adductor magnus problems, lower back pain inujries, strained hamstring injury, trigger points
Injury clinic - Adductor magnus
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Adductor magnus problems in athletes: here are two revealing case studies
Powerlifters, weightlifters, cyclists, sprinters and rugby players: if you regularly deal with these types of athlete, then this article may be of interest to you. Athletes participating in these sports have something important in common; they all perform powerful movements of hip extension from varying positions of hip flexion. The muscles responsible for this action are of course the hamstrings and the gluteal muscle group, but more importantly for the scope of this paper, the adductor magnus also plays a significant role in this movement. Repetitive overuse of the adductor magnus may potentially lead to hypertonicity/trigger point development within the muscle. The short case studies to follow will illustrate the importance of this muscle as a contributor to dysfunction.
Case study 1: the powerlifter with lower back pain
A 24-year-old state level powerlifter presented to the Agilitas clinic with a six-month history of left-sided lower back pain, exacerbated by heavy squatting and deadlifting, and more recently lumbar flexion. There was no history of trauma before onset of the pain. Previous treatment had consisted of anti-inflammatory medications, previous physiotherapy treatments focusing primarily on the development of muscle control using transversus abdominus and multifidus, and at late stage an epidural cortisone injection around the L5/S1 disc. His pain had not improved for the duration of the six months, with only temporary relief following the epidural cortisone. Plain x-rays were normal; however, CT scan showed a small left posterolateral L5/S1 disc bulge without nerve root compromise.
Examination
This showed full range of motion of the lumbar spine in extension, pain limited lumbar spine flexion, reduced hip flexion range of motion especially on the left, a hypomobile or 'blocked' left sacroiliac joint with a posteriorly rotated ilium and increased muscle tone through the right TFL/psoas and left gluteals and adductor magnus. With squatting movements, the patient demonstrated a right lateral pelvic shift with increasing depth of squat (increasing hip flexion). His transversus abdominus activation was reasonably good and was maintained with leg loading.
It was reasoned that the patient had indeed suffered a L5/S1 disc injury, although I was not convinced that poor muscle activation of his deep stabilisers was the primary cause of the problem. I felt that his lumbar spine-SIJ-hip mechanics on the left side might be influencing the loading of his left-sided lumbar spine during squat and deadlift movements. Based on the assessment findings of a blocked left SIJ, poor hip flexion, and the relative abduction of his left femur demonstrated while squatting (pelvis shifting laterally to the right), I decided to focus my treatments on improving these by releasing the tone through the left gluteals and adductor magnus.
Treatment
Gluteal releases are performed with the patient side lying with the hips in flexion, and direct elbow pressure applied to the taut 'bands' felt through the gluteals, particularly the posterior fibres of the gluteus medius. Discouragingly, release of the left gluteals only marginally improved his forward bending pain and SIJ mechanics. Persisting further, I then targeted the left adductor magnus. I performed this by applying direct pressure to the posterior fibres of the adductor magnus (just inferior to the ischial tuberosity) whilst the patient was prone lying. It was interesting that only a small amount of pressure produced a significant amount of discomfort for the patient; however, the pain response reduced significantly after a few minutes. The releases continued for a good 10 minutes, finding multiple spots of increased tone through the adductor magnus. On reassessment, the movement of his left SIJ improved markedly; more excitingly however, his forward bending was completely painfree.
Treatment over the next few weeks continued with releases of the left adductor magnus, and painfree forward bending and normal SIJ mechanics were maintained. The patient was shown ways of self-releasing the adductor magnus, and this was continued at home. The easiest way to do this is sitting on a firm chair with one end of small dumbell under the adductor magnus. The patient resumed light squatting and deadlifting four weeks after initial treatment, and within two months had progressed to similar loads on the squats and deadlifts pre-injury. One year following onset of symptoms, he was still painfree and progressively improving his PB's on both lifts.
