As I was having my hair cut a few weeks ago, I overheard a conversation between the receptionist and a hairdresser. The receptionist was saying how frustrated she was at being unable to run for more than five minutes because of groin pain. This was despite having had massage treatments every couple of weeks for more than a year.
It didn’t take long before I decided to join in the conversation, and soon found myself taking the receptionist’s history while my stylist wielded comb and scissors overhead. Groin pain is a particularly problematic area for sports therapists, and in my experience it is all too common to address the site of pain rather than look elsewhere for the cause of the injury. I explained to the receptionist that it seemed as though the regular treatment of her symptomatic pain was not proving successful, and that her presenting pain was unlikely to be the cause of her inability to run.
Two days later I received a phone call from the frustrated runner: the challenge was on!
Rose, aged 49, has been working for many years as a receptionist. Before the onset of her injury, she was going for 45-min runs approximately four times a week . About 18 months ago she was toning her abdominals by doing bilateral leg lifts off the end of the bed, when she felt a sharp pain in her right groin. She stopped exercising immediately.
She rested for a few days and when most of the pain had disappeared, went for a run. To her surprise, the pain returned within minutes. She continued in this way for a few weeks, resting until the pain went, but managing to reignite it every time she recommenced her runs.
Walking up and down stairs was painful and at night she would particularly notice the pain when shifting from side to side, when that involved lifting her right leg up (abduction). She eventually went to visit her GP, who ordered an x-ray of her hip, which proved negative, and put her on the waiting list for physiotherapy.
Physiotherapy was not a happy experience. Rose felt that the exercises she was given after her first session exacerbated her injury. Her second session consisted of five minutes’ advice, which she felt was a complete waste of time. She returned to the GP.
This time the GP referred her for an ultrasound scan, which showed a tear of one of her adductors at its origin on the pubis. Despite this evidence, she was given no further advice or help, so she decided to pay for sports massage sessions every two weeks, which continued for the next 16 months. The massage treatments were very painful, although at the time she felt they were of some benefit.
As a lecturer in sports massage, I regu- larly explain to my students that the adductors as a group do tend to become shortened and tight. They undoubtedly benefit from manual therapy techniques to help normalise the hypertonicity. I also emphasise, however, that if you repeatedly manip- ulate an area of pain, there is a likelihood in the longer term of aggravating, rather than easing the symptoms.
Potentially, Rose’s symptoms could have improved without being continually massaged. But in any case, there has to come a point when we consider that the treatment we are giving as therapists is having no beneficial effect.
This is a matter of ethics: to continue with treatments, the patient has to have at least a feeling of improvement. In this case, Rose and her massage therapist had become stuck in a very untherapeutic cycle, in which she would have a treatment, be tender to the area for a couple of days but as she experienced an easing of symptoms, would make another attempt at running – only to have the pain return.
I do understand how easy it is to treat patients with sports massage on a regular basis – I have done it myself and still do. But if we are treating patients with pathologies, we need continually to be adapting and re- evaluating our thought processes and clin- ical reasoning in line with the patient’s response to treatment, be that improvement, no change or even deterioration.
The ultrasound scan had shown some tearing of one of the adductors. But Rose located the site of her pain to somewhere very close to the ischial tuberosity and I considered it to be either the adductor magnus or possibly one of the medial hamstrings.
To recap on the receptionist’s problem: her pain would come on within a few minutes of running and was particularly painful on the stance phase of gait leading to heel lift to toe off.
If one understands the musculature involved during the gait cycle then we can hypothesise as to why the adductor magnus was becomingreactive rather than proactive. If the posterior chain muscles are inhibited for some reason then other muscles natu- rally assume a compensatory role.
In my work treating athletes I frequently see the following presentation:
* short hypertonic psoas, rectus femoris and adductors
* overactive hamstrings and ipsilateral (same-sided) erector spinae with conse- quential inhibition of the gluteus maximus
* gluteus medius weakness, especially in the posterior fibres.
And this was exactly what I found in Rose’s case.
A shortened hip flexor group can potentially produce an inhibition weakness into the antagonist muscle (glute max) because of the restriction to hip extension caused by the hypertonic psoas. This would in turn create overactivity in the hamstrings and erector spinae, but more importantly the vertical fibres of the adductor magnus would be used during extension of the hip.
The posterior fibres of glute med control external rotation, alongside gluteus maximus. Glute med is part of the lateral oblique sling pattern, and its function is to control pelvic alignment. Because of the weakness of the gluteals, when the patient stands on one leg, the adductor group becomes the dominant control, which causes a subtle adduction and internal rotation of the hip. This in turn causes the adductor group to become hypertonic.
The research teaches us that if we lengthen the antagonist muscle, which is held in a shortened and tight position, then we can have an immediate effect on the tone of the inhibited muscle. However, my experience of real people teaches me that it never seems to be straightforward, especially where patients with longstanding chronic prob- lems are involved.
I lengthened the psoas and rectus femoris using muscle energy techniques (see box, above) but decided to leave the adductor group alone for the time being.
I also gave Rose some glute max re-education exercises to promote the correct firing sequence for hip extension, and some functional exercises for glute med to help control pelvic and hip alignment. She was to do 12 reps of each exercise twice a day, progressing to 15 to 18 reps 3 to 4 times a day, over the next 10 days.
Glute max activation exercises
1. Pelvic tilt (Figure 1, below):Lie supine, feet planted hip width apart and knees bent. Perform a pelvic tilt, with the emphasis on squeezing the glutes to lift the hip into extension. Hold, carefully reverse the move and repeat.
2. Swiss ball squats (Figure 2, below): place a Swiss ball against the wall and lean the lower back against the ball. Squat down, allowing the ball to move up the body. On the upward, concentric phase of the squat, emphasise the squeezing of glute max, giving a subtle pelvic lift at the end of the movement.
Glute med exercises
I always try to be functional (ie, weight bearing) with these, and get clients to learn where the muscle is and how it feels when it is activated.
Sideways step-down (see Figure 3, below): Stand on one leg on the bottom step of a staircase, with the other leg lowered so that the pelvis is visibly tilted lower on that side. Lift the pelvis back into alignment by activating glute med on the weight- bearing leg. For even better performance, slightly externally rotate the weight-bearing leg as you squeeze, to help activate the posterior fibres of the glute med.
At Rose’s follow up appointment, 10 days later, I reassessed her muscle imbalances and was pleasantly surprised to find a major improvement. Her night pain had also reduced, enabling her to sleep better.
Subsequently I was able to ask the receptionist to go out to the running track and run for seven minutes. She was understandably apprehensive but agreed it was necessary in order to assess her progress. After running for seven minutes she was ecstatic, because she had no pain and felt so much stronger that she wanted to carry on.
I advised Rose that she could recommence her runs every other day, starting at seven minutes and adding two minutes at each run to build up gradually. I added some light hand-held weights (starting with 2kg and progressing to 5kg) for the ball-supported squats and asked her to continue the exer- cises daily for another 10 days, after which she could drop back and do them on the rest days between her runs.
Every month, when I go for my regular haircut, I am updated on Rose’s progress. She is now running for 40 minutes and is free of pain. She has rejoined her original running club.
This case study underlines how important it is that sports therapists have a solid understanding of functional (ie, sport- specific) anatomy and how that relates to the presentation of injury. It is not good enough simply to treat the site of pain without considering the source and cause of injury. Only with this deeper understanding is it possible to formulate an effective treatment plan, rather than an ultimately unsatisfactory ‘sticking plaster’ approach.