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Home , Adductor longus muscle, Composite muscle, Iliacus muscle, Inguinal ligament, Lacunar ligament, Pectineus muscle

OVERUSE IN ATHLETICS APPROACHING 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 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 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 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 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 along the iliacus tendon might also be present16. The muscle from its femoral insertion. In both 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 , slightly inferior to the (Figure 3a)19. When palpating the iliopsoas muscles Iliopsoas is a made of below the 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 outside of the vertebral bodies and discs related pain only. pass through the invaginated , 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 ring is located halfway along the inguinal their 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 . It serves as a pathway the ilioinguinal and genital branch the psoas muscle belly contracting under for important anatomical structures to pass of the , 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 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 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 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 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 by asking the patient to perform a Valsalva maneuver while you feel the canal.

PUBIC SYMPHYSIS Pubic Lacunar Inguinal tubercle ligament ligament The 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 , 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 , 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. They had the was really variable. Pulling on the adductor adductor longus aponeurosis, which we great idea to use painful injections into the longus resulted in more force, less force or believe is an incorrect term, that should no adductor longus insertion and see where no change at all, in different specimens. longer be used. The relationship between healthy athletes felt pain23. Aside from the A recent anatomical study serves to the adductor longus, rectus abdominus, obvious insertional pain where they were remind us of the large insertions of both and pyramidalis is beautifully shown in injected, one third of the athletes also felt adductor longus and rectus abdominus Figure 5. pain in the lower abdomen. They point onto the pubic bone20. It’s not surprising that Our current thinking on how to interpret out that it is important to examine the these large force-producing muscles, have this has changed over the last decade. adductors carefully if athletes present with large bony insertions, as you would expect Where we previously would imagine some pain felt in the lower abdomen and not just anywhere else in the body. This also includes kind of loose pre-symphyseal aponeurosis, check the abdominal wall.

274 3a 3b 3c

3d

Figure 3: Iliopsoas. a) Psoas major and iliacus converge around the level of the inguinal ligament to form the iliopsoas muscle, the most powerful hip flexor. b) The psoas major can 3e be palpated in the abdomen by asking the athlete to relax the abdominal wall, gently moving your finger deep just lateral to the border of the rectus abdominus and then having them lift their leg off the couch. You will feel the psoas contracting if you are in the right place. c) The distal iliopsoas can be palpated distal to the inguinal ligament. Palpate lateral to the sartorius which you can identify by getting the athlete to lift their leg of the couch. d) Stretching the iliopsoas is done in the modified Thomas position and you can also do resistance testing by getting them to raise the leg in the same position. Alternatively, you can test the iliopsoas with the hip flexed to 90 degrees as shown in 3e. Reproduced with permission from Brukner & Khan’s Clinical Sports Medicine, 2017.

WE MADE GROIN PAIN COMPLEX! defect. These are all pretty closely related, call medical conditions influences which We, the experts in the field, are partly but the same athlete was also diagnosed treatment patients think they should have25, responsible for groin pains’ dark and with pubic ring failure, pubic bone stress, and in turn which treatment clinicians then difficult reputation. Yes, there is complex femoroacetabular impingement syndrome select. anatomy and yes, there are numerous organ and pubic plate tear. systems that can cause groin pain, but one In the second case of inguinal-related Clinical pearl of the most confusing aspects of groin pain groin pain the terminology was extremely is the ridiculous number of diagnostic terms heterogeneous. If this athlete had gone to all The crazy number of diagnostic terms introduced over the years. of the 23 experts, he would have been told he we have coined explains why we The team from Sports Groin Pain Centre had: sportsman’s , inguinal disruption, think the groin region is complex! set out to investigate how bad the problem posterior wall weakness, posterior wall tear, of terminology was. Using a Delphi method, Gilmore’s groin, superficial inguinal ring CLASSIFICATION AND DIAGNOSIS OF we sent 2 clinical cases of football players, insufficiency, inguinal canal aponeurosis GROIN PAIN IN ATHLETES one adductor-related and one inguinal- strain, inguinal ligament enthesopathy or As far as we know, all international related groin pain, to 23 groin experts24. transversus abdominus strain. All these experts agree that history and clinical These international experts were sports point in the direction of the inguinal canal, examination remain the cornerstones for physicians, sports physiotherapists, general but other diagnoses were also: muscle diagnosing athletes with groin pain1,26. This surgeons and orthopedic surgeons. For the injury, hip labral tear, femoroacetabular is not to say that imaging has no role, but first case 23 experts used 18 different terms to impingement syndrome, pubic symphysis imaging should never be done in isolation describe the diagnosis and 22 for the second pathology and pubic cleft arthritis. without a full clinical examination first. The case! The list for the first case of adductor- While many different terms do create primary role of imaging should be to rule related groin pain included: adductor confusion among clinicians, we should out potential serious problems that might tendinopathy, adductor enthesopathy, still ask the question; “is this important not be immediately obvious. adductor strain, adductor tear, adductor for patients?” We think it is. There is an In 2014, we organized the first world tendinitis and adductor teno-osseous emerging body of evidence that what we conference on groin pain in athletes. The

