Physiotherapy with 7 options to stretch hip adductor anterior fibers

Hip adductor strain groin pain in soccer
(Ref: https://www.limpinleapoutphysiotherapy.com.au/blog1/groin-pain-in-soccer-players)

There are several musculoskeletal disorders involve groin pain, for example, osteitis pubis, Insertional adductor and rectus abdominis tendinopathy, Apophyseal avulsion fractures, Femoroacetabular impingement (FAI) syndrome that hip adductors strain is one of the most common injuries in athletes.  

Normally, groin injuries make up 2% – 5% of all sport ‑ induced injuries, of which adductor strain is the usual musculoskeletal etiology of the pain. The most common sports that put athletes at risk for adductor strains are football, soccer, hockey, basketball, tennis, figure skating, baseball, horseback riding, karate, softball, and cricket. 

Hip adductors strain have risk multifactorial; include, different forms of sports, high level of play, age and core stability, previous hip adductor injury, hip adductor - to - abductor strength imbalance, and adductor tightness.

Anterior thigh view with hip adductor are in medial side
(Ref: https://www.britannica.com/science/quadriceps-femoris-muscle)

Hip adductor muscles shortening affected pelvic tilt posture both of anterior - posterior plane and lateral plane. The position is one of lateral pelvic tilt, with the pelvis so high on the side of contracture in standing. Legs alignment would be changed because of this deformity. Tightness  of  secondary hip flexors, such as adductor brevis, gracilis, and anterior fibers of the gluteus minimus,  would, in  theory, contribute to an excessive anterior pelvic tilt and exaggerated lumbar lordosis.

Some hip adductor fibers which arise from the anterior surface of pubic will assist to flex the hip joint. By the way, all of them contract to adduct and internally rotate the hip joint.

7 ways to stretch hip adductors 

Exercise #1: stand hip abduction with lateral pelvic shift stretch: spread both legs 2 - 3 times shoulder wide. Then, tilt up the opposite pelvic side of target leg laterally.

Exercise #2: stand lateral lunge stretch: spread both legs 2 - 3 times shoulder wide. Then, bend supported leg like lateral lunge squat to stretch target leg which is opposite side.

Exercise #3: supine frog stretch: For standard stretching, keep both feet together during stretching. For advance stretching, separate both feet away.

Exercise #4: modified lion stretch: keep both feet together during stretching. Control hips in extension postition, not back extension.

Exercise #5: figure of 4 stretch: for more stretch, we needs move knee close to floor as far as possible.

Exercise #6: Half kneeling lateral shift stretch: it is used for stretching leg which is kneeling.

Exercise #7: stand lateral lunge with hip extension stretch: spread both legs 2 - 3 times shoulder wide with hands are on the wall. Then, target leg turn to toe out. And supported leg step forward to prepare squating. Supported leg squat with shift weight forwatd and laterally for position target leg in hip extension, hip external rotation, hip abduction.

A common mechanism of the injury is sudden change of direction or violent external rotation with abduction at hip joint while the foot is planted on ground with eccentric contraction that my patients and I underwent before. The most common hip adductor strain is hip adductor longus.

Once, I got a hip adductor strain during soccer games. It happened very fast, I stepped my right leg to the ball with poor leg position because of fatigue. Then, I stepped my left leg to the right to keep balance and play on. Suddenly, my torso twisted with a "pop sound" at my left hip. I fell on the ground and was carried afterward. I had stopped all my exercise for 4 months. 

The five primary hip adductors include the pectineus, gracilis, adductor longus, adductor  brevis, and adductor magnus (both anterior and posterior heads). Secondary adductors include the biceps femoris (long head), the gluteus maximus (especially the posterior fibers), quadratus femoris, and obturator externus. 

The muscles testing and function textbook which was written by Kendall, stated primary hip adductors anatomy that: 

The pectineus arise at the surface of superior ramus of the pubis ventral to pecten between ilioppectineal eminence and pubic tubercle, and inserted at pectineal line of femur distally. 

Pectineus muscle
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The adductor magnus derived tendon at inferior pubic rami, ramus of ischium (anterior fiber), and ischial tuberosity (posterior fibers), then had insertion at medial to gluteal tuberosity, middle of linea aspera, medial supracondylar line, and adductor tubercle of medial condyle of femur.

Hip adductor magnus
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The origin of adductor brevis was at the outer surface of inferior ramus of pubis, and had distal attachment at distal two thirds of pectineal line, and proximal half of medial lip of linea aspera.

