Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

The management of a professional footballer recovering from a surgical repair of the proximal adductor longus tendon through a return-to-performance pathway. A case report

This case report details the management of a 23-year-old professional footballer who sustained a rupture of the proximal adductor longus (AL) tendon. Following surgical reattachment of the tendon, the player completed an eleven-phase return to performance (RTPerf) pathway designed to ensure a rapid and safe return to play (RTPlay). The pathway uses distinct phases that incorporate clinical, performance, and sport-specific criteria to guide decision-making throughout the process. This case report outlines the phases and criteria used in conjunction with shared decision-making by the interdisciplinary team (IDT) to ensure a successful RTPlay. The effectiveness of this pathway was demonstrated by the player's return to competitive play 12 weeks post-surgery.

The Role of MRI in Groin Pain Syndrome in Athletes

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Adductor longus and brevis lesion in an amateur soccer player: platelet rich plasma and multifractioned hyaluronic acid injections to enhance clinical recovery

Groin pain is a common issue in athletes, with a particularly high incidence in male soccer players. Adductor muscles are the most involved site of the groin, accounting for up to one-fourth of muscle injuries of that region. Physical therapy and rehabilitation programs for adductor-related groin pain using active exercises are effective in getting athletes back to sport. However, the return-to-play time varies according to the injury severity. Minor lesions can recover in 1-2 weeks, while severer injuries require 8-12 weeks. To enhance tendon healing and shorten the return to play time, intrandentinous injections of Platelet Rich Plasma (PRP) have been proposed. An increasing body of evidence in literature have shown efficacy of platelet rich plasma in aiding the healing process in tendinopathies. Similarly, more recent evidences have proven hyaluronic (HA) acid to have anti-inflammatory, proliferative, repairing, and analgesic effects. This case report presents the clinical application of combined PRP and a multifractioned (a mixture of different molecular weights) HA in a 24-year-old athlete suffering from a hip adductor rupture.

Acute Adductor Muscle Injury: A Systematic Review on Diagnostic Imaging, Treatment, and Prevention

BACKGROUND

Controversies remain regarding the diagnosis, imaging, and treatment of acute adductor injuries in athletes.

PURPOSE

To investigate the diagnostic imaging, treatment, and prevention of acute adductor injuries based on the most recent and relevant scientific evidence.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed and Web of Science databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles studying acute adductor injury in athletes. Inclusion criteria were original publication on acute adductor injury in amateur or professional athletes, level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or the methodological index for non-randomized studies criteria. Articles were grouped as imaging, treatment, prevention focused, or mixed.

RESULTS

A total of 30 studies published between 2001 and 2021 were selected, involving 594 male patients with a mean age 26.2 years (range, 16-68 years). The most frequent sports were soccer (62%), basketball (14%), futsal (6%), American football (3%), and ice hockey and handball (2%). Risk factors for acute adductor injury were previous acute groin injury, adductor weakness compared with the uninjured side, any injury in the previous season, and reduced rotational hip range of motion. The frequency of complete adductor muscle tears on magnetic resonance imaging was 21% to 25%. For complete adductor tears, the average time to return to play was 8.9 weeks in patients treated nonoperatively and 14.2 weeks for patients treated surgically. Greater stump retraction was observed in individuals treated surgically. Partial acute adductor tears were treated nonoperatively with physical therapy in all studies in the present systematic review. The average time to return to play was 1 to 6.9 weeks depending on the injury grade. The efficacy of adductor strengthening on preventing acute adductor tears has controversial results in the literature.

CONCLUSION

Athletes with partial adductor injuries returned to play 1 to 7 weeks after injury with physical therapy treatment. Nonoperative or surgical treatment is an acceptable option for complete adductor longus tendon tear.

