Chronic Addudor Tendinitis in a Female

Transcription

1 C A S E S T U D Y Chronic Addudor Tendinitis in a Female Philip A. Tonsoline, MS, PT, ATC' T he incidence of significant groin injuries among competitive athletes is thought to be quite rare (6,lO). In European countries, there is growing recognition of a higher incidence of injury to the groin area (4,8). Renstrom and Peterson reported that as high as 5% of soccer injuries studied over a 2-year period affected the groin (7). Others have suggested that the ratio is as high as 28% for soccer (4). A review of literature for adductor injuries for nonweight-bearing activities, such as swimming, indicates that the condition is rare. Groin pain can arise from a variety of conditions ( ). The correct diagnosis may be confounded as a result of multiple joints in the proximity and musculotendinous, neurologic, and internal structures in the area. Groin symptoms as a result of joint problems may occur in the pubic symphysis or hip joint. Injuries to the pubic symphysis may include osteitis pubis, pubic symphysitis, or osteochondritis (6). Hip joint pathology such as osteoarthritis or bursitis may also be considered for referral of groin pain (8). Musculotendinous causes of groin pain include adductor or rectus avulsion, tendinitis, and strain (4-6,8). Ilioinguinal neuralgia is the primary nerve consideration for groin pain (4). Internal sources of pain include inguinal hernia, prostatitis, urethritis, epididymitis, and primary or sec- Although hip and groin pathologies are not as prevalent as other lower extremity injuries, information on the course of physical therapy to remedy these injuries is needed. This case study reviews an episode of chronic adductor tendinitis and the subsequent course of treatment. A 16- year-old female swimmer developed symptoms of an adductor strain that failed to respond to varied conservative treatments over 1 year. A unilateral tenotomy was performed, and follow-up treatment was provided. Although this patient is not symptom-free, she is swimming competitively at a major Division I college. Consideration of more than one causative factor and aggressive early diagnosis must be performed to prevent groin pain from becoming chronic. Key Words: tendinitis, hip adductor, swimmer ' Physical Therapist, Buffalo Physical Therapy and Sports Care Services, 1321 Millersport Highway, Williarnsville, NY Paper submitted before conversion to 51 units was required. ondary tumors (4-10). Specific palpable structural tenderness and careful radiographic examination appear to be the key for differential diagnosis (6,9); lack of point tenderness may indicate the necessity for more detailed laboratory testing of internal structures (4). Multiple factors must be considered in the early diagnosis of groin pain to prevent the condition from becoming chronic. The following case study demonstrates an apparent acute muscle strain that evolved into a chronic groin problem which did not respond to conservative treatment. The purpose of this case study was to report the rehabilitation program for a patient with long-standing groin pain. CASE HISTORY A 16-year-old nationalcaliber female swimmer began to develop bilateral groin pain rather insidiously during the competitive swimming season in February In retrospect, the patient attributed the development of symptoms to rigorous, breast-stroke training. The patient did not seek medical consultation until April, at which point there had been a significant decrease in performance and symptoms occurred with normal activities of daily living. Routine examination indicated an apparent adductor strain. The patient was treated conservatively for 2 to 3 months with physical therapy modalities, stretching exercises, and anti-inflammatory medication without significant relief. A routine X- ray and bone scan 4 months following the onset of symptoms failed to reveal any significant pathology. The patient was referred for a second orthopaedic consultation in August At that time, she was unable to swim any type of stroke without experiencing disabling pain. Subsequent referral to this therapist was made in August 1988 with a diagnosis of chronic bilateral adductor tendinitis. JOSPT Volume 18 Number 5 November 1993

