Managing Adductor Managing Adductor Tendonopathy in Tendonopathy in

Football Football

Jon Fearn MSc MACP MCSPJon Fearn MSc MACP MCSPFirst Team PhysiotherapistFirst Team Physiotherapist

Chelsea FCChelsea FC

Abdominal aortic aneurysm Abdominal aortic aneurysm Hydrocoele/varicocoele Hydrocoele/varicocoele Postpartum symphysis separation Postpartum symphysis separation

Acetabular disorders Acetabular disorders Inflammatory bowel disease Inflammatory bowel disease Prostatitis Prostatitis

Adductor strain Adductor strain Inguinal or femoral hernia Inguinal or femoral hernia Pubic instability Pubic instability

Adductor tendinopathy Adductor tendinopathy Intra-abdominal abscess Intra-abdominal abscess Sacroiliac joint problems Sacroiliac joint problems

Apophysitis Apophysitis Legg-Calve´-Perthes disease Legg-Calve´-Perthes disease Seronegative spondyloarthropathy Seronegative spondyloarthropathy

Appendicitis Appendicitis Lumbar spine pathology Lumbar spine pathology Slipped capital femoral epiphysis Slipped capital femoral epiphysis

AVN of femoral head AVN of femoral head Lymphadenopathy Lymphadenopathy Snapping hip syndrome Snapping hip syndrome

Avulsion fracture Avulsion fracture Muscle strain Muscle strain Sports hernia Sports hernia

Bursitis Bursitis Myositis ossificans Myositis ossificans Stress fractures Stress fractures

Conjoined tendon dehiscence Conjoined tendon dehiscence Nerve entrapment Nerve entrapment Synovitis Synovitis

Crohn’s disease Crohn’s disease Obturator nerve entrapment Obturator nerve entrapment Tendon (Adductor): Partial Tendon (Adductor): Partial tear / tear / Adductor Shear injury Adductor Shear injury

Diverticular disease Diverticular disease Osteitis pubis Osteitis pubis Tendon (Adductor): RuptureTendon (Adductor): RuptureEpididymitis Epididymitis Osteoarthritis PS / HipOsteoarthritis PS / Hip Testicular neoplasm Testicular neoplasm

FAIFAI Ovarian cyst Ovarian cyst Testicular torsion Testicular torsion

Herniated nucleus pulposus Herniated nucleus pulposus Pelvic inflammatory diseasePelvic inflammatory disease Urethritis Urethritis

Hockey player’s syndrome Hockey player’s syndrome Pelvic stress fracture Urinary tract infectionPelvic stress fracture Urinary tract infection

69% of groin injuries in football have Adductor complex issues 69% of groin injuries in football have Adductor complex issues

(Holmich 2007)(Holmich 2007)

Possible causes of groin pain in Possible causes of groin pain in athletes reported in the literatureathletes reported in the literature

Long Standing Adductor Long Standing Adductor Related Groin Pain (LSARGP)Related Groin Pain (LSARGP)• ‘‘Groin pain’ is 4Groin pain’ is 4thth most common injury affecting soccer players most common injury affecting soccer players (10%) (10%) (Walden 2007, Hawkins 2001)(Walden 2007, Hawkins 2001)

• Causes 3Causes 3rdrd longest absence from sport behind fracture & ACL longest absence from sport behind fracture & ACL injuryinjury

• Acute Groin injury: 86% heal within 3 weeksAcute Groin injury: 86% heal within 3 weeks But 13.5% Don’t!!But 13.5% Don’t!!

• Previous groin injury: 9% chance of recurrence Previous groin injury: 9% chance of recurrence

(No Hx GP =2%) (Arnason et al 2004)(No Hx GP =2%) (Arnason et al 2004)

• Tendon pain is common in athletes Tendon pain is common in athletes

• Adductor tendon issues common issue in LSARGPAdductor tendon issues common issue in LSARGP

Adductor Longus EnthesisAdductor Longus Enthesis

• Anterior AL: TendinousAnterior AL: Tendinous

• Posterior AL: Muscular Posterior AL: Muscular

• Area of concentrated stress Area of concentrated stress at Bone-tendon junctionat Bone-tendon junction

(Tuite et al 1998, Strauss (Tuite et al 1998, Strauss 2007)2007)

• Pathology involves: AL (70%), Pathology involves: AL (70%), Magnus (15%), other (15%) Magnus (15%), other (15%)

(Lovell (Lovell 2001)2001)

• Enthesopathy rather than Enthesopathy rather than tendinopathy!tendinopathy!

