Hip adductor tendinopathy (HAT) describes a series of conditions that develop in and around the tendon in response to chronic overuse of the tendon. At the histopathological level, changes occur in the molecular structure of the tendon, typically collagen separation and degeneration, and at the macroscopic level, tendon thickening, loss of mechanical properties and pain are usually observed. The role of inflammation is increasingly being questioned as studies have shown that there are no inflammatory cells around the affected area, making the term "tendinitis" obsolete.
Clinically Relevant Anatomy
The adductors of the thigh consist of 5 muscles that can be divided into long (gracilis and adductor magnus) and short (pectineus, adductor brevis and adductor longus) adductors. These muscles help stabilize the pelvis and bring the hips toward the midline.
The adductor muscles originate from the lower part of the pelvic bone and attach to the femur, located between the hip flexors and extensors. They are used when we cross our legs, or, more importantly, when balancing the pelvis while standing and walking.
The adductor magnus is the largest muscle of this group, located behind all the others. There are 2 parts of this muscle - a part that functionally belongs to the adductors and a part that belongs to the hamstrings. The adductor portion extends from the inferior ramus of the pubis and the ramus of the ischium, attaching to the linea aspera of the femur and the medial epicondyle (to its tendinous attachment). The part related to the hamstrings extends from the tuberosity of the ischium to the adductor tubercle and the medial supracondylar line. The function of the adductor magnus muscle is adduction, assisting in hip flexion (adductor part) and hip extension (hamstring part).
The adductor longus muscle extends from the superior ramus of the pubis and the pubic symphysis and inserts into the linea aspera of the femur. It is a large and flat fan-shaped muscle that forms part of the medial border of the femoral triangle. It also forms an aponeurosis at its distal insertion, which extends to the vastus medialis muscle. The adductor longus muscle adducts and medially rotates the thigh.
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The adductor brevis muscle is located under the long muscle and extends from the inferior ramus of the pubis to the posterior part of the linea aspera of the femur. The short muscle adducts the thigh.
The gracilis is a single biarticular muscle, extending from its insertion on the inferior border of the symphysis pubis to the medial surface of the tibia, inserting into the pes anserine between the tendons of the sartorius and semitendinosus. It is the most superficial muscle of the adductor group, whose function is to adduct the hip and flex the knee.
Causes and symptoms
Symptoms of sciatica occur due to irritation of the sciatic nerve. It is still unclear why the piriformis muscle begins to affect the nerve. Many people believe that this occurs when the piriformis muscle spasms and begins to press the nerve against the pelvic bone. In some cases, the piriformis muscle is damaged as a result of a fall on the buttocks. Bleeding in and around the muscle as a result of injury leads to the appearance of a hematoma. The piriformis muscle becomes inflamed and begins to put pressure on the nerve. The hematoma gradually resolves, but muscle spasm persists.
The muscle spasm continues to affect the nerve. As they regenerate, some of the muscle fibers are replaced by scar tissue, which has less elasticity, which can lead to thickening of the muscle tissue (this can also be a factor in pressure on the nerve).
Most often, piriformis syndrome manifests itself as pain along the back of the thigh (buttock). As a rule, the pain occurs on one side (but sometimes the sensation can be on both sides). The pain may radiate to the foot, resembling the symptoms of a herniated disc in the lumbar spine. Sensory disturbances and weakness in the leg are extremely rare. Some patients may experience a tingling sensation in the leg.
Patients are uncomfortable sitting and try to avoid sitting. And if you have to sit down, they lift the affected side instead of sitting unevenly.
Etiology
The hip adductors are active in many sports such as running, football, horse riding, gymnastics and swimming. The repetitive nature of the movements in some of these sports and the constant changes in direction place increased demands on the adductor tendons. This makes athletes more vulnerable to developing TPMB as well as groin pain. Other causes may include overstretching the hip adductor tendons or a sudden increase in the number or intensity of exercise.
Clinical picture
TPMB is usually felt as pain in the groin when palpating the adductor tendons, adductor and/or the injured leg. The pain may develop gradually or appear as a sharp, sharp pain.
