1. Managing Adductor Tendonopathy in Football Jon Fearn MSc MACP MCSP First Team Physiotherapist Chelsea FC

2. Possible causes of groin pain in athletes reported in the literature
Abdominal aortic aneurysm Hydrocoele/varicocoele Postpartum symphysis separation
Acetabular disorders Inflammatory bowel disease Prostatitis
Adductor strain Inguinal or femoral hernia Pubic instability
Adductor tendinopathy Intra-abdominal abscess Sacroiliac joint problems
Apophysitis Legg-Calve´-Perthes disease Seronegative spondyloarthropathy
Appendicitis Lumbar spine pathology Slipped capital femoral epiphysis
AVN of femoral head Lymphadenopathy Snapping hip syndrome
Avulsion fracture Muscle strain Sports hernia
Bursitis Myositis ossificans Stress fractures
Conjoined tendon dehiscence Nerve entrapment Synovitis
Crohn’s disease Obturator nerve entrapment Tendon (Adductor): Partial tear / Adductor Shear injury
Diverticular disease Osteitis pubis Tendon (Adductor): Rupture
Epididymitis Osteoarthritis PS / Hip Testicular neoplasm
FAI Ovarian cyst Testicular torsion
Herniated nucleus pulposus Pelvic inflammatory disease Urethritis
Hockey player’s syndrome Pelvic stress fracture Urinary tract infection
69% of groin injuries in football have Adductor complex issues
(Holmich 2007)

3. Long Standing Adductor Related Groin Pain (LSARGP)
‘Groin pain’ is 4th most common injury affecting soccer players (10%) (Walden 2007, Hawkins 2001)
Causes 3rd longest absence from sport behind fracture & ACL injury
Acute Groin injury: 86% heal within 3 weeks But 13.5% Don’t!!
Previous groin injury: 9% chance of recurrence
(No Hx GP =2%) (Arnason et al 2004)
Tendon pain is common in athletes
Adductor tendon issues common issue in LSARGP

4. Adductor Longus Enthesis
Anterior AL: Tendinous
Posterior AL: Muscular
Area of concentrated stress at Bone-tendon junction
(Tuite et al 1998, Strauss 2007)
Pathology involves: AL (70%), Magnus (15%), other (15%)
(Lovell 2001)
Enthesopathy rather than tendinopathy!

5. Tendon (Site v Function)
Achilles
Adductor
Long mid-tendon
Excellent shock absorber
Dissipates energy quickly and efficiently
Tendon is short
Exposed to tensile and Shear forces
Has to dissipate forces quickly+

6. Main Clinical Findings in LSARGP
Pain – strong association between location of pain felt and site of pathology
(Lovell 1995)
Weakness
(? pain inhibition or actual)
Reduced Performance e.g. kicking, cutting, agility

7. Predisposing factors for Tendon injury
Optimal load is essential for healthy tendon (‘Mechanotransduction’ : Khan & Scott 2009)
‘Too little’ / Sudden Underload e.g. injury, holiday
‘Too much’ / Sudden Overload e.g. excessive increase in training
Compression e.g. trauma
Poor Conditioning of MT unit
Poor biomechanics
Mechanically active gene presence: Predispose or Protect? (Mokone et al 2002 or September et al 2008)
Baar slide 22 Mechanically activated genes
Tenasin-C gene - x 6 Risk of AT (Mokone et al 2002) COL12A1 polymorphs protect tendon rupture (September et al 2008) 7

8. Common Clinical findings Tendonopathy
Pain associated with activity / load
Specific location of pain (30% Bilateral )
AM pain/stiffness (VAS score)
Eases with activity (VISA questionnaire)
Local tenderness (not pathological specific!)
Functional impairments
(Test battery: CMJ, Hop, Drop CMJ, Toe-raise strength tests - Silbernagel et al 2006)
Imaging: Decide degree of pathology initially with a Good History
Battery of test are 88% sensitive 8

