DIAGNOSIS

CHRONIC ADDUCTOR STRAIN As discussed, acute adductor strain may be possible to diagnose when the patient provides a clear history of pain at the site of a lesion associated with a recognised mechanism of injury. However, when a patient presents the symptoms of adductor strain and persistent pain over a period of weeks or months, the diagnosis is more involved and may require a multidisciplinary approach to establish a diagnosis.

In such a situation the clinician requires a sound knowledge of all the diagnostic entities which may present with pain in the adduc- tor region. Differential diagnosis for chronic adductor muscle injury includes stress fracture, hernias, urological disorders, low back dysfunction, sacroiliac dysfunction and tumours (21). Some of these differential diagnoses are listed in Box 2. Clearly it may be necessary to involve different fields of medicine to rule out pathologies for example urology and gynaecology.

Subjective history It is essential to spend time taking the subjective history of a patient with chronic groin pain to assist in establishing a diag- nosis. Often the patient has already consulted several clinicians over many months and been through the process already but it is of great value.

■ The patient will often report slow insidious onset of pain ■ The pain is more diffuse and less local - the patient struggles to pin point the location of the pain themselves but will describe deep pain which then radiates down from pubic rami to adductor muscle group

■ The patient often cannot remember an incident which brought on the pain

■ The patient reports pain and stiffness in the groin region in the morning

■ Pain is often felt at the beginning of a match or training which often decreases or disappears after warming up. The pain can reappear at the end of a match.

■ The patient can run in a straight line and at a moderate speed without pain.

■ Running with a change of direction aggravates symptoms (21) ■ Functional difficulties – for example getting out of a car.

Clinical findings ■ Tenderness on palpation over the origin of adductors on the pubic rami

■ General tightness through the adductor muscle group and fas- cial tissue

■ Deep pain at the origin of the adductors on the pubic rami with passive hip abduction

■ Muscle weakness on resisted testing of adductors ■ Deep pain on resisted testing of the adductors ■ Decreased hip range of movement – abduction, extension and rotation

■ Neural tests for obturator nerve may be positive

Further investigations in chronic groin pain A thorough subjective history and careful objective examination may provide a sound diagnosis in the majority of cases of adduc- tor related pain. However, as discussed other synergistic muscles may functionally compensate which makes clinical diagnosis dif-

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ficult (16). Radiologic investigations such as plain x-ray, CT scan- ning, MRI, bone scans or ultrasonography can be useful in this situation as a supplement to assist in diagnosis and also in ruling out other pathology (22). Muscle and tendon injuries can be investigated by ultrasound, MRI or both.

In chronic adductor strain, myositis ossificans can develop which can be detected early by MRI or later by plain x-rays and CT scan. In athletes the most common sites of this injury are the biceps femoris and quadriceps femoris muscles. In horse riders myositis ossificans may develop in the adductor longus muscle (16).

In chronic muscle tears which have not repaired in the early acute phase or have not been allowed to heal properly there are sever- al features characteristic which will be visible on MRI (16). 1. Loss of muscle tissue with normal appearance at the site of injury 2. The loss of muscle tissue is replaced by fibrous tissue 3. Fatty changes within the muscle 4. Atrophy of muscle – lower muscle volume than the unaffected side (16).

Ultrasound has been reported to be reliable in the diagnosis of chronic adductor muscle and tendon injuries with findings corre- lating well to surgical findings in one study of patients with adduc- tor related pain (33). Diagnostic ultrasound has the advantage over MRI as it is much quicker and far less expensive. Ultrasound examination is painless and there is no radiation (21). Diagnostic ultrasound demonstrates muscle tears with fluid accumulation, dis- ruption of bundles and changes in the tissue configuration (16).

Sports medicine assessment and treatment techniques are con- stantly developing. Traditional musculoskeletal assessment is changing to incorporate tests for neural tissue pathology and altered haemodynamics. There are many formats for assessing a patient who presents with chronic groin pain and clinicians vary in their own personal approach and order of assessment.

Note: References can be found at the end of Part 3 on page 20.

3rd Joint sportEX and Sports Massage Association Conference

at Loughborough University 2nd-3rd September 2005

Highlights include:

■ Keynote presentation - The Practical Dynamics of Soft Tissue Treatment of Adductor Strains - by Stuart Hinds, lecturer in remedial soft tissue techniques at Victoria University and RMIT University, Melbourne, Australia

■ Multidisciplinary presentations from the medical support teams of 4 national sports governing bodies ■ Visceral Massage by Stuart Robertson, physiotherapist

For the first time the conference will feature two dif- ferent experience levels. For more information see the back cover or telephone 020 8287 3312.

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