Chronic myotendinous groin injuries

In the athlete with longstanding groin pain the symptoms are often more diffuse. In some cases the symptoms even seem to be contradictory and confusing. The athlete describes the pain as 'moving around' and the examiner will have to be aware of the possibility that more than one cause for the chronic groin pain very often can be found [11,16]. The multiple clinical entities responsible for the chronic groin pain are probably the result of the 'first' injury causing an imbalance and altered function affecting the pelvic stability, thus stressing other structures related to the pelvis. Pain from the sacroiliac joints, the low back or the sacrotuberal ligaments are not uncommonly found in combination with myotendinous groin injuries.

In the literature the three most frequently mentioned causes for chronic groin pain in athletes are (i) adductor-related groin pain, (ii) lesions to the inguinal canal and associated structures and (iii) iliopsoas-related groin pain.

Etiology

Adductor-related pain is a frequent cause of groin pain [S,:7]. Fatigue, overuse or acute overload of the adductor muscles during sports activities may lead to injuries. The adductor muscles act as very important stabilizers of the hip joint [18], and as such are at risk if the load on the hip joints and the pelvis is no longer balanced. Injuries influencing the stability of the hip joints and the pelvis might thus precipitate overuse problems of the adductor muscles.

The iliopsoas muscle (Fig. 6.3.7) is a very important contributor to the pelvic stability constantly involved in most sports activities. The precise functions of the iliopsoas muscle apart from hip flexion are not yet fully understood, but the muscle seems to work as a pelvic stabilizer as well as a stabilizer for the lumbar spine [19]. One reason why the muscle is at risk could be that the workload on the muscle includes a considerable amount of both eccentric and concentric work and fast changes between these work forms. Another reason could be that this muscle is 'hidden' to the athlete's knowledge and is difficult to examine clinically. Knowledge of the preventive measures usually practiced for other muscles at risk such as strength training and stretching is thus sparse, and both strains and overuse injuries in the iliopsoas muscle might develop into a chronic problem.

Lesions to the inguinal canal and associated structures are probably in most cases of a myotendinous nature as well. In some cases a predisposition to hernia development might be present. In other cases an acute trauma or a period of overuse as a result of a misbalanced pelvis combined with a period of strenuous athletic activity can result in a chronic lesion. The primary lesion can be in the rectus abdominis muscle or insertion, the external oblique, internal oblique and/or transversalis muscle(s) or aponeurosis, and the conjoined tendon [8]. The nature of the lesion is not clear, since it may be a strain or tear, an inflammation or degeneration of certain points of excessive stress, or an avulsion, a

Fig. 6.3.7 The pelvis with the iliopsoas muscle complex.

Fig. 6.3.7 The pelvis with the iliopsoas muscle complex.

hemorrhage or an edema. The problem is discussed further in the section on 'Sports hernia'.

Clinical presentation

The typical complaints from an athlete with myotendinous-related chronic groin injury are pain and stiffness in this region in the morning and at the beginning of athletic activity. This pain and stiffness decreases and sometimes disappears after a period of warming up, but may reappear when the athlete gets fatigued or after the sports activity has ceased. Pain when coughing and sneezing and when standing on one leg to pull on socks or pants is a frequent complaint. The athlete can usually run forward and straight without pain at a moderate speed, but with increasing speed and/or sudden changes of direction the groin pain reappears. Characteristic activities causing pain include sprinting, making cutting movements, kicking the ball and making a sliding tackle.

When the pain is adductor related it is localized medially in the groin and may radiate down along the adductor group on the medial side of the thigh, whereas when the injury is iliopsoas related, the pain is localized to the central anterior part of the proximal thigh, and thus more laterally in the groin. It sometimes radiates down the anterior thigh and sometimes involves an element of lower abdominal pain lateral to the rectus abdominis muscle.

Myotendinous pain localized to the lower abdomen is most prominent around the conjoined tendon insertion at the pubic bone and may radiate into the adductor region and in males to the scrotum.

Chronic injuries related to the rectus femons or the sartorius are more rare. They are usually located at the proximal end of the muscle and tendon close to the insertion.

Chronic groin injuries are in some cases preceded by an acute episode, but more frequently the athlete has no recollection of this. A pattern of a sudden increase in training, including the intensity, the training methods or the total amount, in the period before the appearance of injury is typical. For example, an iliopsoas-related overuse problem can typically be sustained by increased repetitive hip flexion as when running uphill or by intensive kicking exercises in soccer or football.

Stress fracture is an important differential diagnosis including stress fracture of the femoral neck, the sacrum, the pubis and the ischium (see below). When there is a sudden onset of pain without an adequate trauma, when weight bearing is painful and when the pain is persistent without a corresponding palpation pain, a stress fracture should be considered.

When clinically examining the athlete with longstanding groin pain, it is important that the palpation and functional testing is very accurate, as the muscle insertions as well as other potentially injured structures are closely located (Fig. 6.3.2), and the functions of the muscle groups are somewhat similar.

