10

the adductors

demystifying them

The puck is sailing toward the lower corner at about 100 mph, and there’s little chance of its not settling into the back of the net. Goal!

Until the goalie flings his foot over his head and to the side and redirects the compressed rubber disk into the corner. Kick save—and a beauty (Figure 10-1).

Goalies have to repeat that kind of behavior several times during a game and hundreds of times throughout a season. They stretch and strengthen and do everything they can to create the flexibility necessary to play their position. But it doesn’t always work.

Ask Dominik Hasek. The outstanding goalie tried to kick away a puck and suffered a big tear of the adductor.¹ He said he heard a pop and felt a burning in his groin. He wasn’t kidding. That’s some serious stuff.

The adductors help goalies do the splits. They allow pitchers to overstride in their wind-ups to generate maximum speed on pitches. They help defensive linemen charge forward to overpower blocks by sturdy offensive linemen or drop back into pass coverage to prevent backs from getting open. Without good strength and flexibility in the area, disaster can strike, repair might be necessary, and the puck can end up in the net.

THE TOP TEN POINTS TO “GET” ABOUT THE ADDUCTORS (TABLE 10-1)

1. Most docs do not know the subtleties of adductor function.
   
2. The most important function of the adductors is their role in the core’s harness. The individual adductors do not usually work in isolation. And as a group of muscles, they work alongside other muscles that complement their forces.
   
3. Simple distal muscle belly strains are common and usually resolve spontaneously,^2,3 whereas proximal injuries at the pubic plate part of the harness are usually more serious.
   
4. The 3 most important adductors in the core are the pectineus, the adductor longus, and the adductor brevis. The adductor magnus is large and the gracilis long, but neither muscle is nearly as important as the other 3. The latter 2 do not attach to the more central portion of the pubic apparatus and therefore are not fundamental to the harness mechanism. In fact, the more central obturator externus has considerably more harness function than the gracilis or magnus (Figures 10-2 and 10-3).
   
   
   

   

   
   

   Figure 10-2.

   
   

   
   

   
   

   

   
   

   Figure 10-3. Adductors and their attachments.

   
   
5. Most proximal adductor injuries also involve the pubic plate, other adductors, and the rectus abdominis.
   
6. Bilateral injuries are common, via the pubic plate/harness mechanism.
   
7. Adductor repairs should be the primary type of surgical intervention for detached adductors, along with repairs of adjacent injured structures. Repairs usually require loosening (decompressing; eg, fasciotomies and epimysiotomies) the muscle belly compartments. Those are sometimes called compartmental releases, which may cause confusion. See the next point.
   
8. Adductor “releases”4–6 are bad. The term commonly describes detaching the adductor muscle from its attachment on the pubic bone. Detaching any muscle from its attachment, as one should expect, causes weakness. This is particularly true of the adductors. Such detachments may relieve pain but detaching something, by its nature, creates weakness. Significant weakness in a high-performance athlete certainly usually requires reattachment. The important question looms: Why not just repair the adductors? The answer is that proper repair requires keen understandings of both the anatomy and pathophysiology of the injuries. Those understandings have not been part of surgeons’ knowledge bases. The techniques for successful repairs turn out to be straightforward; there are many and one needs to choose the right one for each patient.
   
9. The anatomy of each adductor is readily identifiable, yet most people think in terms of old paradigms. The most important anatomical points to know are:
   
   
   
   • Adductor attachments onto the pubic plate are very important.
     
   • Very little tendon exists. One may argue that the attachments look like “tendons.”⁷ Forget that, that gets everybody thinking wrong when it comes to repairing them. Instead, think in terms of the muscles attaching directly into that fibrocartilaginous plate.
     
   • A number of anatomic subtleties exist. These relate to both various structural configurations and relative sizes of muscle, fasciae, and epimysia. There are distinct anatomical patterns for each adductor. Actually, the sport makes a difference. For example, skaters—both figure skaters and ice hockey players—have large pectinei, relative to the other 2 adductors of the harness.
   
   
10. A wide variety of adductor injuries exists varying from complete avulsions at the pubic attachments (which usually involve other structures) to more distal muscle belly injuries that do not involve the plate. The injuries may be acute or chronic and often involve a combination of acute and chronic processes. Any of the 3 main adductors may be involved, and commonly more than one adductor is involved at the same time.

OLD BELIEFS THAT ARE JUST PLAIN WRONG

• Adductor injuries are all “groin strains” and an athlete can grit through these.
  
• Surgery is rarely necessary.
  
• When surgery is necessary, one should do a “release” (ie, cut the adductor from its origin). One can do this without worry. It cures the problem. There is no loss of strength, etc.
  
• If you really want to repair the adductors, anchor them back to the pubic bone.
  
• Adductors all do the same thing.
  
• The tendon is the important part of adductor structure.

DEBUNKING OLD DOGMA (FIGURE 10-4)

We are not going to spend time exhaustively explaining why each of those old beliefs just ain’t true. That would only fuel controversy.

Instead, accept as reality that this area of the body has (had) remained mysterious for a long time. And accept that successful surgical experience in about 20,000 patients says that these old beliefs are wrong.

Plus, consider all the athletes that you have read about, whose careers ended or failed due to groin injuries. Logic should also enter into the debunking. For example, doesn’t it make sense that… detaching a muscle would cause weakness? Or that repairing muscles so that they function normally should help? Think about other questions: Shouldn’t the fact matter that the adductors don’t attach directly into bone? Might not anchoring them to bone, where all the nerves are, cause pain? Shouldn’t anatomical variations matter and enter into formulas for choosing the best type of repair?

The main point: Keep on reading. Ask Dick-and-Jane type questions. Continue the logic.

ANATOMICAL REALITIES

Three important anatomic points stand out.

1. The arrangement and muscular integrity of the adductors matter. Think of muscle as the functional tissue and muscular attachment as all important. Fascia and epimysium protect the muscle and provide some firmness but this tissue does not contract.
   
2. When muscle pulls away from its attachment, collagenous tissue may be all that is left. Function suffers and pain ensues. With time, the fibrous tissue thickens and tension increases. Our guess is that most pain comes from the pubic fibrocartilage pulling away from the periosteum, which has a rich, neural complex.
   
3. The harness adductors are primary protectors of the hip. As depicted in Figure 10-5, we performed multiple studies in fresh cadavers that showed this. Other structures sometimes played roles as well, such as the femoral artery and nerve. In fact, cutting the adductors sometimes produced impingement in fresh cadavers with cam or pincer anatomy. This led us to the conclusion that adductor or harness injury could cause clinical impingement signs and symptoms. Empirically, the clinical corollary rings true in many of our patients—that the harness adductors are primary protectors of the hip.

Many of our patients with manifest femoroacetabular impingement also have elicitable adductor signs. They also have adductor strictures, certainly the consequence of longstanding injury and the fibrosis related to injury and sustained compensatory contraction. From the combination of anatomic and clinical information, we could not help but conclude that the harness adductors serve as primary protectors against hip impingement.

Related posts:

Putting It All Together—A Patient’s Perspective on the Core How the Core Universe Forms The Eureka Moment for the Core Don’t Forget the Thorax New Eyes—Medicine’s Inability to See the Core Presenting…the Core!

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