Hip adductor brevis
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The adductor longus had origin not far from its friends which is the anterior surface of pubis at junction of crest and symphysis, and had insertion at the middle one thirds of medial lip of linea aspera. 

Hip adductor longus
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

         
        The gracilis started at the inferior half of symphysis pubis and medial margin of inferior ramus of pubic bone, then passed on medial side of femur to the medial surface of body of tibia, distal to condyle, proximal to insertion of semitendinosus, and lateral to insertion of sartorius. It is only one muscle which is two joint muscle of hip adductor group.

Gracilis
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

All of the above provide adduct hip joints, majorly. The pectineus, adductor brevis, and adductor longus flex the hip joint. The anterior fibers of the adductor magnus which arise from the rami of the pubis and ischium may assist in flexion, while the posterior fibers that arise from the ischial tuberosity may assist in extension. The gracilis, in addition to adducting the hip joint, flexes and medially rotates the knee joint. In addition to hip adduction, these muscles help stabilize the hip and lower limbs during the standing phase of the gait. Therefore, their function consists of hip adduction, hip flexion, hip internal rotation, and some fibers of them assist hip extension.      

      

           To prevent hip adductor strain needs to strengthen the hip adductor in eccentric function especially in standing or step in, and stretch them with the same as the other muscles: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

https://www.jospt.org/doi/epdf/10.2519/jospt.2010.3025 

https://www.researchgate.net/publication/51823221_A_review_of_the_anatomy_of_the_hip_abductor_muscles_gluteus_medius_gluteus_minimus_and_tensor_fascia_lata 

https://core.ac.uk/download/pdf/270251533.pdf 

https://aassjournal.com/article-1-1057-en.pdf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714133/pdf/10.1177_2325967115625055.pdf 

https://www.researchgate.net/publication/317366152_Assessment_and_management_of_adductor_strain 

My secret of TFL stretching from my physiotherapy experience

       

Tensor fascia lata (TFL) muscle
(Ref: https://learnmuscles.com/glossary/tensor-fasciae-latae-tfl/)

      I have taken care of many patients with ITB syndrome (IT band syndrome) for many years who were soccer players, tennis players, runners, cyclists, triathletes, the most. One of my routine treatments was ITB stretching as Ober’s maneuver that I have felt does not satisfy the outcome.  

Ober's stretch
(Ref: https://www.aafp.org/pubs/afp/issues/2005/0415/p1545.html)

Then, I changed stretching to be another TFL (Tensor fascia lata) stretching because I found some factors from TFL related to ITB tightness which was demonstrated in exercise #5. However, I still have not felt stretched enough. Moreover,  the TFL muscle stretching in standing position is difficult to apply to subjects who have unstable knee joints or have leg pain with the weight bearing.  

Exercise #5: Stand TFL stretching: Step target leg backward, then put it behind the fore - leg. Then rotate the hip external rotation as the toe out. Final, shift pelvic forward like over - pressure hip extension.  

Finally, I would like to present one normal stretching that may stretch TFL directly. Due to, TFL is one joint muscle that passes only the hip joint; additionally, IT band stretching is not the way to release IT band tension. Therefore, I focus on stretching only the TFL at the hip joint by reversing all its muscle action. 

“To perform TFL stretch, the main direction consists of hip extension, hip external rotation and hip adduction.” 

4 options to stretch Tensor fascia lata (TFL) muscle

Exercise #1: Single leg stand TFL stretch

Exercise #2: Half kneeling TFL stretch

Exercise #3: Prone TFL stretch

Exercise #4: Supine TFL stretch

Anatomically, TFL muscle is located on the lateral portion of the femur. TFL merged into the IT band, So do gluteus maximus. The fasciae of these two muscles join the iliotibial band just distal to the greater trochanter forming a triangular ‘‘pelvic deltoid”.

TFL originates from the outer lip of the iliac crest, the anterolateral iliac fossa just below the iliac crest, the deep surface of the fascia lata, the iliac tubercle, the lateral aspect of the anterior superior iliac spine and a notch below the anterior superior iliac spine. TFL attaches to two layers of the IT band of the fascia lata and ends usually around the greater trochanter.

