Adductor tendinopathy in a hockey player with persistent groin pain: a case report.
Abstract: Groin pain may stem from a variety of different causes. Adductor tendinopathy is a common but infrequently recognised cause of chronic groin pain especially in athletes. This case report describes a case of clinically suspected adductor tendinopathy in an amateur athlete confirmed by MRI (Magnetic Resonance Imaging). Relevant literature on musculotendinous injuries of the groin along with differential diagnosis for groin pain is discussed. There are several differential diagnoses for athletes that present with groin pain. Therefore, it is important to accurately diagnose the origin of groin pain as the plan of management is dependent of the specificity of the diagnosis. The diagnosis of adductor tendinopathy is made with a history of chronic groin pain along with pain/weakness during isometric adduction of the hip muscles. It is confirmed by MR imaging.

(JCCA 2010; 54(4):264-270)

KEY WORDS: adductor muscle, tendinopathy, MRI, groin pain, tenoperiosteal disease, enthesopathy, adductor strain

La douleur a l'aine peut etre causee par differents facteurs. La tendinopathie adductrice est une cause courante mais rarement reconnue de douleur chronique a l'aine, particulierement chez les athletes. Cette etude de cas decrit une tendinopathie adductrice cliniquement soupconnee chez un athlete amateur, puis confirmee par une imagerie par resonance magnetique (IRM). La documentation pertinente sur les blessures musculotendineuses de l'aine ainsi que le diagnostic differentiel des blessures de l'aine fait l'objet d'une discussion. Il existe plusieurs diagnostics differentiels pour les athletes qui ont des douleurs a l'aine. Il est donc important de diagnostiquer avec exactitude l'origine des douleurs a l'aine, car le plan de gestion depend de la specificite du diagnostic. Le diagnostic de tendinopathie adductrice est prononce lorsqu'il y a antecedents de douleur chronique a l'aine ainsi qu'une douleur/faiblesse durant l'adduction isometrique des muscles de la hanche. Le tout est confirme par une imagerie RM.

(JCCA 2010; 54(4):264-270)

MOTS CLES : muscle adducteur, tendinopathie, IRM, douleur a l'aine, maladie tenoperiosteale, enthesopathie, fouleur de l'adducteur
Article Type: Case study
Subject: Hockey players (Health aspects)
Tendinitis (Risk factors)
Tendinitis (Diagnosis)
Tendinitis (Care and treatment)
Tendinitis (Case studies)
Pain (Care and treatment)
Pain (Case studies)
Magnetic resonance imaging (Usage)
Authors: Avrahami, Daniel
Choudur, Hema N.
Pub Date: 10/01/2010
Publication: Name: Journal of the Canadian Chiropractic Association Publisher: Canadian Chiropractic Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Canadian Chiropractic Association ISSN: 0008-3194
Issue: Date: Oct, 2010 Source Volume: 54 Source Issue: 4
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 259589969
Full Text: Introduction

Groin pain is a common problem found in many athletes. (1) Many athletes will present to clinicians with a history of groin pain that may be acute or chronic in nature, and may stem from a single traumatic event or repeated microtrauma to the region. (2) However, multiple pathologies may exist in individuals with chronic groin pain, (3) adding complexity to the diagnosis and management of these patients. (4) There are several common causes of groin pain. The groin pain may stem from the lumbar spine, sacroiliac joint, symphysis pubis stress, rectus abdominis tear, sports hernia, iliopsoas pathology or adductor musculotendinous pathology. (1,3,5)

The cases of groin pain in athletes that actually involve adductor muscle pathology can present in various forms. Adductor related groin pain can be due to muscle strain, tendinosis, tendinitis, paratenonitis, enthesopathy or a combination of the aforementioned (Table 1). (6) Therefore the specific diagnosis is crucial for the plan of management. Since the list of differential diagnoses for groin pain is large, MRI (Magnetic Resonance Imaging) is necessary to localize pathology and define its type.

