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 

Physiotherapy with 5 options of the sartorius stretching exercise which we always neglect.

Ref: https://www.yoganatomy.com/sartorius-muscle/

 

The incidence of upper thigh injuries include the adductor (23%), hamstring (12– 37%) or quadriceps (19%), whilst  sartorius muscle injuries occur in 31–46%. The pathogenesis of muscle injuries is divided into extrinsic and intrinsic injuries. 

Intrinsic injuries are caused by contraction or elongation of the muscle that mainly involve type II muscle fibers which rapidly contract. It extends between two joints, contracts eccentrically and has a fusiform muscle fiber arrangement, leading to destruction of the internal muscle fiber. There are 3 grade injuries categories based on the extent of the lesion: grade I involves a few muscle fibers within a bundle; grade 2 involves up to three/fourths of the affected muscle portion; and grade 3 involves more than three/fourths, and the lesion may then involve the entire muscle belly.

Extrinsic injuries include factors such as contusions and penetrating wounds that can involve all types of muscle fibers.

5 options of the sartorius stretching exercise

Exercise #1: Sartorius stand wall stretch: Hands are on the wall for maintain balance. Step target leg backward, then adduct as behind front leg, then medial rotation as toe in, then move pelvic forward.

Exercise #2: Sartorius stand leg curl stretch: Bend target knee with hand support, then situate target shin laterally, then extend hip joint without arch lower back.

Exercise #3: Sartorius semi side lying stretch: Lying on the side to the opposite side of the target leg that makes the target leg is behind. Target leg was pushed by hand forward. Then rotate the torso to mid line again. 

Exercise #4: Sartorius side lying stretch: Shin should be lateral to thigh in the end of pose setting.

Exercise #5: Sartorius supine stretch: For beginners, you should supine on the elbow. For advances, you can lie on the back. 

I hardly have seen patients with sartorius injury. Most of my rare cases always complained e.g. proximal anteromedial tibia pain which was pes anserine, VMO pain, fore - thigh pain, proximal lateral groin pain, MCL pain. I had to evaluate carefully to clear the root curse and site of injury. 

One sample case, He was overlapped by one soccer player on the leg  while his knee was bending. He went to see a doctor and he was diagnosed with a knee tendon or ligament injury. A few days later, he came and saw me at physio clinic for more investigation and needed some advice. After subjective examination and physical evaluation, they indicated sartorius tendon more than MCL. To answer the question was how long should he rest? I investigated him by sonography, then the injured site demonstrated grade I. So, we can say his injury was the result of an extrinsic factor.

One author found that injuries of the sartorius muscle most often occur in the area of proximal and distal attachment. At the proximal part, common activity of the sartorius muscle and TFL can cause ASIS avulsion that may be observed. At distal insertion, frequently repetitive movements leading to micro injuries and tissue loads in this area are met. In the result of this, inflammations of bursa anserina, tendon strains and rupture may take place in what was pes anserinus. Such injuries happen to: i.a. athletes, runners, jumpers and football players.

Pes anserine bursitis site
(Ref: http://therundoctor.com/pes-anserine-bursitis/)

The sartorius muscle is the longest muscle in humans. Its name derives from a Latin word “sartor” that did mean “a tailor”. 

The sartorius muscle is situated superficially, moreover, it is distinguished by an original shape and a course. It has got a transverse section in the shape of a triangle with the base upturned. The proximal tendon of the sartorius arises from the anterior superior iliac spine. The muscle belly is like an S-shaped running obliquely across the upper anterior third of the thigh in an inferomedial direction and tape twists around the anterior to the medial surface of the thigh. The belly of the sartorius constitutes the anterior wall of the adductor canal. Then the belly turns slantwise forward at the medial epicondyle of femur which together with quadriceps — its medial head — serves as a “trochlea” for the sartorius muscle. Its distal insertion onto the anteromedial proximal tibia as a flat divergent tendon creating in its further section superficial part of the pes anserinus. 