Current Clinical Concepts: Exercise and Load Management of Adductor Strains, Adductor Ruptures, and Long-Standing Adductor-Related Groin Pain

Adductor-related groin pain is a common problem in sports. Evidence-based management of athletes with adductor strains, adductor ruptures, and long-standing adductor-related groin pain can be approached in a simple yet effective and individualized manner. In most cases, managing adductor-related pain in athletes should be based on specific exercises and loading strategies. In this article, I provide an overview of the different types of adductor injuries, from acute to overuse, including their underlying pathology, functional anatomy, diagnosis, prognosis, mechanisms, and risk factors. This information leads to optimal assessment and management of acute to long-standing adductor-related problems and includes primary, secondary, and tertiary prevention strategies that focus on exercise and load-based strategies. In addition, information on different options and contexts for exercise selection and execution for athletes, athletic trainers, and sports physical therapists in adductor injury rehabilitation is provided.

Quantifying the shear modulus of the adductor longus muscle during hip joint motion using shear wave elastography

The present study aims to assess the effect of the hip flexion angle on the shear modulus of the adductor longus (AL) muscle associated with passive hip abduction and rotation. Sixteen men participated in the study. For the hip abduction task, the hip flexion angles used were - 20, 0, 20, 40, 60, and 80°, and the hip abduction angles were 0, 10, 20, 30, and 40°. For the hip rotation task, the hip flexion angles used were - 20, 0, 20, 40, 60, and 80°, hip abduction angles were 0 and 40°, and hip rotation angles were 20° internal rotation, 0° rotation, and 20° external rotation. The shear modulus at 20° extension was significantly higher than that at 80° flexion for the 10, 20, 30 and 40° hip abduction (i.e., P < 0.05). The shear modulus at 20° internal rotation and 20° extension was significantly higher than that at 0° rotation and 20° external rotation, regardless of the hip abduction angle (i.e., P < 0.05). The mechanical stress of the AL muscle associated with hip abduction was higher in the extended position. Furthermore, the mechanical stress could increase with internal rotation only at the hip-extended position.

Development and Predictive Validation of the Brazilian Adductor Performance Test for Estimating the Chance of Hip Adductor Injuries in Elite Soccer Athletes

PURPOSE

To develop and validate the Brazilian Adductor Performance Test (BAPT) for predicting hip adductor muscle injuries in elite soccer athletes.

METHODS

A total of 108 soccer athletes were assessed, followed up for 3 months, and evaluated for a history of adductor injury 6 months before BAPT evaluation. The Shapiro-Wilk test was used as the normality test. The Mann-Whitney U test was used to compare BAPT scores between injured and uninjured athletes. Binary logistic regression was performed to identify the athletes' chances of injury based on their BAPT scores. A receiver operating characteristic curve was used to determine the cutoff point for the number of repetitions in the BAPT and Spearman bivariate correlation and identify factors potentially related to the test score. Furthermore, the intraclass correlation coefficient was used to determine interexaminer agreement. The level of significance was set at 95%.

RESULTS

The BAPT scores for hip adductor injury history did not differ significantly (P = .08). A significant deficit was identified in the BAPT scores of the injured athletes at the 3-month follow-up (P = .001). The cutoff point identified was 33 repetitions. Low BAPT scores increased the chance of injury by 20% (odds ratio, 1.20%; P = .001). The interexaminer agreement was .96 (P = .001).

CONCLUSION

BAPT can be used to identify athletes most likely to sustain hip adductor muscle injuries, indirectly reducing the rate of this injury in soccer clubs.

Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders

Damage to the fascia can cause significant performance deficits in high-performance sports and recreational exercise and may contribute to the development of musculoskeletal disorders and persistent potential pain. The fascia is widely distributed from head to toe, encompassing muscles, bones, blood vessels, nerves, and internal organs and comprising various layers of different depths, indicating the complexity of its pathogenesis. It is a connective tissue composed of irregularly arranged collagen fibers, distinctly different from the regularly arranged collagen fibers found in tendons, ligaments, or periosteum, and mechanical changes in the fascia (stiffness or tension) can produce changes in its connective tissue that can cause pain. While these mechanical changes induce inflammation associated with mechanical loading, they are also affected by biochemical influences such as aging, sex hormones, and obesity. Therefore, this paper will review the current state of knowledge on the molecular level response to the mechanical properties of the fascia and its response to other physiological challenges, including mechanical changes, innervation, injury, and aging; imaging techniques available to study the fascial system; and therapeutic interventions targeting fascial tissue in sports medicine. This article aims to summarize contemporary views.

