images Intra-abdominal disorders

NONOPERATIVE MANAGEMENT

images Adductor-related acute strains and overuse injuries are all initially managed with rest, ice, compression, and elevation (the RICE method) and a brief period of nonsteroidal antiinflammatory drugs (NSAIDs). Differentiation between a strain and an enthesopathy is critical, because musculotendinous strains are managed much more aggressively with early, active therapy.

images Early on, active and passive range of motion without pain is initiated.

images Once full, painless range of motion has been achieved, a progressive strengthening regimen is started. Increased emphasis is placed on core stabilzation and strengthening of the pelvic musculature.

images Resistance training consists predominantly of eccentric exercise for the hip and pelvic musculature.

images Holmich et al5 demonstrated that an active strengthening and coordination program for the pelvic musculature was significantly better than conventional physical therapy in treating chronic athletic-related groin pain.

images Nonoperative therapy is completed with sport-specific training and eventual return to play.

images Early return to play is not advised because of the high risk of recurrent injury. Tyler et al14,15 showed the best predictor of a future groin strain was an adductor-to-abductor muscle strength ratio of less than 80%.

images Acute adductor avulsions are best managed with nonoperative means, despite reports of successful repair.8,11

images Schlegel et al11 reported on 19 acute avulsions in NFL players, where those managed nonoperatively had good outcomes and a markedly shorter recovery time.

images Verall16 reported on a specific nonoperative regimen for sports-related groin pain with MRI-documented pubic stress changes. Twenty-seven athletes were rested for 12 weeks, followed by an active therapy regimen. When evaluated by return to sport criteria, outcomes were excellent.

images However, results were satisfcatory only if the criterion of ongoing symptoms was used, because nearly a third of individuals remained symptomatic during their second season post–nonoperative treatment.

images Additionally, 26% of these athletes were participating at a lower level of competition.

images Holmich et al5 reported on 23 of 29 athletes with chronic adductor-related groin pain returning to symptom-free play at 19 weeks as a result of an active therapy program. Long-term follow-up was not obtained, and these injuries were not stratified regarding strain versus enthesopathy versus avulsion.

SURGICAL MANAGEMENT

images Chronic adductor-related groin pain that has failed nonoperative measures, including an active therapy program focused on strengthening of the pelvic musculature and core stabilization, can be successfully treated with tenotomy of the adductor longus.1 Although adductor tenotomy previously was reserved for patients with spasticity, it clearly has a role in the management of chronic and disabling groin pain in the athlete. Tenotomy is performed as an isolated procedure or in conjunction with a sports hernia repair.

images Individuals suspected of having a concomitant sports hernia are referred to a general surgeon for definitive management.

Preoperative Planning

images Surgical planning consists primarily of an extensive history and physical examination to confirm that the pain is isolated to the adductor and that all appropriate nonoperative measures have been exhausted.

images Additionally, a confirmatory MRI revealing enthesopathy or chronic strain with associated pubic marrow changes or cleft sign is warranted.

Positioning

images The patient is placed in the supine position with the operative extremity in an abducted and externally rotated position (FIG 3). The adductor origin is easily palpated in this position. Only the ipsilateral groin is prepped and draped.

Approach

images The adductor longus is superficial and proximal to the adductor brevis and adductor magnus origins.

images A 3-cm incision is marked about 1 cm inferior and parallel to the inguinal crease. This incision is centered over the palpable tendinous mass.

images

FIG 3  The operative thigh is flexed, abducted, and externally rotated to provide excellent exposure and easy palpation of the adductor origin.