2 REHABILITATION Stage I Initial evaluation in August 1988 revealed local tenderness to palpation over the right adductor origin. Pain and weakness with adduction against manual resistance presented primarily on the right side, although it was also present to a degree on the left. At evaluation, the patient noted gradual improvement in the condition on the left and reported that the left side was no longer a significant complaint. The patient reported discomfort with any elastic pressure directly over the right adductor area (ie., from underwear or swim suit), which continued throughout treatment and following surgery. Treatment consisted of stationary biking; stretching for the hip musculature utilizing standard positions (butterfly, V-sit, lunge); and isometric and isotonic resistive exercises for all hip movements including flexion, extension, internal and external rotation, abduction and adduction, with emphasis on adduction and abdominal strengthening. Therapeutic modali- ties in the form of electrical stimulation and phonophoresis had been used extensively from April to June 1988 and proved unsuccessful; thus, only cryotherapy was utilized during this phase. Ice massage or cold pack was used intermittently before and after exercise. Over a period of 3 months, the patient was seen one time per week, with the suggested frequency for home exercises three times per week. Progression on the exercise program included the addition of isotonic lower extremity machinery (Figure 1) and isokinetic exercise for hip abduction/adduction (Figure 2), with emphasis once again on the adductors. The patient attempted a return to swimming in December 1988 but was unable to perform even light training because of recurring symptoms on the right side. Stage II In December 1988 the right groin was injected with a cortisone steroid, and rest followed for 4 weeks. Therapy was resumed in mid- January. At this point, phonophoresis and stretching were initially started three times a week for 2 weeks. Following this treatment, gradual progression into an exercise program utilizing pool exercises and isotonics was performed. The pool exercises consisted of straight hip movements in water in a direction of flexion/extension and adduction/abduction with no additional resistive devices other than the water. No kicking or swimming was performed. Isotonic exercise consisted of progressive resistive exercises using ankle weights for all hip movements. Isotonic strengthening in the form of leg press and knee extension were also performed for general conditioning. Two months of total treatment once again failed to show any significant relief. During this stage the patient was examined by a general surgeon for a hernia or other internal pathologies. No significant pathology was diagnosed. Stage Ill A second cortisone injection in February 1989 was performed, followed by complete rest. After 3 months of rest, the patient noted no significant change and resumed phonophoresis and stretching only for eight treatments. The injured athlete continued to complain of direct tenderness to palpation or pressure (swimsuit elastic) as well as continued weakness or pain with any right lower extremity activity. Failure of conservative treatment and therapy eventually led to the decision to perform surgery with the hope of alleviating the symptoms. Stage IV Surgery for the release of the symptomatic right adductor longus was performed in August Adhesions were found in the area of the overlying fascia as well as a different appearance to the cortical bone and its attachment. Biopsy of the right pubic ramus did not reveal any pathologic finding. Postsurgical recovery progressed with no complications, and therapy was initiated 2 weeks following surgery. Two to 4 Weeks Postsurgery FIGURE 1. lsotonic hrp ilex~on. FIGURE 2. Icokmetrc hrp ahductron/adductron At 2 weeks, a flexibility and strengthening program was initiated for the hip musculature. Modalities used were moist heat prior to exercise as a passive warm-up and ice 630 Volume 18 Number 5 November 1993 JOSPT

3 massage following treatment. Ice massage, chosen because of its localization of application, was continued throughout the entire postsurgical phase. The patient had never demonstrated any particular limitation in hip range of motion compared with standard acceptable ranges. However, this degree of flexibility was based on average standards not specific to swimming. The stretching program was continued as a general rehabilitation protocol, once again emphasizing the adductors and flexors of the right hip. Routine stretches for the remaining lower extremity musculature were also performed. All stretches were maintained for a minimum of 10 seconds. Longer stretch periods of 30 seconds had been previously attempted prior to surgery and did not prove successful; decreased stretch time appeared to create better patient compliance. Strengthening was simultaneously initiated beginning with submaximal isometric movements of the hip adductors. The patient performed the exercise in a butterfly position, with resistance provided isometrically by the patient's elbows or hands (contract-relax method). Within 1 week, straight., leg. raises,, hip abduction, and prone extension exercises were introduced. Strengthening was initiated with a standard progression of three sets of 10 repetitions and progressed to three sets of 15 repetitions. Ankle-weight resistance was introduced by the end of the fourth postsurgical week. Stationary biking had been attempted almost immediately; however, the