Tendon (Site v Function)Tendon (Site v Function)

AchillesAchilles• Tendon is shortTendon is short

• Exposed to tensile and Exposed to tensile and Shear forcesShear forces

• Has to dissipate forces Has to dissipate forces quickly+quickly+

AdductorAdductor

• Long mid-tendonLong mid-tendon

• Excellent shock Excellent shock absorber absorber

• Dissipates energy Dissipates energy quickly and efficientlyquickly and efficiently

Main Clinical Findings in Main Clinical Findings in LSARGPLSARGP• Pain – strong association between location Pain – strong association between location

of pain felt and site of pathologyof pain felt and site of pathology

(Lovell 1995)(Lovell 1995)

• WeaknessWeakness

(? pain inhibition or actual)(? pain inhibition or actual)

• Reduced Performance Reduced Performance e.g. kicking, cutting, e.g. kicking, cutting, agilityagility

• Optimal load is essential for healthy tendon Optimal load is essential for healthy tendon (‘Mechanotransduction’ : Khan & Scott 2009)(‘Mechanotransduction’ : Khan & Scott 2009)

• ‘‘Too little’ Too little’ / Sudden Underload / Sudden Underload e.g. injury, e.g. injury, holidayholiday

• ‘‘Too much’ Too much’ / Sudden Overload / Sudden Overload e.g. excessive e.g. excessive increase in trainingincrease in training

• CompressionCompression e.g. trauma e.g. trauma

• Poor Conditioning of MT unitPoor Conditioning of MT unit

• Poor biomechanicsPoor biomechanics• Mechanically active gene presence: Predispose Mechanically active gene presence: Predispose

or Protect? or Protect? (Mokone et al 2002 or September et al (Mokone et al 2002 or September et al 2008)2008)

Predisposing factors for Predisposing factors for Tendon injuryTendon injury

Common Clinical findings Common Clinical findings TendonopathyTendonopathy

• Pain associated with activity / loadPain associated with activity / load

• Specific location of pain (30% Bilateral )Specific location of pain (30% Bilateral )

• AM pain/stiffness AM pain/stiffness (VAS score)(VAS score)

• Eases with activity Eases with activity (VISA questionnaire)(VISA questionnaire)

• Local tenderness (not pathological specific!)Local tenderness (not pathological specific!)

• Functional impairments Functional impairments

(Test battery: CMJ, Hop, Drop CMJ, Toe-raise strength (Test battery: CMJ, Hop, Drop CMJ, Toe-raise strength tests - Silbernagel et al 2006)tests - Silbernagel et al 2006)

• Imaging: Decide degree of pathology Imaging: Decide degree of pathology initially with a initially with a Good HistoryGood History

Pain v PathologyPain v PathologyImaging = Pathology Imaging = Pathology

(Khan 1996, Yu 1995,etc)(Khan 1996, Yu 1995,etc)

Pain ≠ Pathology Pain ≠ Pathology

...but dictates our success!!...but dictates our success!!

(Ohberg et al 2001; (Ohberg et al 2001;

Fredberg & Stengaard-Pedersen 2007)Fredberg & Stengaard-Pedersen 2007)

• Abnormalities on imaging are present Abnormalities on imaging are present before they become symptomatic before they become symptomatic

(Lovell et al 2006; (Lovell et al 2006; Malliaras 2006Malliaras 2006, , Fredberg et al 2008)Fredberg et al 2008)

• Explains relapse of symptoms if Explains relapse of symptoms if resume activity too soon!resume activity too soon!