There are several review articles examining groin and hip pain with associated adductor pathology. (2,3,7,8) There are articles examining adductor tears (9) and calcific tendinitis of the adductor magnus. (10) However, the case report literature is sparse in examining groin pain in athletes with a proven diagnosis of adductor tendinopathy through radiological evidence. (5,11,12)

Due to the complexity of groin pain in athletes and the difficulty to specifically diagnose the accurate pathological structure, it is important to have radiological evidence in combination with physical examination outcomes to appropriately manage these problematic patients. Delay in diagnosis and treatment may result in undesired complications and lost time from sport participation. The diagnosis of adductor tendinopathy through clinical history of chronic groin pain along with pain/weakness during isometric adduction of the hip muscles needs to be confirmed by advanced imaging to definitively exclude the many other possible anatomical structures that have been implicated in groin pain. This report reviews the relevant literature on adductor musculotendinous pathology, examines the common differential diagnosis for athletes with groin pain and adds one more case report to the literature where the diagnosis has been made clinically and was confirmed by MRI.

Case report

A 21 year old male previously competitive hockey player with persistent groin pain was referred for an MRI at our hospital. This athlete was competing recreationally and had symptoms of chronic pain in the region of the groin. The patient described his pain as localized to one specific region in the proximal portion of his left groin. Palpatory pin point tenderness was elicited at the proximal portion of the left groin at the tendinous insertion. A physical examination revealed pain and weakness of isometric adduction of the hip muscles. A clinical diagnosis of an adductor tendinopathy from repeated microtrauma and overuse was suspected and MR imaging was taken to confirm the diagnosis.

The MRI was performed on a Siemens 1.5 tesla scanner. Coronal T1 and coronal STIR in the plane of the body of the pubis, axial T1 and T2 fat saturation and sagittal gradient sequences were obtained.

The Axial T2 MRI, located at the level of the inferior body of the pubis at the adductor longus tendons, demonstrated an intense bright marrow signal within the body of the pubis bilaterally (Figure 1). This finding is suggestive of focal intense marrow edema at the attachment of the adductor longus tendons.

The Serial coronal T2 MRI, located at the level of the body of the pubis and the attachment of the adductor tendons, demonstrated an intense bright signal within the bone marrow of the body of the pubis bilaterally and the adductor longus tendon at its attachment to the body of the pubis (Figure 2). This finding is indicative of intense focal marrow edema and suggestive of adductor tendinopathy. The bright signal within the tendon is more obvious on the left side than the right.

Discussion

This case report demonstrates the diagnosis of adductor tendinopathy through a history of chronic groin pain, physical findings of pain/weakness during isometric adduction of the hip muscles, palpatory pin point tenderness and confirmed by MRI.

Chronic groin pain can develop from muscle strain, tendinosis, tendinitis, paratenonitis, enthesopathy or a combination of the aforementioned (Table 1). (6) Treatment for these conditions varies and therefore necessitates an aggressive early diagnosis to prevent undesired complications such as chronic groin pain and lost time from sport participation. Muscle strain, musculotendinous strain and tendinopathy disorders responds well to conservative rehabilitation therapy whereas enthesopathy, micro-tears at the tendon-periosteal junction, often progresses to prolonged, chronic groin pain. (13)

Pathology

The scientific literature for the sprain/strain injury process, for a large proportion of groin injuries, has progressed from an inflammatory injury ("-itis") to a degenerative process ("-osis") with connective tissue degenerative change in the presence of a paucity of leukocytes. (14) Connective tissue insufficiency is a term to describe the loss of tissue strength related to degenerative change, which results in loading and stimulation of relatively fixed-length pain mechanoreceptors. (15)

[FIGURE 1 OMITTED]

Enthopathy injuries stem from damage to the fibrocartilage enthesis between the tendon and periosteum as being the potential source of the problem. (13) Repair results in symphyseal sclerosis and irregularity, which is a secondary process rather than an active process, and that is why conventional radiographs and isotope bone scans can be inaccurate.