Case study 2: the rugby player with a 'strained' hamstring
A 26-year-old élite level Rugby Union player felt a 'strain' through his left hamstring while performing shuttle sprints during a squad training session. The day before he had completed a heavy leg training session in the gym without incident. This included deep one-leg squats and leg presses. The pain was localised to the mid belly of the medial hamstring muscles, and he could run to 75% of full speed painfree. Walking was painless.
Examination
He was examined immediately and the following were found. Passive straight leg raise felt 'tight' at 60 degrees compared to the contralateral side of 100 degrees. Straight leg and knee bent bridging reproduced a 'tight' sensation through the hamstring. Muscle power was normal. Left SIJ movements were blocked. Lumbar spine movements and palpation essentially normal. There was significantly increased tone through the medial hamstring muscles, the left gluteals and left adductor magnus. This player had no history of hamstring tears.
Treatment
It was felt that this player had not 'torn' or 'strained' his hamstring, but had suffered an acute 'spasm' through the muscle. He was immediately treated with deep trigger-point releases through the hamstring and left gluteals. His straight leg raise had improved to 80 degrees with less 'tightness'. Functional bridging movements felt better although not 100%. His left SIJ had improved, although still marginally 'blocked'.
Still not satisfied with a few of these issues, I then directed my attention to the left adductor magnus. Deep releases of this muscle produced marked discomfort locally in the muscle, and after a few minutes pain began to refer down the medial hamstrings with visible 'twitches' of the muscle. Deep but gentle releases continued until the visible twitching ceased. On reassessment, straight leg raise was equal to the other side, functional bridging was painfree, and the left SIJ was 'unblocked'. Forty minutes after being dragged off the training field, he was back on there again completing 90-metre run-throughs. He was able to run at 95% pace painfree, although he still felt hesitant to push to full speed. That night he was instructed to self trigger/release the left gluteals and adductor magnus, and apply heat packs to his hamstring.
The following day he was treated with deep adductor magnus releases prior to training, and completed the entire training session totally painfree and without restriction.
Discussion
The above case studies highlight a number of interesting things about the adductor magnus. Firstly, adductor magnus muscle tone can have a significant direct contribution to pain pathologies and musculo-skeletal dysfunction. The two case studies above were chosen for one very good reason. They both involve LEFT sided adductor magnus problems, and in my experience, the majority (although not all) of adductor magnus problems are left sided. Secondly, SIB readers who are familiar with traditional 'osteopathic' assessment of the pelvis will be well aware of the contribution of muscle 'tone' around the pelvis. The more fancied muscles contributing to pelvic/SIJ dysfunction have been the TFL/gluteals/iliopsoas. These case studies highlight the contribution of adductor magnus as a culprit in this dysfunction. This can be particularly important if you are treating a posteriorly rotated ilium that is resistant to treatment. Thirdly, both case studies give examples of athletes using powerful hip extension movements from positions of hip flexion, whereby the adductor magnus can exert a considerable influence in the force production of this movement.
Looking for reasons
It is interesting to speculate why adductor magnus has an influence in these presentations. Is it because of weakness in the gluteals? Does the adductor magnus compensate for weakness in the gluteals and as a result become overactive and hypertonic? Is there a direct causal relationship between gluteal weakness and adductor magnus hypertonicity? In the above examples I have purposely not included the findings of gluteal strength in these athletes, because the differences between left and right were only subtle. Furthermore, it is difficult to infer cause and effect in these cases. Is it possible that a 'true' weakness exists, or is it a temporary inhibition caused by active trigger points in the gluteals or satellite trigger points in an agonist muscle group? It was interesting that in both cases, reassessment of gluteal strength did appear to have improved after adductor magnus releases.
Is the influence of adductor magnus more to do with its action in particular positions? Any avid weight-trainer returning from a long lay-off will comment on the soreness he or she experiences in the adductor magnus following deep squats. Is it that the adductor magnus is always active in a deep-squat position, even in the presence of normal gluteal strength?
