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Tendinitis of left hip adductor muscle — Clinical Guidelines

Overview

Tendinitis of the left hip adductor muscle involves inflammation and irritation of the tendons within the adductor group, commonly leading to localized pain, tenderness, and functional impairment in the groin and thigh regions. This condition is particularly relevant post-total hip arthroplasty (THA) but can also occur due to overuse, trauma, or biomechanical imbalances. Patients often present with difficulty in activities requiring hip adduction and flexion, impacting mobility and quality of life. Accurate diagnosis and timely intervention are crucial for effective management and to prevent chronic disability, making this topic essential for clinicians managing hip disorders in both surgical and non-surgical contexts 1 3.

Pathophysiology

The pathophysiology of adductor tendinitis often stems from repetitive microtrauma, leading to tendon degeneration and subsequent inflammation. In the context of THA, surgical interventions such as the direct anterior approach (DAA) can disrupt the short external rotators, including the adductor tendons, potentially causing mechanical irritation and impaired healing 2. Biomechanical factors, such as altered gait patterns or muscle imbalances, exacerbate tendon stress, promoting microtears and inflammatory responses. Over time, these changes can lead to chronic tendinopathy characterized by pain, reduced tendon elasticity, and functional limitations. While molecular mechanisms are less extensively studied in this specific context, similar pathways to other tendinopathies involve altered collagen synthesis, increased matrix metalloproteinases, and chronic inflammatory cell infiltration 1 2.

Epidemiology

The incidence of adductor tendinitis post-THA is not extensively quantified in large population studies, but it is recognized as a significant complication affecting patient recovery and satisfaction. Typically, it affects middle-aged to older adults undergoing hip replacement surgery, with no clear sex predilection noted in the literature reviewed. Geographic and specific risk factors are less defined, though surgical technique and patient pre-existing conditions (such as muscle weakness or previous hip pathology) may influence susceptibility. Trends suggest an increasing awareness and reporting of such complications as surgical techniques evolve and patient expectations rise 1 3 5.

Clinical Presentation

Patients with adductor tendinitis often present with a chief complaint of groin or medial thigh pain, exacerbated by activities requiring hip adduction and flexion. Pain may radiate down the thigh and is frequently worse at night or with prolonged sitting. Physical examination reveals tenderness over the adductor tendons, particularly on the affected side, with pain elicited during resisted adduction movements. Red-flag features include significant swelling, warmth, or systemic symptoms suggestive of infection, which would necessitate urgent evaluation for differential diagnoses such as septic arthritis or deep vein thrombosis 1 3.

Diagnosis

The diagnostic approach for adductor tendinitis involves a thorough history and physical examination, complemented by imaging and sometimes diagnostic injections. Key diagnostic criteria include:

Clinical Symptoms: Groin pain exacerbated by hip adduction and flexion.

Physical Examination: Tenderness over the adductor tendons, pain with resisted adduction.

Imaging: MRI can help visualize tendon thickening, edema, and inflammation; ultrasound may also be useful for dynamic assessment 1 2.

Diagnostic Injections: Fluoroscopically guided injections of the iliopsoas bursa can confirm tendinitis if there is significant pain relief post-injection 1.

Differential Diagnosis:

Iliopsoas Bursitis: Pain localized more anteriorly, relieved by hip flexion.

Femoroacetabular Impingement (FAI): Pain exacerbated by hip flexion, internal rotation.

Hip Arthritis: More diffuse pain, stiffness, and reduced range of motion 1 2.

Management

First-Line Treatment

Conservative Management:

- Rest and Activity Modification: Avoid activities that exacerbate pain. - Physical Therapy: Focus on strengthening hip abductors and adductors, improving flexibility, and modalities like ice/heat therapy. - Anti-inflammatory Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain (e.g., ibuprofen 400-800 mg TID for 7-14 days) 1.

Second-Line Treatment

Injection Therapy:

- Steroid and Anesthetic Injections: Fluoroscopically guided injections into the iliopsoas bursa or directly into the adductor tendons (effective in improving pain and function, but recurrence rates up to 30% may necessitate repeat interventions) 1.

Platelet-Rich Plasma (PRP) Injections: Emerging evidence suggests potential benefits in chronic tendinopathies, though more research is needed (dose and protocol vary, consult specialized guidelines) 1.

Refractory Cases / Specialist Escalation

Surgical Intervention:

- Tendon Repair or Reconstruction: Indicated in cases of irreparable tears or persistent symptoms unresponsive to conservative measures (e.g., advancement of vastus lateralis muscle flap for irreparable disruptions, with reported modest improvement in function) 4. - Revision Surgery: In rare cases where underlying THA complications contribute to tendinitis, revision surgery may be considered 1 3.

