Adductor-related groin pain in competitive athletes - Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections

University of Leeds, Leeds, England, United Kingdom
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 11/2007; 89(10):2173-8. DOI: 10.2106/JBJS.F.00567
Source: PubMed


Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids.
We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms.
On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p < 0.001) at a mean of five weeks (range, one to sixteen weeks) after the injection.
A single entheseal pubic cleft injection can be expected to afford at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of enthesopathy on magnetic resonance imaging.

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    • "The changes at the symphysis may be asymptomatic, but athletes often present debilitating symptoms, slow recover, and high recurrence rate2. The pathogenesis is still debated, the terminology unclear, and many causes, including “sports hernia”3, “athletic hernia”4,5, “osteitis pubis”6,7,8,9, “athletic pubalgia”10, and “adductor-related groin pain”11, and “dynamic pubic osteopathy” may have to be taken into account as differential diagnose. The new concepts of “sports-related chronic groin injury” and ‘groin disruption injury’ describe a condition of chronic groin pain associated with pubic instability12, an overuse syndrome often observed in footballers, ice hockey and tennis players, and, occasionally, in non-athletes, in whom the pelvic instability may occur as consequence of post-partum diastasis of the symphysis or traumatic pelvic diastasis. "
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    ABSTRACT: Background and purpose: In elite athletes, osteitis pubis is a common painful degenerative process of the pubic symphysis and surrounding soft tissues and tendons. We report the diagnostic pathway and the rehabilitation protocol of six elite athletes with osteitis pubis in three different sports, and compare protocol stages and time to return to competition. Methods: 6 athletes (2 soccer, 2 basketball, 2 rugby players) were diagnosed with osteitis pubis stage III and IV according to Rodriguez classification using standard clinical and imaging criteria. After performing a baseline lumbo-pelvic assessment, the rehabilitation protocol described by Verrall was adapted to each individual athlete. Results: The length of time for each stage of the protocol was as follows; Stage 1 (rest from sport) was 26 +/- 5 days, Stage 2 (to achieve pain free running), 18 +/- 5 days, Stage 3 (squad training) 63 +/- 7, Stage 4 (return to competition) 86 +/- 15. Soccer players took longer to return to competition than basketball and rugby players. No recurrences were reported at 2 year follow-up. Conclusion: The protocol presented ensures a safe return to elite athletes. The time from diagnosis to full recovery is longer in football players, and seems to increase with age.
    Full-text · Article · Sep 2014
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    • "Other reasons for referred hip pain might be synovitis or mechanical blockade or the sacroiliac joint, osteitis pubis, muscle injuries and enthesiopathies of the adductors, iliopsoas or hamstrings. Chronic microtrauma and injury to the adductors might be caused by an externally rotating cam-avoidance gait pattern in cam-FAI-patients.28,29 A sports hip triad has been described recently decribed, consisting of a labral tear, adductor strain and rectus strain.30 "
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    ABSTRACT: Hip joint instability and impingement are the most common biomechanical risk factors that put the hip joint at risk to develop premature osteoarthritis. Several surgical procedures like periacetabular osteotomy for hip dysplasia or hip arthroscopy or safe surgical hip dislocation for femoroacetabular impingement aim at restoring the hip anatomy. However, the success of joint preserving surgical procedures is limited by the amount of pre-existing cartilage damage. Biochemically sensitive MRI techniques like delayed Gadolinium Enhanced MRI of Cartilage (dGEMRIC) might help to monitor the effect of surgical or non-surgical procedures in the effort to halt or even reverse joint damage.
    Full-text · Article · Sep 2011 · Orthopedic Reviews
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    • "In this study, use of one or two injections in the pubic symphisis allowed seven out of eight athletes to return to sporting activities after conservative treatment with rest, oral anti-inflammatory medication and hip stretching exercises had failed. A recent non-randomized study examining the effects of an entheseal pubic cleft injection with a local anesthetic and corticosteroid reported good results up to 1 year in a group of patients without magnetic resonance imaging (MRI) abnormalities at the adductor enthesis (Schilders et al., 2007). "
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    ABSTRACT: The objective was to retrospectively examine whether a manual therapy technique is effective in the treatment of chronic adductor-related groin pain in athletes. Thirty-three athletes with chronic adductor-related groin pain were approached. Thirty patients gave their consent to participate in the study. Patient satisfaction, return to activity and numeric pain score were recorded. Patients were treated after prewarming of the muscles; one hand is used to control the tension in the adductor muscles and the other hand is used to move the hip into abduction and external rotation. This flowing, circular motion stretches the adductor muscle group. The movement is repeated three times in one treatment session. Twenty-five out of 30 (83%) athletes reported a good or excellent satisfaction. Twenty-seven out of 30 (90%) athletes had resumed sport at (15/30) or below (12/30) their previous level of activity. The pain score for during or after activity decreased significantly from 8.7 to 2.2 after the treatment (P<0.01). This study shows that the manual therapy treatment might be a promising treatment for chronic adductor-related groin pain in athletes.
    Full-text · Article · Aug 2008 · Scandinavian Journal of Medicine and Science in Sports
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