Using a set of precisely defined and reproducible examination techniques, it has been suggested that a number of diagnostic entities concerning athletes with groin pain should be defined [11]. It is recommended that the term 'diagnostic entities' is used instead of the term 'diagnosis' since the evidence-based data needed to define a precise diagnosis are not yet available. Terms such as adductor tendinitis, osteitis pubis, sym-physitis and others in relation to these patients are so far without scientific basis.

Tenderness of the origin of the adductor longus and/or the gracilis at the inferior pubic ramus, and groin pain on resisted adduction are typical findings in what has been suggested to be defined as 'adductor-related groin pain' (Fig. 6.3.8). Decreased adductor muscle strength and groin pain on full passive abduction often with a decreased range of abduction are also frequent signs. Tenderness over the pubic symphysis

Painful Insertion Pic
Fig. 6.3.8 Palpation of the adductor longus and gracilis insertions. The painful site is usually found at the bony part of the insertion into the pubic bone. Pain at the tendon itself is a more rare finding indicating a tendinosis inside the tendon.
Table 6.3.1 Clinical signs of the three most common musculotendinous groin injuries in athletes.

Adductor-related

Iliopsoas-related

Inguinal canal-

groin pain

groin pain

related groin pain

Tenderness at the adductor tendon insertion

***

Pain at adduction against resistance

***

Decreased muscle strength of the adductors

**

Pain with passive stretching of the adductors

*

Tenderness of the iliopsoas in the lower abdomen

***

Pain with passive stretching of the iliopsoas

***

Tightness of the iliopsoas

**

Tenderness at the symphysis joint

**

**

**

Tenderness at the conjoined tendon

***

Tenderness of the inguinal canal

***

***,Most common presenting sign;**,common presenting sign; *,less common presenting sign.

***,Most common presenting sign;**,common presenting sign; *,less common presenting sign.

and sometimes also of the insertion of the rectus abdominis muscle on the pubic bone are findings often seen with adductor-related groin pain (Table 6.3.1). Examination techniques for these finding have proven to be reproducible [11].

The definition of 'iliopsoas-related groin pain' includes pain when palpating the muscle through the lower abdominal wall combined with pain at passive stretching of the muscle using the Thomas test position [21]. Frequently the iliopsoas muscle is also tight and palpating it just distal to the inguinal ligament is often painful (Table 6.3.1). The palpation of the muscle is done above the inguinal ligament and lateral to the rectus abdominis. It can also be palpated in the area just below the inguinal ligament lateral to the femoral artery and medial to the sartorius muscle (the only area where the iliopsoas is directly palpable). The Thomas test should be performed to assess the tightness of the iliopsoas, and if passive stretching of the muscle is painful. The test is done in the supine position: both knees are brought to the chest and then one leg is held in this position while the other leg is allowed to return to extension; the patient might lift the head and shoulders in order to straighten the lumbar lordosis (Fig. 6.3.9). Incomplete extension is a sign of a tight iliopsoas muscle. Pressure by the examiner's hand to extend the hip further is a test for pain on passive stretching. The above-mentioned tests for the iliopsoas were all found to be reproducible [11].

Muscle weakness and pain when flexing the hip joint

Fig. 6.3.9 The Thomas test is very useful for evaluating the flexibility of the iliopsoas muscle and the rectus femoris muscle. The position is also valuable in order to passively stretch the iliopsoas muscle and in testing it for pain during passive stretching.

against resistance at 90° is often found. Sitting with the legs stretched and then elevating the heels might result in pain since only the active hip flexor in this position is the iliopsoas: this is known as Ludloff's sign [22].

Imaging techniques can sometimes be helpful in the diagnosis of musculotendinous groin pain. Osteitis pubis-like radiologic changes around the symphysis joint are frequently found but are not specific enough (see elsewhere in this chapter). Calcified spurs can in some instances be seen along the adductor insertions. Increased uptake on the affected side in a bone scan seems to be correlated with adductor-related groin

Fig. 6.3.10 Ultrasound examination of the iliopsoas tendon (indicated by arrows) near the insertion at the trochanter minor of the femur (indicated by asterisk). The tendon is thickened and the signals from this part of the tendon are more hypoechoic than in the normal tendon. Courtesy of Michael Bachmann Nielsen.

Fig. 6.3.10 Ultrasound examination of the iliopsoas tendon (indicated by arrows) near the insertion at the trochanter minor of the femur (indicated by asterisk). The tendon is thickened and the signals from this part of the tendon are more hypoechoic than in the normal tendon. Courtesy of Michael Bachmann Nielsen.

pain [11,12]. MRI also seems to show increased uptake in the same region (Fig. 6.3.5). Ultrasonography can visualize the enthesopathy of the adductors, and is also useful in detecting pathology in the lower part of the iliopsoas muscle and tendon (Fig. 6.3.10). At the time of writing all three imaging techniques lack scientific documentation for these conditions.