The major muscle action of TFL includes three directions that are hip abduction, hip internal rotation, and hip flexion. By mechanical, the gluteus medius and minimus are at a major disadvantage to act as the primary hip abductors, whereas the tensor fasciae latae is at a major advantage to exert the necessary force to counterbalance the force of weight during the full stance phase of the gait cycle. TFL function depends on the position of the hip. It helps the gluteal abductors prevent the Trendelenburg gait and stance so that we can conclude that it is one of the posture muscles. The anterior fibers flex the hip and the posterior fibers abduct and internally rotate the hip. 

Trendelenburg sign (Ref: https://www.pinterest.com/)

Mechanism of TFL shortening happened after hip abductor fatigue. The TFL muscle was in spasm, it is pulling hard on ITB and developing pain at the insertion point on the outside of the knee. Shortening of the TFL and ITB can pose problems in the behavior of walking and running. Additionally, they often develop clinical symptoms such as the iliotibial band syndrome or the patellofemoral syndrome.

Patellofemoral pain syndrome
(Ref: https://www.enzopierromassagetherapy.it/)

IT band syndrome
(Ref: https://www.kaizo-health.com/)

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

"However, I would like to recommend strengthening exercise for gluteus maximus and gluteus medius. It is very crucial part of treatment and be able to release IT band tension, afterward".

Reference:

https://www.researchgate.net/publication/337228717_Detailed_Morphological_Study_of_Tensor_Fasia_Lata_TFL_and_its_Clinical_Significance 

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.908.4975&rep=rep1&type=pdf 

https://www.researchgate.net/publication/322583917_Morphometric_properties_of_the_tensor_fascia_lata_muscle_in_human_fetuses 

https://www.ijsr.net/archive/v7i10/ART20191686.pdf 

https://www.koreascience.or.kr/article/JAKO202018436566234.pdf 

Physiotherapy with 9 options to stretch quadriceps femoris

 

Quadriceps Femoris strain in soccer players
Ref: https://talksport.com/football/

Quadriceps Femoris (QF) composes the main part of the anterior muscles of the thigh, being a powerful extensor of the leg, considered the most beautiful and largest and most powerful muscle. Its name is derived from Latin, hip  +  caput, or thigh muscle with four heads. 

The quadriceps femoris (QF) is a major extensor of the knee joint that is crucial for human movements. There are sharing working functions in the locomotion, for example, the rectus femoris (RF) swings the leg forward when a step is taken. During walking or running, quadriceps muscles such as the vastus medialis (VM) stabilize the patella and knee joint.  

Quadriceps Femoris anatomy
(Ref: https://www.corewalking.com/rectus-femoris-tendon/)

“Its main functions include knee extension and hip flexion”. 

The QF is important in sport owing to its potential for injury, which can be painful and debilitating. Strains, tears, and contusions are relatively common and require recovery time. I underwent treatment caring for professional soccer players with proximal and distal QF strain or inflammation. In proximal injury cases, I have seen muscle strain at the origin of the tendon of QF. In distal injury cases, I have seen patellar tendonitis and patellofemoral pain. I rarely have seen muscle strain at mid QF muscle in soccer players, but opposite in sprint runners. 

Ball shooting composes hip flexion and knee extension
(Ref: https://scialert.net/fulltext/?doi=jas.2010.1286.1292)

I have used stretching not only physiotherapy treatment and prevention for QF but also hamstring strain prevention. Moreover, it has been applied to my many case e.g. IT band syndrome and low back pain.

9 options to stretch quadriceps femoris

Exercise #1: Half kneeling QF stretching; target leg is rear that need some cushion under it. For more comfortable, put opposite hand on any stable furnitures or wall for balance. During stretching, try to set hip joint to be neutral or extension.

Exercise #2: Stand QF stretch: For more comfortable, put opposite hand on any stable furnitures or wall for balance. During stretching, try to set hip joint to be neutral or extension.

Exercise #3: Chair single kneeling QF stretch: During stretching, try to set hip joint to be neutral or extension.

Exercise #4: Supine with double knees bending QF stretch: You can try to lying on the back if possible.

Exercise #5: Supine with double knees bending QF stretch: You can try to lying on the back if possible.

Exercise #6: Side lying QF stretch: the target leg is above. During stretching, try to set hip joint to be neutral or extension.

Exercise #7: Prone QF stretch

Exercise #8: Side lying QF stretch with cable assisted: During stretching, try to set hip joint to be neutral or extension.

Exercise #9: Prone QF stretch with cable assisted: During stretching, try to set hip joint to be neutral or extension.

The members of quadriceps femoris consists of one rectus plus three vasti that are sum of four; include,

(1) Rectus Femoris (RF)

The RF is a long, fusiform muscle forming the anterior superficial portion of the quadriceps muscle group that originates from the small area of bony pelvis which is the anterior inferior iliac spine (AIIS). The proximal rectus femoris has two tendinous origins: the direct (straight) head, arising from the anterior–inferior iliac spine, and the indirect (reflected) head, arising slightly more inferiorly and posteriorly from the superior acetabular ridge and hip joint capsule.

The Superficial Layer of the Quadriceps Tendon The RF, the most superficial muscle of the quadriceps group, inserts into the anterior portion of the base and the superior third of the anterior surface of the patella

Due to the RF being the most superficial muscle of the QF complex, its insertion is on a layer of the superficial layer of the quadriceps tendon that is attached into the anterior portion of the base and the superior third of the anterior surface of the patella.

Its main functions include knee extension and hip flexion. 

Rectus Femoris muscle anatomy
(Ref: https://pixels.com/)

(2) Vastus Intermedius (VI)

VI typically arose muscularly from the anterior and lateral aspect of the femur without an origin tendon. The VI originates from the upper two-thirds of the anterior and lateral surfaces of the femur and the intermuscular septum and forms the quadriceps tendon. The shape and area of the origin domain of the VI was much more diverse than those of the vastus lateralis and vastus medialis.

Classification of the origin domain of the VI into contacting and non-contacting types on the basis of its positional relationship to the origin domain of vastus lateralis. The origin domain of the contact type attached muscularly to the anterior and lateral surface of the femoral shaft. The muscle belly decreased in thickness from its anterior to its lateral parts. The origin domain of the VI adjoined the longus part of vastus lateralis at the lateral line of linea aspera to form a common origin domain. The muscle belly and origin domain of the non - contacting type were much smaller than the contacting type; they were narrow and almost corresponded to the width of the femoral shaft. The origin domain of the VI attached only to the anterior surface of the femur and did not contact the lateral line of the linea aspera and lay between the origin domains of the VI and VL.

Vastus Intermedius muscle anatomy
(Ref: https://www.getbodysmart.com/leg-muscles/vastus-intermedius-muscle)

Insertion of VI involves insertion of VL, VM, and RF that are located in the deep layer of the quadriceps tendon. The VI has an intimate origin with VL proximally and the lateral intermuscular septum distally. It inserts through a broad, thin tendon into the base of the patella posterior to the VL and VM or merged with them. The VI also may join with the RF to form the suprapatellar tendon, which inserts on the base of the patella. Medially and laterally, this insertion reinforces the patellofemoral ligaments.

(3) Vastus Medialis (VM)

The VM seems to be a complicated muscle which stays at the anterior surface of the femur. It originates on the lower part of the intertrochanteric line, and the upper third of the medial supracondylar line and has attachments to the medial lip of the linea aspera as it wraps around the femur. 

The division of the vastus in two parts, one long and one oblique. VM was identified into the VML and VMO by three features identification; include, fiber angle, the presence or absence of a fascial plane of separation, and the pattern of innervation. The trajectory of the muscle fibers of the vastus medialis split into  3 parts: the first would be  1/3 of the top is composed of parallel fibers that arise vertically from the intertrochanteric line, converging toward the top edge of a muscle aponeurosis found deeply, the second would be  1/3 middle part which is composed of parallel fibers obliquely, running about 15-35° to the longitudinal axis of the femur, arising from the lip of the linea aspera femoris and the medial intermuscular septum inserting the medial margin and the anterior surface of the aponeurosis found and, finally, the third, which would be the bottom 1/3 of the muscle was composed of parallel fibers being in mostly aligned more obliquely to 40-55° to the longitudinal axis of the femur presenting appearance almost horizontal, arising mainly from the adductor magnus tendon and partially on the medial intermuscular septum. The vastus medialis oblique is the distal part having its origin mainly in the adductor magnus tendon and its insertion into the medial margin of the patella.

Vastus Medialis Longus is medial to Vastus Medialis Oblique
(Ref: https://alliedanatomy.com/)

Insertion of VM is in the intermediate layer of the quadriceps tendon. The most inserted fibers of the VM end in an aponeurosis that blends with the medial side of the suprapatellar tendon or the RF tendon. They attach directly to the medial edge of the patella and extend more distally than fibers originating from any other part of the quadriceps group. From the distal edge of the VM, a tendinous expansion passes along the medial side of the patella. Deep fibers of this expansion reinforce the joint capsule as part of the medial patellar retinaculum. 

Vastus medialis longus is responsible for knee extension, whereas the primary function of the vastus medialis oblique (VMO) is medial stabilization of the patellar throughout extension. Medial stabilization is the function of preventing a lateral subluxation of the patella by maintaining the alignment of the patella to slip on the femoral condyles, providing medial force directly to counterbalance the forces directed laterally by the vastus lateralis. Therefore, VMO is considered  an acceptable solution to problems involving the rehabilitation of the stabilization of the patella. 

(4) Vastus Lateralis (VL). 

VL is considered the largest part of the quadriceps femoris to form thick, wide, and fusiform appearance is intimately attached to the vastus intermedius in its middle third.

The origin of the vastus lateralis is on the greater trochanter, lateral lip of linea aspera femoris and the lateral intermuscular septum and its insertion at the base patellar ligament using the patellar and tibial tuberosity.

Vastus lateralis muscle has presented two parts; include, long and oblique parts. The oblique portion arises from the linea aspera of the femur and lateral intermuscular septum, a more fibrous expansion of the iliotibial tract by insertion the tendon itself, which is directed inferior and lateral to the VL over this by joining the superolateral border of the patellar tendon to form a single, often attached to the joint capsule. The distal fibers of the vastus lateralis oblique Were presented in interdigitated lateral retinaculum, which is formed from the expansions of tedious insertions of the VL, inserted in the tibia and patella which, in turn, reinforces the anterolateral region of knee, and iliotibial tract. Morphologically, the vastus lateralis oblique is divided into: a distal surface and a spiral proximal portion with deep longitudinal fibers in the femoral shift below the belly of the VL along, mingling with the vastus intermedius.

Vastus Lateralis muscle anatomy
(Ref: https://learnmuscles.com/glossary/vastus-lateralis/)

The vastus lateralis longus has its origin in the femoral trochanter and lateral lip of linea aspera of the femur, as found in the anatomical literature showing extensive superficial aponeurosis in more than two thirds of the proximal surface and a deep aponeurosis in the distal one thirds separating it from vastus lateralis oblique. Its insertion is on the superolateral border of the patellar ligament by means of union with the tendon of vastus lateralis oblique, forming a single tendon.

The VL muscle consists of three layers: superficial, intermediate, and deep: (i) The superficial part originates from the lateral surface of the greater trochanter. Its fibers arch medially downward to the tendon lamina and then to the QF tendon (ii) The intermediate part originates from the upper level of the greater trochanter’s anterior surface where it joins the intertrochanteric and gluteus medius ridge (iii) The deep part is the one-third proximal to the femur.

Vastus lateralis beneath IT band
(Ref: https://www.shutterstock.com/)

The distal insertion of the VL and VM unite to form a continuous aponeurosis that inserts into the base of the patella, just posterior to the insertion of RF, and also continues laterally and medially to insert into the sides of the patella that happen in the iIntermediate layer of the quadriceps tendon. The VL ends in an aponeurosis that blends with the lateral side of the suprapatellar or RF tendon and sends an expansion distally to the superolateral side of the patella. Other fibers cross superficial to the patella and attach to the medial condyle of the tibia. The lateral expansion of VL then blends with the capsule of the knee, thereby forming part of the lateral patellar retinaculum. 

Conclusion, RF is two joint muscles of hip and knee that responsible for hip flexion with knee extension. Others are one joint muscle of knee that function for knee extension.

In my physiotherapy experience, stretching this muscle was not as easy as many muscles because it did not provide obvious tension. However, the principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hole at the point for 30 seconds of 3 - 5 reputations as demonstrated VIDEO.

 

Reference:

https://www.researchgate.net/publication/307885598_Structural_diversity_of_the_vastus_intermedius_origin_revealed_by_analysis_of_isolated_muscle_specimens 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941577/ 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404765/ 

https://www.hindawi.com/journals/bmri/2022/9569101/ 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2772911/ 

https://www.scielo.br/j/rbme/a/htP9y5rrfQdkGFLDkZPQF6r/?lang=en&format=pdf

http://www.jms.periodikos.com.br/article/587cb49f7f8c9d0d058b47a1/pdf/jms-28-4-587cb49f7f8c9d0d058b47a1.pdf 

https://www.ajronline.org/doi/pdf/10.2214/AJR.07.2947 

https://www.researchgate.net/publication/234012902_Vastus_medialis_a_reappraisal_of_VMO_and_VML