Tenotomy of the adductor longus tendon the treatment of chronic groin pain in
From the *Stockholm
Sports Medicine Center, Stockholm, Sweden, and the ‡Section of Sports Medicine, Department of Orthopaedic Surgery, Karolinska Institute, Huddinge Hospital, Huddinge, Sweden
and ice hockey players, chronic groin pain is, in our experience, often caused by an isolated overuse injury to the adductor longus muscle or tendon. soccer
Eighteen tenotomies of the adductor longus tendon performed in 16 consecutive male athletes (aged 20 to 42) as treatment for chronic groin pain. The criteria for surgery was a history of long-standing (range, 2.5 to 48 months) and distinct pain at the origin of the adductor longus muscle, refractory to conservative were
There has been little published on surgical treatment of chronic groin pain.3°5 These articles have reported surgical methods dealing either with the gracilis muscle5 or with a more extensive surgical procedure including several groin structures but not the adductor longus muscle.3 In cases of long-standing pain localized at the origin of the adductor longus muscle, a tenotomy close to the origin at the pubic bone may be of value. This surgical procedure was presented at the 1981 annual meeting of the AOSSM in Lake Tahoe by one the authors (CA) and, to our knowledge, has not been previously described in the literature. The purpose of this study was to evaluate the long-term functional results of tenotomy of the adductor longus tendon in 16 athletes with chronic groin pain that was refractory to conservative treatment.
At followup 35 months (range, 4 to 84) after surgery, all patients were improved or free of symptoms. All but 1 of the athletes returned to the same sport within a mean of 6.6 weeks, and 12 of 16 returned to competitive sports within a mean of 14 weeks after surgery. A majority of the patients (10 of 16) returned to full athletic activity, whereas 5 of 16 performed at a reduced level. One patient discontinued his sports activity due to other causes.
In conclusion, when conservative treatment fails, te-
notomy of the adductor longus tendon gives good long-
MATERIALS AND METHODS
term functional results in the treatment of chronic groin pain that is localized at the origin of the adductor longus
competitive athletes with a mean age of 28.5 42) were operated on with tenotomy of the adductor longus tendon at the origin on the pubic bone (2 athletes had bilateral injuries). All surgery was performed by the senior surgeon (Ck). All patients sustained their initial symptoms during sports activities. Soccer (N 4) and ice hockey (N 4) were the most common sports. The remaining injuries occurred during running (N 3), orienteering (N 2), and during bandy, cross-country skiing, and team handball (N 1 each). Participation in the sports of soccer and ice hockey produces repetitive minor traumas to the structures in the groin area. In 2 athletes a more distinct minor trauma was thought to have initiated the injury. The majority (14 of 16) had a gradual onset of symptoms. Preoperatively, all athletes related a history of long-stand-
muscle. A decreased muscle strength was observed in this study and did not seem to influence participation in
Conservative treatment of athletes with chronic groin pain is known to be difficult and the rate of reinjury is high.4 This condition has been referred to as a complex syndrome because various diagnoses such as pubic osteitis, prostatitis, and inguinal hernias may also cause chronic groin pain. In
t Address correspondence and reprnt requests to Chnstian Akermark, MD, Stockholm Sports Medicine Center, Riddargatan 12A, Box 5704, 11487 Stockholm, Sweden 640
ing pain at exertion, clinically localized to the proximal part of the adductor longus muscle; 12 of 16 athletes had to stop their athletic activity due to pain. The mean duration of symptoms was 18.3 months (range, 2.5 to 48). A thorough
history and a clinical examination was performed in all patients to rule out the presence of hernias, entrapment neuropathies, tumors in the groin area, urogenital diseases, and injuries in the lumbar region or sacroiliac joint, all of which can be present with groin pain. The clinical examination included active and passive muscle testing and palpation of the different adductor muscles as well as of the rectus femoris and rectus abdominus muscles to determine that adductor longus exclusively was affected. Radiographs of the pelvic and hip region were performed in all cases. The criteria for surgery was restricted to patients with a longstanding history of reappearing isolated pain at the adductor longus tendon that was refractory to conservative treatment (rest from painful activities, analysis of training errors, prophylactic training advices, physical therapy that included stretching exercises, nonsteroidal antiinflammatory medications, and cortisone injections).
