adductor tears athletes

Adductor Tears in Athletes: Diagnosis and Rehabilitation

introduction

An injury to Pro Bowl tackle Lane Johnson of the Philadelphia Eagles has been prominent in headlines recently.  He was forced to leave the week 14 matchup against the New York Giants and was initially diagnosed with an abdominal strain.  Lane was then a limited participant for a portion of the practice the following week but was ruled out for week 15. 

He has had further imaging with an MRI of the area and a consult with Dr. William Meyers, who is the most prominent surgeon in the field of core muscle injuries in athletes.  An update afterwards followed stating that he will delay surgery until after the playoffs are finished for the now 13-4 Philadelphia Eagles. 

Lane Johnson Adductor tear

Image 1: Lane Johnson walks off the field. Adopted from [9].

We will try to briefly describe the nature of adductor injuries, treatment and return to play.   However, this is an extremely complicated area when dealing with chronic injuries.  Lane Johnson’s injury was initially described as an abdominal injury and then reports came out it was an adductor tear, but no official diagnosis has been made public to our knowledge. It is likely the low abdomen/adductor region given his course and plan.

The core area superficially includes the rectus abdominis, external oblique, inguinal ligament, adductor muscle group and pectineus (Figure).  The psoas major, iliacus and tensor fascia lata are all more lateral in nature but can contribute to adductor and core muscle pain.  A lesser known area that is extremely important is the pubic aponeurosis and surrounding area.  This includes the external oblique aponeurosis, internal oblique aponeurosis, transverse abdominis aponeurosis, superficial inguinal ring and conjoint tendon (Image 2)

Adductor anatomy

Image 2.  Adductor anatomy including pubic aponeurosis.  Adopted from [1].

The First World Conference on Groin Pain in Athletes brought together a group of leaders in the field of core muscle injuries and groin pain. The results of this Doha agreement were published in 2015 and provided four new subcategories of groin pain: adductor-related, inguinal-related, pubic-related, and iliopsoas-related groin pain [1]. These terms are useful in that they promote more precise descriptions of the anatomic structures involved and reflect that there are many processes that contribute to groin pain in athletes.

Adductor injuries account for 2 to 5 percent of sports injuries and five to eighteen percent of injuries in professional tennis and soccer athletes due to the nature of the sport.  They are also common in track, hockey, rugby and tend to affect men more than women [1]. Previous groin injury, higher level of play, reduced hip adduction (absolute and relative to abduction) strength and lower levels of sport-specific training are associated with an increased risk of groin injury in athletes [1].

Many times acute adductor injuries are acute on chronic injuries.  Some athletes will have some underlying tendinosis before any acute injuries occur.  The mechanism usually involves quick kicking or cutting activity.  There is usually a history of acute pain over the region and the athlete is unable to continue in some cases.  Many athletes describe pain with any walking or weight bearing activity.  Some may describe a tearing sensation or a “pop” in the region.

physical examination

On physical examination, the provider should visualize the area.  Ecchymosis or soft tissue swelling may be present in the area and it is important to compare both sides.  The proximal adductors and pubic rami should be palpated and will likely be tender to palpation and a defect may be present.  The abdominal obliques, transversus abdominis, and conjoined tendon/rectus abdominis should also be palpated for tenderness [2]. There may be localized tenderness at or just above the pubic tubercle, near the rectus abdominis insertion, lateral edge of the rectus or along the conjoined tendon.  If there was an acute injury, there will likely be significant weakness with resisted adduction.  The valsalva maneuver may elicit pain in the region.  A Trendelenberg or antalgic gait may be present.  It is rare to have sensory deficits in adductor injuries.  The hip should also be examined to rule out pathology involving the hip directly.

imaging

Many providers will begin imaging evaluation with plain radiographs.  This should include an AP pelvis view to rule out any type of avulsion fracture and to evaluate the pubic symphysis.  The hip is usually evaluated with plain radiographs in many cases also due to the nature of the injuries and anatomy of the region.  Documenting the presence of femoroacetabular impingement and hip dysplasia is useful in understanding and treating the acute injury, aids in the workup of future injuries or pain, and informs how an athlete should train with respect to injury prevention [3].

Depending on the nature of the injury, additional imaging may be ordered or performed.  An ultrasound may be performed at bedside and can help evaluate the adductor musculature for any defects in the musculature and rule out any type of avulsion.  For imaging the adductor muscles and tendons, most suggest using a high-frequency transducer (7 to 17 mHz) probe as opposed to a lower frequency.  Magnetic resonance imaging (MRI) is ordered in some cases and can be very helpful in evaluating acute on chronic pain.  If acute on chronic pain is being evaluated or if the area of tenderness is more widespread than anticipated, the surrounding areas may be best evaluated with an MRI.

Adductor tear on US and MRI

Image 3: Ultrasound of adductor tear in sagittal plane (a) and T2 weighted MRI of adductor tear.  Adopted from [8].

Grading for acute or isolated injuries falls under similar grading as hamstring injuries.  Grade 1 involves a tear of a small number of muscle and/or tendon fibers that causes pain but no or minimal loss of strength or motion.  Grade 2 injuries involve tearing of a significant number of muscle and/or tendon fibers causing pain, swelling, decreased motion, and decreased strength but not complete loss of function.  Grade 3 injuries involve complete disruption of the muscle-tendon unit with loss of function.

treatment

Management depends on the grade of the injury and should be determined on a case by base basis.  If a lower grade injury is suspected or confirmed, nonoperative treatment will likely be used.  Some providers will use crutches and suggest either protected (partial) or non weightbearing until the athlete can comfortably bear weight without limping.  This can be quick for some athletes and up to a couple weeks in others.

