Case Study: Groin Injury

Case Report: Adductor Strain in a Dancer

Written By: Melissa Buehler, SPT

Disclaimer: I am a student of physical therapy and received guidance from my clinical instructor for this case. Most of what was done for this patient was based off of the clinical experience of my CI. I hope that this case, and others to come, will serve as a vehicle to help develop our clinical reasoning skills and is not to be used for diagnosing and/or treatment of a patient. If you have had experience treating a similar condition and found other treatment strategies useful, please share them with us below in the comments section of the post.

If you are a dancer who has recently experienced a similar injury, please contact your physical therapist. Thank you.


Subjective

Image 1: Courtesy of Google Images

A 20 year-old amateur dancer reports to physical therapy with c/o left sided groin pain.  During rehearsal a couple days prior, she was performing a tilt (see Image 1) when she heard a couple of “pops” in her standing leg.  She immediately felt pain and was unable to continue dancing.  Her trainers treated the area with ice and told the dancer to monitor the area, in which she noted no bruising or excessive swelling to the area.   Since the injury she has not danced, has been unable to walk without pain and has also been unable to sit on a chair for an extended amount  of time due to pain in the area. She desires a quick recovery because she has an important audition for a professional dance company in three weeks.

Clinical Impression I

Based off of the symptoms described by the patient, a musculoskeletal sprain or tendon injury of the adductors and/or hamstrings are suspected.  Adductor strains occurs when there is a strong eccentric contraction of the adductors musculature (Tyler 2014), which would occur in the dance moved described above.  The most common groin injuries involve the adductor longus, rectus abdominis, iliopsoas and rectus femoris (Renstrom 1980).  Tendon injuries also can happen under similar circumstances. 

Physical Exam Findings   

Range of Motion

Active range of motion was limited by pain in hip adduction, internal rotation and hip extension.  Passive ROM was found to be painful at end range in abduction, external rotation and flexion.  Hip mobility was estimated to be 20% of full ROM when compared to her unaffected side.

Muscle Testing

See Table 1. for manual muscle testing values.

Table 1. MMT Initial Eval

Hip Adduction 3 limited by pain
Hip Extension 3 limited by pain
Hip Abduction 3+ limited by pain
Hip Flexion 3+ limited by pain
Knee flexion 4 limited by pain


Palpation

The dancer was tender to palpation along the insertion of the adductor magnus muscle (inferior ramus of the pubis & ischium bones & tuberosity of the Ischium). Although, Adductor longus is thought to be the most frequently injured adductor muscle (Renstrom 1980), this muscle was ruled out due to location of tenderness.  It is likely that semimembranosus mm. was also affected. This is based off of palpation and in the subjective, the dancer stated that she heard a couple of pops during the injury.

Objective Measures

Patient Specific Functional Scale was used to individualize the goals for this patient. The activities included are:

Dancing 2/10
Walking 2/10
Getting out of a car 2/10
Average Score 2


Clinical Impression II

Differentiating between the adductor and hamstrings may appear to be straightforward;  manual muscle test the adductors (resisted hip adduction) versus the hamstrings (resisted hip extension or knee flexion), but there is overlap between the two muscle groups, especially with semimembranosus, adductor longus and adductor magnus.  Palpation may be the best way to determine what muscle or tendon is affected in this situation.  Based off of the subjective and physical exam, a tendon injuries of adductor magnus and semimembranosus are suspected. Based off of this, the timeline for her recovery is extended when compared to a muscle strain (see discussion for protocol), although the treatment will be similar.

Treatment

The primary interventions for this acute case of an adductor tendon injury was to relieve pain, restore range of motion, maintain strength and to return to dance.  Interventions such as cold laser, ultrasound, massage, e-stim and gravity eliminated exercises were used for the two weeks of treatment.  Her exercises began with gentle isometrics to the adductors and abductor strengthening all in non weight bearing.  Dance movement patterns were practiced in a non-weight bearing position.

An ACE Bandage was used to provide extra support to her adductor and hamstring muscles.  Immediately, this improved her gait mechanics and was used for 3 weeks following the initial evaluation. She was instructed to dance at a level that was 25% of her typical dance load.

To apply the ace bandage:

1. Begin by wrapping the ace bandage counterclockwise a couple times around the thigh, about 3-5inches above the knee (creates an anchor)

2a-b. Apply tension to the ace bandage as you wrap up and behind the hip and around the contralateral hip

3. Continue to wrap around the anterior pelvis keeping the bandage below the ASIS’s

4. Wrap back and down towards the medial aspect of the thigh, completing the figure 8 pattern that wraps around the thigh and pelvis.

5. Continue to overlap the figure-8 pattern, keeping the tension on the first part of the wrap from the posterior thigh to the contralateral ASIS

Four Week Re-eval

She felt that the injury had improvement in function and said that pain levels had decreased in intensity and frequency.  She reported that she was still experiencing sharp pains that shot down her leg with some activities, like getting out of a car, kicking up into a handstand and certain dance movements.  She has been dancing at a higher intensity, although she is unable to do moves that require flexion or abduction above 90˚ with her left leg and movements into extension and adduction with her right leg (her left leg is stabilizing).  She had been experiencing incontinence with impact (landing from a jump), but stated that it is currently not a problem anymore.

