proximal adductor avulsion

Surgical anatomy. This phenomenon occurs when there is a UCL tear that results in entrapment of the adductor pollicis aponeurosis within the UCL. - adductor mechanism: - adductor pollicis has superficial insertion into the the extensor mechanism of the thumb (which cover the dorsal capsule and ulnar collateral ligament), and a deep insertion into the proximal phalanx; 2. proximal and superficial to the proximal edge of the intact adductor aponeurosis. The musculoskeletal radiology team initially interpreted the MRI as a soft tissue proximal hamstring avulsion. Adductor longus is the most commonly injured adductor muscle;… The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. The presence and quality of the greater trochanter or proximal bone. Background: The adductor magnus (AM) has historically been a potential source of confusion in patients with suspected proximal hamstring avulsion injuries. 1-4 However, the sciatic nerve can be difficult to identify and mobilize intraoperatively, placing the nerve at risk of iatrogenic injury at the time of repair. The superficial insertion of the adductor mechanism is the extensor expansion via the adductor aponeurosis; the deep insertion extends to the palmar aspect of the proximal phalanx via the ulnar sesamoid of the metacarpophalangeal joint. proximal adductor longus tendon - avulsion - groin injury - suture anchor repair Literatur 1 Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. a displaced avulsion fracture; the presence of a Stener lesion (interposition of the adductor pollicis muscle and adductor aponeurosis between the torn end of the UCL and the base of the proximal phalanx) 3. A common scenario is the patient with severe adverse local soft-tissue reaction due to metal ions with muscle necrosis. 3 The tendinous attachments of the hamstrings include the semimembranosus and the conjoined tendon of the semitendinosus and biceps femoris. • Hip Flexor and Adductor Injuries ‒Typically Acute Event ‒Gymnastics or Martial Arts on occasion ‒Soccer Athletes ‒Typically treated conservatively ‒Rare need to fix large displaced rectus avulsion Hip Flexors and Adductors • Acute injuries typically resolve with appropriate non-surgical care ‒Rest, Therapy, Rehab, slow RTP program This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Deepak Patkar. 4,10 Active contraction of the adductor at the time of injury has been implicated in the pathogenesis of this injury. Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes. It is related to chronic traction stress of the adductor muscles at their insertion site along the posterior margin of the proximal and mid-femoral diaphysis, and it can get complicated by stress fracture. Am J Sports Med. The adductor magnus (AM) has historically been a potential source of confusion in patients with suspected proximal hamstring avulsion injuries. Injury Mechanism: A valgus stress to the 1 st metatarsal phalangeal joint resulting in the stretching force to the ulnar collateral ligament of the joint. b. Vertical head – ischial tuberosity. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. When lying in a supine position he was unable to perform a straight leg raise. Stress fractures involving the posteromedial aspect of the femoral diaphysis are less common than tibial and proximal femoral stress fractures and are thought to be on the continuum of osseous fatigue-/stress-related injuries. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. proximal insertion in 26%, the musculotendinous junction in 37%, and the distal insertion in 37%.6 Of those injuries that occurred at the proximal insertion, 75% were complete avulsion injuries.6 Partial and distal avulsions of the adductor longus have been shown to … Significant ecchymosis and a palpable defect may be present at the medial aspect of the ischial tuberosity. Another specific, albeit much less common, type of osseous fatigue injury is the adductor insertion avulsion syndrome, also known as "thigh splints." The adductor longus seems to be the most commonly injured muscle but other adductors such as adductor brevis, pectineus, and gracilis may be injured [56-58]. Shilpa Sankhe. Stener 6 has reported 7 such cases and feels that displacement proximal to the adductor aponeurosis can be suggested on radiographic evidence alone. Gamradt SC, Brophy RH, Barnes R, Warren RF, Thomas Byrd JW, Kelly BT. 3 Avulsion fracture sustained by a 45-year-old man. Moderate osteitis pubis with an associated chronic partial avulsion of the left common adductor-rectus Fig. Anatomy of the Adductor Magnus Origin: Implications for Proximal Hamstring Injuries. The most frequent site of injury