Adductor Tendinopathy: Difference between revisions
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== Treatment == | == Treatment == | ||
For the treatment of adductor tendinopathy, rest from aggravating activities is indicated for an acute injury in the first couple of days. Apply RICE treatment 3times a day for 10-20minutes, to help reduce any swelling and inflammation from any sudden trauma.<ref name="5" /><ref name="6" /><ref name="7" /> When the swelling has decreased, blood flow stimulation therapy may be started to increase the healing process.<ref name="6" /> Active treatment is then indicated to maximise rehabilitation. The aim of rehabilitation protocols is to restore muscle and tendon properties, where strength training is beneficial to the tendon matrix structure, muscle properties and limb biomchanics <ref>Ebonie Rio; Dawson Kidgell; G Lorimer Moseley; Jamie Gaida; Sean Docking; Craig Purdam; Jill Cook, Changing the Way we Think About Tendon Rehabilitation A Narrative Review Br J Sports Med. 2016;50(4):209-215.</ref> Current evidence suggests that eccentric based exercise programme is the most effective as well as heavy-slow eccentric and concentric exercises for improving both pain and function in the tendon. Load provides a | For the treatment of adductor tendinopathy, rest from aggravating activities is indicated for an acute injury in the first couple of days. Apply RICE treatment 3times a day for 10-20minutes, to help reduce any swelling and inflammation from any sudden trauma.<ref name="5" /><ref name="6" /><ref name="7" /> When the swelling has decreased, blood flow stimulation therapy may be started to increase the healing process.<ref name="6" /> Active treatment is then indicated to maximise rehabilitation. The aim of rehabilitation protocols is to restore muscle and tendon properties, where strength training is beneficial to the tendon matrix structure, muscle properties and limb biomchanics <ref>Ebonie Rio; Dawson Kidgell; G Lorimer Moseley; Jamie Gaida; Sean Docking; Craig Purdam; Jill Cook, Changing the Way we Think About Tendon Rehabilitation A Narrative Review Br J Sports Med. 2016;50(4):209-215.</ref> Current evidence suggests that eccentric based exercise programme is the most effective as well as heavy-slow eccentric and concentric exercises for improving both pain and function in the tendon. Load provides a positive stimulus to both the tendon and muscle tissues, yet no gold standard exists for tendon rehabilitation, with variations in repetitions, sets and the load applied depending on the stage of rehabilitation and the patient's muscle-tendon response to the exercises. Exercises aim to address the neuromuscular and tendon changes (strength and capacity) in tendinopathy<br> | ||
When the patient is able to do his physical activities without pain, he may resume them gradually by being careful. Physiotherapy is necessary: flexibility and strengthening programs will influence the healing process and avoid the reappearance. <br>The stretching exercises should be executed 3 times daily, complementary to the physiotherapeutic sessions; and the patient may only execute them if they do not cause or increase symptoms. The patient can start with them from day 1, but only if they can be done without pain! <br>The strengthening exercises should be executed daily, and when the patient got back to full activity, he may do them 3times a week. These exercises can begin after the acute phase, when the pain has diminished in time: this may take 5days. <br>The stretching exercises must be done throughout the strengthening program: before and after the session.<ref name="5" /><ref name="8" /> | When the patient is able to do his physical activities without pain, he may resume them gradually by being careful. Physiotherapy is necessary: flexibility and strengthening programs will influence the healing process and avoid the reappearance. <br>The stretching exercises should be executed 3 times daily, complementary to the physiotherapeutic sessions; and the patient may only execute them if they do not cause or increase symptoms. The patient can start with them from day 1, but only if they can be done without pain! <br>The strengthening exercises should be executed daily, and when the patient got back to full activity, he may do them 3times a week. These exercises can begin after the acute phase, when the pain has diminished in time: this may take 5days. <br>The stretching exercises must be done throughout the strengthening program: before and after the session.<ref name="5" /><ref name="8" /> | ||
Revision as of 16:17, 1 June 2017
Description
[edit | edit source]
Adductor tendonopathy describes a number of conditions that develop in and around the tendon in response to overuse [1] At a hispathological level there are changes in the molecular structure of the tendon, typically collagen seperation and collagen degneration [2] and at a macroscopic level typically see tendon thickening, a loss of mechanical mechanical properties and pain [3]. The role of inflammation is still debated as research has demonstrated that there is usually an absence of imflammatory cells around the lesion [4] hence the terminology 'tendonitis' is outdated. The adductors consists of 5 muscles, which can be divided into the long and short adductors: the long adductors (Gracilis & Adductor Magnus) attach at the pelvis extending to the knee and the short adductors (Pectineus, Adductor Brevis & Longus) also attach at the pelvis and extend to the thigh bone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title These adductor muscles help to stabilize the pelvis and pull the legs towards the mid line (adduction).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy[edit | edit source]
These muscles extend from the lower pelvic bone, attaching to the lower femur area around the knee and sit inbetween the flexor and extensor muscles of the thigh. They are used when we cross our legs and help to balance the pelvis in standing and walking.