• Tendon mechanics remains Tendon mechanics remains unalteredunaltered in tendonopathy in tendonopathy (Hansen et al 2006; (Hansen et al 2006; Kongsgaard et al 2009)Kongsgaard et al 2009)

LoadLoad ‘‘Iceberg Theory’Iceberg Theory’

PAIN DETECTION THRESHOLDPAIN DETECTION THRESHOLD

TimeTime

‘‘Load-induced’ Tendon Load-induced’ Tendon Pathology ContinuumPathology Continuum

NORMAL TENDONNORMAL TENDON

FASCIITIS? FASCIITIS? (Franklyn-Miller et al (Franklyn-Miller et al 2009)2009)

PROLIFERATIVE / REACTIVE TENDONOPATHY PROLIFERATIVE / REACTIVE TENDONOPATHY

?? TENDON DYSREPAIR (failed healing)TENDON DYSREPAIR (failed healing) DEGENERATIVE TENDONOPATHY DEGENERATIVE TENDONOPATHY

… …..RUPTURE?..RUPTURE? (Cook 2009)(Cook 2009)

NB: Mixed pathology is often present !NB: Mixed pathology is often present !

(Khan et al 1999, Llan et al 2007)(Khan et al 1999, Llan et al 2007)

In theory:In theory:

To attempt to remodel the tendon matrixTo attempt to remodel the tendon matrix

In practise:In practise:

To attempt to remove painTo attempt to remove pain

Restore muscle tendon function Restore muscle tendon function

Aim of Tendonopathy Aim of Tendonopathy ManagementManagement

How do we manage these How do we manage these patients?patients?• RestRest• Injection therapy / Dry needlingInjection therapy / Dry needling• MedicationMedication• ElectrotherapyElectrotherapy• Compression shortsCompression shorts

• SurgerySurgery• Manual therapyManual therapy• Exercise TherapyExercise Therapy

‘‘Surgery takes longer to return to sport than Surgery takes longer to return to sport than conservative management!’conservative management!’

• Adductor tendon ruptures; NFL playersAdductor tendon ruptures; NFL players

• Surgery (n=5); Conservative (n=14)Surgery (n=5); Conservative (n=14)

• Surgery RTS: 12 weeks (10-16)Surgery RTS: 12 weeks (10-16)

• Conservative RTS: 6 weeks (3-12)Conservative RTS: 6 weeks (3-12)

(Schlegel 2010)(Schlegel 2010)

The Surgical option…?The Surgical option…?

Manual TechniquesManual Techniques

SSTM SSTM • PhysiologicalPhysiological• AccessoryAccessory• DynamicDynamic• Combined Combined (Hunter 1990)(Hunter 1990)

Van Den Aaker methodVan Den Aaker methodMulti modality treatment (MMT) Multi modality treatment (MMT)

(Heat/STM/Stretching/Running program; 90% RTS: Weir 2008)(Heat/STM/Stretching/Running program; 90% RTS: Weir 2008)NB: Thomas’ test: ITB/TFL stiffnessNB: Thomas’ test: ITB/TFL stiffness

Manual Therapy v Exercise Manual Therapy v Exercise therapytherapyn=ET:25/MT:29;+ive local Adductor pain signs n=ET:25/MT:29;+ive local Adductor pain signs

(Holmich 2004)(Holmich 2004)

• ET group (n=25);ET group (n=25);

Allowed to run Allowed to run

at at 6 weeks!6 weeks!

• MT group (n=29);MT group (n=29);

Allowed to run at Allowed to run at 14 days or earlier!14 days or earlier!

Return to running program (Phase 1-3: Return to running program (Phase 1-3: slow jog, straight line, cutting)slow jog, straight line, cutting)

(Weir 2011)(Weir 2011)

• MT: 50%Return to Sport at MT: 50%Return to Sport at 12.8 weeks12.8 weeks

• ET: 55% RTS at 17.5 ET: 55% RTS at 17.5 weeksweeks

• Home exs programme!Home exs programme!

• Unsupervised!Unsupervised!

• No controlNo control

• Recurrences after 4 month Recurrences after 4 month F/U?F/U?

