1. Chronic groin pain in athletes
Charl Carstens
CLL 705
September 2012

2. OVERVIEW Case Presentation Clinical Progress Special Investigations
Treatment
Introduction
Summary
Discussion

3. Case Presentation 26 year Male rugby player- hooker
C/O: Pain left supra inguinal area
(illiopsoas)
Conservative treatment 1/12
Surgeon referral

4. Clinical Progress Re-injured- acute pain left groin X-ray- NAD
Ultrasound- ?Partial tear or
tendinopathy adductor
brevis

5. Progress Cont. Treatment 9/52 Rest/Rehab: Core stabilizers, hip muscle
activation and strengthening
Slipped – pain left groin again

6. Re- Evaluation Tender Proximal adductors
Adductor squeeze test- Extension & 90° Hip flexion - adductor longus
FABER (+)

7. Special Investigations
MRI: Partial avulsion enthesis left pectineus and adductor brevis anterior at inferior attachment of symphysis pubis.
Oedema medially in both muscles.

8. Surgical Treatment 5 months post injury
Surgery: Extensive tendinopathy of Adductor longus – unilateral tenotomy

9. Summary Clinical Chronic groin injury Personal
Professional rugby player
Contextual
Pressure from club RTP

10. Introduction Non-specific exercise related groin pain
Osteitis Pubis/Athletic Pubalgia
Adductor tendinopathy(enthesopathy)
Iliopsoas dysfunction
Sportsman’s hernia/sports hernia
Gilmore’s groin

11. Discussion 4 Groin Entities A. Adductor- related B. Iliopsoas- related
C. Abdominal wall- related
D. Pubic bone stress –
related
(Brukner & Khan 2012)

12. 4 Groin Entities Anatomy: - Adductor Longus & Rectus
Abdominus directly linked
- Indirectly to Transversus
Abdominus & Internal Oblique via
Rectus Abdominus sheath

13. Pubic Joint Anatomy- 2 Pubic symphyseal bones - 3 Muscle Compartments
Anterior: Abdom, Quads, Sartorius,
Iliopsoas + Pectineus
Medial: 3 Adductors, Gracillis +
Obturator externus
Posterior: Hamstrings +Part Add Magnus
(Meyers et al 2012)

15. Adductor Longus Related
Enthesopathy rather tendinopathy
Conservative treatment- soft tissue treatment, core stability program & strengthening local muscle groups
If all else fails- cut

16. Treatment Cont.
Partial tenotomy – transferring load from superficial to deep part
(Orchard J.W et al 2004)
?RTP after 4-6 weeks
(Brukner & Khan 2012)
Complete Tenotomy

17. Advocated 10 – 12 weeks rehabilitation
Treatment Cont.
Unilateral Adductor tenotomy return to pre-injury level of sport:
Atkinson et al %
Akermark et al 1992 – 62%
Robertson et al 2011 – 68%
Advocated 10 – 12 weeks rehabilitation

18. Treatment Cont.
Bilateral Adductor tenotomy return to pre-injury level of sport or higher:
Maffuli et al 2012 – 76% with 16 weeks rehabilitation

19. References
Brukner P., Khan K., et al, Brukner & Khan’s Clinical Sports Medicine. 4th ed. Australia: Mcgraw-Hill Australia
Akermark C. and Johansson C Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 20:
Atkinson H.D., Johal P., Falworth M.S., et al Adductor tenotomy: its role in the management of sports related chronic groin pain. Arch Orthop Trauma Surg. 130(8):
Hackney R.G Groin pain in athletes. Othop & Trauma 26(1):

20. References Cont.
Maffuli N., Loppini M., Longo U.G., et al Bilateral Mini-Invasive Adductor Tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med. 40(8):
Meyers W.C., Yoo E., Devon O.N., et al Understanding “Sports Hernia”(Athletic Pubalgia): The Anatomic and Pathophysiological Basis for Abdominal and Groin Pain in Athletes. Oper Tech Sports Med. 20:
Orchard J.W., Cook J.L. and Halpin N Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports the theory. J Sci Med Sport. 7(4):
Robertson I.J., Curran C., McCaffrey N., et al Adductor tenopathy in the management of groin pain in athletes. Int J Sports Med. 32(1):