Adductor Tendon Injection for Adductor Tendonitis

Indications and Clinical Considerations

The musculotendinous unit of the hip joint responsible for hip adduction is susceptible to developing tendinitis from overuse or trauma from stretch injuries. Inciting factors may include the vigorous use of exercise equipment for lower extremity strengthening and acute stretching of the musculotendinous units as a result of sports injuries. The pain of adductor tendinitis is sharp, constant, and severe, with sleep disturbance often reported. The patient may attempt to splint the inflamed tendons by adopting an adductor lurch type of gait (i.e., shifting the trunk of the body over the affected extremity when walking).

On physical examination, the patient will report pain on palpation of the origins of the adductor tendons. Active resisted adduction and passive abduction reproduce the pain. Patients with adductor tendinitis will also exhibit a positive Waldman knee squeeze test, which is performed by having the patient sit on the edge of the examination table. The examiner places a tennis ball between the patient’s knees and asks the patient to hold it there with gentle pressure from the knees ( Fig. 124.1A ). The patient is then instructed to quickly squeeze the ball between the knees as hard as possible. Patients with adductor tendinitis will reflexively abduct the affected extremity because of the pain of forced adduction, causing the ball to drop to the floor ( Fig. 124.1B ). Tendinitis of the musculotendinous unit of the hip frequently coexists with bursitis of the associated bursae of the hip joint, creating additional pain and functional disability.

FIG. 124.1, A and B, Waldman knee squeeze test for adductor tendinitis.

In addition to the previously mentioned pain, patients with adductor tendinitis often experience a gradual decrease in functional ability with decreasing hip range of motion, making simple, everyday tasks such as getting in or out of a car quite difficult. With continued disuse, muscle wasting may occur and an adhesive capsulitis of the hip may develop.

Plain radiographs are indicated for all patients with hip pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance and ultrasound imaging of the hip and pubis symphysis are indicated if tendinitis, aseptic necrosis of the hip, tear of the adductor muscles, or occult mass is suspected ( Figs. 124.2, 124.3, 124.4, and 124.5 ). The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

FIG. 124.2, A, Coronal fat-saturated T2-weighted magnetic resonance (MR) image. Bilateral severe adductor longus origin tendinosis (arrows) . B, Coronal fat-saturated T2-weighted MR image. Bilateral secondary clefts extending from the pubic symphysis into the adductor attachments, indicating some disruption of the prepubic aponeurotic complex tissue (curved arrows) . C, Axial fat-saturated T2-weighted MR image demonstrating bilateral adductor longus tendinosis (arrows) . D, Three-dimensional axial fat-saturated T2-weighted MR image. Small tear of the left adductor longus tendon (arrow) . E, Sagittal fat-saturated T2-weighted MR image. Small tears of the origin of the left adductor longus tendon (arrow) . F, Sagittal fat-saturated T2-weighted MR image. This image demonstrates more severe adductor longus tendinosis that involves the prepubic aponeurotic complex (curved arrow) .

FIG. 124.3, A T1 coronal magnetic resonance sequence (A) and axial short tau inversion recovery magnetic resonance sequence (B) show a chronically retracted adductor longus muscle belly (black arrow) at the proximal medial right thigh with abrupt termination evidenced by lack of continuation on the short tau inversion recovery image (white arrow) . C, A T1 axial MR sequence shows only thin disorganized strands of T1 hypointense scar along the course of the adductor longus muscle to the femoral attachment (arrow) .

FIG. 124.4, Longitudinal ultrasound image demonstrating a tear of the adductor muscles. Note the fatty infiltration.

FIG. 124.5, Transverse ultrasound image demonstrating an acute tear of the adductor muscles. Note the hematoma surrounding the tear.

Clinically Relevant Anatomy

The adductor muscles of the hip include the gracilis, adductor longus, adductor brevis, and adductor magnus muscles ( Fig. 124.6 ). The adductor function of these muscles is innervated by the obturator nerve, which is susceptible to trauma from pelvic fractures and compression by tumor. The tendons of the adductor muscles of the hip have their origin along the pubis and ischial ramus, and it is at this point that tendinitis frequently occurs ( Figs. 124.7 and 127.8 ; also see Fig. 124.5 ).