(Weir et al 2011)(Weir et al 2011)

Isometric Adductor strength in Isometric Adductor strength in FootballersFootballers

• Adduction > Abduction irrespective of Adduction > Abduction irrespective of dominancedominance

• Dominant > non-dominant (3% Dominant > non-dominant (3% Adduction / 4% Abduction)Adduction / 4% Abduction)

• Hip Add/Abd ratio is 1.05 in footballerHip Add/Abd ratio is 1.05 in footballer(Thorborg et al 2010)(Thorborg et al 2010)

Nicholas & Tyler 2002 suggestNicholas & Tyler 2002 suggest Add:Abd ratio: >90%; Adductor strength L=R Add:Abd ratio: >90%; Adductor strength L=R

before for RTSbefore for RTS

Adductor Weakness in Adductor Weakness in LSARGPLSARGP

• Add : Abductor Ratio was 24% lower in groin Add : Abductor Ratio was 24% lower in groin pain athletes pain athletes (Thorborg et al 2010)(Thorborg et al 2010)

• Squeeze test was significantly weaker (20%) in Squeeze test was significantly weaker (20%) in players with longstanding groin pain players with longstanding groin pain

(Malliaras et al 2009)(Malliaras et al 2009)

• Player was Player was 17 TIMES 17 TIMES more likely to get more likely to get adductor muscle strain if Adductor strength adductor muscle strain if Adductor strength was <80% of Abductor strengthwas <80% of Abductor strength

(Tyler et al 2001, O’Connor 2004)(Tyler et al 2001, O’Connor 2004)

• Verrall et al 2007: Verrall et al 2007: 63% return to sport but 63% return to sport but only 41% to pre-injury level (rest, swim, bike, only 41% to pre-injury level (rest, swim, bike, stepping, core exs) in Pro Aussie Rulesstepping, core exs) in Pro Aussie Rules

• 10 weeks RTS with ET 10 weeks RTS with ET (Wollin & Lovell 2006)(Wollin & Lovell 2006)

• Rodriguez et al 2001Rodriguez et al 2001: combined local passive : combined local passive Rx (ET, ice) and progressive strength Rx (ET, ice) and progressive strength program over 10 weeks – 100% successprogram over 10 weeks – 100% success

• Ekstrand & Ringborg 2001: Ekstrand & Ringborg 2001: strengthening exs strengthening exs had short term benefit but poor adherence had short term benefit but poor adherence long termlong term

BUT ALL STUDIES SHOW BENEFITS!BUT ALL STUDIES SHOW BENEFITS!

‘‘Exercise Therapy’ in LSARGP Exercise Therapy’ in LSARGP varies!varies!

Exercise therapy v Exercise therapy v ‘Physiotherapy’‘Physiotherapy’

At 4 months:At 4 months:

• 79% 79% of AT group had no of AT group had no residual groin pain and RTS residual groin pain and RTS

NB: ONLY 14% of PT NB: ONLY 14% of PT group!group!

• Return to sport took Return to sport took between 13-26 weeks between 13-26 weeks (median 18.5 weeks)(median 18.5 weeks)

(Holmich et al 1999)(Holmich et al 1999)

Active Training Active Training (n=30)(n=30)

e.g. Abd/adduction strength e.g. Abd/adduction strength exs, sit ups, balance exs, sit ups, balance training, slide board training, slide board

Physiotherapy Physiotherapy Treatment (n=29)Treatment (n=29)

Laser, Frictions, Stretching, TNSLaser, Frictions, Stretching, TNSNB: Hx of Groin pain (NB: Hx of Groin pain (≈≈ 40 weeks) 40 weeks)

Amateur athletesAmateur athletes

Take care with excess load on Take care with excess load on tendon!tendon!

• After After single bout of prolonged single bout of prolonged exercise exercise

(3 hour run) (3 hour run) leads to increase in leads to increase in type 1 collagen synthesis in the type 1 collagen synthesis in the peritendon peritendon

(Langberg et al 1999)(Langberg et al 1999)

• Seen in Proliferative/Reactive Seen in Proliferative/Reactive tendinopathytendinopathy

• Care reintroducing into exercise Care reintroducing into exercise within 72 hours!within 72 hours!

