Issue link: https://www.massageandbodyworkdigital.com/i/465652
F r e e m u s i c d o w n l o a d s f o r C e r t i f i e d m e m b e r s : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 91 Distal iliopsoas tendon attaching near the hip. Image is from 3D4Medical's Essential Anatomy 5 application. 2 Iliopsoas tendon During range-of-motion testing, Michael reported pain with active adduction but no pain with passive adduction. There was also groin pain with resisted adduction. This pattern of pain would indicate a primary pathology in one of the contractile tissues (muscle or tendon) that produces adduction, so a proximal adductor injury is the most likely cause of his problem. Refl ecting on his initial history, Michael reported a mild aching sensation in this area prior to the ski accident, so it is quite possible he had a moderate muscle/ tendon dysfunction or minor strain prior to the fall. Prior existing injury in the muscle/tendon unit is the most common characteristic leading to muscle strain. Because the proximal tendons of the adductor group are so close together, it can be diffi cult to isolate the specifi c muscle injured. There may also be more than one muscle involved. Consequently, treatment should address all the muscles in the medial thigh region. Palpating superfi cial tissues in the upper medial thigh reproduces Michael's pain, and the pain pattern is reproduced with range-of-motion testing. This scenario validates the likelihood of upper adductor muscle pathology. However, he also reports pain that feels related to, but deeper than, the adductor pathology. Additional examination is needed to explore the cause of this secondary pain. During physical evaluation, Michael reported the secondary pain as feeling closer to his hip than the groin area, but also deeper as well. He was unable to press on anything that reproduced this pain, so a superfi cial tissue is likely not the cause. The pain is reproduced with active hip fl exion from a standing position. Passive hip fl exion did not cause discomfort, but resisted hip fl exion did. Again, this is the same pattern present with the adductor muscles (pain with active and resisted movement in the same direction, but not with passive movement in that direction) and would indicate pathology in a contractile tissue (muscle or tendon). The most likely culprit in this secondary pain is the distal tendon of the iliopsoas muscle, which is the strongest hip fl exor. Image 2 shows the location of the distal iliopsoas tendon. Recalling Michael's initial history, he mentioned that his leg was pulled back (extension) and away (abduction) when the branch caught his leg. The forceful abduction put a high eccentric load on the adductors and the forceful extension put a high eccentric load on the hip fl exors, both likely leading to musculotendinous injury. TREATMENT STRATEGY It appeared that the primary issues for Michael involved muscle/tendon pathology (likely a strain injury) to one or more of the proximal adductor muscles, and also to the distal iliopsoas muscle. Treatment would therefore focus primarily on these areas, although other areas such as the anterior and posterior thigh region, gluteal region, and low back should also be addressed because of their close biomechanical relationships. Treating these other regions helps maintain biomechanical balance and proper muscle pattern coordination. The fi rst treatment goal in any soft-tissue injury is to normalize the soft-tissue dysfunction. In a muscle strain, this means reducing tightness in the injured muscle and working on the injury site to help encourage the development of a functional scar. Michael's ski accident was over a week old when he came in for treatment, so it was not in the acute phase. He still had signifi cant movement capability and the pain during range-of-motion testing was at a level indicating the strain was not severe. Consequently, massage therapy would be safe and appropriate. The entire adductor muscle group of the medial thigh should be treated, because there is frequently hypertonicity in a muscle group as a result of strain injury. Reducing tightness throughout the muscle group also helps restore proper biomechanical balance and encourages faster healing of the injury. Earn FREE CE credit for this article!