Sartorius muscle
(Ref: https://www.pinterest.com/)

The sartorius muscle is a biarticular muscle or two joint muscles. It is the only muscle of the thigh which bends both hip joint and knee joint. The sartorius is mainly a flexor of the hip  with the accessory function of lateral rotation and abduction of the hip as well as flexion and medial rotation of the knee. So, there are 4 directions of muscle activity including hip flexion, hip abduction, hip lateral rotation, and tibia medial rotation with knee flexion which action is like a cross single leg chair sitting. 

Ref: https://quizlet.com/

Moreover, it has worked as a hip and knee flexor starter that initializes the movement of flexion in both joints from the phase of full extension. Although the sartorius muscle is a weak external rotator and a weak abductor of the hip joint, it plays an important part in stabilization of the pelvis, especially in women. 

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/266027219_Anatomy_of_sartorius_muscle 

https://theultrasoundjournal.springeropen.com/track/pdf/10.1186/s13089-019-0132-9.pdf 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf 

Physiotherapy with 6 tips to stretch iliopsoas muscle

Ref: https://www.rowperfect.co.uk/

     

        Hip flexion or anterior hip bending was caused by hip flexor muscles contraction. A group of hip flexor muscles consist of iliopsoas, sartorius, tensor fascia lata, and rectus femoris which work as prime - mover, and, pectineus, adductor longus, adductor brevis, and the most anterior fibers of the adductor magnus and the gluteus (medius and minimus) which work as accessory muscle. 

My experience in the physiotherapy clinic, I have seen tightness in some or all of the hip flexor muscles in patients with IT band syndrome, groin pain, and low back pain. One muscle which differs from others is “iliopsoas” because its origins connect to the spine. 

“To stretch the tightness of iliopsoas is used in my physiotherapy session to improve the symptoms often.” 

6 options to stretch iliopsoas muscle

Exercise #1: Standard half kneeling stretch where the target muscle is on the rear leg. The pose need keep back straight with shift pelvic in front that no need to arch the back.

Exercise #2: Supine leg off the side bed

Exercise #3: Basic Thomas stretch that the target muscle is straight leg

Exercise #4: Advance Thomas stretch that the target muscle is off bed

Exercise #5: Upward - Facing dog pose. The pose need elevation of pelvic.

Exercise #6: Chair stand posterior pelvic tilt

    The iliopsoas is the most powerful of the hip flexors. The function of iliopsoas such as sit up, elevate leg, leg swing during walking, control sitting balance, and control lordotic curve of lumbar spine. 

Ref: https://womencycles.com/blog/

  

    Iliopsoas is a compound muscle which consists of the psoas major and iliacus. The psoas major is placed lateral to the vertebral column. It corresponding intervertebral discs of the last thoracic and all the lumbar vertebrae that originates at  the 12th thoracic vertebrae until to the vertebral body of the lateral surface of the 5th lumbar vertebrae and extends to the transverse process of the lumbar vertebrae 1st to 5th, and, the superior two-thirds of the bony iliac fossa and the iliolumbar and ventral sacroiliac ligaments. It goes down and palpable just deep to the inguinal ligament, where it lies bordered by the sartorius muscle laterally and the femoral artery medially, and, finally attaches to the femur lesser trochanter and the linea aspera medial. 

Ref: https://www.optimaphysio.com/

The iliacus has several points of origin; it starts with the iliac crest, anterior inferior iliac spine, iliolumbar ligament, and anterior sacroiliac ligament. And eventually attaches to femur lesser trochanter and linea aspera medial that seem to be the same tendon of psoas major. 

Ref: https://www.osteopathyny.com/

While sitting or standing, the iliopsoas is constantly active and plays an important role in stabilizing the pelvis and lumbar region along with the erector spinae and quadratus lumborum. Hence shortening or straining of the iliopsoas can cause excessive pelvic anterior tilt or increased spine extension during hip joint motion, thereby acting as a risk factor for low back pain. A shortening of the iliopsoas muscle can result in anterior pelvic tilt and trunk extension. Finally, it is leading to low back pain.