• Tendon loading magnitude (e.g. Tendon loading magnitude (e.g. HSR) positively relates to HSR) positively relates to anabolic gene expressive anabolic gene expressive (Lavagnino 2003, Arnoczky 2007)(Lavagnino 2003, Arnoczky 2007)

Undulating Tendon Loading Undulating Tendon Loading ProgrammeProgramme• No / minimal pain during No / minimal pain during

exercise (VAS 3/10 max)exercise (VAS 3/10 max)

• 3 sec per Rep / 2 min rest3 sec per Rep / 2 min rest

• Varying loads and repsVarying loads and reps

• Aim to mimic athletic Aim to mimic athletic movement in different waysmovement in different ways(e.g. Isometrics, strengthening, (e.g. Isometrics, strengthening, running, jumping, kicking, etc)running, jumping, kicking, etc)

• Progress Range, Load, SpeedProgress Range, Load, Speed

• High load every High load every 3-4 days3-4 days!!

• Type 1 production requires Type 1 production requires 2-3 days to peak 2-3 days to peak

(Fredberg 2004)(Fredberg 2004)

SessionSession ExerciseExercise SetsSets RepsReps Intensity Intensity (%)(%)

11 AA 33 66 8080

BB 33 66 8585

CC 33 66 8585

22 AA 33 1515 4040

BB 33 1515 4040

CC 33 1515 4040

33 AA 33 1010 6060

BB 33 1010 7070

CC 33 1010 7070

Periodising Tendon Load Periodising Tendon Load in Late stage rehabilitationin Late stage rehabilitation

Why do Eccentrics on Why do Eccentrics on Tendonopathy?Tendonopathy?‘‘Is it too aggressive for some tendons?’Is it too aggressive for some tendons?’

‘‘Are there better methods?Are there better methods?

Not for every tendon problem!Not for every tendon problem!

Does high load eccentric training just strengthen the Does high load eccentric training just strengthen the MT unit?MT unit?

Why not just get the unit stronger through Why not just get the unit stronger through conventional means (concentric and eccentric)?conventional means (concentric and eccentric)?

• Effective in Achilles tendon Effective in Achilles tendon (Silbernagel et al 2001)(Silbernagel et al 2001)

• Effective in Patellar tendon Effective in Patellar tendon (Kongsgaard et al 2009)(Kongsgaard et al 2009)

Don’t avoid concentric!Don’t avoid concentric!

Control movement velocity! (‘Time under tension’)Control movement velocity! (‘Time under tension’)

Is it ‘Strength’ that’s Is it ‘Strength’ that’s essential?essential?

Motor controlMotor control Work capacityWork capacity‘‘TO FATIGUE’TO FATIGUE’

Maximal Maximal StrengthStrength

PowerPower

VolumeVolumeIsometricIsometric

3-5 x 20+ Reps3-5 x 20+ Reps3-5 x 30-60sec3-5 x 30-60sec

3-5 x 5-12 Reps3-5 x 5-12 Reps3-5 x 3-5 x

(4-6 x 30-20 sec)(4-6 x 30-20 sec)

3-5 x 6-2 Reps3-5 x 6-2 Reps3-5 x(10 x 6sec)3-5 x(10 x 6sec)

3-6 x 2-3 Reps3-6 x 2-3 Reps3-6 x 5-10 Plyos3-6 x 5-10 Plyos

FrequencyFrequency 3-7 x / week3-7 x / week 2-3 x / week2-3 x / week 1-3 x / week1-3 x / week 1-3 x / week1-3 x / week

Muscle Muscle AdaptationAdaptation

Slow twitch Slow twitch hypertrophyhypertrophy

Whole muscle Whole muscle hypertrophyhypertrophy

Fast twitch Fast twitch hypertrophyhypertrophy

Fast twitch Fast twitch hypertrophyhypertrophy

Tendon Tendon AdaptationAdaptation

NoneNone Tendon Tendon hypertrophy – hypertrophy – 5% at each end5% at each end

i.e. ‘areas of i.e. ‘areas of most stress’most stress’

Tendon Tendon hypertrophyhypertrophy

Increased Increased passive passive stiffnessstiffness

If high volume: If high volume: tendon tendon

hypertrophy hypertrophy Increased passive Increased passive

stiffnessstiffness

Classic Strength TrainingClassic Strength Training‘Are players working hard enough?’

(Brandon 2010, Foure et al 2009, Arruda et al 2006)

Remember Tendon is slow to Remember Tendon is slow to adapt!adapt!