Further treatments can be used in the next phase.  These include joint and soft tissue mobilization, myofascial release, mechanical and proprioceptive support through taping, stretching, reeducation of motor control, and strengthening of the injured muscle and related kinetic chain. A basic rehabilitation program for acute uncomplicated adductor muscle and tendon strains is a common practice for many athletic trainers and physical therapists.  An important aspect of treatment is assessment of the patient’s posture and movement patterns to identify factors or other reasons that may have predisposed the athlete to the injury.  Recognizing and addressing these biomechanical flaws are important to successful rehabilitation and prevention of recurrence.

Athletes performing rehabilitation for acute adductor muscle and tendon injuries may return to sport based on clinical criteria.  This includes pain-free completion of clinical assessments and sport-specific drills [4].  Clinical assessments often include muscle and tendon palpation, active and passive stretch, isometric and dynamic muscle contraction against resistance.

High-grade and complete (grade 3) tendon tears may require surgery and referral to an orthopedic surgeon is warranted. The same holds true for chronic injuries (≥3 months duration) of the adductor longus origin, which may also involve the conjoined tendon and/or be part of a complex injury.  However, it has been shown that surgery is rarely necessary for isolated adductor injuries. 

In a 16-year study of Union of European Football Associations (UEFA) soccer athletes with adductor injuries, 4 percent required surgery [5]. Another systematic review of surgical versus conservative management of traumatic proximal adductor longus avulsion injuries in 46 athletes concluded that both treatments enabled patients to resume their preinjury activity level, but that surgically treated patients required a longer time to return to sport .  This same study also showed that injuries graded 0-2 returned within 3 weeks and grade 3 injuries average return to full sport at around 3 months.

One 2009 study compared nonoperative versus operative treatment in nineteen NFL athletes with adductor longus ruptures.  Fourteen were treated nonoperatively and five were treated operatively.  Mean time for return to play was 6 weeks (range 3-12 weeks) for the non operative group and 12 weeks (range 10-16 weeks) for the operative group.  The study concluded that nonoperative treatment showed a similar return to play likelihood but was much quicker and avoided any risks of surgery.

Return from adductor injuries in NBA athletes from 2010 to 2019 was recently evaluated.  Seventy nine adductor injuries across 65 NBA athletes were identified [7].   Guards were injured more frequently than forwards or centers (49% vs 25% vs 25%, respectively).  There was an average of 7.7 games (between 16-17 days) missed after the first injury and additional injuries to the adductor occurred in 12/65 NBA athletes.  The vast majority of injuries were treated conservatively (74 or 94%), while five players (6%) were treated surgically, only one of which was reported as a complete tear [7].

It is important to note the terminology when discussing adductor injuries can lead to confusion in regards to return to play.  Core muscle injuries or other causes of groin pain besides adductor related groin pain are not discussed here.  These would fall under the groin pain lasting more than 3 months and the chronic injuries are treated differently than acute injuries.

Summary

In summary, acute adductor injuries occur more frequently in soccer and tennis athletes, but can happen in any sport that involves acceleration and deceleration.  Acute injuries are treated similar to hamstring injuries as far as grading and rehabilitation.  Chronic adductor and chronic core muscle pain are treated much differently.  Most athletes respond well with conservative management and a very low percentage go on to have surgery. 

Lane Johnson was able to play last night and it is yet to be seen whether or not he does indeed have surgery.  It is likely he has either chronic tendinosis ongoing, a grade 3 adductor injury or multiple areas involved.  He commented “It’s just one of those things you’ve got to bandage up and just go out and play. It’s very common among hockey players. It’s a little different in the trenches. But I’ll make it work.”

– Read more about Adductor Injuries at @Wiki Sports Medicine: https://wikism.org/Adductor_Strain

– More hip and groin pain: https://www.sportsmedreview.com/by-joint/hip/

References

  1. Weir, Adam et al. “Doha Agreement Meeting on Terminology and Definitions in Groin Pain in Athletes.” British Journal of Sports Medicine 49.12 (2015): 768–774. PMC. Web. 31 Jan. 2018.
  2. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6:139-144. 
  3. Stull JD, Philippon MJ, LaPrade RF. “At-risk” positioning and hip biomechanics of the Peewee ice hockey sprint start. Am. J. Sports Med. 2011; (Suppl 39):29S–35.
  4. Serner A, Weir A, Tol JL, Thorborg K, Lanzinger S, Otten R, Hölmich P. Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study. Orthop J Sports Med. 2020 Jan 29;8(1):2325967119897247
  5. Lavoie-Gagne O, Mehta N, Patel S, Cohn MR, Forlenza E, Nwachukwu BU, Forsythe B. Adductor Muscle Injuries in UEFA Soccer Athletes: A Matched-Cohort Analysis of Injury Rate, Return to Play, and Player Performance From 2000 to 2015. Orthop J Sports Med. 2021 Sep 23;9(9):23259671211023098
  6. Serner A, Weir A, Tol JL, Thorborg K, Lanzinger S, Otten R, Hölmich P. Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study. Orthop J Sports Med. 2020 Jan 29;8(1):2325967119897247
  7. Patel, Bhavik H., et al. “Adductor injuries in the National Basketball Association: an analysis of return to play and player performance from 2010 to 2019.” The Physician and sportsmedicine 48.4 (2020): 450-457.
  8. Bou Antoun, Myriame, et al. “Imaging of inguinal-related groin pain in athletes.” The British Journal of Radiology 91.1092 (2018): 20170856.
  9. https://www.inquirer.com/eagles/eagles-tackle-lane-johnson-core-muscle-surgery-delay-20221228.html