Ref: https://www.pinterest.com/

            Shortening of the iliopsoas muscle was found to be the primary cause of lumbar hyperlordosis and excessive anterior pelvic tilt. This abnormal alignment may inhibit the function of the Transversus Abdominis (TrA). Back muscle guarding from lumbar hyperlordosis resulted from the shortening of the iliopsoas muscle. This is impaired circulation by muscle guarding, leading to increased pain (pain-spasm-pain model). 

Back pain and improved excessive lumbar lordosis angle can be reduced by lengthening the iliopsoas muscle and increasing TrA activation capacity.

The principle of muscle stretching is simple: 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 in one muscle as demonstrated VIDEO. 

Reference: 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf 

https://www.jptrs.org/journal/view.html?doi=10.14474/ptrs.2021.10.2.225 

https://www.thaiscience.info/journals/Article/JMAT/10971199.pdf

To release IT band syndrome by 5 ways foam roll massage

     

Ref: https://www.runwell.net.au/blog/

        Foam roll massage and tennis ball massage is a popular technique of muscle - fascia tension release for prevent and treatment benefits. It is applied to many parts of the body and musculoskeletal impairments including the IT band syndrome. 

In my physiotherapy clinic experience with IT band syndrome patients, I have used this technique many times that roll on the IT band directly as the standard management. The outcomes demonstrated both effectiveness and ineffectiveness. Finally, I found a way to massage with the foam that I always recommend to patients who are with IT band syndrome. 

Ref: https://physioworks.com.au/pain-injury/knee-pain/itb-friction-syndrome/

I have seen muscle spasm not only at mid IT band but also above knee cap, rear hip joint, calf muscles. 

5 ways to do roll massage in IT band syndrome

Exercise #1: IT band: lying on the side to roll.

Exercise #2: Gluteus maximus: it is necessary to bend hip joint with half - prone in front.

Exercise #3: Tensor Fascia Lata: prone on the ball to roll.

Exercise #4: Biceps femoris: lying on the side with half - supine.

Exercise #5: Vastus lateralis: lying on the side with half - prone.

I would like to introduce all muscles anatomy  which I have recommended to do foam roll; include,

    (1) The IT band

    IT band is a strong thick wide tendinous band located on the lateral thigh. IT band origin is insertion attachment of gluteus maximus (Gmax) and Tensor Fascia Latae (TFL) that extend their part into the IT band directly. The mass of the IT band descended along the lateral thigh to the knee joint that covers the vastus lateralis muscle. The IT band has 2 primary attachments, including the lateral epicondyle and the Gerdy tubercle. 

Ref: https://www.mygcphysio.com.au/

The first iliotibial band attachment is into the distal femur at the upper edge of the lateral epicondyle. The histologic makeup is consistent with tendon and has a layer of adipose tissue underneath the iliotibial band attachment area. The adipose tissue contains pacinian corpuscles, is highly vascular, and may be “the site of the inflammation” that causes pain during compression.

The second attachment of the iliotibial band is the insertion into the Gerdy tubercle of the tibia and serves as a ligament in structure and function. The Gerdy tubercle attachment is tensed during tibia internal rotation as the knee flexes during the weight-acceptance phase of gait. Internal tibial rotation explains the occasional connection between toeing in and iliotibial band “strain”

Moreover, there are many distal attachments that span out to the lateral border of the patella (by way of epicondylopatellar ligament and patellar retinaculum), patellar tendon, lateral patellar retinaculum before its insertion on Gerdy’s tubercle of the tibia, the biceps femoris, and vastus lateralis. 

About this muscle, I have seen trigger points at mid IT band and 2 - 5 cm. above knee joint the most. 