Mechanism of Injury

Groin injuries are common in sports that involve repeated kicking and rapid change of direction. (16) Some of the most prevalent sports include soccer, rugby, Australian Rules football, hockey and American football. (13,16) These conditions tend to relate to pathology with the symphysis pubis and/or surrounding soft tissues. However, these injuries are thought to develop secondary to mechanical stress forces through the anterior pelvis. (13) The combination of these forces along with inadequate abdominal strength or lack of flexibility can result in chronic damage to the pubic symphysis, enthesis, tendon, myotendinous junction and adductor muscles.

[FIGURE 2 OMITTED]

Clinical Symptoms and Examination

These athletes will present with chronic groin pain, hip stiffness and pain with active leg adduction. Enthesis disease tends to stem from the adductor longus and gracilis as they are positioned together at the symphysis. (13) The adductor brevis and magnus muscles arise more posterolaterally and are rarely implicated in chronic groin pain. (2)

Muscle strains tend to occur at the myotendinous junction. These injuries typically occur after a single traumatic event. However, tendinopathy injuries do not occur due to a single bout of trauma. They are simply an insidious onset of groin pain that is generally a result of overuse, progressive in nature and aggravated with sporting activity. Adductor tendinopathy should be suspected in cases of groin pain with localised tenderness, weakness and unilateral pain. (3) The patient may complain of groin, inner leg or lower abdomen pain with quick bursts of activity such as cutting, pivoting and skating. (2) In addition, compensatory mechanisms may result in symptoms extending to the rectus abdominis insertion and/or to the opposite groin. (2) There is increasing pain after activity and soreness the following day.

Intense physical activity, overloading the tendons and tendinous insertions, is needed to tease out the clinical symptoms and reproduce the patients' groin pain. (2) Pain can also be reproduced with adduction of the thigh against resistance and with passive stretching of the adductors.

Differential Diagnosis for Groin Pain

Some classify groin pain as adductor tendinopathy when isometric adduction is painful, pain caused by isometric contraction of hip muscles is not necessarily caused by an injury of adductor muscles or tendons. (17) However, athletes with groin pain can be extremely difficult to diagnose due to the several anatomical structures that have been implicated in exhibiting groin pain. The symptoms of groin pain in many patients have been found to stem from the sacro-iliac joint. For example, patients with pelvic girdle pain feel groin pain during isometric hip adduction. (18) Furthermore, studies have shown that these patients with groin pain can alleviate their pain wearing a pelvic belt. (1)

Patients with symphysis pubis stress injury (Commonly known as osteitis pubis. Osteitis pubis is frequently associated with infection, a finding notably absent among athletes with symphyseal stress injury (19)) tend to present with a history of increasing groin, pubic, or lower abdominal pain. These patients may have tenderness to palpation focally to the proximal adductor muscles, the symphysis pubis or the superior pubic ramus. (20) Both adductor originating injuries and symphysis pubis stress injuries have similarities in inciting mechanisms. Osteitis pubis often coexists with adductor related conditions and may be seen concurrently. Traction on the pubic ramus by the adductor muscles may lead directly to disruption of the fibrocartilaginous symphyseal disc. (21)

The osseous ring of the pelvis may be interrupted at the symphysis pubis and/or the left and/or right sacroiliac joints. Abnormal motion at one of these joints causes altered biomechanics with increased stress at the other two. (20) Clinicians that examine athletes that complain of groin pain should entertain the possibility of sacro-iliac joint dysfunction or symphysis pubis stress injuries.