9. Pain v Pathology Time Imaging = Pathology (Khan 1996, Yu 1995,etc)
Pain ≠ Pathology
...but dictates our success!!
(Ohberg et al 2001;
Fredberg & Stengaard-Pedersen 2007)
Abnormalities on imaging are present before they become symptomatic
(Lovell et al 2006; Malliaras 2006, Fredberg et al 2008)
Explains relapse of symptoms if resume activity too soon!
Tendon mechanics remains unaltered in tendonopathy (Hansen et al 2006; Kongsgaard et al 2009)
Load ‘Iceberg Theory’
PAIN DETECTION THRESHOLD
Time

10. ‘Load-induced’ Tendon Pathology Continuum
NORMAL TENDON
FASCIITIS? (Franklyn-Miller et al 2009)
PROLIFERATIVE / REACTIVE TENDONOPATHY
? TENDON DYSREPAIR (failed healing) DEGENERATIVE TENDONOPATHY
…..RUPTURE? (Cook 2009)
NB: Mixed pathology is often present !
(Khan et al 1999, Llan et al 2007)
A degenerative tendon with acute overload may develop proliferative changes in previously normal parts of the tendon!!
Proteins produced = proteoglycan and collagen
97% OF RUPTURED TENDONS ARE DEGENERATIVE (Kannus and Jozsa 1991)
‘Injury for Life’!!! 10

11. Aim of Tendonopathy Management
In theory: To attempt to remodel the tendon matrix In practise: To attempt to remove pain Restore muscle tendon function

12. How do we manage these patients?
Rest
Injection therapy / Dry needling
Medication
Electrotherapy
Compression shorts
Surgery
Manual therapy
Exercise Therapy
Medication: NSIADs; Naproxen, ibuprofen, GTN patches, polypil
Electrotherapy: ECSWT, ultrasound?, laser, EPI 12

13. The Surgical option…?
‘Surgery takes longer to return to sport than conservative management!’
Adductor tendon ruptures; NFL players
Surgery (n=5); Conservative (n=14)
Surgery RTS: 12 weeks (10-16)
Conservative RTS: 6 weeks (3-12)
(Schlegel 2010)

14. Manual Techniques SSTM Physiological Accessory Dynamic
Combined (Hunter 1990)
Van Den Aaker method
Multi modality treatment (MMT)
(Heat/STM/Stretching/Running program; 90% RTS: Weir 2008)
NB: Thomas’ test: ITB/TFL stiffness
Heat + STM + Stretching + Return to running program No Exercise therapy
90% return to sporting activity
No control
(Weir 2008) 14

15. Manual Therapy v Exercise therapy
n=ET:25/MT:29;+ive local Adductor pain signs (Holmich 2004)
ET group (n=25);
Allowed to run
at 6 weeks!
MT group (n=29);
Allowed to run at 14 days or earlier!
Return to running program (Phase 1-3: slow jog, straight line, cutting)
(Weir 2011)
MT: 50%Return to Sport at 12.8 weeks
ET: 55% RTS at 17.5 weeks
Home exs programme!
Unsupervised!
No control
Recurrences after 4 month F/U?
(Weir et al 2011)
Adductor tests: pain on adductor resistanced activation and palpation of tendon insertion
2/4: Hx: pain at night/stiffness in am/ pain on cough/sneeze; pain at PS palpn; osteitis pubis on scan
*if painfree
***reviewed 3 times 15

16. Isometric Adductor strength in Footballers
Adduction > Abduction irrespective of dominance
Dominant > non-dominant (3% Adduction / 4% Abduction)
Hip Add/Abd ratio is 1.05 in footballer
(Thorborg et al 2010)
Nicholas & Tyler 2002 suggest
Add:Abd ratio: >90%; Adductor strength L=R before for RTS

17. Adductor Weakness in LSARGP
Add : Abductor Ratio was 24% lower in groin pain athletes (Thorborg et al 2010)
Squeeze test was significantly weaker (20%) in players with longstanding groin pain (Malliaras et al 2009)
Player was 17 TIMES more likely to get adductor muscle strain if Adductor strength was <80% of Abductor strength
(Tyler et al 2001, O’Connor 2004)

18. ‘Exercise Therapy’ in LSARGP varies!
Verrall et al 2007: 63% return to sport but only 41% to pre-injury level (rest, swim, bike, stepping, core exs) in Pro Aussie Rules
10 weeks RTS with ET (Wollin & Lovell 2006)
Rodriguez et al 2001: combined local passive Rx (ET, ice) and progressive strength program over 10 weeks – 100% success
Ekstrand & Ringborg 2001: strengthening exs had short term benefit but poor adherence long term
BUT ALL STUDIES SHOW BENEFITS!