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4a 4b

4c

Figure 4: Inguinal canal. a) Inguinal canal anatomy – the different layers of the abdominal muscles – transversus abdominus, internal and external oblique are all parts of the inguinal canal. b) Superficial palpation of the external inguinal ring. Feel just lateral to the rectus abdominus sheath and above the pubic tubercle. In athletic subjects you will find a soft spot, which is the external ring. c) Scrotal invagination: in males you can feel inside the external ring for recognizable injury pain, and also check for an if you get them do perform Valsalva. Reproduced with permission from Brukner & Khan’s Clinical Sports Medicine, 2017. same 23 experts who took part in the Delphi wanted to stress that you should never common clinical entity (61%) as others have research gathered and agreed on a new set forget the hip joint as a possible cause of also found in different countries2,27. But in of terminology and definitions1. The group groin pain in athletes. more than half of the cases of adductor- comprised people from different specialties, related groin pain the athletes also had different countries, different ages, clinical Clinical pearl another groin problem. In fact, multiple and scientific background. We are obviously causes were found in 44% of all athletes. biased when it comes to our approach in Never forget to examine the hip joint We also found other causes including hip clinical practice having been involved in in every athlete who presents with osteoarthritis, labral tear, nerve entrapment the Doha agreement. Our aim was to have groin pain. Clinical examination is and inguinal hernias. As clinicians we need a system based on clinical examination so very good at ruling out the hip as a to be aware of these other possibilities when that both doctors and physiotherapists can cause of pain if the tests are negative. athletes present with groin pain. use it to be able to communicate clearly with each other and with patients. The Many other organs and conditions can Clinical pearl system is aimed at long-standing groin pain also cause groin pain. Athletes, although cases. We hope clinicians in daily practice they sometimes perform superhuman Always check the whole groin region find it useful. feats, are also humans. They can get tumors, in athletes with groin pain – multiple Figure 6 shows an overview of the Doha infections, systemic diseases and every causes are frequent. agreement’s way of approaching athletes clinician needs to keep a broad differential with groin pain. diagnosis in mind when examining ADDUCTOR-RELATED GROIN PAIN The main outcome was defining 4 them. It’s also good practice to do a brief This is by far the most common entity of common clinical entities that link with the examination of the lumbar spine and groin pain. If you don’t see many athletes anatomy discussed in the first half of this in all groin pain cases too. This gives with groin pain, get familiar with adductor- article. Most athletes who you see with groin the opportunity to briefly zoom out and related groin pain as this is what you will pain will have one or more of these entities. consider the bigger picture. see most. The findings are pain on palpation The general examination techniques for We tracked our diagnoses according to the of the adductors along with pain in the groin pain were already described by Prof. Doha Agreement in 100 athletes who came adductors on resisted adduction testing. Per Hölmich back in 2004, when he showed to the sports groin pain clinic in Aspetar13. Figure 1 shows the anatomy and how to that these can be done reliably9. We also Adductor-related groin pain was the most palpate the adductor and perform resistance