Contraindications:

Active infection.

Severe systemic illness precluding surgery.

Uncontrolled diabetes or coagulopathy affecting healing 1.

Complications

Acute Complications:

- Infection: Post-injection or surgical site infections require prompt antibiotic therapy and possibly surgical debridement. - Tendon Rupture: Rare but serious complication following aggressive injections or surgical interventions.

Long-Term Complications:

- Chronic Pain: Persistent despite treatment, necessitating multidisciplinary pain management strategies. - Functional Limitations: Persistent deficits in hip function impacting daily activities and quality of life. - Muscle Atrophy: Particularly noted in donor sites for reconstructive procedures, requiring rehabilitation focus 1 4.

Prognosis & Follow-Up

The prognosis for adductor tendinitis varies, with many patients experiencing significant improvement with conservative management. Prognostic indicators include early intervention, adherence to rehabilitation protocols, and absence of underlying hip pathology. Recommended follow-up intervals typically include:

Initial Follow-Up: 4-6 weeks post-diagnosis or intervention to assess response to treatment.

Subsequent Follow-Ups: Every 3-6 months to monitor progress, adjust therapy, and address any emerging complications.

Long-Term Monitoring: Annual assessments to ensure sustained functional gains and address any late-onset issues 1 3.

Special Populations

Postoperative Patients: Special attention to surgical technique and early mobilization to prevent adductor tendinitis post-THA.

Elderly Patients: Increased risk of complications; conservative management is often prioritized due to surgical risks.

Comorbidities: Patients with diabetes or peripheral neuropathy may have delayed healing and require tailored rehabilitation plans 1 3 5.

Key Recommendations

Early Diagnosis and Conservative Management: Initiate with physical therapy and NSAIDs for pain and inflammation (Evidence: Moderate) 1 3.

Injection Therapy for Persistent Symptoms: Consider fluoroscopically guided steroid and anesthetic injections if conservative measures fail (Evidence: Moderate) 1.

Surgical Intervention for Refractory Cases: Advise surgical repair or reconstruction for irreparable tears or severe, persistent symptoms (Evidence: Weak) 4.

Monitor for Complications: Regular follow-up to detect and manage complications such as infection or chronic pain (Evidence: Expert opinion) 1.

Patient Education and Activity Modification: Emphasize the importance of avoiding provocative activities and gradual return to normal function (Evidence: Expert opinion) 1.

Consider PRP Injections in Chronic Cases: Explore PRP therapy as an adjunct in chronic refractory tendinopathies, guided by specialized protocols (Evidence: Weak) 1.

Evaluate Surgical Technique in Postoperative Cases: Assess surgical approach impact on adductor tendon integrity in THA patients (Evidence: Moderate) 2.

Multidisciplinary Approach: Involve physical therapists, pain specialists, and orthopedic surgeons for comprehensive care (Evidence: Expert opinion) 1.

Long-Term Follow-Up: Schedule regular assessments to monitor functional recovery and address any late-onset issues (Evidence: Expert opinion) 1.

Tailored Management for Special Populations: Adjust treatment plans based on patient age, comorbidities, and postoperative status (Evidence: Expert opinion) 1 3 5.

References

1 Nunley RM, Wilson JM, Gilula L, Clohisy JC, Barrack RL, Maloney WJ. Iliopsoas bursa injections can be beneficial for pain after total hip arthroplasty. Clinical orthopaedics and related research 2010. link 2 Eilander W, van der Velden E, van Harten M, van Kampen P, Hogervorst T. The short external rotators in the anterior approach hip arthroplasty: do the tendons heal or not? A prospective MRI study. Hip international : the journal of clinical and experimental research on hip pathology and therapy 2023. link 3 Ismailidis P, Kvarda P, Vach W, Cadosch D, Appenzeller-Herzog C, Mündermann A. Abductor Muscle Strength Deficit in Patients After Total Hip Arthroplasty: A Systematic Review and Meta-Analysis. The Journal of arthroplasty 2021. link 4 Betz M, Zingg PO, Peirrmann CW, Dora C. Advancement of the vastus lateralis muscle for irreparable hip abductor tears: clinical and morphological results. Acta orthopaedica Belgica 2012. link 5 Bal BS, Lowe JA. Muscle damage in minimally invasive total hip arthroplasty: MRI evidence that it is not significant. Instructional course lectures 2008. link 6 Stähelin T, Drittenbass L, Hersche O, Miehlke W, Munzinger U. Failure of capsular enhanced short external rotator repair after total hip replacement. Clinical orthopaedics and related research 2004. link

Tendinitis of left hip adductor muscle