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

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Presentation on theme: "Managing Adductor Tendonopathy in Football Jon Fearn MSc MACP MCSP First Team Physiotherapist Chelsea FC."— Presentation transcript:

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

2 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) Possible causes of groin pain in athletes reported in the literature

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

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

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

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

7 Optimal load is essential for healthy tendon (‘Mechanotransduction’ : Khan & Scott 2009) Optimal load is essential for healthy tendon (‘Mechanotransduction’ : Khan & Scott 2009) ‘Too little’ / Sudden Underload e.g. injury, holiday ‘Too little’ / Sudden Underload e.g. injury, holiday ‘Too much’ / Sudden Overload e.g. excessive increase in training ‘Too much’ / Sudden Overload e.g. excessive increase in training Compression e.g. trauma Compression e.g. trauma Poor Conditioning of MT unit Poor Conditioning of MT unit Poor biomechanics Poor biomechanics Mechanically active gene presence: Predispose or Protect? (Mokone et al 2002 or September et al 2008) Mechanically active gene presence: Predispose or Protect? (Mokone et al 2002 or September et al 2008) Predisposing factors for Tendon injury

8 Common Clinical findings Tendonopathy Pain associated with activity / load Pain associated with activity / load Specific location of pain (30% Bilateral ) Specific location of pain (30% Bilateral ) AM pain/stiffness (VAS score) AM pain/stiffness (VAS score) Eases with activity (VISA questionnaire) Eases with activity (VISA questionnaire) Local tenderness (not pathological specific!) Local tenderness (not pathological specific!) Functional impairments 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 Imaging: Decide degree of pathology initially with a Good History

9 Pain v Pathology 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 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! Explains relapse of symptoms if resume activity too soon! Tendon mechanics remains unaltered in tendonopathy (Hansen et al 2006; Kongsgaard et al 2009) Tendon mechanics remains unaltered in tendonopathy (Hansen et al 2006; Kongsgaard et al 2009) Load ‘Iceberg Theory’ PAIN DETECTION THRESHOLD Time Time

10 ‘Load-induced’ Tendon Pathology Continuum NORMAL TENDON FASCIITIS? (Franklyn-Miller et al 2009) FASCIITIS? (Franklyn-Miller et al 2009) PROLIFERATIVE / REACTIVE TENDONOPATHY ? TENDON DYSREPAIR (failed healing) DEGENERATIVE TENDONOPATHY ? TENDON DYSREPAIR (failed healing) DEGENERATIVE TENDONOPATHY …..RUPTURE? (Cook 2009) …..RUPTURE? (Cook 2009) NB: Mixed pathology is often present ! (Khan et al 1999, Llan et al 2007)

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

12 How do we manage these patients? Rest Rest Injection therapy / Dry needling Injection therapy / Dry needling Medication Medication Electrotherapy Electrotherapy Compression shorts Compression shorts Surgery Surgery Manual therapy Manual therapy Exercise Therapy Exercise Therapy

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

14 Manual Techniques SSTM Physiological Physiological Accessory Accessory Dynamic Dynamic Combined (Hunter 1990) 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

15 Manual Therapy v Exercise therapy n=ET:25/MT:29;+ive local Adductor pain signs (Holmich 2004) ET group (n=25); ET group (n=25); Allowed to run at 6 weeks! MT group (n=29); 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 MT: 50%Return to Sport at 12.8 weeks ET: 55% RTS at 17.5 weeks ET: 55% RTS at 17.5 weeks Home exs programme! Home exs programme! Unsupervised! Unsupervised! No control No control Recurrences after 4 month F/U? Recurrences after 4 month F/U? (Weir et al 2011)

16 Isometric Adductor strength in Footballers Adduction > Abduction irrespective of dominance Adduction > Abduction irrespective of dominance Dominant > non-dominant (3% Adduction / 4% Abduction) Dominant > non-dominant (3% Adduction / 4% Abduction) Hip Add/Abd ratio is 1.05 in footballer 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 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) 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) 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 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 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 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) 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 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 Ekstrand & Ringborg 2001: strengthening exs had short term benefit but poor adherence long term BUT ALL STUDIES SHOW BENEFITS! ‘Exercise Therapy’ in LSARGP varies!

