This is the case report for a 28 year old semi-professional rugby player with a 5 week history of right-sided groin pain aggravated by running and sprinting, with limited hip range of movement. The patient main complaint was the inability of continuing playing rugby at a semi-professional level and to enjoy running at a recreational level.
Risk Factors and Sports Specific Aspects
Rugby is an impact sport where the occurrence of injuries is considerable due to the level of contact during games. In a prospective survey of injuries in to first-rugby union players, Hughes and Fricker (1) reported tackling was by far the most dangerous element in rugby-union play; the act of either tackling or being tackled was associated with 59% of all injuries – and 66% of the severe injuries. The lower limbs were the most commonly injured area, with 52% of all injuries, with the knee and the groin at 14% respectively. In a three year prospective study amongst professional rugby union players, the commonest specific injuries were to the medial collateral ligament of the knee and to the groin musculotendinous unit (10.6% each) (2).
The risk factors associated with the recurrence of groin pain are linked to:
- Overuse during training
- Inadequate warm-up prior to athletic activities
- Sudden dynamic movements, such as directional changes and starting a sprint
- Forceful contact with an opponent during games
The implication for the patient was to modify his training regime and stop his participation to games. It is paramount to diagnose the injury on time and produce an appropriate treatment plan with a specific gradual return to training.
Adductor Longus Musculotendinous Disruption
Adductor longus is the most superficial of the adductor muscle group and apart from being a prime mover it has an important synergic and stabilising role in relation to hip and pelvic movement. Hip adduction injuries are common in rugby and football following overuse or/and acute trauma characterised by hyper-abduction of the hip associated with hyperextension and rotation of the abdomen. In the orthopaedic classification of groin pain proposed by Holmich and colleagues (4), it was reported that 58% of all pathologies were adductor related, 35% were iliopsoas related and 7% were “other” clinical entities. These data differ notably with the findings by Bradshaw et al (5) in their assessment of the Holmich classification in a sport medicine primary care clinic. Hip pathology (50.4%) was the most common form of injury, with pubic pathology seen in 21% of cases. There was no diagnosis of conjoint tendon pathologies or “sports hernia” which may reflect a setting and geographical bias exist.
Positive signs in resisted adduction, passive stretching symptoms in abduction, absent capsular signs, with localized pain in the adductor longus insertion, indicate a valid diagnosis of adductor longus tendon disruption. The assessment testing procedures for adductor longus strength, mobility and palpation followed the practical setting by Holmich and colleagues (3) which were all reported to have good intra- and inter-observer reliability.
The iliopsoas muscle is a flexor of the hip, together with the tensor of the fascia lata and the Sartorius muscle. It is also an external rotator and abductor of the hip and bilateral contraction causes a lumbar lordosis. Unilateral contraction is used considerably in athletic movements, specifically in running, jumping and throwing. Myotendinous injuries typically occur in muscle that cross two joints and have a high proportion of fast twitch muscle fibers while undergoing eccentric contraction.
After reviewing the subjective and objective findings of the initial assessment, the author feels that Iliopsoas tendon disruption existed concomitant to the primary injury at the adductor longus musculotendinous junction. During the patient’s examination, slight discomfort (VAS 3/10) was elicited with resisted hip flexion at 45° and foot externally rotated. The modified Thomas’s test for Iliopsoas was positive and palpation on the muscle was also tender.
This is a self-limiting painful condition of the symphysis pubis secondary to repetitive micro trauma. Athletes affected by this condition are generally man between their 30s and 40s, who participate in sports that involve sprinting, sudden changes in direction, rapid acceleration and deceleration, such as running, football, and rugby. In a review of medical records for 59 athletes diagnosed with osteitis pubis between 1985 and 1990 (9), the most frequent symptoms were pubic pain and adductor pain for both genders and with men also presenting with lower abdominal, hip and perineal or scrotal pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor adductor longs origin and men also revealed tenderness of one or both the superior pubic rami and evidence of decreased hip rotation (unilateral or bilateral). Pelvic malalignment and sacroiliac dysfunction was also frequently seen in both men and women. Patient’s presentation is progressively worsening and is characterized by a “burning sensation” over the symphysis radiating to the lower abdomen, testicles, scrotum and perineum.