You may also experience swelling or tightness in the adductor muscle(s), stiffness in the groin area, or an inability to contract or stretch the adductor muscles. In severe cases, exercise will be limited as the tendon can no longer withstand repeated stress.
Prevention
To prevent the development of TPMB, an athlete must continually work on factors such as strength and coordination. At the same time, he must comply with all the requirements for recovery and adaptation in the intervals between training sessions.
The athlete must develop muscle strength to maintain pelvic stability through specific exercises that are appropriate to the demands of their activity/sport and have varying levels of difficulty (eg, speed training and jumping). Another important aspect is muscle flexibility. Regular stretching is recommended.
Treatment
Drug treatment
Pain management is recommended first, although NSAIDs may not be effective due to the non-inflammatory nature of the injury. Steroid injections are not always indicated due to the potential for tendon damage (if they are injected directly into the tendon).
Physical therapy
Physical therapy is recommended for the treatment of TPMB. Active therapy through an exercise program is superior to a more passive treatment approach. Recovery varies greatly between individuals as the disease can be degenerative. In general, patients may respond well to rehabilitation programs, but in some cases the tendon may be refractory to a range of treatments.
Strengthening the abdominal muscles is recommended to support the adductors during exercises as well as hip flexion exercises. Exercises should be tailored to the specific sport to avoid recurrence of injury. In most cases, return to normal function can occur within a few weeks, but in more severe cases, rehabilitation may take several months to return to normal, pain-free activity.
Why is biceps tendonitis difficult to treat?
Superior biceps tendinopathy is a stubborn and difficult to treat injury.
Additionally, due to its relative rarity (especially outside of athletics) and the paucity of review studies on potential treatments, scientifically supported treatment protocols remain lacking.
However, since this is a known problem of tendon degeneration, the same treatment strategies that work for Achilles and patellar tendon injuries should also be effective for superior biceps tendinopathy.
According to Frederickson, a progressive strength program that focuses on strengthening the core and glutes and promoting healing of the proximal biceps tendon (through eccentric exercises) should be the foundation of any rehabilitation program.
Due to the similarity of some of the symptoms of this injury to other injuries localized to the pelvic area, proper diagnosis is important and requires a physical examination and MRI.
Additionally, due to the individual nature of this injury, it is recommended that you find a good podiatrist and physical therapist to monitor your rehabilitation process and receive advice on returning to running.
Lead tactics
Rest is necessary for the first 48 hours after injury. Apply the RICE concept (rest, ice, compression and elevation) 3 times daily for 10-20 minutes to help reduce swelling and inflammation. Once the swelling has subsided, blood flow stimulation therapy can be started to enhance the healing process. Active treatment is then indicated to maximize rehabilitation. Its goal is to restore the properties of muscles and tendons, since strength training has a beneficial effect on the structure of the tendon matrix, muscle properties and biomechanics of the limbs. Recent evidence suggests that an eccentric exercise program is most effective. You can also slowly perform eccentric and concentric exercises with heavy weights to improve pain and tendon function. However, Cook et al. proposed a new, 3-stage model of tendinopathy, where exercise treatment differs between stages. They suggest that the current treatment protocol of adding eccentric loading used for stages 2 and 3 may be detrimental to stage 1 tendinopathy. For effective treatment, staging the tendinopathy is critical.
Loading provides a positive stimulus to both tendon and muscle tissues, however there is no single effective method for tendon rehabilitation, with variations in repetitions, sets and load applied depending on the stage of rehabilitation and the patient's muscle-tendon response to training. The exercises are aimed at eliminating neuromuscular and tendon changes (strength and functional ability) associated with tendinopathy.
The stages suggested by Cook et al: reactive tendinopathy, tendon injury (failed healing) and degenerative tendinopathy. In the early, reactive stages, the key is to change the load to an acceptable level at which the tendon can repair and heal. Cook suggests, however, that the tendons may have a latent reaction for about 24 hours. This means that what appears to be non-reactive immediately after activity may flare up 24 hours later. At this stage, the use of non-steroidal anti-inflammatory drugs is not clear-cut, but it is believed that their use may be beneficial. Always consult your doctor before taking any medications.