How does adductor magnus contribute to pain pathologies? As mentioned earlier, does adductor magnus exert its influence in dysfunction by holding a posteriorly rotated ilium and 'blocking' SIJ movements? Any reader interested in 'muscle energy' concepts will know the contribution a rotated ilium has on dysfunction. Or in the case of the powerlifter, does it restrict hip flexion range of motion and therefore require that the lumbar spine utilise more lumbar flexion to make up for the lack of movement? Is the lumbar spine therefore more predisposed to injury in the presence of a hypertonic adductor magnus, if hip flexion is a dominant action required in the sport?
Not connected to foot dominance
It is also interesting to speculate on the possible causes of the observed side preference of adductor magnus problems (Note: this is merely a clinical observation, and has not been validated with empirical evidence). Side preference may not be exclusive to the adductor magnus. It is also apparent that the TFL and psoas tends to be hypertonic on the right side more often. Similarly, the gluteals and long adductors (graceless etc...) tend to have a dominance on the left. Some clinicians have suggested that it may be as simple as the foot dominance of an individual. That is, right footers tend to have the right TFL/psoas combination with the left gluteals/ adductors. This is an interesting concept, because it suggests that we have developed motor patterns with our muscles that may favour movement on one side, while stabilising with the other side. For example, a right- foot kicker will stabilise on the left leg while moving the right leg. Therefore, the stability muscles on the left (gluteals and adductors) may become more dominant, while on the right the movement muscles (hip flexors such as TFL and psoas) become more dominant. However, clinically there appears to be no correlation between the two. Some left footers will show the patterns of the right hip flexors and left gluteals, etc. And others still show completely confusing patterns. For example, right psoas but left TFL. The combinations can become infinite.
Conclusion
It has been highlighted enough in the preceding text that the posterior fibres of the adductor magnus are not the only muscle involved in musculoskeletal dysfunction. However, I have found it to be consistently involved in causing problems in athletes who perform hip extension movements from a position of flexion. If your patient/client population does fit this description, and you are having trouble solving their problems, whether it be pelvic mechanics, low back pain, lower limb muscle injuries or simply trouble with their running style, then have a look at the adductor magnus. Your patient/client and yourself may be pleasantly surprised how simple a solution it can be.
Chris Mallac
Case study 1: the powerlifter with lower back pain
A 24-year-old state level powerlifter presented to the Agilitas clinic with a six-month history of left-sided lower back pain, exacerbated by heavy squatting and deadlifting, and more recently lumbar flexion. There was no history of trauma before onset of the pain. Previous treatment had consisted of anti-inflammatory medications, previous physiotherapy treatments focusing primarily on the development of muscle control using transversus abdominus and multifidus, and at late stage an epidural cortisone injection around the L5/S1 disc. His pain had not improved for the duration of the six months, with only temporary relief following the epidural cortisone. Plain x-rays were normal; however, CT scan showed a small left posterolateral L5/S1 disc bulge without nerve root compromise.
Examination
This showed full range of motion of the lumbar spine in extension, pain limited lumbar spine flexion, reduced hip flexion range of motion especially on the left, a hypomobile or 'blocked' left sacroiliac joint with a posteriorly rotated ilium and increased muscle tone through the right TFL/psoas and left gluteals and adductor magnus. With squatting movements, the patient demonstrated a right lateral pelvic shift with increasing depth of squat (increasing hip flexion). His transversus abdominus activation was reasonably good and was maintained with leg loading.
It was reasoned that the patient had indeed suffered a L5/S1 disc injury, although I was not convinced that poor muscle activation of his deep stabilisers was the primary cause of the problem. I felt that his lumbar spine-SIJ-hip mechanics on the left side might be influencing the loading of his left-sided lumbar spine during squat and deadlift movements. Based on the assessment findings of a blocked left SIJ, poor hip flexion, and the relative abduction of his left femur demonstrated while squatting (pelvis shifting laterally to the right), I decided to focus my treatments on improving these by releasing the tone through the left gluteals and adductor magnus.
