OVERUSE INJURIES IN ATHLETICS APPROACHING GROIN PAIN IN ATHLETICS “THE FALCON’S PERSPECTIVE” – Written by Adam Weir, Netherlands and Qatar, Andreas Serner, Qatar, Andrea Mosler, Australia and Zarko Vuckovic, Qatar Falah the falcon is the mascot of the Doha CLINICALLY RELEVANT ANATOMY OF THE Adductor longus has a proximal 2019 Athletics World Championships. GROIN attachment on the pubic bone8. Palpation Falcons are important in Qatari culture and Adductor-related groin pain (both acute of the proximal tendon can be performed are renowned for their exceptional vision, and long-standing) is by far the most easily and following the tendon proximally even in the dark. For many clinicians, groin common groin injury in athletes2–5, so we with your finger, you can find the insertion9. pain in athletes is considered as an area of will start by looking at the adductors in Recognizable injury pain on palpation is darkness that is difficult to navigate. It seems more detail. There are a number of different one of the key features of adductor-related sometimes that diagnosing in athletes with adductor muscles: adductor longus, adductor groin pain1. The proximal tendon continues groin pain is as challenging as qualifying for brevis, adductor magnus, gracilis, pectineus, superficially, with the lateral part of the the World Championship finals. and obturator externus. The vast majority of tendon transitioning intramuscularly at Doha not only hosts many major sporting groin injuries affect the adductor longus3,6 approximately 1-2.5 cm from the insertion events, but we also hosted the first World and being able to locate and examine this (Figure 1)10. The entire proximal tendon Conference on Groin Pain in Athletes, which muscle is a basic skill we all need to have. becomes intramuscular at about 5.5-8 cm led to the Doha agreement on terminology from the insertion, where it continues as and definitions in groin pain in athletes1. ADDUCTOR LONGUS an intramuscular (central) tendon10. The In this article, we aim to be your mascot Aside from its obvious role as a hip total proximal tendon length is anywhere and provide you with a falcon’s eye view of adductor, the adductor longus is also a hip between 7 and 17 cm11. While long-standing clinically relevant anatomy of the groin area, flexor when the hip is in extension. It works adductor-related groin pain is usually which should enable you to better examine hard eccentrically to turn hip extension related to the insertion, acute adductor your patient and recognize common clinical into flexion, which is part of many athletic longus injuries can occur anywhere along entities. movements7. the musculotendinous junction (MTJ) of the 272 a b Figure 1: Adductor longus. a) Adductor longus: proximal insertion and tendon. One can clearly see the superficially located proximal tendon which becomes an intramuscular tendon c a few cm below the insertion and continues within the muscle. b) Palpation of the adductor longus can be reliably performed and you can locate recognizable injury pain at the insertion in most cases of adductor-related groin pain. The tendon can easily be palpated superficially. c) Resistance testing of the adductors.Figure 1a reproduced with permission from Tuite et al 1998. proximal tendon6. Interestingly, there is also tendons originating from the iliacus and a high proportion of acute injuries at the psoas major muscles15–17. The psoas major MTJ of the distal tendon. The distal tendon tendon is located more medially on the lesser has not yet been examined in anatomical trochanter, while the primary iliacus tendon studies, but is considered to extend as a is located slightly laterally, and an accessory superficial tendon aponeurosis along the iliacus tendon might also be present16. The muscle from its femoral insertion. In both iliacus muscle is divided in postero-medial acute and longstanding adductor-related and antero-lateral parts of the muscle16,18. groin pain, pain at the proximal insertion is The most antero-lateral muscle fibers of the considered to be the most severe. iliacus attach directly on the femur, slightly inferior to the lesser trochanter (Figure 3a)19. ILIOPSOAS When palpating the iliopsoas muscles Iliopsoas is a composite muscle made of below the inguinal ligament, see Figure the psoas major and iliacus muscles which 3d9, it is almost impossible to differentiate function together as the most powerful between the distal insertions, and we flexor of the hip. The psoas arises from the generally record pain as distal iliopsoas- wall and the structures from the abdomen outside of the vertebral bodies and discs related pain only. pass through the invaginated fascia, at from T12 to L3. The psoas can be palpated the deep inguinal ring. The deep inguinal deep in the abdomen if your athletes relax INGUINAL CANAL ring is located halfway along the inguinal their abdominal wall and then gently lift The inguinal canal is in the lower ligament, just superior to it. The following their