Tissue ResponsesTissue Responses

NeuralNeural 1-3 weeks1-3 weeks

MuscleMuscle > 3 weeks> 3 weeks

TendonTendon > 6 weeks> 6 weeks

• Where does pathology sit on the continuum?Where does pathology sit on the continuum?

• High load every other or third day High load every other or third day

• Deliver load in different ways (via strength exs, Deliver load in different ways (via strength exs, plyometrics, functional load plyometrics, functional load e.g. kickinge.g. kicking))

• Combine HSR with eccentric training once able!Combine HSR with eccentric training once able!

• But monitor response & periodise load acordinglyBut monitor response & periodise load acordingly

• Monitor subjective markers (AM pain/stiffness, VAS on Monitor subjective markers (AM pain/stiffness, VAS on activity, VISA)activity, VISA)

• Monitor objective markersMonitor objective markers

• Tendon Rehab takes time despite anatomical site Tendon Rehab takes time despite anatomical site (i.e. 3 (i.e. 3 months!)months!)

Key Tendon Rehab points!Key Tendon Rehab points!

Early phase:Early phase:• Off-load for 7-10 days??? Off-load for 7-10 days???

• Isometric loading (12-5 reps x 5-30 sec)Isometric loading (12-5 reps x 5-30 sec)

Intermediate/Late phase:Intermediate/Late phase:• Heavy Slow Resistance training (3 x/week)Heavy Slow Resistance training (3 x/week)

(3 sec conc/ecc – 4 x 8-15 each exs)(3 sec conc/ecc – 4 x 8-15 each exs)

(Patellar tendon : Kongsgaard et al (Patellar tendon : Kongsgaard et al 2009)2009)

• Eccentric loading dailyEccentric loading daily

(Low/Med/High load every 3 days) (Low/Med/High load every 3 days)

Tendonopathy Exercise Tendonopathy Exercise TherapyTherapy

‘‘Local’ Adductor tendon Local’ Adductor tendon loadingloading• Ensure strength & stability function restoredEnsure strength & stability function restored

• 3 staged Strength Protocol3 staged Strength Protocol• Level 1 targets: Level 1 targets: Squeeze test P1/Max Effort 50%/150mmHg; Squeeze test P1/Max Effort 50%/150mmHg;

Painfree FROM on 7 stretch program; Complete all level 1 Painfree FROM on 7 stretch program; Complete all level 1 exercises painfreeexercises painfree

• Level 2 TargetsLevel 2 Targets: Pubic stress test (max resistance); Squeeze : Pubic stress test (max resistance); Squeeze 200+ mmHg / 75% Normal; Completed all above exercises 200+ mmHg / 75% Normal; Completed all above exercises painfreepainfree

• Level 3 aims: Level 3 aims: Single SL Side bridge painfree; Full high load Single SL Side bridge painfree; Full high load functionfunction

Target all ‘functional’ Global Target all ‘functional’ Global systemssystems1.1. Posterior obliquePosterior oblique

Lat Dorsi BicepsFemoris Lat Dorsi BicepsFemoris Gluteus MaximusGluteus Maximus ST lig TDFST lig TDF

2.2. Anterior oblique*Anterior oblique*EO and contralat IOEO and contralat IOContalat AdductorsContalat AdductorsAnterior Abdominal Fascia and TAAnterior Abdominal Fascia and TA

3.3. Deep longitudinalDeep longitudinalES MTFES MTF Biceps Femoris (long head)Biceps Femoris (long head)Deep lamina TDF, ST, Int & SD ligsDeep lamina TDF, ST, Int & SD ligs

4.4. Lateral slingLateral sling**Gluteus Medius and minimusGluteus Medius and minimusContralateral AdductorsContralateral Adductors TFLTFL (Vleeming 1995)(Vleeming 1995)

Monitor ProgressMonitor Progress

1. Pain during exercise2. Pain +/- ‘stiffness’ next morning3. Squeeze test (0°,60°,90°)4. Isometric strength test5. Pubic symphysis stress test

(Ext/Abd, Resist flex/add)6. Adductor muscle tone (BKFO, ABD ROM,

Palpation)

(Hogan 2003)