276 5a 5b 5c

Figure 5: Anterior pubic symphysis connections in a male cadaver. a) After removal of the spermatic cords and the penis. There is a cord-like (A). The fibers of the external oblique aponeurosis form the medial part of the external inguinal ring (arrow) and are considered to attach to the superficial portion of the anterior pubic ligament (arrowhead). b) Anterior symphyseal area after removal of the entire aponeurosis demonstrates the remnants of the superficial portion of the anterior pubic ligament (white arrowhead). The pyramidalis muscle (P) arises from the pubic crest and the anterior pubic ligament. The proximal adductor longus tendon (white arrow) may partially attach to the deep portion of the anterior pubic ligament (black arrows). c) The anterior symphyseal and peri-symphyseal area after resection of the pyramidalis muscle and the anterior pubic ligament. The rectus abdominis has two attachments; the external tendon of the rectus abdominis at the superior pubic rim (arrowheads) and the internal tendon of the rectus abdominis extending anteriorly across the symphysis (white narrow arrow). There is a separate footprint of the adductor longus fibrocartilage (thick white arrow). The adductor longus tendon (thin arrows) and the fibrocartilage (asterisk) are detached. Images from Schilders et al 2017. Add=; Pect=; G=Gracilis; RA=rectus abdominis muscle.

6a 6b Doha agreement on groin pain classi cation in athletes

De ned clinical entities

Adductor-related Iliopsoas-related Inguinal-related Pubic-related Hip-related Other

Figure 6: The Doha agreement on groin pain in athletes. Reproduced with permission from Weir et al 2015.

testing. The most common location is the adding manual soft tissue treatment to the iliopsoas gets overloaded compensating for insertion of the adductor longus on the management strategy can be useful. this. pubic bone. The pain is bilateral in about If adductor pain has been present for a The other common combination is 1/3 of cases. Both resistance testing and few months, then the ipsilateral iliopsoas adductor- and inguinal-related groin pain at flexibility testing are important. If there is often becomes painful too. That may be the same time. In our series of 100 athletes unilateral shortening on the symptomatic due to the fact that the painful adductor inguinal-related groin pain was present in side together with high muscle tone, then contributes less to hip flexion and the 1/3 of the cases of adductor-related groin

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pain13. A Danish study showed that the time athlete to differentiate between the general common clinical entity. It is diagnosed when to return to sport was longer when these discomfort of invagination with palpation there is recognizable pain on palpating two presented together2. and their actual injury pain. In general, the pubic symphysis and immediately athletes distinguish them very well. Pain adjacent bone (Figure 2b). It is really ILIOPSOAS-RELATED GROIN PAIN in the inguinal canal on abdominal muscle important to differentiate between the Iliopsoas-related groin pain in isolation resistance testing makes inguinal-related normal discomfort of palpating the pubic is uncommon. It is mainly associated with groin pain more likely, and you can get them symphysis from actual recognizable injury linear sports, such as long-distance runners, to do the Valsalva maneuver to provoke pain. This can be seen more commonly in and especially in females. It can also occur their pain too. If you feel an actual inguinal endurance athletes and female athletes. as a long-standing problem following an hernia, then they do not have inguinal- acute injury, but it usually presents along related groin pain, but rather a symptomatic FUTURE PERSPECTIVES with adductor- or hip-related groin pain. inguinal hernia, which is categorized as Our goal within the diagnosis of groin Iliopsoas-related groin pain is diagnosed ‘other’ according to the Doha agreement. pain should be to further define exact when there is recognizable injury pain on There is always discussion about the bulging anatomical locations and pathophysiology palpation. This is most common at the distal of the posterior wall of the inguinal canal. within the different entities of groin pain. insertion, see Figure 3. This defined clinical In our opinion this is sometimes present Without this, we are unlikely to be able to entity is more likely if stretching the muscle on invagination during Valsalva, but not in examine treatment strategies sufficiently. or resistance testing produces pain, as also all cases. We need to do more work to see New scientific studies are needed to provide shown in Figure 3. if we can reliably classify possible bulging more detailed overviews of the most during clinical examination and ultrasound common sites of groin pain in different INGUINAL-RELATED GROIN PAIN in order to determine its clinical significance sports. While most clinicians know that the The entity of inguinal-related groin pain in terms of prognosis and management. insertion of the proximal adductor longus is defined as recognizable pain on palpation Inguinal-related groin pain often co exists tendon is the most common site of adductor- of the inguinal canal. In men, this is best with adductor-related groin pain, but we related groin pain, the understanding of the performed via invagination of the scrotal found it in isolation around 1/3 of the time. importance of specific clinical and imaging skin. In practice we usually do the inguinal findings are still unclear. This could for examination last as this is the most intimate PUBIC-RELATED GROIN PAIN instance include the association of pubic part of the clinical examination. Just as for Our experience and data show that bone marrow edema (either diffuse or for the pubic symphysis, you need to get your pubic-related groin pain is the least example localized towards the symphysis © Bryn Lennon/Getty Images