Surgical technique In the first seven cases a regional spinal anesthesia was used. The anesthetic effect was incomplete in two of these cases and thus general anesthesia was added. The remaining nine cases were operated under local anesthesia. Spinal and local anesthesia have advatanges in comparison with general anesthesia in permitting the patient to cooperate and freely move the leg during surgery. This facilities surgery as the different adductor muscles can easily be identified and separated. The patient was dressed to allow free movement of the affected leg, and placed supine with the leg abducted. A slightly oblique, 6-cm long incision was made distally and parallel to the groin crease, centered over the most proximal part of the adductor longus muscle. The fascia was split longitudinally and the adductor longus (Fig. 1), the gracilis, the pectineus, and the adductor brevis muscles were identified, inspected, and palpated to detect scar tissue formations, partial ruptures, or other abnormalities. Before tenotomy, a longitudinal incision was made in the proximal part of the adductor longus to exclude any partial ruptures (Fig. 2). Tenotomy was performed 1 cm from the muscle origin at the pubic bone. Before sectioning, the distal tendon end was secured by foreceps. Hemostasis at both ends was maintained with electrocautery. The distal end of the divided tendon was then sutured to the overlying fascia (Fig. 3) or in some cases to the underlying adductor brevis muscle approximately 4 to 5 cm distal to the tenotomy. Care was taken to avoid damage to the obturator nerve branches that pierce into the adductor muscle. The skin incision was closed in a standard manner without drain. An elastic compression bandage was applied and the patients were encouraged to resume ambulation as soon as possible, using crutches for a few days. The patients were also advised to keep the operated leg in abduction when in bed the lst postoperative day. All patients had a standard-
1. The proximal part of the isolated adductor muscle is elevated for inspection (arrow).
ized rehabilitation program for strength and flexibility supervised by physical therapists. The postoperative followup was performed 34.8 months (range, 4 to 84) after surgery. A questionnaire, including individual data on clinical history and subjective assessment of symptoms and activity rate before and after surgery, was completed by all patients and compared with the medical records from the time of surgery. The subjective assessment of pre- and postoperative changes in symptoms was categorized as symptom-free, improved, unchanged, or worse. Postoperative activity rate was graded in comparison with preinjury activity as full intensity, reduced intensity, and no activity. Palpation of the operated area did not reveal tenderness or pain at active or passive motion. Isokinetic adductor muscle performance was measured at followup with a regularly calibrated Cybex II dynamometer (Cybex, Ronkonkoma, NY) at angular velocities of 30 and 120 deg/sec. After a standardized warming up, the test was performed as described by the manufacturers, with the subject lying down on one side with the pelvis, chest, and resting leg firmly strapped to the table. The range of motion was individually set from maximal abduction, similar for both legs in all patients. The highest torque of three maximal attempts was used. All patients could subjectively maintain maximal force throughout the entire range of motion in both legs. The operated leg was compared with the healthy side in each
(31% ) levels. One athlete who assessed himself as symptomfree discontinued his athletic activity as an ice hockey player when he was transferred to another city because of his occupation. There was only one postoperative complication, in an ice hockey goaltender. During the first 2 months after surgery, when sliding down he complained of minor pain along the medial proximal part of the thigh. Radiographs were normal in all cases. The results from the isokinetic muscle testing are shown in Table 1. At both tested angular velocities the operated leg was weaker in maximum adduction torque in comparison with the healthy
leg (P < 0.02). z
Figure 2. A longitudinal incision (arrow) of the adductor longus muscle has been performed to exclude partial ruptures.