Game-play affects hamstring but not adductor muscle fibre mechanics in elite U20 basketball athletes

Muscle tendon unit fibre mechanics of hamstring and adductor strain injuries are not well studied, with factors such as fatigue promoted as risk factors in the absence of mechanistic evidence. In this study, musculoskeletal modelling was used to estimate fibre mechanics of four hamstring (biceps femoris long head, biceps femoris short head, semimembranosus and semitendinosus) and four adductor (adductor brevis, adductor longus, adductor magnus and gracilis) muscles during an anticipated cut task. The cut task was performed by 10 healthy elite male U20 basketball players both before and immediately after they played in one (of four) competitive basketball game. Biceps femoris long head produced significantly lower (p = 0.032) submaximal force post-game in the latter part of swing (30.7% to 35.0% of stride), though its peak force occurred later (37%) and remained unchanged. Semimembranosus produced significantly lower (p = 0.006) force post-game (32.9% to 44.9% of stride), which encompassed the instance of peak force (39%). Neither fibre velocity nor fibre length of the investigated muscles were significantly affected by game-play. These finding suggest that if fatigue is a factor in hamstring and adductor muscle strain injuries and is brought about by game-play, it is unlikely through the fibre mechanisms investigated in this study.

Reconstruction of a Chronic and Retracted Distal Adductor Longus Tear Using Achilles Allograft: A Case Report

UPDATE

This article was updated on January 27, 2023, because of a previous error. One of the author's degrees was incorrect. Anirudh Eranki's degree was listed as BS, but this author did not have a degree at time of publication.An erratum (JBJS Case Connect. 2023;13[1]:e22.00522ER) has been published for this article.

Adductor longus: An anatomical study to better understand groin pain

INTRODUCTION

We investigated the shear modulus-passive force relationship in the hip adductor longus (AL) muscles of human cadavers and explored the effect of muscle architecture on the elastic properties of the AL muscle using shear wave elastography (SWE).

MATERIALS AND METHODS

Nine AL muscles were harvested from a soft, embalmed cadaver. The AL muscles were affixed to a custom-built device comprising two clamps, a pulley, and a cable to provide passive loads, which were increased from 0 to 600 g in 60-g increments. The shear modulus of the AL muscle was measured in the proximal (Pro), middle (Mid), and distal (Dis) regions. The masses and anatomical cross-sectional areas (ACSAs) of the AL muscles were measured. The shear modulus-passive load relationship of each tested muscle region was analyzed by fitting a least-squares regression line. Moreover, the rate of increase in the shear modulus per unit load (s) was calculated.

RESULTS

The shear modulus and passive force were linearly correlated for all AL muscles in each region (P<0.01). The mean coefficients of determination (R² ) for Pro, Mid, and Dis were 0.989, 0.986, and 0.982, respectively. The rate of increase in the shear modulus per unit load significantly correlated with the reciprocal of the muscle mass (r=0.77, P=0.02) and ACSA (r=0.43, P=0.03).

CONCLUSION

Shear wave elastography can be used as an indirect measure of passive force in any region of the AL muscle. Additionally, the rate of increase in the shear modulus per unit load could be associated with muscle architectural parameters. This article is protected by copyright. All rights reserved.

Adductor Muscle Injuries in UEFA Soccer Athletes: A Matched-Cohort Analysis of Injury Rate, Return to Play, and Player Performance From 2000 to 2015

Background:

The effects of adductor muscle injury on performance in soccer athletes are unknown.

Purpose:

To (1) determine the rate and time to return to play (RTP) after adductor muscle injury, (2) investigate the rate of reinjury after RTP, and (3) investigate any long-term effects of injury on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, athletes sustaining adductor muscle injury were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2015. Injured athletes were matched to controls by demographic characteristics and performance metrics from 1 season before the index timepoint. Investigations included the rate of RTP, reinjuries, player characteristics associated with RTP within 2 seasons, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 671 players with adductor muscle injury were included. Based on time to RTP, 86% of injuries were mild to moderate (4-28 days missed), and 4% required surgical intervention. Players with adductor muscle injury were absent for a median of 22 days (range, 1-700 days) and 4 games (range, 1-76 games). A total of 521 (78%) players returned at the same level, with no demographic or clinical characteristics associated with RTP on the multivariable regression. Of those returning to play, 143 (21%) experienced adductor reinjury. After RTP, defenders demonstrated decreased field time compared with controls (P < .05). As compared with controls, defenders and midfielders scored more points and goals per game during the season of the injury (P < .01), while attackers recorded more goals and assists per game the season after injury (P < .05).