(2) Gluteus maximus (Gmax)

We can see Gmax at the rear hip which is the biggest muscle that is why origin attachment of Gmax covered large area; include, posterior ilium, posterior layer of thoracolumbar fascia, posterior superior iliac spine (PSIS), posterior gluteal line, posteroinferior sacrum, coccyx, sacrotuberous ligament, and over on gluteal fascia. It is used for support and bumpers while sitting in our daily lives. Gmax has two distinct portions that consist of inserts into the IT band and the inferior portion inserts into the femur. The Gmax pulls posteriorly on the IT band and femur to extend the hip.    

According to its insertion, there is thickening and stiff soft tissue behind the greater trochanter. 

     (3)Tensor Fascia Lata (TFL)

Origin of TFL started on anterolateral of an iliac crest that is approximately 15 - 76 millimeters wide. TFL has many origin attachments; include, the lateral aspect of the anterior superior iliac spine (ASIS). The iliac tubercle, a notch located below the superior spine of the ilium, the anterolateral iliac fossa that is slightly below the crest, and the deep surface of the fascia lata of the thigh. 

Insertion of TFL has been recorded in many locations. There are disputes , for example, on greater trochanter or around there, to the middle layer of the IT band. So, It is not clear whether such tendinous tissue belongs to the fascia lata, or is the muscle’s own tendon. However, the TFL pulls anterosuperiorly on the ITB to flex the hip generally.

I have found tightness, stiffness, and trigger points on this muscle often that related IT band tension progressively.  

Ref: https://www.pinterest.com/pin/

   

(4) Biceps femoris

Biceps femoris is a member of the hamstring muscle which is located on the lateral side of the posterior thigh. They consist of long head and short head that short head originated medial to the linea aspera of the distal femur and descended distally and laterally. 

The first component of the short head was a proximal muscular attachment to the anterior and medial side of the tendon of the long head. Other significant insertions included an attachment of the capsular arm to the posterolateral joint capsule,  the attachment of the capsuloosseous layer to the iliotibial tract (biceps-capsuloosseous iliotibial tract confluens),  a lateral aponeurosis, two tendinous attachments-the direct arm,  the anterior arm, and capsular attachment in the interval between the tendon of the lateral head of the gastrocnemius. Perhaps, insertion anatomy caused patients with IT band syndrome to feel tense calf muscle. 

My own opinion, it is not clear between biceps femoris tightness or posterior fiber of IT band stiffness. 

Ref: https://anatomy.app/encyclopedia/biceps-femoris

     

(5) Vastus lateralis (VL)

VL is a member of quadriceps composed structurally of four distinct muscles; include, the rectus femoris, vastus lateralis, vastus medialis and vastus intermedius. The vastus lateralis 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 patella 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 inserting the tendon itself, which is directed inferior and lateral to the vastus lateralis muscle over this by joining the superolateral border of the patella 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 tendinous insertions of the vastus lateralis muscle, 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 shaft below the belly of the vastus lateralis muscle along, mingling with the vastus intermedius. 

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  1/3 separating it from the vastus lateralis obliquus.  Its insertion is on the superolateral border of the patella by the patellar ligament by means of union with the tendon of vastus lateralis oblique, forming a single tendon. 

Therefore, the extensive lateral oblique is clouded by the IT band giving rise to the lateral retinaculum and completely covering the vastus lateralis oblique.

Bridging kneeout to strength glut
(Ref: https://www.skimble.com/)

Finally, I would like to recommend you to make rolling massage combine strengthening glut muscles that is very important and stretching that follow on https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-6-optionals-tfl-itb.html 

Reference: 

https://www.researchgate.net/publication/51211560_Iliotibial_Band_Syndrome_Soft_Tissue_and_Biomechanical_Factors_in_Evaluation_and_Treatment/link/59dce6f8458515e59df9eeca/download 

https://link.springer.com/content/pdf/10.1007/s40279-021-01634-3.pdf 

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.researchgate.net/publication/14561312_The_Biceps_Femoris_Muscle_Complex_at_the_Knee/link/5421e5de0cf2a39f4af766e9/download 

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