19. Exercise therapy v ‘Physiotherapy’
At 4 months:
79% of AT group had no residual groin pain and RTS
NB: ONLY 14% of PT group!
Return to sport took between weeks (median 18.5 weeks)
(Holmich et al 1999)
Active Training (n=30)
e.g. Abd/adduction strength exs, sit ups, balance training, slide board
Physiotherapy Treatment (n=29)
Laser, Frictions, Stretching, TNS
NB: Hx of Groin pain (≈ 40 weeks)
Amateur athletes

20. Take care with excess load on tendon!
After single bout of prolonged exercise
(3 hour run) leads to increase in type 1 collagen synthesis in the peritendon
(Langberg et al 1999)
Seen in Proliferative/Reactive tendinopathy
Care reintroducing into exercise within 72 hours!
Tendon loading magnitude (e.g. HSR) positively relates to anabolic gene expressive (Lavagnino 2003, Arnoczky 2007)
Carboxy-terminal propeptide of type 1 collagen is a marker for collagen synthesis
Reintroducing exercise when?? After 72 hours too soon?? 20

21. Undulating Tendon Loading Programme
No / minimal pain during exercise (VAS 3/10 max)
3 sec per Rep / 2 min rest
Varying loads and reps
Aim to mimic athletic movement in different ways
(e.g. Isometrics, strengthening, running, jumping, kicking, etc)
Progress Range, Load, Speed
High load every 3-4 days!
Type 1 production requires 2-3 days to peak
(Fredberg 2004)
Session
Exercise
Sets
Reps
Intensity (%) 1 A 3 6 80 B 85 C 2 15 40 10 60 70

22. Periodising Tendon Load in Late stage rehabilitation

23. Why do Eccentrics on Tendonopathy?
‘Is it too aggressive for some tendons?’
‘Are there better methods?
Not for every tendon problem!

24. Is it ‘Strength’ that’s essential?
Does high load eccentric training just strengthen the MT unit?
Why not just get the unit stronger through conventional means (concentric and eccentric)?
Effective in Achilles tendon (Silbernagel et al 2001)
Effective in Patellar tendon (Kongsgaard et al 2009)
Don’t avoid concentric!
Control movement velocity! (‘Time under tension’)

25. Classic Strength Training
‘Are players working hard enough?’
(Brandon 2010, Foure et al 2009, Arruda et al 2006)
Motor control
Work capacity
‘TO FATIGUE’
Maximal Strength
Power
Volume
Isometric
3-5 x 20+ Reps
3-5 x 30-60sec
3-5 x 5-12 Reps
3-5 x
(4-6 x sec)
3-5 x 6-2 Reps
3-5 x(10 x 6sec)
3-6 x 2-3 Reps
3-6 x 5-10 Plyos
Frequency
3-7 x / week
2-3 x / week
1-3 x / week
Muscle Adaptation
Slow twitch hypertrophy
Whole muscle hypertrophy
Fast twitch hypertrophy
Tendon Adaptation
None
Tendon hypertrophy – 5% at each end
i.e. ‘areas of most stress’
Tendon hypertrophy
Increased passive stiffness
If high volume: tendon hypertrophy

26. Remember Tendon is slow to adapt!
Tissue Responses
Neural
1-3 weeks
Muscle
> 3 weeks
Tendon
> 6 weeks

27. Key Tendon Rehab points!
Where does pathology sit on the continuum?
High load every other or third day
Deliver load in different ways (via strength exs, plyometrics, functional load e.g. kicking)
Combine HSR with eccentric training once able!
But monitor response & periodise load acordingly
Monitor subjective markers (AM pain/stiffness, VAS on activity, VISA)
Monitor objective markers
Tendon Rehab takes time despite anatomical site (i.e. 3 months!)
Adductor rehab evidence Holmich 1999 and weir 2010 = 3 months rts 27