Outcome measures

Her PSFS score was now 6.33 (Walking 8/10, dancing 5/10, getting out of a car 6/10). Minimal detectable change for average score is 2 points and for a single activity is 3 points, both of which had been met. (Stratford).  Her strength had improved, although it was not at full functional capacity yet.

Table 2. MMT at 4 weeks

Hip Adduction 4 limited by pain
Hip Extension 4 limited by pain
Hip ABD 4 limited by pain
Hip flexion 5 with some pain
Knee flexion 5 with some pain


She her passive range of motion was within normal limits, although painful at end range ABD and flexion. Her hamstring muscle group has increased in tension, which is thought to have been due to compensation from the injury.  Soft tissue and modalities will continue to be applied to that area when she comes in for treatment.

Continued Care

The dancer was making excellent progress with her treatment, although she had not reached full function.  Since it’d had been only four weeks since initial injury, full healing at this time is not to be expected.  The dancer is still very active. She attends dance classes daily and is doing “probably more than she should”.  She has one more month left of school before she will be able to take a break before her professional dance group starts rehearsing.  

Her exercises are now in full weight bearing and include stretching and strengthening exercises.  This includes single leg raises with resistance in standing, single leg deadlifts, lunges and squats.  Therapist-assist stretching into flexion and into abduction, such as combination isotonic, contract/relax and hold/relax, will be used to increase her range.  Her home exercise program now includes active eccentric lengthening of the hamstrings (single leg deadlifts) and active stretching (split training). She will continue to dance daily for school and study.

Image 3

Dynamic taping was used instead of the ace bandage that supported adductor magnus and semimembranosus (See Image 3).  To apply the dynamic tape:

  1. Patient position: prone with hip in extension (place a pillow under her leg)
  2. Two strips of tape were placed:Tape 1: start medially on her upper leg and apply the tape in the direction of the pull of adductor magnus (posterior and superior).
  3. Tape 2: start 4-5 inches below the gluteal fold and apply the tape with stretch into the superior direction.

She was able to participate in the audition and was waiting to hear whether or not she made the cut.  She is now preparing for the final exams in dance classes, which was another four weeks out.

Discussion

Functional Testing could have been performed as another objective measure in her treatment. The Medial and Lateral Triple Hop Tests has both been determined to have good reliability and the medial hop test has been proven to have good validity for testing dancers with unilateral hip pain (Kivlan). This test is functional to dancers since it attempts to simulate the demands of leaping and landing in dance class.  In this specific case, hoping in the lateral direction requires concentric and eccentric contraction of the adductors and may be more appropriate for this case report.

Instructions for performing the Medial & Lateral Triple Hop Test 

Image from: Kivian (2012)
  1. Subject places their foot perpendicular to the end of a measuring tape
  2. The subject stands on a single leg and hops 3 times in the medial and/or lateral direction
  3. Three trials are completed before three additional test trials which are then averaged.

Table 3 Results (Kivian (2012))

Test Standard Error Measurement (SEM) Minimal Detectable Change (MDC)
Medial Triple Hop 7.51cm 20.81 cm
Lateral Triple Hop 8.17 cm 22.62 cm

The treatment of an adductor muscles/tendon strain should be centered on tissue healing principles and sport specific functional training.  Treatment should consist of therapeutic modalities, stretching, core and hip stabilizations/strengthening, functional movement/muscle re-education and manual therapy. There has been some research published on adductor muscles strains in hockey players and a post-injury program has been developed by Tyler, et al. (2014). See Table 4 for his recommendations for treatment based off of healing phases of tissue.  Although we may not be working with hockey players, we can extrapolate their research finding to help develop a plan of care based of off tissue healing and return to sport functional training.

Table 4 Adductor Strain Protocol (Tyler 2014)

Once tissue healing is no longer an issue, functional/return to sport training is appropriate for these athletes.  A RCT by Homich et al. (1999) found that passive physical therapy programs, such as massage, stretching and modalities were proven ineffective, while active programs aimed at improving strength, coordination of the adductor muscles and other muscles of the pelvis was effective in athletes with long-standing adductor related groin pain.  This dancer was just starting this stage of rehab at 4-6 weeks post injury.  This time frame will be different for each person depending on the demands of their daily lives and severity of the injury.

References

Kivlan BR, Martin RL. Functional performance testing of the hip in athletes: a systematic review for reliability and validity. International Journal of Sports Physical Therapy. 2012(4):402-412

Renström, P. A. F. H., and L. Peterson. “Groin injuries in athletes.” British Journal of Sports Medicine 14.1 (1980): 30.

Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263

Tyler T, Takumi F, Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis. International Journal of Sports Physical Therapy. 2014; 9(6): 785-797.


If you have any other treatment ideas for Adductor/Hamstring tendon or muscles strains, please comment below!

Thank you for reading

 

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