ADDUCTOR INJURIES

cise and can be introduced as early as pain allows. ■ Bridging – place theraband around knees and take hips into slight abduction then lift bottom

■ Bridging – place ball or pillow between knees then lift bottom ■ Non-contractile lengthening, slow and controlled – abduction and extention sling suspension in inner range as pain allows

■ Isometric adduction – supine - start with knees and hips flexed and progress to knees extended and hips neutral

■ Coactivation of adductors with abdominals (31) ■ Hip stabilisation ■ Start functional sports specific exercises as early as possible and gradually increase the programme to include dynamic exer- cises

■ Address factors such as foot biomechanics and technique early in the rehabilitation.

Management of an adductor strain is complicated by the strong desire for early return to sport by both players and coaches. When a player returns to sport too soon there is a danger that the mus- cle sustains repetitive microtrauma leading to scar tissue and ongoing inflammation resulting in recurrence of injury. It is essential to discuss timescales with the patient and explain the injury fully so that they understand the consequence of returning too soon to sport.

Further rehabilitation principles are discussed later in the paper.

FACTORS AFFECTING THE HEALING AND REHABILITATION OF ADDUCTOR STRAINS There are several factors which influence the healing, recovery and rehabilitation of a patient presenting with adductor injury. It is important to be aware of the anatomical features which predis- pose the adductor group to slower healing and to the many fac- tors which result in an acute adductor strain reoccurring and becoming a chronic injury.

1. Anatomical features There are several anatomical features of these muscles which make diagnosis difficult and predispose them to slower healing times and recurrence of injury: ■ The pubic bone has relatively poor blood supply from the periosteal plexus (10). This has a direct impact on the healing rate of damaged tissues attaching on the pubic bone as tissue healing requires good blood supply. In some individuals the adductor longus tendon connects directly with collagen fibres of the pubic bone passing through a partly calcified zone of cartilage. This zone is characterised by poor blood supply and healing is very slow (22)

■ The adductor muscles all arise from a very small surface area on the pubic bone and have very short tendons despite being able to generate large forces for acceleration, deceleration and change of direction

■ Anatomically it is difficult to apply ice and electrotherapy to the groin region.

2 . Pain The adductor muscles are intimately related to the internal layer of fascia which they must split in order to obtain a bony attach- ment on the exterior of the pubic rami (6). This has clinical rele- vance to the patient with adductor strain. Deep fascia is very sen-

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sitive to pulling and stretching. Deep fascia has the same nerve supply as that of the adjacent periosteum and the overlying skin. Following muscle injury scar tissue forms along with adhesions to the deep fascia. Deep fascia is richly innervated and so is scar tissue and when a contracting muscle pulls on scar tissue the pain refers to the nearest overlying skin (6). This helps to explain why some athletes experience a great deal of ‘deep pain’ following adductor muscle injury and they are reluctant to move into range and start concentric and eccentric activities to strengthen. However if these muscles are allowed to become short and tight they contribute to pelvic instability and a vicious cycle develops.

3. Adductor magnus or biceps femoris? As already discussed it can be difficult to correctly diagnose which muscle is injured, even when an athlete presents with an acute adductor strain and a clear mechanism of injury. Many acute injuries go on to become chronic because the muscle or muscle group diagnosed was incorrect, and the rehabilitation selected for the injury was inappropriate.

An excellent example of this situation arising is in the treatment and rehabilitation of an apparent hamstring strain. The athlete presents with buttock or posterior thigh pain and have often self- diagnosed a hamstring strain as they relate pain at the ischial tuberosity to the hamstring muscle (most patients relate pain from adductor muscles to be on the inner thigh and groin area). However both the biceps femoris muscle and the adductor magnus muscle have an origin close together on the ischial tuberosity and the adductor magnus muscle is a one joint muscle capable of gen- erating large forces around the hip and assisting the hamstring muscle group in hip extension.

Following activities such as squats or lunging type activities (for example a game of squash) there may be tenderness over adduc- tor magnus because it assists in hip extension.

It is essential to differentiate between these two muscles. A reha- bilitation regime appropriate for biceps femoris will not include strengthening exercises including hip rotation for full rehabilita- tion of adductor magnus. The adductor magnus muscle may well breakdown and the injury recur. It is worth considering the adduc- tor magnus muscle with the patient who is struggling with ongoing recurring hamstring injury.

4. Muscle imbalances Muscle imbalances can result in a disturbance of the combined

Figure 2: Adductor magnus or biceps femoris? www.sportex.net