is at the attachment of the ligament to the proximal phalanx bone, and a bony avulsion occurs in approximately 50% of injuries . The pectineus muscle continues downward and in a posterolateral direction (behind and to the side) and inserts into the pectineal line of the femur(thigh bone). Purpose: To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique. In the thumb however, the avulsed fragment may displace dorsal to the adductor aponeurosis. •Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football. The junction between the tendons of the hamstrings and the ischial tuberosity is the area affected by high hamstring tendinopathy. Proximal Adductor Avulsions. In 25% of complete UCL ruptures, an avulsion fracture is evident at the base of the proximal phalanx of the thumb (25%) . a. Oblique head – inferior ramus of pubis & ischial ramus. Proximal adductor avulsion injuries occur in the athletic male population. Diagnosis is made clinically with groin pain with tenderness over the inferior pubic rami and decreased strength with resisted leg adduction compared to the other leg. Acute avulsion of the proximal fibrocartilaginous origin of the adductor longus (AL) is an injury mostly occurring in individuals that perform cutting and rapid lateral movements such as in hockey, soccer, and rugby. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Serner A, Weir A, Tol JL, et al. A3 – Avulsion fracture to include the distal insertion of the ulnar collateral ligament (UCL) involving the base of the medial proximal phalanx. There was tenderness on palpation in the proximal adductor region without any obvious swelling. Arch Orthop Trauma Surg 2007; 127:613. This fragment may be a small fleck or may be of substantial size. firmed acute avulsion of the left adductor longus from the pubic origin, with 4 cm of distal retraction and mild surround-ing hematoma. dductor insertion avulsion syn-drome, or thigh splints, is a stress-related avulsion injury of the adductor muscles that occurs at the medial aspect of the proximal or mid-femoral shaft. than tibial and proximal femoral stress fractures and are thought to be on the continuum of osseous fatigue-/stress-related injuries. Sona Pungavkar. 1. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance at a mean of 4.8 months, with a low risk of complications. A1 – Skiing. When this occurs a large amount of bleeding ... (such as a hip adductor … Study Design: Descriptive laboratory study. Descriptive laboratory study. Pain typically localises to the proximal adductor longus insertion and is provoked by shooting, passing, running, and ‘cutting’ (a rapid change in direction when running). An adductor strain is a common injury to the adductor muscle group that occurs as a result of forceful hip extension & external rotation of an abducted leg. The purpose of this study was to investigate the detailed anatomy of the entheses and proximal musculotendinous junctions (MTJs) of adductor longus (AL), adductor brevis (AB) and gracilis. Gamekeeper's thumb (also known as skier's thumb or UCL tear) is a type of injury to the ulnar collateral ligament (UCL) of the thumb.The UCL may be merely stretched, or it may be torn from its insertion site into the proximal phalanx of the thumb; in approximately 90% of cases part of the bone is actually avulsed from (sheared away from) the joint. Cacchio A, Borra F, Severini G, Foglia A, Musarra F, Taddio N, et al. To investigate the anatomic characteristics of the AM, including its osseous origin, anatomic dimensions, and relationship to the proximal hamstring tendons. The adductor longus arises from the anterior pubic body below the pubic crest via a consistently seen tendon and a deeper, more variable muscular attachment 7 (4a,5a). To our knowledge a complete osseous avulsion of the adductor sleeve has not been described previously. 5, 6 The degree of anatomic distortion derived from the injury is highly variable. The adductor insertion avulsion syndrome, also called “thigh splints,” is usually considered a sports injury, causing thigh and groin pain. Note the difference in origin of the 2 components of the adductor magnus muscle and the medial location compared with the semimembranosus and conjoint tendons. Figure 2 – Adductor muscle insertion onto D1 Proximal phalanx that can obstruct proximal portion of UCL ligament . A–C, Proximal‐to‐distal axial US scans (left), as described in the US anatomy part of the article, with MRI comparison (right); amt indicates adductor magnus tendon; ct, conjoint tendon; gm, gluteus maximus; it, ischial tuberosity; smt, semimembranosus tendon; sn, sciatic nerve; and st, semitendinosus muscle. History and etymology Adductor Strain. We report the first case of an acute adductor longus avulsion injury which was surgically repaired in a professional equestrian rider. Return to full preinjury function was achieved at 3 months with surgical repair using 3 suture anchors. 