Treatment—chronic injuries

Various treatment modalities for chronic groin pain have been suggested in the literature. Most modalities are based on the experiences of clinical practice, lacking randomized trials.

Adductor-related pain

One clinical randomized trial [11] has described a specific exercise program found to be highly effective in the treatment of adductor-related groin pain. The trial included 68 male athletes. Seventy-five per cent of the patients trained at least 3 times a week in the period before they sustained the injury. On average they had had their symptoms for 9 months, and 75% had ceased to participate in sport. The control group was randomized to receive physiotherapy without training. The exercise group received a training program including static and dynamic exercises aimed at improving the muscles stabilizing the pelvis and the hip joints, in particular the adductor muscles. Both groups received the same amount of physiotherapy, and after the treatment period they received identical instructions about sport-related rehabilitation before returning to sports participation.

At follow-up 4 months after the end of the treatment period, 79% of the patients in the exercise group vs. 14% in the physiotherapy group were without pain at clinical examination and could participate in sport at the same or a higher level of activity without any groin pain. The patients' subjective assessment accorded with the objective outcome measures.

The exercise program consisted of two modules. The first module was a period of 2 weeks with careful static and dynamic exercises to teach the patient to reactivate the adductor muscles (Fig. 6.3.11). In most cases the athlete with adductor-related groin pain has difficulties activating these muscles, probably as a result of negative feedback caused by the pain. In the second module the exercises were gradually more demanding; heavier resistance training as well as challenging balance and coordination exercises were added (Fig. 6.3.12). The groin exercise program was performed three times a week and the exercises from module 1 were done on the days in between the treatment days. The total length of the exercise training period was between 8 and 12 weeks. Sports activities were not allowed in the treatment period. Riding a bicycle was allowed if it did not cause any pain. After 6 weeks of the treatment period jogging was allowed as long as it did not provoke any groin pain. The exercise rehabilitation program stopped when neither the treatment nor the jogging caused any pain. The athletes were then allowed to increasingly progress to demanding sports-specific training towards final sports participation.

No stretching of the adductor muscles was allowed during this 2-3-month exercise training period. However, stretching of the other lower extremity muscles was recommended, in particular stretching of the il-iopsoas muscle. The iliopsoas muscle is often affected in patients with longstanding groin pain and it is the experience that proper stretching is a good treatment and prevention of iliopsoas-related pain.

We do not recommend steroid injections to athletes with adductor-related groin pain. In our experience

Fig. 6.3.11 (a) Static adduction against soccer ball for 30 s with 10 repetitions to reactivate the adductor muscles. (b) One foot sliding with pressure against the floor to activate the adductors and abductors, both eccentric and concentric, since both the sliding leg and the standing leg will be active.

Fig. 6.3.11 (a) Static adduction against soccer ball for 30 s with 10 repetitions to reactivate the adductor muscles. (b) One foot sliding with pressure against the floor to activate the adductors and abductors, both eccentric and concentric, since both the sliding leg and the standing leg will be active.

Image Coordination Exercise
Fig. 6.3.12 One-leg coordination exercise flexing and extending the knee and swinging the arms in the same rhythm and at the same time keeping the truncus stable (cross-country skiing on one leg); five series of 1 min for each leg.

there is no long-term beneficial effect in these patients, and if the injections affect the pain temporarily, it only makes it more difficult to monitor the training program needed to cure the groin pain [11].

There are a limited number of scientific studies supporting surgery in the treatment of adductor-related chronic groin pain. A number of papers concerning adductor tenotomy have been published. Akermark and Rolf [24] suggest an adductor longus tenotomy 1 cm from the insertion, and Neuhaus [23] suggests that the tendon be cut at the insertion. Meyers et al.

[25] suggest that the adductor longus tendon be released 2-3 cm from the insertion and that multiple longitudinal incisions are made into the tendinous insertion. On the other hand Martens et al. [26] suggest a tenotomy of the gracilis tendon close to the insertion combined with a rectus abdominis plasty.

It is the experience of the authors that a tenotomy of the adductors is seldom indicated. Most patients can probably be treated successfully with the above-mentioned training program combined with sufficient treatment of concomitant injuries.

Iliopsoas-related groin pain

The authors' preferred treatment of this pain entity consists of stretching and careful dynamic strengthening—both concentric and eccentric — combined with a series of pelvic stabilization and balance exercises. Supplementary physiotherapy including massage and trigger point stimulation might also be helpful. If the treatment regimen is not progressing satisfactorily a steroid injection may be considered. The injection seems to alleviate the pain and the tension of the muscle thereby making it easier to stretch and strengthen the muscle. The injection can be technically difficult. It is placed just under the muscle fascia and along the tendon. Preferably the injection is done guided by real-time ultrasound. If ultrasound is not available the injection should be placed in the area just distal to the inguinal ligament, lateral to the femoral vessels and nerve and medial to the sartorius muscle.

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