Managing Adductor
Tendonopathy in Football
Jon Fearn MSc MACP MCSP
First Team Physiotherapist
Chelsea FC
Possible causes of groin pain in
athletes reported in the literature
Abdominal aortic aneurysm
Acetabular disorders
Adductor strain
Hydrocoele/varicocoele
Inflammatory bowel disease
Inguinal or femoral hernia
Postpartum symphysis separation
Prostatitis
Pubic instability
Adductor tendinopathy
Apophysitis
Appendicitis
AVN of femoral head
Avulsion fracture
Bursitis
Conjoined tendon dehiscence
Intra-abdominal abscess
Legg-Calve´-Perthes disease
Lumbar spine pathology
Lymphadenopathy
Muscle strain
Myositis ossificans
Nerve entrapment
Sacroiliac joint problems
Seronegative spondyloarthropathy
Slipped capital femoral epiphysis
Snapping hip syndrome
Sports hernia
Stress fractures
Synovitis
Crohn’s disease
Obturator nerve entrapment
Tendon (Adductor): Partial
Adductor Shear
Osteitis pubis
Osteoarthritis PS / Hip
Ovarian cyst
Pelvic inflammatory disease
Pelvic stress fracture
Tendon (Adductor): Rupture
tear /
injury
Diverticular disease
Epididymitis
FAI
Herniated nucleus pulposus
Hockey player’s syndrome
Testicular neoplasm
Testicular torsion
Urethritis
Urinary tract infection
69% of groin injuries in football have Adductor complex issues
(Holmich 2007)
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
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!
Tendon (Site v Function)
•
•
•
Achilles
•
Long mid-tendon
Excellent shock absorber •
Dissipates energy quickly
•
and efficiently
Adductor
Tendon is short
Exposed to tensile and
Shear forces
Has to dissipate forces
quickly+
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
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)
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
Pain v Pathology
Imaging = Pathology
(Khan 1996, Yu 1995,etc)
Pain ≠ Pathology
Load
‘Iceberg Theory’
...but dictates our success!!
(Ohberg et al 2001;
Fredberg & Stengaard-Pedersen 2007) PAIN DETECTION THRESHOLD
• Abnormalities on imaging are present
before they become symptomatic
(Lovell et al 2006; Malliaras 2006,
Fredberg et al 2008)
Time
• Explains relapse of symptoms if
resume activity too soon!
• Tendon mechanics remains
unaltered in tendonopathy (Hansen
et al 2006; Kongsgaard et al 2009)
‘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)
Aim of Tendonopathy
Management
In theory:
To attempt to remodel the tendon matrix
In practise:
To attempt to remove pain
Restore muscle tendon function
How do we manage these
patients?
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•
•
•
•
Rest
Injection therapy / Dry needling
Medication
Electrotherapy
Compression shorts
• Surgery
• Manual therapy
• Exercise Therapy
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)
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
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)
• 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)
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
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)
‘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!
Exercise therapy v ‘Physiotherapy’
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
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
13-26 weeks (median 18.5
weeks)
(Holmich et al 1999)
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)
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 23 days to peak
(Fredberg 2004)
Session
Exercise
Sets
Reps
Intensity
(%)
1
A
3
6
80
B
3
6
85
C
3
6
85
A
3
15
40
B
3
15
40
C
3
15
40
A
3
10
60
B
3
10
70
C
3
10
70
2
3
Periodising Tendon Load
in Late stage rehabilitation
Why do Eccentrics on
Tendonopathy?
‘Is it too aggressive for some tendons?’
‘Are there better methods?
Not for every tendon problem!
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’)
Classic Strength Training
‘Are players working hard enough?’
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 30-20 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
1-3 x / week
Muscle
Adaptation
Slow twitch
hypertrophy
Whole muscle
hypertrophy
Fast twitch
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
(Brandon 2010, Foure et al 2009, Arruda et al 2006)
Remember Tendon is slow to
adapt!
Tissue Responses
Neural
1-3 weeks
Muscle
> 3 weeks
Tendon
> 6 weeks
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,
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•
•
•
•
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!)
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)
‘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
Target all ‘functional’ Global
systems
1.
Posterior oblique
2.
Anterior oblique*
Lat Dorsi BicepsFemoris Gluteus Maximus ST lig TDF
EO and contralat IO
Contalat Adductors
Anterior Abdominal Fascia and TA
3.
Deep longitudinal
4.
Lateral sling*
ES MTF
Biceps Femoris (long head)
Deep lamina TDF, ST, Int & SD ligs
Gluteus Medius and minimus
Contralateral Adductors
TFL
(Vleeming 1995)
Monitor Progress
1.
2.
3.
4.
5.
Pain during exercise
Pain +/- ‘stiffness’ next morning
Squeeze test (0°,60°,90°)
Isometric strength test
Pubic symphysis stress test
(Ext/Abd, Resist flex/add)
6. Adductor muscle tone (BKFO, ABD ROM,
Palpation)
(Hogan 2003)
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
‘High load’ functional activities
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SL loading+
Med ball drills
Tackling + Kicking
Agility + Cutting drills
Comprehensive treatment plan
• All with proximal insertional adductor pain on palpation and
pain on squeeze
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•
•
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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 (70-221 days)
70% competing at 22 months (within 6.5-51 months)
But 26% re-occurred…therefore ensure MAINTENENCE
WORK continues!
(Weir et al 2010)
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?)
Rehabilitation into Training!
High intensity lateral movement
ESSENTIAL!
Especially…
Agility / Accelerations (GPS data)
Evidence based Adductor
rehabilitation
• dysfunction
Local Adductor strengthening
(Isometric test)
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•
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•
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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