Adductor Magnus is the largest of the group, sitting posterior to the others. There are 2 parts to the muscle, the adductor part and the hamstring part. The adductor part extends from the inferior pubic ramus and the ischila ramus attaching to the linea aspera of the femur and the medial epicondyle (its tendonous insertion). The Hamstring extends from the ischial tuberosity to the adductor tubercle and the medail supracondyle line. Its actions are adduction, aidng in flexion of the thigh (adductor part) and extension of the thigh (hamstring part).
Adductor longus extends from the superior pubic ramus and the pubic symphysis attaching at the linea aspera. It is a large and flat fan shaped muscle which forms part of the medail border of the femoral triangle. It also forms an aponeurosis which extends to the vastus medialus muscle. It adducts and medially rotates the thigh.
Adductor brevis sits under longus and extends from the inferior pubic ramus to the posterior aspect of the linea aspera. Brevis adducts the thigh.
Gracilis is the only 2 joint muscle, extending from its attachment at the inferior border of the pubic symphysis to the medial surface of the tibia, inserting into the pes anserinus between the tendons of sartorius and semitendinosus. It is the most superficial of the group and acts to adduct the thigh and flex the leg at the knee.
Epidemiology /Etiology[edit | edit source]
The adductors are active in many sports such as: running, football, horse riding, gymnastics and swimming. The repetitive nature of the movements in some of these sports and the constant change of direction in others heavily stresses the adductor tendon.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title which makes athletes more prevelant to adductor tendonopathy and also groin injuries. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Another cause can be the overstretching of the adductor tendons.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The development of adductor tendinopathy is multifactorial. One such factor is a significant (more than 7mm) >REF> leg length difference which affects the gait pattern.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Performing wrong movements during physical activity may also overly stress the adductor tendons. Muscular length differences, strength differences or muscular weakness can also be influencial in developing adductor tendonopathy. Other factors can be; a lack of warming up, inactivity, fatigue, obesity, age-related weaknesses, degeneration or genetics.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Characteristics/Symptoms[edit | edit source]
Adductor tendinopathy is usually felt as groin pain on palpation of the adductor tendons, adduction of the legs and/or of the affected leg. Pain can develop gradually or appear an acute, sharp pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A swelling or a lump may also be felt affected in the adductor muscle(s), stiffness in the groin area or an inability to contract or stretch the adductors.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In severe cases physical activities will be restricted.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis[edit | edit source]
The causes of groin pain can be numerous. Osteitis can be difficult to distnguish with tendinopthy. Other diagnosis' can be; sports or inguinal hernia, iliopsoaas bursitis, stress fracture, avulsion fracture, nerve compression, snapping hip syndrome or chronic prostatitis.
Diagnostic Procedures[edit | edit source]
A physiotherpaist can make an objective diagnosis or further investigations can be undertaken such as; X-ray, Ultrasound, MRI or CT-scan.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Outcome Measures[edit | edit source]
Return to sport at the previous level without pain. (also see Outcome Measures Database)
Prevention[edit | edit source]
To prevent the development of adductor tendonopathy, an athlete should ideally engage in a strength and conditioning programme to work on the factors mentioned, such as improving tsrength and coordination of the muscles, but allowing sufficient periods of recovery and adaptation inbetween training sessions, i.e. not too much training too soon. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The athlete has to develop muscular strength and stability around the groin and pelvic areas by engaging in specific exercises relevant to the demands of their activity/sport and with different levels of difficulty, such as training for speed and jumping for example.
Another important aspect is muscular flexibility. Regular stretching is recommended.
Products such as mobility and muscular supports may also help by alleviating high impacts.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Medical Management
[edit | edit source]
Pain relief recommended in the first instance, although NSAIDS may be ineffective due to non inflammatory nature of the injury. Steriod injections are not always indicated due to the potential for tendon rupture if injected directly into the tendon.
