groin pull…adductor strain

Sunday, August 9, 2015

Imagine the pain, unless you’re a gymnast or dancer, as you watch an athlete do the splits. The groin muscles are stretched beyond their breaking point and then break… actually tear… and a season or career can come to an abrupt end. As it turns out that isn’t the only way to tear the groin muscle but regardless of the mechanism, Houston Texans’ running back Arian Foster, required a surgery to repair his injury to try to get him back on the football field within 3 months.

A pulled groin is the lay term for a strained adductor muscle. The hip is a ball and socket joint, with movements in multiple directions. The hip adductors (and there are six) are responsible for moving the hip towards the midline of the body and resisting movement laterally, like doing the splits. A strain occurs when the muscle fibers stretch beyond their capability to rebound, just like an elastic band. The muscle can be overstretched (a grade 1 strain), partially torn (grade 2) or completely torn (grade 3).

adductor_anatomy

The bad news about the hip adductor muscles when it comes to anatomy is its poor design and how it attaches to bone. Some muscle fibers attach to a small area in the pubic bone of the pelvis and the transition point from bone to muscle is blessed with very poor blood supply and very rich nerve supply. As well, other parts of the adductors muscles where the cells transition from tendon to muscle there is also very poor blood supply. When injury occurs, the muscle heals poorly because the lack of blood supply means that the body cannot deliver building blocks needed for repair, plus the muscle causes significant amount of pain because of the numerous nerve endings.

The diagnosis is relatively easy, based on the history of the injury and the physical examination that confirms the area of pain and tenderness. Occasionally x-rays are done to look for small fleck fractures, where a sliver of bone has been pulled off the pubic ramus. It’s a different story for elite athletes, where knowing the difference between a grade 1, 2 or 3 strain will affect the treatment plan.

Most people get better in 12+ weeks, if they look after their body and don’t try to push the healing. It just takes that long. Those who don’t follow therapy guidelines can expect a recovery time that can last six months or longer. For an elite athlete, 12-24 weeks is forever, especially in football, where a dozen games lost is a disaster, especially when the average career lasts only 3-4 years. MRI scans are often done to help decide whether a grade 3 strain is a candidate for surgical repair.

Surgery is potentially indicated for those patients who have a complete rupture of an adductor muscle, or in a few select patients who have a chronic strain that has failed to improve even after prolonged therapy. Fixing the tear and reattaching the muscle to bone, then requires significant time for everything to scar down so that early movement does not rip things apart again. Supported walking can begin within a couple of days, some running as long as it is without pain happens in about 5 weeks and the goal for unrestricted activity is 10-12 weeks. These are great goals if the athlete’s body reads the textbook, but there have been studies on NFL players with ruptured adductors, albeit with very tiny numbers, that shows return to play might occur within 6 weeks just with rest.

The decision for most elite athletes is pragmatic. If surgery gets them onto the field in 12 weeks, that known time frame is preferable to the potential that the conservative treatment without surgery might fail and they are stuck with surgery anyway 6 weeks later. Mr. Foster chose immediate surgery based on his risk-reward analysis. Backyard athletes and construction workers may choose differently. It is always a reminder that in medicine, statistics and studies are wonderful to contemplate, but in the real world for the individual patient, the results will not always be 100% positive. As the Security and Exchange Commission puts it, past performance does not necessarily predict future results.

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low back pain

Monday, November 11, 2013

The shelf life of an NFL running back is much too short. The body is asked to absorb repeated hits and that is coupled with turf that is unforgiving on knees and ankles. The career life expectancy of an NFL player is about 6 years but running backs may or may not last that long. Last month, Houston Texan Arian Foster made news by offering fans the opportunity to buy shares in his future earnings, but that was forever ago and now his stock is dropping because of planned season ending back surgery for a bulging disc.

Mr. Foster joins the 40% of the American population who suffer from low back pain. Most often it is because of a pulled muscle and the pain resolves with a little time and TLC. But sometimes, the cause of the pain is damage to one of the structural elements of the back and surgery may be required. It is rare that surgery is emergent and often, an operation is planned when other options like physical therapy, chiropractic care and medication injections fail.

The spine is made up of stacked vertebrae that are supported by muscles and ligaments. In between the bones lay the discs that act as shock absorbers to cushion the force of walking, running, jumping and twisting. The vertebrae also protect the spinal cord and the nerves that enter and leave, transmitting signals to and from the brain. Over time, because of age or due to trauma, the spine can degenerate and arthritis can set in, limiting the function of the back to move and to absorb the shocks of daily life. This may cause the muscles and ligaments to become inflamed but it can also cause the discs to bulge or rupture.

spinal disc

While the damaged disc can cause pain because of the local inflammation of the injury, the potential complication is that the disc can irritate a nerve root as it leaves the spine. In the lumbar spine, the low back, these nerve roots come together to form the sciatic nerve and the pain can radiate into the buttock and down the leg causing significant distress. The disc can also bulge and press back into the spinal canal where the cord is located and press on the cord, causing the pain and numbness to be felt in both legs.

bulging disc

The initial treatment remains the same for most patients but when muscles begin to weaken or reflexes are lost, an urgency exists to consider surgery to relieve the pressure on the nerve root or spinal cord. This progresses to a true emergency if the ability to urinate is lost and the patient becomes incontinent of stool, a condition known as cauda equine surgery, and if there is hope for the spinal cord, surgery needs to be done within hours.

Arian Foster’s medical course seems to be following the urgent, non-emergent course.  His back pain has been diagnosed as a bulging disc and he is seeking opinions as to when it is best to have an operation. He may opt to have surgery sooner than later because he is reaching the halfway point of his NFL career and may not want to spend months waiting to see if therapy may work. Add to the equation is that his job is not sitting at a desk or standing in front of a classroom, it is being hit by 300 pound linemen who do not care that he has a fragile low back.

For most people, ice, heat, over the counter anti-inflammatory medications and activity as tolerated is the mantra to healing low back pain. Better yet is maintaining good back health by keeping weight under control, working on abdomen and back core strength, stretching to maximize flexibility and using proper lifting techniques. Unfortunately for Mr. Foster, he and his running back fraternity, are not like most people.

 

Illustration attribution: webmd.com, denverchiropractor.com

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