Lumbar disc or facet joint abnormalities may result in radicular symptoms referred to the pelvis or groin. The ilioinguinal nerve originates from the T12 and L1 roots and the genitofemoral nerve originates from the L1 and L2 roots. Symptoms from these nerve roots may be provoked with slide or femoral nerve stretch tests. (17) In addition, research has shown that provocation of lumbar facet joints can have a distribution of pain provoked from L2 to L5. (22)

Bursitis, after direct blunt trauma or as the result of chronic irritation secondary to friction syndromes, can cause groin pain in many athlete. The groin pain can result from irritation to the bursa between the iliotibial tract and the greater trochanter, subgluteus minimus, medius and maximus bursae along with the sub-iliopsoas bursa. (23,24)

The iliopsoas can also be implicated in athletes with groin pain. Iliopsoas tendinosis or iliopsoas spasm can produce symptoms of groin pain and these pathologies are commonly seen in repetitive hip flexion sports or total hip replacement that has been caused by impingement of a malpositioned acetabular cup. (6)

Tears within the rectus abdominis and sports hernia are common causes of groin pain in many athletes. (25-27) Sports hernia is due to a posterior inguinal wall deficiency or Gilmore's groin. Posterior inguinal wall deficiency can result from tearing of the conjoint tendon and transversalis fascia which forms the posterior wall of the inguinal canal. (26) Gilmore's groin involves tears in the medial aspect of the external oblique aponeurosis which forms the anterior wall of the canal. (27)

Imaging

Radiological confirmation may require plain radiographs to exclude avulsion injury or heterotopic calcification. (28) Normal MRI of tendons show low signal intensity on all pulse sequences. Myxoid degeneration of tendons occurs with aging or from chronic overuse. On MR imaging, a degenerate tendon is normal or enlarged and has high signal intensity within the substance of the tendon on both T1W and any type of T2W sequences. The abnormal tendon is compatible with degeneration and micro tears, as they generally coexist.

MRI is also the imaging of choice for myotendinous strains. First-degree strains show hemorrhage at the myotendinous junction. There is also a feathery pattern of edema that runs from the myotendinous junction along the muscle fascicles. Second-degree strains will show a hematoma at the myotendinous junction along with increased fluid adjacent to the fascicles. Third-degree strains demonstrate complete disruption of the myotendinous unit. (29)

MRI for enthesopathy will show periostitis and adjacent marrow edema. The surrounding muscles will also demonstrate edema with thickening of the tendinous insertion of the adductor muscle. (13) Gadolinium enhancement of the adductor enthesis has been demonstrated to correlate with the symptomatic side. (13)

Treatment

Historically, conservative management may include cessation of physical activity, local anaesthetic/corticosteroid injection in addition to graduated strengthening of the core muscles, passive physical therapy modalities, anti-inflammatory drug medication, stretching exercises and prolotherapy. (2,7,30,31) Enthesopathy disorders of the adductor muscle group will sometimes require surgical repair. (20)

Treatment for muscle strains generally includes rest, ice, and compression. The goal of the treatment is to limit haemorrhaging and soft tissue swelling. Once the patient is pain free, progressive range-of-motion and strengthening exercises will begin. (17)

Conclusion

Groin pain in athletes may be acute or chronic in nature, may stem from a single traumatic event or repeated microtrauma and may arise from a variety of structures including muscle, tendon, ligament or joint. One of the most common causes of persistent groin pain in the athlete is adductor tendinopathy. The diagnosis of adductor tendinopathy through clinical history and physical examination can be confirmed by MR imaging. This case report demonstrates the importance of MR imaging in the accurate diagnosis of a patient with chronic groin pain.

References

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(2) Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med. 1987; 15:353-356.

(3) Braun P, Jensen S. Hip pain - a focus on the sporting population. Aust Fam Physician. 2007; 36:406-3.

(4) Biedert RM, Warnke K, Meyer S. Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clin J Sport Med. 2003; 13:278-284.

(5) Baeyens L. An unusual clinical variant of pubic pain in females: the case of an athlete. J Gynecol Obstet Biol Reprod (Paris). 1987; 16:339-341.

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(8) Ashby EC. Chronic obscure groin pain is commonly caused by enthesopathy: "tennis elbow" of the groin. Br J Surg. 1994; 81:1632-1634.

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(10) Hayes CW, Rosenthal DI, Plata MJ, Hudson TM. Calcific tendinitis in unusual sites associated with cortical bone erosion. AJR Am J Roentgenol. 1987; 149:967-970.