Conclusion:

Only 3 in 4 players (78%) returned to participate in an official match, and the reinjury rate was high (21%). After RTP, defenders demonstrated decreased field time versus controls. On the other hand, defenders and midfielders recorded more points and goals per game, while attackers recorded more goals and assists per game versus controls. Although the multivariable analysis results did not identify player characteristics associated with RTP, there was a position-dependent association on player performance after RTP.

Traumatic Leg Fractures in UEFA Football Athletes: A Matched-Cohort Analysis of Return to Play, Reinjury, Player Retention, and Performance Outcomes

Background:

The average professional soccer team experiences 1 to 2 traumatic leg fractures per season, with unknown effects on player performance.

Purpose:

To (1) determine the rate and time to return to play (RTP) following leg fracture, (2) investigate the rate of reinjury following RTP, and (3) investigate long-term effects that lower extremity (LE) fracture may have on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, we identified athletes sustaining a traumatic leg fracture across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2016. Athletes with leg fracture (femur, tibia, and/or fibula) were matched 1:2 to controls by demographic characteristics and performance metrics 1 season before the index timepoint. Investigations included the RTP rate, reinjury rate, player characteristics associated with RTP within 2 seasons, long-term player retention, performance metrics during the 4 following seasons, and subgroup analysis by player position.

Results:

A total of 112 players with LE fracture and 224 controls were identified. Players with LE fractures were absent for a mean of 157 days (range, 24-601 days) and 21 games (range, 2-68 games). The rate of RTP within 1 season was 80%, with 4% experiencing subsequent refracture. Injured players remained active in the league at a higher rate than their uninjured counterparts. As compared with controls, injured athletes played 309 fewer total minutes (P < .05), scored 0.09 more assists per game (P < .01) 1 season after injury, and scored 0.12 more points per game 4 seasons after injury (P < .01). Defenders were most affected by an LE fracture, playing 5.24 fewer games (P < .05), 603 fewer total minutes (P < .01), and recording 0.19 more assists per 90 minutes of play as compared with controls 1 season after injury (P < .001). Attackers and midfielders demonstrated no significant difference in metrics after RTP when compared with controls.

Conclusion:

Most players sustaining an LE fracture returned to elite soccer at the same level after a significant loss of playing time, with a 4% rate of refracture. Player retention was higher for those sustaining an LE fracture versus uninjured controls. Overall, injured players did not experience a decline in performance after recovery from an LE fracture.

One-Year Clinical and Imaging Follow-up After Exercise-Based Treatment for Acute Complete Adductor Longus Tendon Avulsions in Athletes: A Prospective Case Series

BACKGROUND

Complete avulsions of the adductor longus tendon are serious injuries, yet we have few data to inform clinical decisions on management. Previous studies are limited by a lack of detailed follow-up.

PURPOSE

To describe detailed clinical and imaging measures 1 year after complete proximal adductor longus avulsion injuries in athletes who received exercise-based treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 16 adult male competitive athletes were included in this study <7 days after an acute adductor longus tendon avulsion injury. All athletes were advised to complete a supervised standardized criterion-based rehabilitation protocol. Standardized clinical examination, a modified Copenhagen Hip and Groin Outcome Score (HAGOS), the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O), and detailed magnetic resonance imaging (MRI) assessment were performed after inclusion, on the day of completion of the treatment protocol (return to sport), and at 1-year follow-up after injury.