After reviewing the clinical finding for the patients, the author believes that a diagnosis of Osteitis pubis is unlikely due to:
- Lack of localized tenderness on the pubic symphysis
- Symptoms were gradually improving since the initial traumatic event
- Osteitis pubis is usually of insidious onset
In order to confirm the diagnosis of adductor longus musculotendinous dysfunction, the author would initially recommend an Ultrasound scan. Ultrasound has a considerable number of advantages including dynamic muscle assessment, speed of examination and the ability to perform real time intervention. However, the large muscle bulk often present in athletes means that the depth of resolution and field of view offered by ultrasound can be limiting in the pelvic area requiring familiarity with imaging techniques (10). In partial tear, US demonstrate an irregular, hypo-echoic and ill-defined adductor origin over the symphysis pubis, whereas a complete separation of the adductor longus from the pubis is seen in complete rupture. In acute trauma of the adductor longus tendon, the area closer to the pubis may exhibit a mixed appearance due to hematoma, debris and possible damage of the fibro cartilage enthesis (11) (Figure3). During healing, ultrasound can show the development of more normal appearing muscle architecture over the following weeks (10). Once this is the predominant finding, it is suggested that more rigorous rehabilitation can commence. To evaluate the extent of adductor enthesis abnormality, MRI scan is the preferred investigation since it is more sensitive in detecting changes in enthesis relevant to athletes (12). MRI is the technique of choice in Osteitis pubis demonstrating generalized and often, symmetrical symphysis bone marrow oedema which classically extends into the soft tissues with intact adjacent muscle and tendons .
Physiotherapy would be the initial choice of treatment for adductor longus tendinosis and will be gradually structured as follows:
- Acute phase: R.I.C.E, rest
- Gentle stretches in a non weight-bearing position
- PNF techniques, gentle tissue mobilization
- Isometric strengthening
- Eccentric loading
- Myofascial release, friction/deep tissue massage
- Once stretching is pain free in a weight bearing position, functional and sports specific activities are incorporated
- Core stability and proprioceptive skills re-education
- Gradual return to training regime
It is understood that the demands applied on professional athletes especially during competition season is considerable. For this reason, Schilder and colleagues (13) advocate that single entheseal pubic cleft injection can be a quicker treatment option for Groin pain and is expected to offer at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magneticresonance imaging scan. However, they stress that it should be employed only as a diagnostic test or short-term treatment for a competitive athlete.
- Hughes, D. a. F. P. (1994). “A Prospective Survey of Injuries to First-Grade Rugby Union Players ” Clinical Journal of Sport Medicine 4(4): 249-256.
- Gibbs, N. (1993). “Injuries in professional rugby league. A three-year prospective study of the South Sydney Professional Rugby League Football Club.” Am J Sports Med 21(5): 696-700.
- Holmich, P., Holmich, L. and Bjerg, A. (2004). “Clinical examination of athletes with froin pain: an intraobserver and interobserver reliability study.” British Journal of Sports Medicine 38: 446-451.
- Holmich, P. (2007). “Long-standing groin pain in sports people falls into three primary patterns, a clinical entity approach prospective study of 207 patients.” British Journal of Sports Medicine 41: 247-252.
- Bradshaw, C. B. M. a. F. E. (2008). “The diagnosis of long-standing groin pain: a prospective clinical cohort study.” British Journal of Sports Medicine 42: 551-554.
- Hureibi, K. A. and G. R. McLatchie (2010). “Groin pain in athletes.” Scott Med J 55(2): 8-11.
- Bird, S., Black, N. and Newton P. (1997). “Sports injuries: causes, disagnosis, treatment and prevention.” 106-115.
- Major, N. M. and C. A. Helms (1997). “Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes.” Skeletal Radiol 26(12): 711-717.
- Fricker, P. A., J. E. Taunton, et al. (1991). “Osteitis pubis in athletes. Infection, inflammation or injury?” Sports Med 12(4): 266-279.
- Brittenden, J. and P. Robinson (2005). “Imaging of pelvic injuries in athletes.” Br J Radiol 78(929): 457-468.
- Frontera, W., Herring, S., Micheli, L., Silver, J., Young, T. (2007). “Clinical sports medicine: medical management and rehabilitation.” 391-410.
- Koh, E. S., J. C. Lee, et al. (2007). “MRI of overuse injury in elite athletes.” Clin Radiol 62(11): 1036-1043.
- E. Schilders, J. C. T., P. Robinson, A. Dimitrakopoulou, W. W. Gibbon, and Q. Bismil (2009). “Adductor-Related Groin Pain in Recreational Athletes. Role of the Adductor Enthesis, Magnetic Resonance Imaging, and Entheseal Pubic Cleft Injections.” J. Bone Joint Surg. Am. 91(10): 2455-2460.
- Feeley, B. T., J. W. Powell, et al. (2008). “Hip injuries and labral tears in the national football league.” Am J Sports Med 36(11): 2187-2195.
- Kachingwe, A. F. and S. Grech (2008). “Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series.” J Orthop Sports Phys Ther 38(12): 768-781.