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(12) Weinstein RN, Kraushaar BS, Fulkerson JP. Adductor tendinosis in a professional hockey player. Orthopedics. 1998; 21:809-810.

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(18) Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001; 26:1167-1171.

(19) Major NM, Helms CA. Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes. Skeletal Radiol. 1997; 26:711-717.

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(21) Brennan D, O'Connell MJ, Ryan M et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology. 2005; 235:162-167.

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(23) Nunley RM, Wilson JM, Gilula L, Clohisy JC, Barrack RL, Maloney WJ. Iliopsoas bursa injections can be beneficial for pain after total hip arthroplasty. Clin Orthop Relat Res. 2010; 468:519-526.

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(26) Koulouris G. Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. AJR Am J Roentgenol. 2008; 191:962-972.

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(28) Kalebo P, Karlsson J, Sward L, Peterson L. Ultrasonography of chronic tendon injuries in the groin. Am J Sports Med. 1992; 20:634-639.

(29) Kaplan P et al. Musculoskeletal MRI. Philadelphia: 2001.

(30) Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005; 86:697-702.

(31) Schilders E, Bismil Q, Robinson P, O'Connor PJ, Gibbon WW, Talbot JC. Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am. 2007; 89:2173-2178.

(32) Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999; 27:393-408.

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Daniel Avrahami, BPHE, DC, MSc * Hema N. Choudur, MBBS, DNBt

* Private Practice dr.danavrahami@gmail.com

[dagger] Department of Radiology, McMaster University, 237 Barton St East., Hamilton, Ontario, L9L 2X2 [C] JCCA 2010
Table 1 Classification of tendon and muscle injuries (32,33)

Pathological Diagnosis   Concept (Macroscopic Pathology)

Tendinosis               Intratendinous degeneration (commonly
                         caused by ageing, microtrauma and
                         vascular compromise)

Tendinitis/partial       Symptomatic degeneration of the tendon
rupture                  with vascular disruption and inflammatory
                         repair response

Paratenonitis            "Inflammation" of the outer layer of the
                         tendon (paratenon) alone, regardless
                         of whether the paratenon is lined by
                         synovium

Paratenonitis with       Paratenonitis associated with
tendinosis               intratendinous degeneration

Enthesopathy             An inflammation or disease of an enthesis
                         (the point at which a tendon joins to a
                         bone)

Muscle Strain            An injury to a muscle in which the muscle
                         fibers tear as a result of overstretching

Pathological Diagnosis   Histological Appearance

Tendinosis               Collagen disorientation,
                         disorganisation and fibre separation
                         with an increase in mucoid ground
                         substance, increased prominence
                         of cells and vascular spaces with or
                         without neovascularisation, and focal
                         necrosis or calcification

Tendinitis/partial       Degenerative changes as noted
rupture                  above with superimposed evidence
                         of tear, including fibroblastic and
                         myofibroblastic proliferation,
                         haemorrhage and organising
                         granulation tissue

Paratenonitis            Mucoid degeneration in the areolar
                         tissue is seen. A scattered mild
                         mononuclear infiltrate with or without
                         focal fibrin deposition and fibrinous
                         exudate is also seen

Paratenonitis with       Degenerative changes as noted for
tendinosis               tendinosis with mucoid degeneration
                         with or without fibrosis and scattered
                         inflammatory cells in the paratenon
                         alveolar tissue

Enthesopathy             Similar to tendinitis

Muscle Strain            Destruction phase--Rupture and
                         ensuing necrosis of the myofibers, the
                         formation of a hematoma between
                         the ruptured muscle stumps, and the
                         inflammatory cell reaction

                         Repair phase--Phagocytosis of the
                         necrotized tissue, the regeneration
                         of the myofibers, the concomitant
                         production of a connective tissue scar
                         and capillary ingrowth

                         Remodeling phase--Maturation of the
                         regenerated myofibers, the contraction
                         and reorganization of the scar tissue
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