Physical Therapy Management
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Physiotherapy is recommended for the treatment of adductor tendinopathy, where active therapy through an exercise programme is superior to a more passive treatment approach [5] Strengthening abdominal core muscles is also recommended to support the adductors durting activity as well as hip flexion exercises. Exercises should then be tailored to the athlete's specific sport to avoid reccurance. In acute cases, a return to a normal function can be within in a few weeks, but in more chronic cases, rehabilitation can take a number of months before returning to normal, pain free, activities.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Treatment[edit | edit source]
For the treatment of adductor tendinopathy, rest from aggravating activities is indicated for an acute injury in the first couple of days. Apply RICE treatment 3times a day for 10-20minutes, to help reduce any swelling and inflammation from any sudden trauma.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title When the swelling has decreased, blood flow stimulation therapy may be started to increase the healing process.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Active treatment is then indicated to maximise rehabilitation. The aim of rehabilitation protocols is to restore muscle and tendon properties, where strength training is beneficial to the tendon matrix structure, muscle properties and limb biomchanics [6] Current evidence suggests that eccentric based exercise programme is the most effective as well as heavy-slow eccentric and concentric exercises for improving both pain and function in the tendon. Load provides a positive stimulus to both the tendon and muscle tissues, yet no gold standard exists for tendon rehabilitation, with variations in repetitions, sets and the load applied depending on the stage of rehabilitation and the patient's muscle-tendon response to the exercises. Exercises aim to address the neuromuscular and tendon changes (strength and capacity) in tendinopathy
When the patient is able to do his physical activities without pain, he may resume them gradually by being careful. Physiotherapy is necessary: flexibility and strengthening programs will influence the healing process and avoid the reappearance.
The stretching exercises should be executed 3 times daily, complementary to the physiotherapeutic sessions; and the patient may only execute them if they do not cause or increase symptoms. The patient can start with them from day 1, but only if they can be done without pain!
The strengthening exercises should be executed daily, and when the patient got back to full activity, he may do them 3times a week. These exercises can begin after the acute phase, when the pain has diminished in time: this may take 5days.
The stretching exercises must be done throughout the strengthening program: before and after the session.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A few examples: stretching exercises:
- The short adductors:
- sit down like the person on the picture.
- The patient must quietly press the elbows onto the knees until he feels the stretch.
- This may not be painful!
- Hold for 20-30secondsCite error: Invalid
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2. The long adductors:
- stand and open the legs.
- The patient must bend the non-stretching knee and lean to the side of this knee until he feels the stretch
- This may not be painful!
- Hold for 20-30secondsCite error: Invalid
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Strengthening exercises:
- Stand near a table with the blessed leg, with a resistance band around the ankle.
He must keep his back and knee straight. Slowly move you leg away from the table.Cite error: Invalid<ref>tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid<ref>tag; name cannot be a simple integer. Use a descriptive title - A variant: the patient sits down on a chair with the resistance band above the knee.
Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Resources
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add appropriate resources here
Clinical Bottom Line[edit | edit source]
add text here
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
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References[edit | edit source]
1. Tonsoline, P.A., chronic adductor tendinitis in a female swimmer, Buffalo Physical Therapy and Sports Care Services, Williamsville, NY 14221, J Orthop Sports Phys Ther. 1993 Nov;18(5):629-33.
(http://www.ncbi.nlm.nih.gov/pubmed/8268966)
(http://www.jospt.org/issues/articleID.1466/article_detail.asp)
Level of evidence: C
2. http://www.sportnetdoc.com/injury/09-06.htm; http://www.sportnetdoc.com/injury/09-03.htm
Level of evidence: D
see adding references tutorial.
- ↑ Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393–408
- ↑ Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999;27:393–408
- ↑ Soslowsky LJ, Thomopoulos S, Tun S, Flanagan CL, Keefer CC, Mastaw J, Carpenter JE. Neer Award 1999. Overuse activity injures the supraspinatus tendon in an animal model: a histologic and biomechanical study. J Shoulder Elbow Surg. 2000;9:79–84
- ↑ Puddu G et al. (1976) A classification of Achilles tendon disease. Am J Sports Med 4: 145–150
- ↑ Dr Per Hölmich, MD, Pernille Uhrskou, PT Lisbeth Ulnits, PT Inge-Lis Kanstrup, DMedSci Michael Bachmann Nielsen, PDMedSci Anders Munch Bjerg, MSc Kim Krogsgaard, Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial, 6 February 1999
- ↑ Ebonie Rio; Dawson Kidgell; G Lorimer Moseley; Jamie Gaida; Sean Docking; Craig Purdam; Jill Cook, Changing the Way we Think About Tendon Rehabilitation A Narrative Review Br J Sports Med. 2016;50(4):209-215.