patient could not tolerate the seated position on the bike due to postsurgical discomfort. Four to 8 Weeks Postsurgery Seated stationary biking was tolerated by the fourth week and was added as an active warm-up following the application of moist heat. Biking remained low in intensity for periods no greater than 15 minutes. Following Week 8, biking would be progressed to cardiovascular training with increased time and intensity. Over the following period (up to 8 weeks following surgery), the program progressed as follows: Stretching Initial exercises were continued with addition of other stretches for the hip adductor/flexors with various degrees of hip flexion and extension (Figures 3 and 4). Hip abductor stretches were also added. Strengthening As a warm-up, stationary biking was continued prior to strengthening exercises, and resisted submaximal isometrics for hip adduction were continued. Isotonic~ for the quadriceps/hamstrings Internal sources of pain include inguinal hernia, prostatitis, urethritis, epididymitis, and primary or secondary tumors. were also performed for general conditioning. Progressive resisted exercises using ankle weights for the hip were started for all hip motions except adduction. Hip adduction was not initiated from the side-lying position due to an inability to perform the movement without discomfort (Figure 5). Eight Weeks Postsurgery to Present Additions to the program following Week 8 were made primarily in the area of strengthening. Hip adduction in the standing position was added using an isotonic pulley resistance system (Figure 6), allowing the motion to be performed through a greater range than could be accomplished in the side-lying position. A FIGURE 3. Hip adductor stretch with minimal hip flexion. FIGURE 4. HIP adductor flexor stretch with the involved extremity in extension. FIGURE 5. Standard hip adductor strengthening through a limited movement. stair-climbing machine was attempted for lower extremity condi-.tioning and cardiovascular training. However, following four attempts on different days, it did not appear to be tolerated well and was discontinued. Surgical tubing exercises for both hip rotations were also added to partially simulate the breast-stroke JOSPT Volume 18 h'umber 5 November 1993

4 . FIGURE 6. Isotonic hip adduction. kick (Figure 7). As a result of speed of movement involved with the stroke, a program of surgical tubing exercises with progression from slow to fast movements similar to the latter stages of rehabilitation for the rotator cuff (1 1) was undertaken. Symptoms that related to movement prior to surgery were no longer present. However, throughout the entire postsurgical phase, the patient continued to note discomfort to direct pressure, which was most evident when any type of elastic, such as a swimsuit, was over the area. Two and one-half months following surgery, the patient's physician recommended that another opinion be obtained regarding the continuing direct pain and tenderness in the right groin. The patient was referred to a local pain clinic in November The examining anesthesiologist did not believe it would be appropriate for any type of sensory block, and the decision was FIGURE 7. Resisted external rotation oi the hip. made to continue conservative treatment. The patient returned to swimming in December By spring 1990, she had qualified for the state amateur competition (Empire State Games). Two years following the onset of symptoms (6 months following surgery), the patient had returned to a competitive status. The patient continues to experience discomfort in the right groin, which increased as a result of dry land conditioning. The patient is still unable to perform the breast stroke and must be cautious during off-season conditioning. The patient reported discomfort with any elastic pressure directly over the right adductor area. Originally, factors such as leg length inequality, foot biomechanics, and sacroiliac dysfunction were considered. The nature of the sport and the onset of symptoms did not indicate that a leg length mechanism was the source of the original problem; however, a mild discrepancy was corrected. As expected, it did not a p preciably change the symptoms. A mild increase in right foot pronation which was present on initial findings was addressed by the patient's athletic trainers at school. A soft orthotic was fabricated and over the summer of 199 1, the patient noted a decrease in right groin discomfort with work and recreational activities; however, discomfort was not completely alleviated. Another factor considered was a possible referral pattern from a sacroiliac joint dysfunction. Originally, the patient's sacroiliac joints were evaluated (2,lO) and appeared negative. The patient's family suggested that the patient be examined by a physician who specialized in spinal disorders. In July 199 1, the patient was examined, and