Treatment
Gluteal releases are performed with the patient side lying with the hips in flexion, and direct elbow pressure applied to the taut 'bands' felt through the gluteals, particularly the posterior fibres of the gluteus medius. Discouragingly, release of the left gluteals only marginally improved his forward bending pain and SIJ mechanics. Persisting further, I then targeted the left adductor magnus. I performed this by applying direct pressure to the posterior fibres of the adductor magnus (just inferior to the ischial tuberosity) whilst the patient was prone lying. It was interesting that only a small amount of pressure produced a significant amount of discomfort for the patient; however, the pain response reduced significantly after a few minutes. The releases continued for a good 10 minutes, finding multiple spots of increased tone through the adductor magnus. On reassessment, the movement of his left SIJ improved markedly; more excitingly however, his forward bending was completely painfree.
Treatment over the next few weeks continued with releases of the left adductor magnus, and painfree forward bending and normal SIJ mechanics were maintained. The patient was shown ways of self-releasing the adductor magnus, and this was continued at home. The easiest way to do this is sitting on a firm chair with one end of small dumbell under the adductor magnus. The patient resumed light squatting and deadlifting four weeks after initial treatment, and within two months had progressed to similar loads on the squats and deadlifts pre-injury. One year following onset of symptoms, he was still painfree and progressively improving his PB's on both lifts.
Case study 2: the rugby player with a 'strained' hamstring
A 26-year-old élite level Rugby Union player felt a 'strain' through his left hamstring while performing shuttle sprints during a squad training session. The day before he had completed a heavy leg training session in the gym without incident. This included deep one-leg squats and leg presses. The pain was localised to the mid belly of the medial hamstring muscles, and he could run to 75% of full speed painfree. Walking was painless.
Examination
He was examined immediately and the following were found. Passive straight leg raise felt 'tight' at 60 degrees compared to the contralateral side of 100 degrees. Straight leg and knee bent bridging reproduced a 'tight' sensation through the hamstring. Muscle power was normal. Left SIJ movements were blocked. Lumbar spine movements and palpation essentially normal. There was significantly increased tone through the medial hamstring muscles, the left gluteals and left adductor magnus. This player had no history of hamstring tears.
It was felt that this player had not 'torn' or 'strained' his hamstring, but had suffered an acute 'spasm' through the muscle. He was immediately treated with deep trigger-point releases through the hamstring and left gluteals. His straight leg raise had improved to 80 degrees with less 'tightness'. Functional bridging movements felt better although not 100%. His left SIJ had improved, although still marginally 'blocked'.
Still not satisfied with a few of these issues, I then directed my attention to the left adductor magnus. Deep releases of this muscle produced marked discomfort locally in the muscle, and after a few minutes pain began to refer down the medial hamstrings with visible 'twitches' of the muscle. Deep but gentle releases continued until the visible twitching ceased. On reassessment, straight leg raise was equal to the other side, functional bridging was painfree, and the left SIJ was 'unblocked'. Forty minutes after being dragged off the training field, he was back on there again completing 90-metre run-throughs. He was able to run at 95% pace painfree, although he still felt hesitant to push to full speed. That night he was instructed to self trigger/release the left gluteals and adductor magnus, and apply heat packs to his hamstring.
The following day he was treated with deep adductor magnus releases prior to training, and completed the entire training session totally painfree and without restriction.
