Case Presentation: Adductor Tendinopathy in a hockey player with persistent groin pain
So a 21 year-old male, previously competitive hockey player with persistent groin pain was referred for an MRI. This athlete was competing recreationally and had some 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 the left groin. Palpatory pin point tenderness was elicited at the proximal portion of the left groin at the tendinous insertion.
Dr. Emily Splichal quickly presents her thoughts on this case presentation.
I actually really like this case presentation, so I’m glad that we’re doing it, because it relates to an injury that I had, and I was given the whole run-around because of confusion related around injuries similar to this. So, classic presentation of where people think of adductor longus tendonitis is in that hockey player, soccer player, football, et cetera. However, one thing that I would want to make sure that is ruled out, and it was mentioned before, is that the diagnosis is correct. Adductor longus tendonitis is often misdiagnosed with a sports hernia or athletic pubalgia, which is the injury that I had, so I’ve done tons of research on this and ended up having to diagnose myself because it was repeatedly misdiagnosed and mistreated in myself.
With the athletic pubalgia, which again often presents as that osteitis pubis, adductor longus strain, adductor longus tendonitis et cetera, is making sure that you have the appropriate MRI imaging. The MRI that actually needs to be done to visualize the rectus abdominis and the tear that’s associated with athletic pubalgia actually has to be angled a little bit differently. And those who, the listeners who wanna learn a little bit more on this, I would highly recommend researching a Dr. Meyers out of Pennsylvania; he’s probably the leader in sports hernia, athletic pubalgia, surgical repair of these injuries et cetera. And he pretty much designed the surgery for this. And the image that they do, or the MRI that they’ll do on the patient, is slightly different. They actually created their own angulation and cut with the MRI machine to visualize these tears easier.
So a traditional pelvic MRI or hip MRI may not show a rectus abdominis tear. Something that’s important to note with adductor longus tendonitis, osteitis pubis, or athletic pubalgia is that there’s an anterior hip joint, is what Dr. Meyers refers to it, and myofascially the adductor longus is continuous with your rectus abdominis. So when there’s an imbalance in the way that forces are going through the anterior hip, that’s where you start to stress and over-recruit the adductor longus tendon. What Dr. Brandon mentioned, what was interesting is he had mentioned about the TFL. And what the research shows is that in the over-active TFL, and if your TFL is engaging before your psoas can actually stabilize your deep hip pelvic joint, then that transverse force is through the adductor longus a little bit more, or on a less stable pelvis joint. And then that over-recruitment of the adductor longus can lead to the increased risk of tear of the rectus abdominis fascia. Again, this is obviously also associated with an imbalance in the obliques and if there is rotation that’s in a dominate side and with hockey, there is. They’re going to be hitting the puck in a very similar fashion, so that can also lead to this oblique imbalance which can then start to stress the adductor longus and then the TFL. One make sure that the diagnosis is correct and make sure that you get the MRI that is the cut that can really visualize.
If it is confirmed that there is athletic pubalgia, I would have a assessment with an appropriate surgeon. These should not be repaired surgically with a mesh like other hernias. They need to repaired primarily without a mesh. A lot of sports hernias that are repaired surgically with a mesh end up having to be re-operated on, have the mesh taken out and have them repaired primarily. That would be important as well.
Post-surgical because, again, I got to rehab myself on the post-surgical athletic pubalgia, is re-establishing that deep pelvic floor, deep hip stabilization, and making sure that your deep rotators, pelvic floor psoas are stabilizing before you put force to the TFL, adductor’s, glutes, et cetera.
There is a piece of equipment that was designed by… It’s called Core X, and essentially it’s kind of a cross X where you hook a resist demand on one foot, the opposite arm… Foot to opposite arm, so you’re getting that oblique system going and that then gets the core and that appropriate fire in between adductors and obliques.
No real podiatry input on this one; however, a lot of research more from the integration of sequencing and stabilization of the human body. And agreeing with what everyone has said before and have experienced this both diagnosis to surgery to post-surgical rehab. This is a topic that I’m very, very passionate about because it’s highly misunderstood and mistreated.
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Dr. Emily Splichal DPM, MS, NASM, NSCA-CPT
Dr Emily Splichal, Podiatrist and Human Movement Specialist, is the Founder of the Evidence Based Fitness Academy and Creator of the Barefoot Training Specialist®, BarefootRx® and BARE® Workout Certifications for health and wellness professionals. With over 15 years in the fitness industry, Dr Splichal has dedicated her medical career towards studying postural alignment and human movement as it relates to foot function and barefoot training.