1. Introduction b. Vertical head – adductor tubercle of femur. The MCP joint was stable on valgus stress testing. Using our previously described anterior pubic symphyseal portal and an anteromedial adductor portal, initial … Less commonly, the athlete who suffers a sudden apophyseal separation or avulsion may present with acute or acute-on-chronic symptoms. Further imaging obtained following surgical consultation revealed a partial We believe that surgical repair using mitek suture anchors is an option worth considering especially in active individuals. is type of injury can take a lengthy time to recover if managed conservatively. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport. The patient may report an acute onset of pain or tearing sensation in the proximal posterior thigh. Surgical repair of proximal hamstring avulsion is associated with good outcomes. Significant ecchymosis and a palpable defect may be present at the medial aspect of the ischial tuberosity. Adductor insertion avulsion syndrome, or “thigh splints,” is a cause of thigh and groin pain in athletes related to chronic traction stress of the adductor muscles at their insertion site along the posterior margin of the proximal and mid femoral diaphysis (25,26). Also found was a par-tial tear of the left adductor brevis and mild strain of the left pectineus (FIGURE 1). While stress injuries in general are a common occurrence in athletes, adductor insertion avulsion syndrome (AIAS) is Purpose: To investigate the anatomic characteristics of the AM, including its osseous origin, anatomic dimensions, and relationship to the proximal hamstring tendons. Six types of PLAC injuries patterns were identified. Patient-reported outcomes offer an objective measure of hip function and pain control. Also found was a par-tial tear of the left adductor brevis and mild strain of the left pectineus (FIGURE 1). After immobiliza-tion for 4 weeks, the thumb was painless and stable. Orthopaedic journal of sports medicine. than tibial and proximal femoral stress fractures and are thought to be on the continuum of osseous fatigue-/stress-related injuries. However, in some cases, due to overexertion, you might end up suffering from hip adductor tendinopathy. “Thigh splints,” also known as the adductor insertion avulsion syndrome, is a painful condition affecting the proximal to mid femur at the insertion of the adductor muscles of the thigh. The return to competition period may take 6-9 months post- surgery and will involve high levels strength work and structured return and return to training programs. 2016;4(1):2325967115625055. In the pelvis, avulsion injuries primarily occur at six sites (, Fig 1).The ischial tuberosity is the most common site. A case of traumatic hallux varus due to avulsion fracture of the lateral side of the base of proximal phalanx was reported. Lateral illustration of the ischial tuberosity demonstrates the relationship of the hamstring tendon and adductor magnus footprints. A 31-year-old male athlete with adductor longus (AL) proximal tendon avulsion and detachment of the rectus abdominis-adductor longus (RA-AL) aponeurosis. However, in more serious cases of adductor injury, surgery can be considered. Dr. Bharam and his team, using minimally invasive techniques, have done groundbreaking work to repair separations of adductor muscles. Conflict of Interests Findings An AP x-ray image conducted at the time of injury shows evidence of a lesser trochanter avulsion fracture. The pectineus originates from the pectineal line of the pubic bone, which is also known as the pectin pubis. Avulsion fractures of the ulnar corner of the proximal phalangeal base of the thumb are treated in a fashion similar to the other proximal phalanges. Proximal avulsion injuries of the adductor longus have been managed both conservatively and operatively with good clinical outcomes, but there is … A2 – Skier’s thumb. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes Knee Surg Sports Traumatol Arthrosc . Indications. History and etymology Another stress-related injury in the femoral region is the adductor insertion avulsion syndrome, also known as “thigh splints” [1, 2]. This syndrome is thought to represent an avulsive injury of the proximal femoral shaft related to one or more of the adductor muscles that insert in this region. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Background: The adductor magnus (AM) has historically been a potential source of confusion in patients with suspected proximal hamstring avulsion injuries. The fibers of the proximal tendon of the adductor longus blend with fibers from the rectus abdominis tendon, a common aponeurosis that covers the anterior aspect of the symphysis pubis and the capsule and disc of the symphysis pubis.The distal attachment of the adductor longus is on the linea aspera of the femur. However, no consensus exists on which option yields the best results, as most study are based on small patient cohorts. Subsequently, the ligament may remain in situ, or the proximal segment may retract proximal to the adductor aponeurosis with continued abduction of the thumb. Case study. a rare injury, particularly avulsion injures at the pubic bone. Occasionally, radiographs will show an avulsion fracture from the ulnar aspect of the base of the proximal phalanx . bony avulsion of the base of the proximal pha-lanx. This may occur in patients with either trochanteric avulsion fracture or complete avulsion of the abductor mechanism from the bone. Optimal treatment of complete grade 3 tears of the adductor longus tendon from the pubic body has support for both nonsurgical management and surgical reattachment. The pectineus muscle is a hip Shilpa Sankhe. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%). Presentation of a patient with proximal adductor magnus avulsion mimics that of a patient with a proximal hamstring avulsion. It was successfully managed by minimally invasive extensor hallucis brevis tenodesis. The majority (up to 87%) of complete ruptures of UCL present a Stener lesion, that is, interposition of the adductor pollicis aponeurosis between the injured ends of … proximal insertion in 26%, the musculotendinous junction in 37%, and the distal insertion in 37%.6 Of those injuries that occurred at the proximal insertion, 75% were complete avulsion injuries.6 Partial and distal avulsions of the adductor longus have been shown to … Case study. Right,Division of the adductor aponeurosis is required for repair of the ligament. The patient may report an acute onset of pain or tearing sensation in the From the Steadman Hawkins CliniceDenver (R.J.M., M.R., J.G. Australasian Radiology, 2007. ), Green- a. Oblique head – gluteal tuberosity, linea aspera and proximal supracondylar line of femur. Objective The adductor muscles are implicated in the pathogenesis of groin strain, but the proximal morphology of this muscle group is poorly defined. Especially in competitive athletes, recent trends have advocated for surgical repair of these acute injuries. On release of Proximal rupture of the adductor longus tendon is a rare injury, particularly avulsion injures at the pubic bone. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. 2009 Jul;37(7):1370-4 •Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Avulsion injuries most commonly involve the entire proximal hamstring complex, but can occasionally be limited to either the semimembranosus or common biceps femoris-semitendinosus tendon. 2020 Aug 6. doi: 10.1007/s00167-020-06180-5. The muscles contain a higher proportion of type 2 muscle fibres than the other muscles of the lower extremity; suggesting high intrinsic force generation. The ischial tuberosity is the site of origin of the hamstring muscles and adductor magnus (Figure 2) and represents the most common location for avulsion injuries in the pelvis. The adductor longus seems to be the most commonly injured muscle but other adductors such as adductor brevis, pectineus, and gracilis may be injured [56-58]. Adductor insertion avulsion syndrome with stress fracture of femoral shaft: MRI findings. The adductor longus lies posterior and medial to the pectineus muscle and is the most anterior of the adductor muscles. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Proximal Hamstring Injury PELVIC INJURIES. • Hip Flexor and Adductor Injuries ‒Typically Acute Event ‒Gymnastics or Martial Arts on occasion ‒Soccer Athletes ‒Typically treated conservatively ‒Rare need to fix large displaced rectus avulsion Hip Flexors and Adductors • Acute injuries typically resolve with appropriate non-surgical care ‒Rest, Therapy, Rehab, slow RTP program proximal adductor magnus avulsion. An intact adductor magnus may mask a complete avulsion of the hamstring tendons on MRI evaluation as it appears to be an “intact but attenuated semimembranosus tendon.” The authors state an intact adductor magnus may result in a misdiagnosis of patients as having only a partial tear rather than a complete avulsion injury. firmed acute avulsion of the left adductor longus from the pubic origin, with 4 cm of distal retraction and mild