Stretching is also not indicated during the reactive stage because it can place compressive stress on the affected tendon, worsening symptoms. One option is massage to maintain muscle length. In this acute stage, treatment with isometric exercises (instead of eccentric exercises) along with rest from excessive physical activity is recommended. Those. It is necessary to rest from activities, which may include parameters such as speed, distance and intensity, and to be cautious of any pain that may occur after 24 hours. Symptoms and pain response should be a guide, so cross-training is recommended to maintain fitness and function. At this stage, reverse changes in the tendon are possible.
Stage 2 tendinopathy is usually characterized by persistent discomfort with local thickening of the tendon from chronic overuse and can occur in patients of different ages depending on the duration of exposure, frequency and intensity of loading. Stage 2 may be difficult to discern clinically.
In stage 3 degenerative tendinopathy, cellular and matrix changes progress to irreversible levels, so treatment is focused on the long term, which includes eccentric loading as well as strengthening and stabilization exercises. Degenerative tendon is usually seen in older athletes and sometimes in younger ones depending on the degree of chronic overload. There may be areas of thickening, and acute attacks of pain may indicate areas of stage 1 tendinopathy. If the tendon is severely degenerated, there is a risk of rupture. Therefore, treatment should address symptoms according to stage 1 until the acute pain subsides, followed by a long-term exercise program.
Malliarus et al. suggest that there is little evidence to highlight the eccentric component in the rehabilitation of Achilles tendinopathy and patellar tendinopathy. In their opinion, a rehabilitation program that includes eccentric, concentric and isometric exercises gives the best results.
There is more than one way to treat tendinopathy, so it is recommended to work with a physical therapist to manage symptoms, and to use rest along with a gradual return to activity. Once symptoms resolve, a gradual return to normal stretching is possible. However, stretching should never cause pain.
Here are some examples of hip adductor stretches:
- Adductor brevis: Sit in a position as shown below (avoid slouching in the lower back);
- Gently press your elbows toward your knees until you feel a stretch in the muscles;
- hold in this position for 20-30 seconds, repeat 3-4 times.
Stretching the short adductor muscles
- Long adductor muscles: stand and spread your legs into a wide stance;
- bend the opposite knee, leaning in the same direction until you feel a stretch;
- hold this position for 20-30 seconds, repeat 3-4 times.
Long adductor muscle stretch
Examples of exercises
An example of an isometric exercise: sit on a chair with an elastic band located above the knee and keep your leg in an adducted position (against the resistance of the elastic band); hold this position as long as it is comfortable; The resistance can be adjusted by stretching the band more or less.
An example of an exercise that strengthens the adductor muscles of the thigh: stand near a table with an elastic band located on the lower leg; stand on the step platform with your healthy leg so that the affected leg can swing freely; Keeping your back and knee straight, slowly move your leg away from the midline, then bring your leg down.
Who should you consult?
If you have been trying to treat your injury for a long period of time and still do not notice relief, then you should seek expert help.
See a physical therapist or chiropractor for manual therapy or massage (including Active Release Technique or Graston Technique) to break up scar tissue and adhesions in the superior biceps femoris tendon.
Make sure that the manipulations are performed on the muscle and tendon tissue and do not affect the ischial tuberosity (do not further irritate this area). Many runners also find sitting on a tennis ball or a hard surface (if sitting for long periods of time) helpful, as they are able to stand up without pain.
Consult with your podiatrist to see if you need a corticosteroid injection (preferably ultrasound-guided).
According to Frederickson, this may be especially helpful in cases where the MRI shows significant swelling near the ischial tuberosity.
Talk to your doctor about the risks and benefits of extracorporeal shock wave therapy.
Although this procedure has not been proven to be effective for superior biceps tendinopathy, it has been used with some success for chronic tendon problems in other parts of the body.