28. Tendonopathy Exercise Therapy
Early phase:
Off-load for 7-10 days???
Isometric loading (12-5 reps x 5-30 sec)
Intermediate/Late phase:
Heavy Slow Resistance training (3 x/week)
(3 sec conc/ecc – 4 x 8-15 each exs)
(Patellar tendon : Kongsgaard et al 2009)
Eccentric loading daily
(Low/Med/High load every 3 days)

29. ‘Local’ Adductor tendon loading
Ensure strength & stability function restored
3 staged Strength Protocol
Level 1 targets: Squeeze test P1/Max Effort 50%/150mmHg; Painfree FROM on 7 stretch program; Complete all level 1 exercises painfree
Level 2 Targets: Pubic stress test (max resistance); Squeeze 200+ mmHg / 75% Normal; Completed all above exercises painfree
Level 3 aims: Single SL Side bridge painfree; Full high load function

30. Target all ‘functional’ Global systems
Posterior oblique
Lat Dorsi BicepsFemoris Gluteus Maximus ST lig TDF
Anterior oblique*
EO and contralat IO
Contalat Adductors
Anterior Abdominal Fascia and TA
Deep longitudinal
ES MTF Biceps Femoris (long head)
Deep lamina TDF, ST, Int & SD ligs
Lateral sling*
Gluteus Medius and minimus
Contralateral Adductors TFL (Vleeming 1995)
Bias these slings* 30

31. Monitor Progress Pain during exercise
Pain +/- ‘stiffness’ next morning
Squeeze test (0°,60°,90°)
Isometric strength test
Pubic symphysis stress test
(Ext/Abd, Resist flex/add)
Adductor muscle tone (BKFO, ABD ROM, Palpation)
(Hogan 2003)

32. SIJ Stabilisation belts
Groin pain patients have less adductor strength than healthy subjects
(N = 44, mean duration of symptoms:16.3 months)
Adding Pelvic belt = Average 10% increase in strength (39% increased by 20%) and reduced pain
Mens et al 2006

33. ‘High load’ functional activities
SL loading+
Med ball drills
Tackling + Kicking
Agility + Cutting drills

34. Comprehensive treatment plan
All with proximal insertional adductor pain on palpation and pain on squeeze
Adductor strength program (Holmich 1999)
TA activation (Cowan et al 2004)
Mobilise Hips (Williams 1978, Ibrahim et al 2007, Verrall et al 2007)
Mobilise SIJ (Marshall & Murphy 2006)
4 phases of recovery; Each stage had goals to achieve
77% Return to pre-injury level without symptoms
In average 20 weeks ( days)
70% competing at 22 months (within months)
But 26% re-occurred…therefore ensure MAINTENENCE WORK continues!
(Weir et al 2010)

35. Return to Training Criteria
Injury based tests
e.g. Squeeze test, Isometric Abd = Add / R=L, Cross hands squeeze, DL abs lowers x 24, Scissor beats x 1 min, SL bridge, level 3 strength R=L
Rehabilitation criteria
e.g. Kicking*, Cut/Agility at High intensity, Sprint, Cross-over hop, etc
Physiological criteria
V02max / Yo-yo, GPS data (Max speed, max accel, loading R=L?)

36. Rehabilitation into Training!
High intensity lateral movement ESSENTIAL! Especially… Agility / Accelerations (GPS data)

37. Evidence based Adductor dysfunction rehabilitation
Local Adductor strengthening (Isometric test)
Normalise Adductor tone / ROM (BKFO)
Local trunk dissociation control (Pilates)
Global functional strength (Squeeze test)
Progressive Functional rehabilitation (3 stage
adductor protocol)
Utilise SIJ belt (enhance force closure)
Bilateral Hip & SIJ mobility (measure, Gillets)
Thoracolumbar junction mobility & Neural tests
Fascial techniques & dSSTM to adductor complex
Pain management / medical intervention