Our results suggest that tenotomy of the adductor longus tendon enables athletes with localized chronic groin pain to regain the functional capacity to participate in sports. This procedure is simple and has a low complication rate. It is obvious that the long duration of symptoms before surgery experienced by our patients and the lack of success from conservative treatment makes it difficult to do a complete prospective study in a randomized manner with a nonsurgically treated control group, although this would have added to the investigation. The criterion for surgery is a history of long-standing groin pain localized at the origin of the adductor longus muscle and refractory to conservative treatment. It should be stressed that several other conditions can be present with groin pain and should be ruled out before tenotomy is performed. We also suggest that tenotomy should be restricted to patients in whom there is a preoperatively well-defined tendon at the proximal part of the muscle, as was the case in our subjects. In some cases where the adductor longus has a fleshy origin at the pubic bone, i.e., there is no well-defined tendon, an excision of adherent scar tissue around the adductor longus muscle seems more appropriate, according to our experience from previous years.
Figure 3. The
distal end is sutured to the
to 5 cm distal to the
patient (the two bilateral cases excluded). The results were statistically analyzed with the Wilcoxon signed rank test for paired data.
The difficulty in using conservative methods to treat chronic groin pain in athletes is well known.4 Muscle rehabilitation of a painful adductor longus muscle is not easy, although it is probably of great importance. Today, prophylactic training advice, such as warming up and stretching and strengthening exercises, and analyses of training errors have been more seriously considered in conjunction with symptomatic treatment of chronic groin pain. We do not know whether the lower muscle torque, as measured in the operated leg, is a result of surgery itself or if it is a persisting weakness due to inactivity from the time of the injury. There were eight left-sided and eight right-sided injuries in our TABLE 1
Comparisons between operated and healthy side of isokinetic peak adduction torque at followup
RESULTS All patients
were found to be free of symptoms (N 10) or improved (N 6). Moreover, all athletes but one returned to their previous sports activity at full (63%) or reduced =
study, with no difference in results. Thus, our measurements not biased by normal variation in the left/right muscle ratio. It may be argued that a maximum isokinetic test may show lower values in the injured leg due to pain, but none of the athletes complained of pain during the postoperative test and all were able to exert maximum effort throughout were
the range of motion. However, pain at exertion was the reason we could not complete a preoperative test in all athletes. Only 7 of 16 athletes could perform isokinetic testing without pain. There was no significant difference in torque in the injured compared with the healthy leg in these patients. A slight but not significant increase in adduction torque was observed in the operated leg in these 7 patients from preoperative test to postoperative followup. It must be stressed that hip adduction in the test procedure is performed by the entire adductor muscle group. The decrease in strength in the adductor longus muscle may be compensated by an increased performance of the agonistic adductor muscles. Our patients were able to maintain functional sports activities despite the unilaterally decreased adductor muscle performance. Groin pain and muscle weakness create reappearing difficulties in sports practice in athletes, preventing them from continuing at competitive level. The purpose of tenotomy is to remove the painful muscle pull from the tendon origin and thus make it possible to restore a pain-free adductor
muscle function. None of our patients showed macroscopic signs of partial ruptures. Microscopic examination for inflammatory cells was not performed. Pubic osteitis creates groin pain similar to that found in our patients, and radiographs often show findings of irregularity and reactive sclerosis.’ In our patients, all radiographs were normal. Furthermore, none of our patients had a history of urogenital disorders or hernias. Thus, we did not perform herniography or any extensive laboratory examination. Our patients all
had, by history and clinical examination, an isolated adduclongus tendon pain syndrome, which was supported by
the results of surgery. In conclusion, we suggest that, in athletes with longstanding groin pain at the origin of the adductor longus muscle that has been refractory to conservative treatment, tenotomy of the adductor longus tendon provides a safe and .
valuable treatment. REFERENCES 1.Ekberg O, Persson NH, Abrahamsson PA, et al Longstanding groin pain in athletes A multidisciplmary approach. Sports Med 6. 56-61, 1988 2 Harris NH, Murray RO Lesions of the symphysis in athletes. Br Med J 4:
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Operative moglichkeiten Orthopade 9: