yogabook / pathologie / gracilis syndrome

gracilis syndrome (adductor syndrome, footballer’s groin, sportsman’s groin, pubalgia)

Definition of

Gracilis syndrome is an insertional tendinopathy, an overuse syndrome of the lower branch of the pubic bone, sometimes accompanied by aseptic bone necrosis of the osseous intertion area, the ostitis pubis. It must not be confused with pes anserinus syndrome, which can also affect the gracilis, but at its distal insertion. Gracilis syndrome often occurs in soccer players as overuse syndrome. The muscles most commonly affected are the adductor longus, adductor magnus, adductor brevis and gracilis.

General information on disorders of the adductor muscles

Adductors can also be affected by strains and muscle fibre tears, partial ruptures occur primarily in the musculotendinous junction, but insertion stenopathies at the pubic arch in the sense of an athlete’s ridge or footballer’s ridge are also not uncommon. Disorders are divided into acute injuries and overuse-related chronic phenomena. Some sports, such as football, but also handball and ice hockey, use the adductors intensively and extensively as the leading thigh and hip flexors. Many of the disorders are caused by repeated use of high muscle performance of the adductor muscles. Imbalances between adductors and abductors predispose to disorders. It is known from ice hockey that the risk of a strain of the adductors is 17 times higher than normal if the force of the adductors falls below 80% of the force of the abductors. Sudden gross overstretching leads to muscle strains and muscle fibre tears. The stop and go is a predisposing factor here. Due to the reduced elasticity of the scar tissue, unhealed or poorly healed disorders predispose to recurrences. Fatigue in the muscular and neuromuscular sense during intensive training and competition as well as a lack of recovery also predisposes to disorders. The athlete’s ridge or footballer’s ridge particularly affects the origin of the
adductor longus. In Finnish professional ice hockey, strains of the adductor longus account for 43% of all muscle injuries, in Sweden 10% of all injuries. Symptomatically, strains are characterised by increasing muscle tone and acute, knife-like pain in the adductor muscles. The intensity of the symptoms depends on the extent of the injury. The muscle fibre tear, on the other hand, is felt as stinging and tearing, it then shows a pressive pain and pain on adduction against resistance. Eventually a haematoma forms. The pain of the footballer’s groin or athlete’s groin is rather dull in nature and close to the symphysis, it is particularly prominent at the beginning of the strain, rest pain is also possible. When palpating muscle injuries, the muscles should be palpated in a relaxed and tense state, in their direction and transversely. Sonography is very suitable for an initial assessment, as it also depicts dynamic movements well. An MRI, which would also show comorbidities and co-factors, would then provide more precise information. For the classification of muscle injuries, see the Munich Consensus Statement, which not only classifies but also provides a therapeutic direction. After the initial
PECH, conservative treatment is given. An avulsion, on the other hand, must be treated surgically. Conservative treatment is physical and physiotherapeutic, but can also include tapes and infiltration therapy. Finally, exercise therapy is essential. In the event of surgical treatment, the leg may only be loaded with 20 to 30 kg for three weeks; active adductions must be avoided. From the third week onwards, training with the bicycle ergonometer is started. The previously permitted 40° to 60° flexion of the hip joint is increased to 90°. The first stretching exercises begin 6 weeks after the operation, running training after 12 weeks. Return to play takes four to five months. If tenotomies of the adductor longus have to be performed, which is quite rare, the resilience in sport is reduced to around two thirds. Acute tendon ruptures, which are also very rare, are also treated surgically. If conservative treatment is possible, the original performance capacity is achieved earlier, namely after around half the time, than in the case of surgical treatment. According to a study by Müller-Wohlfahrt, tears of the adductor longus tendon area can be restored to the original level on average after just under 89 days without any evidence of functional deficits. In handball, the lateral movement of the body is even more important than in football, which is why a reduction in strength of the adductors by a third results in a significant drop in performance. The treatment therefore also depends on the requirements, not just on the entity.

Cause

1. Overuse
2. Traumatic: movement with extreme passive or active eccentric contraction „overstretching“
3. Stress fracture of the pubic bone
4. Bone inflammation of the pubic bone

Predisposing

– Behavior

1. Sports with pronounced stance/playing leg sequences
2. Sports with forced abductionand adduction movements
3. Sports with rapid changes of running direction or contact with opponents such as soccer (also due to kicking technique)
4. Sports with fast acceleration and deceleration
5. Asymmetrical loads such as when hurdling
6. Endurance running
7. All sports that have a muscular effect on the shaving area

– Musculoskeletal system

1. Static incorrect loads such as those caused by leg length discrepancies
2. muscular imbalances
3. shortened adductors, weak adductors
4. Diseases and malpositions of the hip joint

– General factors

1. M > W

Diagnosis

1. Medical history
2. Physical examination(lateral comparison!): Pain on stretching, pain on pressure at the affected origin, pain on straining against resistance
3. MRI shows intraosseous signal enhancement of the parasymphyseal bone marrow

Symptoms

1. Painful pressure in the insertion area
2. slight pain on movement
3. marked pain on exertion, radiating along the course of the gracilis
4. Painful stretching
5. Often, but not necessarily bilateral infestation
6. usually longer existing, gradual onset of symptoms before diagnosis
7. Quick stimulation div after a training break
8. dominance of pain alternating between the sides
9. Starting pain that subsides with normal walking
10. Triggered by jerky movements and changes in direction

Complications

1. Delayed healing due to the difficulty of completely immobilizing the area.
2. Formation of abnormal scar tissue
3. Bone resorption
4. Cysts
5. Stress fracture

Therapy

1. Rest, including a break from sport, followed by a careful return to sport
2. Therapy of risk factors
3. PT
4. NSAIDS
5. Neural therapy
6. Local injections of corticosteroids and local anesthetics
7. If conservative treatment is unsuccessful, symphyseal curettage with removal of the inflammatory tissue

DD

1. Osteomyelitis close to the symphysis, for example after UGT infection or surgery
2. Necrosis of the femoral head
3. Koxitis
4. Nerve bottleneck syndromes
5. Other referred pain
6. Inguinal hernias
7. Athlete’s hernia or „soft groin“
8. Osteomyelitis
9. Strains of the adductors or groin strains
10. SI joint blocks

Asana practice and movement therapy

Since this is an insertion tendinopathy of the adductors, whether of the gracilis or other adductors, good stretching of the adductors must be ensured. The typical pain should be avoided as far as possible. It is also good to stretch the adductors in all rotational situations and at different flexion angles of the hip joint. In addition to stretching, the resilience of the muscles should be increased; all strengthening exercises that are not jerky or jerky, but rather sustained(isometric) or performed calmly and dynamically, are helpful here. Again, the typical pain should not be triggered. As with stretching, various rotation situations and flexion anglesshould also be practiced here.

If the gracilis is to be stretched, a more or less extended knee joint is required. However, it cannot be strengthened in isolation, as other adductor muscles are always involved. However, the degree of flexion in the knee joint changes the length of the sarcomere in which the gracilis works.

In principle, all standing postures that involve moving or holding the adductor group in all possible sarcomere areas are indicated here. However, postures other than standing postures can also have a strengthening effect on the adductors, e.g. the lower leg in jathara parivartanasana is held in position by the adductors. Another example is maricyasana 1, in which the upright leg stabilizes the position of the pelvis and presses against the arm from behind.

It is well known that every muscle must be considered with its group of antagonists. However, the abductors should not play a significant role here, because on the one hand, apart from garudasana, there are hardly any adductions in everyday life or in yoga that are so pronounced that a reduced flexibility of the abductors could cause damage to the adductors or be involved in its development.

Since the adductors, even if they are not counted among the classic hip flexors, do have a hip flexing effect, the extension ability of the hip joint should also be tested and improved if necessary, all the more so as this direction of movement occurs very little in everyday life. In the case of gracilis, because of its knee-bending effect, hip extensions can be practiced with the legs extended or stretched wide, such as urdhva dhanurasana, in addition to the known highly effective exercises.

Because of the hip flexion effect of the adductors, the strength for hip flexions should also be practiced. Even though the hip flexors will certainly provide most of the strength there, depending on the construction of the postures, the feet can be pressed towards each other so that the adductors have to work for two directions of movement. This can be practiced in jathara parivartanasana as well as in tolasana or supta dandasana and similar postures.

Asanas

1. Asanas in 751: Stretching the adductors
2. Asanas in 752: Strengthening the adductors
3. Asanas in 756: Stretching the gracilis
4. Asanas in 757: Strengthening the gracilis
5. Asanas in 711: Stretching the hip flexors
6. Asanas in 816: Stretching the rectus femoris
7. Asanas in 711: Stretching the hip flexors
8. Asanas in 712: Strengthening the hip flexors