TECHNIQUES

OPEN ADDUCTOR LONGUS TENOTOMY

images  The skin is incised in line with the previous mark down to the underlying fascia (TECH FIG 1A). The fascia is incised in a similar fashion, parallel to the skin incision, revealing the underlying adductor longus proximal tendon.

images  The tendon is readily identified, and care is taken to identify the medial and lateral borders, noting that the lateral aspect often is composed of muscle fibers without a true tendinous component.

images  Once the borders are defined, the tendon is elevated from the underlying adductor brevis and divided with cautery about 1 cm from its pubic origin while protecting the underlying adductor brevis (TECH FIG 1B). Note that the undersurface of the adductor longus is entirely muscular.

images  Remaining proximal also protects the anterior division of the obturator nerve as it runs its course along the anterior aspect of the adductor brevis.

images  Although some have reported suturing the distal stump of the cut tendon to the overlying fascia, this is not necessary; no distal retraction or deformity has been encountered in our experience.

images  The fascia is repaired with an absorbable suture, and the overlying skin is approximated.

images

TECH FIG 1  A. The skin incision is 3 to 4 cm long, just inferior and parallel to the inguinal crease, centered over the adductor origin. B. The distal free edge of the transected adductor longus tendon.

images

POSTOPERATIVE CARE

images Immediate ambulation is permitted without assistive devices. Stretching is avoided until the incision has healed.

images Once the incision has healed, a progresive strengthening and stretching routine is initiated, with an emphasis on core stabilization.

OUTCOMES

images Akermark1 performed isolated adductor tenotomy in 16 athletes with chronic adductor-related groin pain. All patients reported significant improvement. Fifteen of 16 returned to sporting activities within 6 to 8 weeks, and 12 of 16 returned to competitive sports by 14 weeks. Only 10 athletes returned to full athletic competition; five returned to a reduced level of competition.

images As one might expect, patients had decreasesd isokinetic testing relative to the nonoperative side. However, these patients were reported to maintain functional sports activity despite the measured deficit.1

images A definitive recommendation to proceed with adductor tenotomy is difficult, particularly in the high-performance athlete. Therefore, adductor tenotomy is reserved as a last-ditch effort to return the chronicaly disabled athlete to competitive sports with the possibility of participation at a reduced level of performance.

images Additional study investigating nonoperative and surgical intervention of adductor-related groin pain clearly is warranted.

COMPLICATIONS

images There are no reported complications for adductor tenotomy, because few series have been reported.

images We suspect that persistent groin pain attributed to an incorrect diagnosis or an untreated concomitant sports hernia is the most prevalent complication from adductor-related surgery.

REFERENCES

1.     Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med 1992;20:640–643.

2.     Albers S, Spritzer C, Garrett WE, et al. MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270–277.

3.     Brennan D, O'Connel M, Ryan M, et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image, appearance and interpretation. Radiology 2005;235:162–167.

4.     Cunningham P, Brennan D, O'Connel M, et al. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol 2007;188:W291–W296.

5.     Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353:1444–1445.

6.     Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med 2007;41:247–252.

7.     Meyers W, Foley D, Garrett W, et al. Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med 2000;28:2–8.

8.     Rizzio L, Salvo J, Schürhoff M, et al. Adductor longus rupture in professional football players: acute repair with suture anchors: a report of two cases. Am J Sports Med 2004;32:243–245.

9.     Robinson P, Salehi F, Grainger A, et al. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol 2007;188:W440–W445.

10. Robinson P, Barron D, Parsons W, et al. Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings. Skeletal Radiol 2004;33:451–457.

11. Schlegel T, Boublik M, Godfrey J. Complete proximal adductor longus ruptures in professional football players. Presented at American Orthopaedic Society for Sports Medicine Specialty Day, Chicago, March 25, 2006.

12. Strauss E, Campbell K, Bosco J. Analysis of the cross-sectional area of the adductor longus tendon. Am J Sports Med 2007;35:996–999. Epub 2007 Feb 16.

13. Tuite D, Finegan P, Siliaris A, et al. Anatomy of the proximal musculotendinous junction of the adductor longus muscle. Knee Surg Sports Traumatol Arthrosc 1998;6:134–137.

14. Tyler T, Nicholas S, Campbell R, et al. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med 2001;29: 124–128.

15. Tyler T, Nicholas S, Campbell R, et al. The effectiveness of a preseason exercise program to prevent adductor muscle strains in professional ice hockey players. Am J Sports Med 2002;30:680–683.

16. Verall G, Slavotinek J, Fon G, et al. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med 2007;35:467–474.



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