19 Exercise therapy v ‘Physiotherapy’ At 4 months: 79% of AT group had no residual groin pain and RTS 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) 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 Amateur athletes

20 Take care with excess load on tendon! After single bout of prolonged exercise 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 Seen in Proliferative/Reactive tendinopathy Care reintroducing into exercise within 72 hours! Care reintroducing into exercise within 72 hours! Tendon loading magnitude (e.g. HSR) positively relates to anabolic gene expressive (Lavagnino 2003, Arnoczky 2007) Tendon loading magnitude (e.g. HSR) positively relates to anabolic gene expressive (Lavagnino 2003, Arnoczky 2007)

21 Undulating Tendon Loading Programme No / minimal pain during exercise (VAS 3/10 max) No / minimal pain during exercise (VAS 3/10 max) 3 sec per Rep / 2 min rest 3 sec per Rep / 2 min rest Varying loads and reps Varying loads and reps Aim to mimic athletic movement in different ways Aim to mimic athletic movement in different ways (e.g. Isometrics, strengthening, running, jumping, kicking, etc) Progress Range, Load, Speed Progress Range, Load, Speed High load every 3-4 days! High load every 3-4 days! Type 1 production requires 2- 3 days to peak Type 1 production requires 2- 3 days to peak (Fredberg 2004) SessionExerciseSetsReps Intensity (%) 1A3680 B3685 C3685 2A31540 B31540 C A31060 B31070 C31070

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 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 Achilles tendon (Silbernagel et al 2001) Effective in Patellar tendon (Kongsgaard et al 2009) Effective in Patellar tendon (Kongsgaard et al 2009) Don’t avoid concentric! Control movement velocity! (‘Time under tension’) Is it ‘Strength’ that’s essential?

25 Motor control Work capacity ‘TO FATIGUE’ Maximal Strength Power VolumeIsometric 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 Increased passive stiffness Classic Strength Training ‘Are players working hard enough?’ (Brandon 2010, Foure et al 2009, Arruda et al 2006)

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

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

28 Early phase: Off-load for 7-10 days??? Off-load for 7-10 days??? Isometric loading (12-5 reps x 5-30 sec) Isometric loading (12-5 reps x 5-30 sec) Intermediate/Late phase: Heavy Slow Resistance training (3 x/week) 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 Eccentric loading daily (Low/Med/High load every 3 days) (Low/Med/High load every 3 days) Tendonopathy Exercise Therapy

29 ‘Local’ Adductor tendon loading Ensure strength & stability function restored Ensure strength & stability function restored 3 staged Strength Protocol 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 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 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 Level 3 aims: Single SL Side bridge painfree; Full high load function

30 Target all ‘functional’ Global systems 1. Posterior oblique Lat Dorsi BicepsFemoris Gluteus Maximus ST lig TDF 2. Anterior oblique* EO and contralat IO Contalat Adductors Anterior Abdominal Fascia and TA 3. Deep longitudinal ES MTFBiceps Femoris (long head) Deep lamina TDF, ST, Int & SD ligs 4. Lateral sling * Gluteus Medius and minimus Contralateral Adductors TFL (Vleeming 1995)

31 Monitor Progress 1. Pain during exercise 2. Pain +/- ‘stiffness’ next morning 3. Squeeze test (0°,60°,90°) 4. Isometric strength test 5. Pubic symphysis stress test (Ext/Abd, Resist flex/add) 6.Adductor muscle tone (BKFO, ABD ROM, Palpation) (Hogan 2003)

32 SIJ Stabilisation belts Groin pain patients have less adductor strength than healthy subjects Groin pain patients have less adductor strength than healthy subjects (N = 44, mean duration of symptoms:16.3 months) (N = 44, mean duration of symptoms:16.3 months) Adding Pelvic belt = Average 10% increase in strength (39% increased by 20%) and reduced pain 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+ SL loading+ Med ball drills Med ball drills Tackling + Kicking Tackling + Kicking Agility + Cutting drills Agility + Cutting drills

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

35 Injury based tests 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 Rehabilitation criteria e.g. Kicking*, Cut/Agility at High intensity, Sprint, Cross-over hop, etc Physiological criteria Physiological criteria V02max / Yo-yo, GPS data (Max speed, max accel, loading R=L?) Return to Training Criteria

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

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


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