ADDUCTOR INJURIES compressed by fascia overlying the adductor brevis muscle (29).

■ Obturator nerve mobility may be affected by the condition of the psoas muscle as the nerve is formed from the roots of L2, 3, 4 within the muscle belly. Therefore excessive tightness or adaptive shortening of this muscle will have implications for nerve mobility.

■ Stiffness of the lumbar spine and altered biomechanics around the pelvis may result in chronic stretching of the nerve suffi- cient to cause pain.

■ The nerve may become compressed between two muscles for example adductor longus or brevis, adductor magnus and obtu- rator externus or pectineus and obturator externus (32). Tightness and hypertrophy could contribute to this mechanism.

Neural tests for obturator nerve mobility The test of neural mobility specific to the obturator nerve was developed by Butler in 1991. Anatomical tests show that the course of the nerve lies antero-medial to the hip joint axis which indicates the nerve could be stressed by abduction and hip exten- tion. The test needs to include hip internal rotation then tested a second time with hip external rotation due to the position of the anterior and posterior branches of the obturator nerve relative to hip joint axis (28).

The ilioinguinal and genitofemoral nerves may also cause symp- toms but these are anatomically distinct in location from the obturator and femoral nerves. The neurodynamic test involves positioning the upper body then adding the movements of hip extention, hip abduction, and hip internal/external rotation. Cervical extention will be added as the sensitising manoeuver determining any change in their symptoms and thus implicating neural tissue involvement. This manoeuver can differentiate pain from the adductor muscles.

If cervical extension decreases the patient’s pain or allows an increase in the range of passive hip movement the test can be considered positive for altered neurodynamics. A positive response from either leg can be considered positive regardless of

BOX 1: MODIFIED SLUMP KNEE BEND TEST

■ The patient is placed in side lying with the leg to be test- ed uppermost and a pillow under the patients head

■ The patient takes hold of their other knee and pulls this into their chest ensuring cervical flexion

■ The therapist then flexes the knee to 90 degrees without rotating the pelvis

■ The response is recorded ■ The hip is then extended to the end of range ■ The response is recorded ■ The hip is then abducted to the end of range ■ The response is recorded ■ The hip is then internally rotated to the end of range ■ The response is recorded

At this point of the test the subjective description is recorded such as pulling, tightness or pain. The patient then extends the neck from a flexed position to a neutral position and any change in sensation in the groin is monitored. Additionally any change in hip range of movement is recorded. The test is then repeated with the final test being external hip rotation. It can be valuable to test the uninjured side first then the injured side.

which leg is symptomatic. The reason for this is that the unaf- fected side if used for comparison may be affected by the same disorder (26).

The nerve can be tested by a slump long sitting test or the mod- ified slump knee bend test (26). latter (Figure 3 and box 1).

This article will describe the

The modified slump knee bend test, as with any neural test, requires careful handling to maintain joint position throughout. Ideally two therapists is best but as this is not usually possible, use of a gym ball or sling suspension to take the limb weight can be very helpful - especially if you are a short therapist assessing a large rugby player!

BOX 2: DIFFERENTIAL DIAGNOSES FOR ADDUCTOR INJURY

■ Bursae – eg. iliopsoas ■ Joint – SIJ, OA hip, osteitis pubis, perthes disease ■ Nerve entrapment – ilioinguinal, obturator, genitofemoral, femoral

■ Spinal – T12 – L5 lumbar nerves ■ Fractures – pelvic, spinal compression fracture ■ Stress fractures – femoral neck, pubic arches ■ Tumours – metastasis of the spine and pelvis, prostate, lym- phoma, myeloma, osteosarcoma

■ Hernia – inguinal, femoral, spermatocele ■ Infection – UTI, prostate inflammation, appendicitis ■ Kidney disease ■ Altered haemodynamics ■ Infection of lymph nodes

Figure 3: Modified slump test using swiss ball 18 www.sportex.net