278 Table 1

Defined clinical entity Symptoms & examination findings

Adductor-related Adductor tenderness & pain on resisted adduction Iliopsoas tenderness & more likely if pain on resisted hip flexion and/or Iliopsoas-related pain on hip flexor stretching Pain in inguinal canal region & tenderness of the inguinal canal Inguinal-related No palpable inguinal hernia present More likely if aggravated by abdominal resistance or Valsalva/cough/sneeze Local tenderness of the pubic symphysis & the immediately adjacent bone Pubic-related No particular resistance tests Table 1: Details of the clinical findings of the 4 defined clinical entities.

joint, the insertion of the adductor longus approach. Examining the adductors, Adam Weir M.D., Ph.D. or the pubic apophysis), and insertional iliopsoas, pubic symphysis, inguinal canal Erasmus M.C. palpation pain. A clearer differentiation and hip joint in every case will prevent Rotterdam, Netherlands between adductor-related groin pain and you missing important findings. Using Sport Beweegkliniek pubic-related groin pain is also needed. the Doha agreement approach provides a Haarlem, Netherlands In inguinal-related groin pain, we structured framework for your history and should attempt to find a way to separate physical examination. It can also help you Aspetar – Orthopaedic and Sports Medicine Hospital nerve compression-related pain from communicate findings with athletes and tendinopathy-type pain in this region other medical professionals in a common Doha, Qatar (possibly arising from the language. Don’t forget that clinical entities or inguinal ligament). Furthermore, studies can, and often do, present together. Andreas Serner P.T., Ph.D. are needed to demonstrate the general Physiotherapist & Clinical Researcher prevalence of inguinal posterior wall weakness in athletes, its possible association Aspetar – Orthopaedic and Sports Medicine Hospital with the development of inguinal-related groin pain during sports, as well as the Doha, Qatar development of potential inguinal hernias later in life. Iliopsoas-related groin pain is References Andrea Mosler P.T., Ph.D. currently an almost unexplored clinical Available at www.aspetar.com/journal Sports Physiotherapist & Research Fellow entity, so the opportunity for further La Trobe University advances in this area are immense. There are still many more unanswered College of Science, Health and Engineering, questions in relation to the diagnosis of Sport and Exercise Medicine Research groin pain in athletes, so we encourage Centre everyone to get involved so we can continue Melbourne, Australia advancing the field.

Zarko Vuckovic M.D. SUMMARY We hope our article has given you a General Surgeon & Groin pain specialist Falcon-like perspective on the diagnosis Aspetar – Orthopaedic and Sports of groin pain in athletes. This overview Medicine Hospital should help you navigate this previously Doha, Qatar dark region with confidence. It’s vital to develop a routine when examining Contact: [email protected] groin pain in athletes. This will stop you forgetting to check the hip and entire groin in all cases. A thorough clinical examination remains the cornerstone for the clinical

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