Adductor Tendinitis

Adductor Tendinitis

The Clinical Syndrome

The increased use of exercise equipment in gyms for lower extremity strengthening has resulted in an increased incidence of adductor tendinitis. The adductor muscles of the hip include the gracilis, adductor longus, adductor brevis, and adductor magnus muscles. The adductor function of these muscles is innervated by the obturator nerve, which is susceptible to trauma from pelvic fractures and compression by tumor. The tendons of the adductor muscles of the hip have their origin along the pubis and ischial ramus, and it is at this point that tendinitis frequently occurs.

These tendons and their associated muscles are susceptible to the development of tendinitis owing to overuse or trauma secondary to stretch injuries. Inciting factors include the vigorous use of exercise equipment for lower extremity strengthening and acute stretching of the musculotendinous units as a result of sports injuries, such as sliding into bases when playing baseball.

The pain of adductor tendinitis is sharp, constant, and severe, with sleep disturbance often reported. The patient may attempt to splint the inflamed tendons by adopting an adductor lurch type of gait—shifting the trunk of the body over the affected extremity when walking. In addition to the previously described pain, patients with adductor tendinitis often experience a gradual decrease in functional ability, with decreasing hip range of motion, making simple everyday tasks such as getting in or out of an automobile quite difficult. With continued disuse, muscle wasting may occur, and an adhesive capsulitis of the hip may develop.

What are the Symptoms of Adductor Tendinitis

On physical examination, a patient with adductor tendinitis reports pain on palpation of the origins of the adductor tendons. Active resisted adduction and passive abduction reproduce the pain.

Patients with adductor tendinitis also exhibit a positive Waldman knee squeeze test for adductor tendinitis. For this test, the patient places a tennis ball between the knees and gently holds it there. The patient is asked to squeeze the ball as hard as possible. Patients with adductor tendinitis reflexively abduct their knees, causing the tennis ball to fall.

Tendinitis of the musculotendinous unit of the hip frequently coexists with bursitis of the associated bursa of the hip joint, creating additional pain and functional disability. Neurological examination of the hip and lower extremity is normal, unless there has been concomitant stretch injury to the plexus or obturator nerve.

How is Adductor Tendinitis diagnosed?

Plain radiographs are indicated in all patients with hip, thigh, and groin pain. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated. Magnetic resonance imaging (MRI) and ultrasound imaging of the hip and pelvis are indicated if aseptic necrosis or occult mass is suspected and to help confirm the diagnosis. Radionucleotide bone scanning should be considered if the possibility of occult fracture of the pelvis is being considered. Electromyography can help rule out compression neuropathy or trauma of the obturator nerve and rule out plexopathy and radiculopathy. Injection of the insertion of the adductor tendons serves as a diagnostic maneuver and a therapeutic maneuver.

Differential Diagnosis

Internal derangement of the hip may mimic the clinical presentation of adductor tendinitis. Occasionally, indirect inguinal hernia can produce pain that can be confused with adductor tendinitis. If trauma has occurred, consideration of the possibility of occult pelvic fracture, especially in individuals with osteopenia or osteoporosis, should be entertained, and radionucleotide bone scanning should be obtained. Avascular necrosis of the hip also may produce hip pain that can mimic the clinical presentation of adductor tendinitis. Entrapment neuropathy or stretch injury to the ilioinguinal, genitofemoral, and obturator nerves and plexopathy and radiculopathy should be considered if the physical finding of neurological deficit is identified in patients thought to have adductor tendinitis, because all of these clinical entities may coexist.

Treatment

Initial treatment of the pain and functional disability associated with adductor tendinitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. For patients who do not respond to these treatment modalities, injection of the insertion of the adductor tendons of the hip with a local anesthetic and steroid may be a reasonable next step. The use of ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.

Complications and Pitfalls

If trauma is present, the possibility of occult pelvic fracture always should be considered, as should the possibility of occult malignancy of the pelvis or hip. Trauma to the adductor tendons from injection of the tendinous insertion remains a possibility. Tendons that are highly inflamed or previously damaged are subject to rupture if they are directly injected. This complication can be greatly decreased if the clinician uses gentle technique and stops injecting immediately if significant resistance to injection is encountered. Approximately 25% of patients report a transient increase in pain after this injection technique; patients should be warned of this possibility.

Clinical Pearls

The proper use of exercise equipment can greatly reduce the incidence of adductor tendinitis. Injection of the adductor tendons is extremely effective in the treatment of pain secondary to the previously mentioned causes of hip pain. Gentle injection technique decreases the incidence of traumatic rupture of the tendons owing to injection. Coexistent bursitis and arthritis may contribute to hip pain and may require additional treatment with a more localized injection of a local anesthetic and depot steroid. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for hip pain. Vigorous exercises should be avoided because they would exacerbate the symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.

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