leg as shown in Figure 3b9. If your anteromedial abdominal wall just above the structures pass through the inguinal canal: fingers are in the right place, you will feel inguinal ligament. It serves as a pathway the ilioinguinal nerve and genital branch the psoas muscle belly contracting under for important anatomical structures to pass of the genitofemoral nerve, spermatic cord your fingertips as the athlete lifts the leg from the abdomen towards the genitalia. Its in men or the round ligament in women off the bed. This should be possible in most floor is the inguinal ligament, which runs and accompanying vessels. The superficial lean athletes, but can become increasingly from the pubic tubercle at its medial end up inguinal ring is just above the pubic tubercle difficult in athletes with a high amount of to the anterior superior iliac spine laterally. and is the medial end of the inguinal canal. body fat, such as different throwing athletes See Figure 4a. The inguinal ligament actually This represents the opening of the inguinal (shot put/discus etc.) represents the shelving edge of the inferior canal in the external oblique facia and you Iliacus arises from inside the iliac fossa part of the external oblique aponeurosis. can palpate the ring through the abdominal and can merge with the psoas around the This thickening, which is reinforced by wall in athletic subjects, as shown in Figure level of the inguinal ligament. Anatomical the lacunar ligament on the medial part, 4b9. The best way to palpate the inguinal studies show that in the majority of cases can be palpated in athletic subjects. The canal in males is by invaginating the skin there are separate and distinct distal transversalis fascia forms the posterior from the scrotum. This allows you to place SPORTS MEDICINE AND SCIENCE IN ATHLETICS TARGETED TOPIC 273 OVERUSE INJURIES IN ATHLETICS Anterior superior the finger into the external ring (see Figure 2a iliac spine 4c), and you can check for inguinal hernias by asking the patient to perform a Valsalva maneuver while you feel the canal. PUBIC SYMPHYSIS Pubic Lacunar Inguinal tubercle ligament ligament The pubic symphysis is a non-synovial joint lined with hyaline cartilage and Superior pubic Ligament of Cooper 12 contains a fibrocartilaginous disk . The ligament symphysial joint is surrounded by a dense Obturator canal capsule that is thickened superiorly and Pubic bone inferiorly to form the superior and inferior Interpubic bro pubic ligaments (Figure 2a). In athletes, the cartilaginous Acetabulum pubic symphysis undergoes considerable lamina mechanical stress, and the joint may be a Inferior pubic Transverse source of pain, including the adjacent bone. ligament acetabular However, pubic-related groin pain is one of ligament the least frequent clinical entities in adult Obturator athletes13. membrane It is very important to note that the pubic apophyses are one of the last areas Ischial in the body to ossify, only fully fusing tuberosity around 20 years of age12,14. These bony islands of endochondral ossification are Figure 2: Pubic symphysis. often misinterpreted on imaging as being 2b a) The pubic symphysis a fragmented or degenerative pubic bone. is a non-synovial joint There is growing attention that groin pain lined with hyaline at the adductor insertion on the pubic cartilage and containing bone, in athletes in the age group 14-19, is a fibrocartilaginous disk. The joint capsule is often pubic apophysitis. This should always thickened superiorly and be considered as a potential differential inferiorly. b) Palpation of diagnosis in adductor-related groin pain in the symphyseal joint and younger athletes. immediately adjacent bone is best performed ANATOMICAL CONNECTIONS from the superior/cranial Numerous authors have noted the side and remember that complexity of interconnections around the the joint slopes downwards pubic symphysis12,20,21. There is no doubt that from superior to inferior. there are superficial fascial connections between many structures in the groin, just like any other region of the body. Whether a focus on the pyramidalis muscle, which is the contemporary literature and dissections this means that these connections transmit often forgotten. This small muscle extends now makes us consider the muscle a lot of force is doubtful. A biomechanical across the pubic bone anteriorly and inserts insertions to be much larger and stronger study, on 10 embalmed cadavers, used strain into the anterior pubic ligament (Figure 5). than before. gauges to see if traction on the adductor On imaging the pyramidalis muscle can be Mick Drew and colleagues from Australia longus resulted in measurable force in mistaken for the rectus abdominis muscle, has also added a new perspective on the contralateral rectus abdominus22. The and this is likely the cause of the mistaken connectivity in the groin with their work results showed that the force transmission terminology of the rectus abdominis- on experimental referred pain.