SIJ Stabilisation beltsSIJ Stabilisation belts

• Groin pain patients have less adductor Groin pain patients have less adductor strength than healthy subjectsstrength than healthy subjects

(N = 44, mean duration of symptoms:16.3 months)(N = 44, mean duration of symptoms:16.3 months)

• Adding Pelvic belt = Average 10% increase Adding Pelvic belt = Average 10% increase in strength (39% increased by 20%) and in strength (39% increased by 20%) and reduced painreduced pain

Mens et al 2006Mens et al 2006

‘‘High load’ functional High load’ functional activitiesactivities

• SL loading+SL loading+

• Med ball drillsMed ball drills

• Tackling + KickingTackling + Kicking

• Agility + Cutting Agility + Cutting drillsdrills

• All with proximal insertional adductor pain on palpation All with proximal insertional adductor pain on palpation and pain on squeezeand pain on squeeze

• Adductor strength program Adductor strength program (Holmich 1999)(Holmich 1999)

• TA activation TA activation (Cowan et al 2004)(Cowan et al 2004)• Mobilise Hips Mobilise Hips (Williams 1978, Ibrahim et al 2007, Verrall et al (Williams 1978, Ibrahim et al 2007, Verrall et al

2007)2007)

• Mobilise SIJ Mobilise SIJ (Marshall & Murphy 2006)(Marshall & Murphy 2006)

• 4 phases of recovery; Each stage had goals to achieve4 phases of recovery; Each stage had goals to achieve

• 77% Return to pre-injury level without symptoms77% Return to pre-injury level without symptoms

• In average 20 weeks (70-221 days)In average 20 weeks (70-221 days)

• 70% competing at 22 months (within 6.5-51 months)70% competing at 22 months (within 6.5-51 months)

• But 26% re-occurred…But 26% re-occurred…therefore ensure therefore ensure MAINTENENCE MAINTENENCE WORK continues!WORK continues!

(Weir et al 2010)(Weir et al 2010)

Comprehensive treatment plan Comprehensive treatment plan

• Injury based testsInjury based testse.g. Squeeze test, Isometric Abd = Add / R=L, Cross e.g. Squeeze test, Isometric Abd = Add / R=L, Cross

hands squeeze, DL abs lowers x 24, Scissor beats x 1 hands squeeze, DL abs lowers x 24, Scissor beats x 1 min, SL bridge, level 3 strength R=Lmin, SL bridge, level 3 strength R=L

• Rehabilitation criteriaRehabilitation criteria

e.g. Kicking*, Cut/Agility at High intensity, Sprint, e.g. Kicking*, Cut/Agility at High intensity, Sprint, Cross-over hop, etcCross-over hop, etc

• Physiological criteriaPhysiological criteria

V02max / Yo-yo, GPS data (Max speed, max V02max / Yo-yo, GPS data (Max speed, max accel, loading R=L?)accel, loading R=L?)

Return to Training CriteriaReturn to Training Criteria

Rehabilitation into Training!Rehabilitation into Training!

High intensity lateral movement High intensity lateral movement ESSENTIAL!ESSENTIAL!

Especially…Especially…Agility / Accelerations (GPS Agility / Accelerations (GPS

data)data)

• Local Adductor strengthening Local Adductor strengthening (Isometric test)(Isometric test)

• Normalise Adductor tone / ROM Normalise Adductor tone / ROM (BKFO)(BKFO)

• Local trunk dissociation control Local trunk dissociation control (Pilates)(Pilates)

• Global functional strength Global functional strength (Squeeze test)(Squeeze test)

• Progressive Functional rehabilitation Progressive Functional rehabilitation (3 stage (3 stage

adductor protocol)adductor protocol)

• Utilise SIJ belt Utilise SIJ belt (enhance force closure)(enhance force closure)

• Bilateral Hip & SIJ mobility Bilateral Hip & SIJ mobility (measure, Gillets)(measure, Gillets)

• Thoracolumbar junction mobility & Neural testsThoracolumbar junction mobility & Neural tests

• Fascial techniques & dSSTM to adductor complexFascial techniques & dSSTM to adductor complex

• Pain management / medical interventionPain management / medical intervention

Evidence based Adductor Evidence based Adductor dysfunction rehabilitation dysfunction rehabilitation