surround-ing hematoma. “Thigh splints,” also known as the adductor insertion avulsion syndrome, is a painful condition affecting the proximal to mid femur at the insertion of the adductor muscles of the thigh. Scintigraphic findings in this syndrome have been described; we report However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair. At the proximal insertion 12 of 16 injuries were complete avulsions. Injury to the UCL, most often at its distal portion,4,14,15 may result in a sprain or full-thickness tear of the ligament. M. Lawande. To our knowledge a complete osseous avulsion of the adductor sleeve has not been described previously. The patient may report an acute onset of pain or tearing sensation in the proximal posterior thigh. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 13, 43, 59 Chronic groin injuries, often falling under the athletic pubalgia spectrum, have been reported to be more common. Magnetic resonance imaging Introduction Adductor insertion avulsion syndrome, or “thigh splints”, is a painful condition affecting the insertion of the ad-ductor muscles of the thigh from the proximal to the mid-femoral level. This has been described as an entity called adductor insertion avulsion syndrome, or thigh splints. Hamstring avulsion injuries in athletes is a rare but debilitating condition that usually takes a surgical intervention. ( a ) Coronal and ( b ) sagittal short tau inversion recovery MRI show avulsion of the proximal tendon of the left AL with an osseous defect at the left pubic tubercle ( red arrow ). If you perform an exercise incorrectly or abruptly, it can cause you to suffer a hip adductor tendinopathy, as indicated in the article Proximal hamstring tendon avulsion: surgical treatment in high-performance athletes. Figure 1. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. Six types of PLAC injuries patterns were identified. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%). Pain typically localises to the proximal adductor longus insertion and is provoked by shooting, passing, running, and ‘cutting’ (a rapid change in direction when running). Complete osseous avulsion of the adductor longus muscle: acute repair with three fiberwire suture anchors. This masterclass will provide you with a complete understanding of the anatomy, pathology and presentation of proximal … Less commonly, the athlete who suffers a sudden apophyseal separation or avulsion may present with acute or acute-on-chronic symptoms. at the proximal musculotendon junction.13 Proximal ... rehabilitation.1, 8 Much less common, but most often much more severe, are the hamstring injuries involving complete avulsion of the hamstring complex off the ischial tuberosity. Avulsion of the attachment of the ulnar collateral ligament to the base of the proximal phalanx of the thumb (Stener’s lesion, gamekeeper’s thumb, or skier’s thumb). Proximal hamstring tendinopathy and avulsion injuries - assessment & treatment with Benoy Mathew Proximal hamstring tendinopathy is common in runners and athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. The adductor mechanism maintains dual insertions. Presentation of a patient with proximal adductor magnus avulsion mimics that of a patient with a proximal hamstring avulsion. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. Associations Between Initial Clinical Examination and Imaging Findings and Return-to-Sport in Male Athletes With Acute Adductor Injuries: A Prospective Cohort Study. However, in some cases, due to overexertion, you might end up suffering from hip adductor tendinopathy. Adductor Tendon Injury Sara N. Raiser, MD Daniel C. Herman, MD, PhD, FAAPMR, FACSM, CAQSM BASICS DESCRIPTION Medial thigh/groin pain and weakness resulting from injury to muscle May be acute or chronic The hip adductors include adductor longus, magnus, and brevis; gracilis; obturator externus; and pectineus. Proximal avulsion injuries of the adductor longus have been managed both conservatively and operatively with good clinical outcomes. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion. H ip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. If you perform an exercise incorrectly or abruptly, it can cause you to suffer a hip adductor tendinopathy, as indicated in the article Proximal hamstring tendon avulsion: surgical treatment in high-performance athletes. Attachments of Adductor Magnus: Origin and Insertion. A significant improvement in PRO scores was experienced. Purpose: To investigate the anatomic characteristics of the AM, including its osseous origin, anatomic dimensions, and relationship to the proximal hamstring tendons.

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