the physician determined that some subtle sacroiliac dysfunction may have existed and suggested a course of myofascial release. The patient was referred to a therapist specializing in this treatment; however, prior to returning to school no significant change occurred in the ongoing symptoms. DISCUSSION Martens et al (5) reported 109 cases of adductor tendinitis and rectus abdominis tendopathy, 8 1 of which were treated operatively. Five of the reported 109 cases presented with bilateral adductor symptoms. Of those treated surgically, the mean age was 26 and only three were female. Martens et al (5) concluded that patients with hip adductor symptoms beyond 3 months a p peared to respond poorly to conservative treatment. The current case Volume 18 Number 5 No\.ember 1993 *JOSPT

5 Velocity Measure Uninjured Injured 10/88 3/90 1 o/88 3/90 60 "/set Peak torque "/set Peak torque "/set Total work TABLE. Bilateral adductor torque comparisons (It-lbs) of peak torque and work. fell outside the mean age and common activity reported by Martens et al; however, the injury did appear to fit the classification of chronic overloading. Conservative treatment for this apparent overuse injury consisted of rest, injection, and therapeutic modalities in an effort to decrease inflammation. However, no combination of treatment appeared to reduce the inflammatory process. The possibility of muscle weakness as the primary underlying cause of symptoms both pre- and postsurgically was considered. As indicated by the treatment program, the patient had been placed through extensive conditioning programs. The Table provides the hip adductor torque outputs from the initial stage (10/88) Symptoms have persisted for 3 yean since onset. to the last recorded test (1/90). Testing was performed according to the established Humac (Computer Sports Medicine, Inc., Cambridge, MA) protocol for the Cybex isokinetic dynamometor (Lumex Inc, Ronkonkoma, NY). Interestingly, peak torque values for hip adduction at the low and high speeds were a p proximately equal. The lack of change in torques as speed of contraction increased should be considered in the future to assess whether it is characteristic of this muscle group or if it was a trait of this particular athlete only. Donatelli (3) has reported on unpublished research regarding isokinetic values for hip abduction/adduction, although this did not provide enough information for comparison. SUMMARY Surgical intervention did appear to improve symptoms and allow the athlete to return to a competitive level with modifications. Persistent low-grade discomfort in the right groin required changes in the athlete's training activities. Modifications included elimination of the breast stroke, running as a dry land activity, and wearing a swimsuit with high cut legs to avoid elastic pressure over the painful area. Several years have passed since the initial onset of symptoms. The athlete appears to have improved but is not symptom-free or competing at her previous level. Attempts continue to be made to find the missing piece to this puzzle. Longstanding groin pain, as Ekberg et al (4) related, may require extensive evaluation and treatment due to the fact that more than one causative factor may exist. Although multiple causative factors appear rare, em- phasis must be placed upon early accurate diagnosis prior to reaching this chronic stage. JOSPT ACKNOWLEDGMENT The author would like to extend special thanks to Dr. Kenneth De- Haven for his assistance and Tammy Iulg for typing this manuscript. Thanks also to Amy Schule, David Stapleton, and Keri Pogorzelski. REFERENCES 1. Balduini FC: Abdominal and groin injuries in tennis. Clin Sports Med 7(2): , Cibulka MT: Rehabilitation of the pelvis, hip, and thigh. Clin Sports Med 8(4): , Donatelli RA: Pathophysiology and mechanics of the lower kinetic chain. Presented at 1991 Northeast Seminars, Portland, MA, August 15-16, Ekberg 0, Persson NH, Abrahamsson P-A, Westlin NE, Lilja B: Long-standing groin pain in athletes: A multi-disciplinary approach. Sports Med 6:56-61, Martens MA, Hansen L, Mulier /C: Adductor tendonitis and mr~sculus rectus abdominis tendopathy. Am / Sports Med 15(4): , Pavlov H: Roentgen examination of groin and hip pain in the athlete. Clin Sports Med 6(4): , Renstrom P, Peterson L: Croin injuries in athletes. Br / Sports Med 14:30-36, Taylor DC, Meyers WC, Moylan FA, Lohnes /, Bassett FH, Garrett WE: Abdominal musculature abnormalities as a cause of groin pain in athletes. Am / Sports Med 19(3): , Smodlaka VN: Croin pain in soccer players. Phys Sportsmed 8(8):57-6 1, Waters PM, Millis MB: Hip and pelvic injuries in the young athlete. Clin Sports Med 7(3): , Wilk KE: Advanced rotator cuff strengthening program. Presented at 1990 Injuries in Baseball Course sponsored by American Sports Medicine Institute, Birmingham, AL, lanuary 26-28, 1990 JOSPT Volume 18 Number 5 November 1993