Discussion
The above case studies highlight a number of interesting things about the adductor magnus. Firstly, adductor magnus muscle tone can have a significant direct contribution to pain pathologies and musculo-skeletal dysfunction. The two case studies above were chosen for one very good reason. They both involve LEFT sided adductor magnus problems, and in my experience, the majority (although not all) of adductor magnus problems are left sided. Secondly, SIB readers who are familiar with traditional 'osteopathic' assessment of the pelvis will be well aware of the contribution of muscle 'tone' around the pelvis. The more fancied muscles contributing to pelvic/SIJ dysfunction have been the TFL/gluteals/iliopsoas. These case studies highlight the contribution of adductor magnus as a culprit in this dysfunction. This can be particularly important if you are treating a posteriorly rotated ilium that is resistant to treatment. Thirdly, both case studies give examples of athletes using powerful hip extension movements from positions of hip flexion, whereby the adductor magnus can exert a considerable influence in the force production of this movement.
Looking for reasons
It is interesting to speculate why adductor magnus has an influence in these presentations. Is it because of weakness in the gluteals? Does the adductor magnus compensate for weakness in the gluteals and as a result become overactive and hypertonic? Is there a direct causal relationship between gluteal weakness and adductor magnus hypertonicity? In the above examples I have purposely not included the findings of gluteal strength in these athletes, because the differences between left and right were only subtle. Furthermore, it is difficult to infer cause and effect in these cases. Is it possible that a 'true' weakness exists, or is it a temporary inhibition caused by active trigger points in the gluteals or satellite trigger points in an agonist muscle group? It was interesting that in both cases, reassessment of gluteal strength did appear to have improved after adductor magnus releases.
Is the influence of adductor magnus more to do with its action in particular positions? Any avid weight-trainer returning from a long lay-off will comment on the soreness he or she experiences in the adductor magnus following deep squats. Is it that the adductor magnus is always active in a deep-squat position, even in the presence of normal gluteal strength?
How does adductor magnus contribute to pain pathologies? As mentioned earlier, does adductor magnus exert its influence in dysfunction by holding a posteriorly rotated ilium and 'blocking' SIJ movements? Any reader interested in 'muscle energy' concepts will know the contribution a rotated ilium has on dysfunction. Or in the case of the powerlifter, does it restrict hip flexion range of motion and therefore require that the lumbar spine utilise more lumbar flexion to make up for the lack of movement? Is the lumbar spine therefore more predisposed to injury in the presence of a hypertonic adductor magnus, if hip flexion is a dominant action required in the sport?
Not connected to foot dominance
It is also interesting to speculate on the possible causes of the observed side preference of adductor magnus problems (Note: this is merely a clinical observation, and has not been validated with empirical evidence). Side preference may not be exclusive to the adductor magnus. It is also apparent that the TFL and psoas tends to be hypertonic on the right side more often. Similarly, the gluteals and long adductors (graceless etc...) tend to have a dominance on the left. Some clinicians have suggested that it may be as simple as the foot dominance of an individual. That is, right footers tend to have the right TFL/psoas combination with the left gluteals/ adductors. This is an interesting concept, because it suggests that we have developed motor patterns with our muscles that may favour movement on one side, while stabilising with the other side. For example, a right- foot kicker will stabilise on the left leg while moving the right leg. Therefore, the stability muscles on the left (gluteals and adductors) may become more dominant, while on the right the movement muscles (hip flexors such as TFL and psoas) become more dominant. However, clinically there appears to be no correlation between the two. Some left footers will show the patterns of the right hip flexors and left gluteals, etc. And others still show completely confusing patterns. For example, right psoas but left TFL. The combinations can become infinite.
Conclusion
It has been highlighted enough in the preceding text that the posterior fibres of the adductor magnus are not the only muscle involved in musculoskeletal dysfunction. However, I have found it to be consistently involved in causing problems in athletes who perform hip extension movements from a position of flexion. If your patient/client population does fit this description, and you are having trouble solving their problems, whether it be pelvic mechanics, low back pain, lower limb muscle injuries or simply trouble with their running style, then have a look at the adductor magnus. Your patient/client and yourself may be pleasantly surprised how simple a solution it can be.
Chris Mallac