RESULTS

One player was lost to follow-up. Median return-to-sport time was 69 days (interquartile range [IQR], 62-84). One player had an early reinjury and performed an additional rehabilitation period. One-year follow-up was completed a median from 405 days (IQR, 372-540) after injury. The median HAGOS score was 100 for all subscales (IQRs from 85-100 to 100-100), and the median OSTRC-O score was 0 (IQR, 0-0). The median range of motion symmetry was 100% (IQR, 97%-130%) for the bent-knee fall-out test and 102% (IQR, 99%-105%) for the side-lying abduction test. Side-lying eccentric adduction strength symmetry was 92% ± 13% (mean ± SD), and median supine eccentric adduction strength symmetry was 93% (IQR, 89%-105%). MRI results at 1-year follow-up showed that from the original complete discontinuity in all cases, 10 athletes (71%) had partial tendon continuity, and 4 (29%) had complete tendon continuity.

CONCLUSION

Nonsurgically treated athletes with a complete acute adductor longus avulsion returned to sport in 2 to 3 months. At the 1-year follow-up after injury, athletes had high self-reported function, no performance limitations, normal adductor strength and range of motion, and signs of partial or full tendon continuity as shown on MRI. This indicates that the primary treatment for athletes with acute adductor longus tendon avulsions should be nonsurgical as the time to return to sport is short, there are good long-term results, and there is no risk of surgical complications.

Isolated distal adductor magnus tendon avulsion as a rare cause of medial knee pain. A case report

Avulsion injuries of adductor frequently involve the proximal origin. We report the first case of avulsion fracture of adductor magnus at its insertion and discuss the relevant anatomy.

Hip Adductor Longus Tendon Origin Anatomy Is Consistent and May Inform Surgical Reattachment

Purpose

To define the topographic anatomy of the footprint of the adductor longus origin on the pubis and its underlying bony morphology to better inform surgical repair of adductor longus tendon injuries.

Methods

Five cadaveric pelvis specimens were dissected, making 10 adductor footprints available for analysis. The adductor longus tendon origin was isolated and the surrounding tissue debrided. The circumference of the tendinous attachment to the pubic crest was marked before excising the tendon and fibrocartilage enthesis from the pubis. Radiopaque paint was prepared by mixing 30 mL of all-purpose acrylic paint (Anita’s no. 11150 Island Blue; Rust-Oleum Corp, Vernon Hills, IL) with 15g of E-Z-HD 98% w/w barium sulfate (Bracco Diagnostics Inc., Anjou Quebec, Canada) and applied to the marked footprint. The specimens underwent a 1.0-mm slice computed tomographic scan with 3-dimensional reconstructions. Synapse PACS (FujiFilm, Valhalla, NY) software for measurements of the tendon footprint and underlying bone.

Results

Average age and weight of the specimens at the time of death was 37 years and 204.6 ± 48.7 lbs, respectively. The width and length of the tendon origin was 12.0 ± 1.1 mm and 10.9 ± 1.1 mm, respectively. The distance of the center of the footprint from the center of the pubic tubercle was 8.5 ± 1.4 mm lateral and 12.2 ± 0.4 mm caudal. The osseous thickness underlying the footprint was 18.7 ± 3.7 mm at an angle of 34.5 ± 1.5° in relation to the sagittal plane. The correlation between specimen body weight and the thickness of the bone underlying the footprint was strongly positive (r = 0.92).

Conclusions

We found that there is a consistent angle from the center of the adductor longus tendon footprint to the point of maximal underlying bony thickness, as well as a positive correlation between body mass index and osseous thickness, which may inform anatomic reattachment of this tendon.

Clinical Relevance

Our findings will assist surgeons in identifying the footprint of the adductor longus tendon and safely perform anatomic repair of adductor longus tendon avulsions.

Variation of pectineus muscle forming a hiatus

Knowledge of the anatomic variations in the pectineus muscle is important for vascular surgeons to minimize complications following surgical approach to the distal part of the deep femoral artery. During routine dissection of the thigh, variations in the bilateral pectineus muscles were identified in an 82-year-old male cadaver. On both sides, the superficial and deep layers of the pectineus were divided at its distal part, forming a triangular-shaped hiatus between them and the femur shaft. Distally, the tendon of the superficial part intermingled with the tendon of the adductor longus. The tendon of the deep part was inserted into the pectineal line. On the right side, the deep femoral artery and its first perforating artery passed through the hiatus. On the left side, the deep femoral artery pierced the hiatus, and then, the first perforating artery was branched from the deep femoral artery. No reported case has described a pectineal hiatus. The variations observed in this study are an ontogenetic vestige of the two different origins of the pectineus. The insertion of the superficial layer into the adductor longus tendon suggests a close relationship between these muscles during prenatal development. Surgeons should be aware of the variation to minimize injury to the pectineus muscle while approaching the deep femoral artery.

Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes

PURPOSE

The purpose of the study is to review the MRI findings in a cohort of athletes who sustained acute traumatic avulsions of the adductor longus fibrocartilaginous entheses, and to investigate related injuries namely the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Associated muscle and soft tissue injuries were also assessed.

METHODS

The MRIs were reviewed for a partial or complete avulsion of the adductor longus fibrocartilage, as well as continuity or separation of the adductor longus from the pyramidalis. The presence of a concurrent partial pectineus tear was noted. Demographic data were analysed. Linear and logistic regression was used to examine associations between injuries.

RESULTS

The mean age was 32.5 (SD 10.9). The pyramidalis was absent in 3 of 145 patients. 85 of 145 athletes were professional and 52 competed in the football Premier League. 132 had complete avulsions and 13 partial. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. Six types of PLAC injuries patterns were identified. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%).

CONCLUSION

The proximal adductor longus forms part of the PLAC and is rarely an isolated injury. The term PLAC injury is more appropriate term. MRI imaging should assess all the anatomical components of the PLAC post-injury, allowing recognition of the different patterns of injury.

LEVEL OF EVIDENCE

Level III.

Associations between clinical findings and MRI injury extent in male athletes with acute adductor injuries - A cross-sectional study

OBJECTIVES

To investigate the association between clinical assessment and MRI measures of oedema and MRI grading in male athletes with acute adductor injuries.

DESIGN

Cross-sectional study.

METHODS

We included 81 consecutive athletes with acute adductor injuries. All athletes received a standardized clinical assessment and magnetic resonance imaging (MRI), blinded to clinical information. We analysed correlations between extent of palpation pain and extent of MRI oedema for the adductor longus. We compared the clinical assessment to MRI adductor injury grading (0-3) using ordinal regression. We analysed positive and negative predictive values (PPV/NPV) of a complete adductor longus avulsion.

RESULTS

Proximal-distal length of adductor longus palpation pain had fair correlation with MRI proximal-distal oedema length oedema (r=0.309, p=0.022). Cross-sectional surface area of palpation pain had poor correlation with corresponding cross-sectional MRI oedema area (r=0.173, p=0.208). The symptoms subscale of the Copenhagen Hip And Groin Outcome Score (HAGOS) for the period since injury (log odds ratio=0.97, p=0.021) and passive adductor stretch pain (log odds ratio=0.35, p=0.046) were associated with MRI injury grading. If there was a palpable defect, MRI always showed a complete avulsion (PPV=100%). Several tests had high negative predictive values: passive adductor stretch (100%), palpation pain at the adductor longus insertion (98%), and the FABER test (98%).

CONCLUSIONS

The extent of palpation pain does not indicate the extent of MRI oedema in acute adductor longus injuries. A worse modified HAGOS symptoms subscale score and passive adductor stretch pain indicate a higher MRI adductor injury grade. Clinical examination tests have high ability to detect or rule out a complete adductor longus avulsion on MRI.

Return to Play and Recurrence After Calf Muscle Strain Injuries in Elite Australian Football Players

BACKGROUND

Calf muscle strain injuries (CMSI) are prevalent in sport, but information about factors associated with time to return to play (RTP) and recurrence is limited.

PURPOSE

To determine whether clinical and magnetic resonance imaging (MRI) data are associated with RTP and recurrence after CMSI.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data of 149 CMSI reported to the Soft Tissue injury Registry of the Australian Football League were explored to evaluate the impact of clinical data and index injury MRI findings on RTP and recurrence. Clinical data included age, previous injury history, ethnicity, and the mechanism of injury.

RESULTS

Irrespective of the anatomical location, players with CMSI with severe aponeurotic disruption (AD) took longer to RTP than players with CMSI with no AD: 31.3 ± 12.6 days vs 19.4 ± 10.8 days (mean ± SD; P = .003). A running-related mechanism of injury was associated with a longer RTP period for CMSI overall (adjusted hazard ratio [AHR], 0.59; P = .02). The presence of AD was associated with a longer RTP period for soleus injuries (AHR, 0.6; P = .025). Early recurrence (ie, ≤2 months of the index injury) was associated with older age (AHR, 1.3; P = .001) and a history of ankle injury (AHR, 3.9; P = .032). Older age (AHR, 1.1; P = .013) and a history of CMSI (AHR, 6.7; P = .002) increased the risk of recurrence within 2 seasons. The index injury MRI findings were not associated with risk of recurrence.

CONCLUSION

A running-related mechanism of injury and the presence of AD on MRI were associated with a longer RTP period. Clinical rather than MRI data best indicate the risk of recurrent CMSI.

Myositis Ossificans of the Adductor Longus in a Soccer Player

A 20-year-old male collegiate soccer goalkeeper presented to an athletic trainer during the season complaining of right (dominant kicking leg) groin pain. The athletic trainer identified a mass and hematoma and suspected myositis ossificans. The patient was referred to the team physician, who ordered radiographs and magnetic resonance imaging to confirm the diagnosis and rule out other injuries. Imaging demonstrated an adductor longus muscle strain with myositis ossificans. J Orthop Sports Phys Ther 2020;50(10):586. doi:10.2519/jospt.2020.9573.

Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study

BACKGROUND

Time to return-to-sport (RTS) after acute adductor injuries varies among athletes, yet we know little about which factors determine this variance.

PURPOSE

To investigate the association between initial clinical and imaging examination findings and time to RTS in male athletes with acute adductor injuries.

STUDY DESIGN

Cohort study (Prognosis); Level of evidence, 2.

METHODS

Male adult athletes with an acute adductor injury were included within 7 days of injury. Standardized patient history and clinical and magnetic resonance imaging (MRI) examinations were conducted for all athletes. Athletes performed a supervised standardized criteria-based exercise treatment program. Three RTS milestones were defined: (1) clinically pain-free, (2) completed controlled sports training, and (3) first full team training. Univariate and multiple regression analyses were performed to determine the association between the specific candidate variables of the initial examinations and the RTS milestones.

RESULTS

We included 81 male adult athletes. The median duration for the 3 RTS milestones were 15 days (interquartile range, 12-28 days), 24 days (16-32 days), and 22 days (15-31 days), respectively. Clinical examination including patient history was able to explain 63%, 74%, and 68% of the variance in time to RTS. The strongest predictors for longer time to RTS were pain on palpation of the proximal adductor longus insertion or a palpable defect. The addition of MRI increased the explained variance with 7%, 0%, and 7%. The strongest MRI predictor was injury at the bone-tendon junction. Post hoc multiple regression analyses of players without the 2 most important clinical findings were able to explain 24% to 31% of the variance, with no added value of the MRI findings.

CONCLUSION

The strongest predictors of a longer time to RTS after acute adductor injury were palpation pain at the proximal adductor longus insertion, a palpable defect, and/or an injury at the bone-tendon junction on MRI. For athletes without any of these findings, even extensive clinical and MRI examination does not assist considerably in providing a more precise estimate of time to RTS.

Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study

Background:

Despite being one of the most common sports injuries, there are no criteria-based rehabilitation programs published for acute adductor injuries.

Purpose:

To evaluate return-to-sport (RTS) outcomes and reinjuries after criteria-based rehabilitation for athletes with acute adductor injuries.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Male adult athletes with an acute adductor injury underwent a supervised, standardized criteria-based exercise rehabilitation program. Magnetic resonance imaging (MRI) was used to grade the injury extent from 0 (negative finding) to 3 (complete tear/avulsion). There were 3 milestones used to evaluate the RTS continuum: (1) clinically pain-free, (2) completion of controlled sports training, and (3) return to full team training. Subsequent injuries were registered within the first year.

Results:

We included 81 athletes with an acute adductor injury (MRI grade 0: n = 14; grade 1: n = 20; grade 2: n = 30; grade 3: n = 17). Of these, 61 (75%) athletes achieved RTS milestone 1, 50 (62%) achieved RTS milestone 2, and 75 (93%) achieved RTS milestone 3. There were no statistical differences in the RTS duration between MRI grade 0, 1, and 2 at any RTS milestone; thus, these were grouped together as grade 0-2. The median time (interquartile range [IQR]) for athletes with grade 0-2 injuries to become clinically pain-free was 13 days (IQR, 11-21 days), to complete controlled sports training was 17 days (IQR, 15-27 days), and to return to full team training was 18 days (IQR, 14-27 days). For athletes with a grade 3 injury, median times were 55 days (IQR, 31-75 days), 68 days (IQR, 51-84 days), and 78 days (IQR, 68-98 days), respectively. The overall 1-year reinjury rate was 8%. Athletes who achieved RTS milestone 1 had a statistically significantly lower reinjury rate than athletes who did not (5% vs 21%, respectively; ϕ = –0.233; P = .048). Athletes who achieved RTS milestone 2 had a nonstatistically significantly lower reinjury rate than athletes who did not (6% vs 13%, respectively; ϕ = –0.107; P = .366).

Conclusion:

We analyzed the results of a criteria-based rehabilitation protocol for athletes with acute adductor injuries. Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks. Most athletes with an MRI grade 3 adductor injury were pain-free and returned to full team training within 3 months. Meeting the clinically pain-free criteria resulted in fewer reinjuries compared with not meeting the criteria.

Epidemiology of hip and groin injuries in Swedish male first football league

PURPOSE

This study aimed to investigate the incidence, pattern, and burden of hip/groin injuries in Swedish professional male football players over five consecutive seasons.

METHODS

Injury history from 16 football teams in the Swedish male first football league was evaluated during five consecutive seasons. The team's medical staff recorded team exposure and time-loss injuries prospectively between 2012 and 2016.

RESULTS

In total, 467 time-loss injuries located in the hip/groin area were recorded among 1,687 professional male football players, with an overall incidence and burden of 0.82/1,000 h and 15.6/1,000 h, respectively. There appeared to be an increased risk of hip/groin injuries during the last two seasons (2015-2016); however, the difference was not statistically significant (n.s). Recurrent injury rate was relatively low (14%), and overuse injuries accounted for the majority of injuries and absence days. Muscle injuries were the main injury type, while kicking and sprinting/running were the primary causes of injury. Goalkeepers had the lowest percentage of injuries and absence days.

CONCLUSION

Hip/groin injuries are a substantial problem in football, but does not seem to be an increasing phenomenon in the Swedish male first football league. Index and overuse injuries accounted for the majority of injuries and absence days. Thus, the focus should be on preventing hip/groin injuries to lower the injury rate. These new findings should be taken into consideration when designing and implementing preventive training interventions.

LEVEL OF EVIDENCE

II.

Open Repair of Acute Proximal Adductor Magnus Avulsion

Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.

Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis

BACKGROUND

Change of direction and kicking have been described as the main actions resulting in adductor longus injury. Video descriptions of inciting events are lacking.

OBJECTIVE

Perform a standardised visual video analysis of a series of acute adductor longus injuries in football.

STUDY DESIGN

Cross-sectional.

METHODS

Video footage was reviewed by players, and assessed independently by five sports medicine professionals. Inciting events were described and categorised using standardised scoring, including playing situation, player/opponent behaviour, movement and body positions.

RESULTS

Videos of acute adductor longus injuries in 17 professional male football players were analysed. Most injuries occurred in non-contact situations (71%), following a quick reaction to a change in play (53%). Injury actions were: change of direction (35%), kicking (29%), reaching (24%) and jumping (12%). Change of direction and reaching injuries were categorised as closed chain movements (59%), characterised by hip extension and abduction with external rotation. Kicking and jumping injuries were categorised as open chain (41%), characterised by a change from hip extension to hip flexion, and hip abduction to adduction, with external rotation.

CONCLUSION

Acute adductor longus injuries in football occur in a variety of situations. Player actions can be categorised into closed (change of direction and reaching) and open (kicking and jumping) chain movements involving triplanar hip motion. A rapid muscle activation during a rapid muscle lengthening appears to be the fundamental injury mechanism for acute adductor longus injuries.

Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management

Synopsis Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.

Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27 years (range 18-37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo-tendinous junction (MTJ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI, with avulsion injuries accounting for three-quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.