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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