A 22-year-old male football player presented one year after an injury to his groin. He described injuring himself while lunging into a heavy tackle. He complained of ongoing pain in his medial thigh, particularly during sporting activities. He had been unable to return to competition. On examination he was found to have pain during adductor stretching and with resisted hip adduction.
X-ray images of the hip and pelvis were obtained and were normal. MRI images show an avulsion of the proximal adductor brevis and longus muscles. Coronal images demonstrate fibrous scarring of the avulsed tendon without significant shortening or ossification. An axial image at the level of the muscle bellies show that there is no evidence of fatty degeneration or amyotrophy. The fibrous scar is adjacent to vascular and nervous structures, particularly the obturator nerve.
This young patient has a chronic avulsion of the adductor brevis and adductor longus muscles and had been unable to play football for one year (despite his best efforts). Given the delay in diagnosis it was not possible to surgically repair the avulsed tendons. In the acute setting it is possible to surgically repair and reattach the tendons. After one year however, this option is not appropriate due to the muscle retraction, the fibrous scar associated with the avulsion and the high risk of failure. The player was managed with a further rehabilitation programme consisting of stretching and eccentric exercises over three months. Unfortunately, this rehabilitation programme was also not effective. The options of a PRP injection or tenotomy of the adductor brevis and adductor longus were discussed. The player opted to trial a PRP injection. Combined with ongoing rehabilitation, the player’s symptoms eventually improved, and he was able to return to sport about 18 months following his initial injury.
The optimal management of proximal adductor avulsion injuries remains unclear. While there has been a trend towards early surgical repair, especially in elite or professional players, many clinicians recommend conservative treatment. Adductor tenotomy is a further option that is generally reserved for specific cases of chronic groin injuries. Nonoperative management generally has good results but as this case highlights, can be unpredictable. This can lead to ongoing groin pain and reduced function. The time lost to failed conservative treatment may prove costly to a professional player. One of the potential benefits of early surgical reattachment is that it restores normal muscle length, it does however come with the risks associated any surgical procedure. The impact of treatment choice on return to play times and performance has not been well studied. One case series showed that NFL kickers returned to sport faster when they did not have surgery.
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