Athletes Treating Athletes

This is part seven in our self muscle massage series. In the introduction to this series we introduced and demonstrated the three techniques that will be used in this post. If you would like to review them, click here. If you would like to see any other parts of the series, click here.

In the next part of our series, we’re going to be talking about the inside of the thigh. This area is home to your adductor muscles and includes the gracilis and the adductor trio (more specifically the adductor magnus, longus, and brevis muscles). Together these muscles work primarily to pull the leg in towards the midline of the body. Their secondary function is to rotate or roll the thigh/leg in towards the body (aka internal rotation). Lastly and most important of all, they assist in extending the hip which is key during endurance sports. Due to their multiple functions and location, this area is a common source of both acute and overuse injuries- the most popular of which is the groin strain/sprain or tear.

Potential causes of injury:

1) On a muscular level, tension is increased in the adductor muscles any time that the knee is pulled in towards the mid-line of the body. This can happen in the presence of weak outer hip muscles (gluteus medius and minimus). If the glutes are unable to hold the pelvis level, the adductors will remain in their shortened position and can develop contractures (chronic shortening of the muscle fibers). This can lead to muscle breakdown and a repetitive overuse injury or an acute “groin” injury in which the muscle is unable to respond to a rapid lengthening movement (aka a sprint, jump, or sudden side-to-side movement). The adductor muscles are also prone to injury due to their role in hip extension. If an athlete is unable to push off normally through the toes and knee, the hamstrings and adductors must work harder to assist with propulsion.

2) On a structural level (meaning bones and joints), the entire leg can be pulled in towards mid-line when there is over-pronation at the foot and ankle (aka the foot is allowed to roll in and flatten out the arch). If this occurs, the adductor muscles are kept in their shortened position. Over time, the outer hip muscles will be unable to compensate and the adductors will develop contractures.

Anatomy:

Landmarks

#1 Upper insertion point (on the pubic bone):

The first key landmark you will need to know when working on the adductors is their upper insertion point on the pubic bone. To do so, start by locating your ASIS (the front part of your hip bone). If you recall from the earlier posts on the hip, start with your lands flat on the top of your hip bones. Then follow them forward towards your stomach. Where they flatten out and end are the ASIS. From here, the rest is easy. Follow the groin line (the crease between hip and thigh) down and towards your pubic bone. As you do so, move your leg in and out from mid-line. You will feel the large common tendon as you move your leg in. On the picture above, the purple X represents the pubic bone and the common adductor insertion point.

#2 Femoral Triangle:

The second key landmark you will need to know when working on the adductor muscles is the femoral triangle. This will help you locate the Adductor Longus (AL) muscle which is the most frequently injured of this muscle group. The triangle is starts at the ASIS and sartorious insertion, runs down the groin line to the pubic bone, and follows the AL in to where it crosses paths with the sartorious muscle. To find the triangle, start at the ASIS and work your way down towards the pubic bone. At the pubic bone, locate the common tendon and follow the upper most muscle in and towards the upper part of the thigh until it meets the quad muscle. Then trace from the ASIS down and you will have your triangle. Note: the triangle is small. If you find yourself halfway down the thigh, you missed it. The outer part of the triangle (the sartorious) is unimportant when working on this muscle group. The primary goal is to locate the AL muscle and trace it all the way to the overlying quad muscles. From there you can use the AL to move up and down through the remaining adductor muscles (the brevis is located above and inside the triangle and the magnus is located below and outside of the triangle).

#3 lower insertion points @ the knee (adductor tubercle + pes anserine):

The last key land marks that you will need to know when working on the adductors are the lower insertion points. The first is the adductor tubercle. This bony landmark is located on the lower femur and lies deep to and between the quad and hamstring muscles. While specifically locating it is not necessary, it is important to note that the adductor trio all insert into the lower femur. It is also important to note that one of the adductor muscles actually crosses the knee joint which brings us to the second landmark, known as the pes anserine. Due to it’s importance in stabilizing the inner knee, we are going to focus on this landmark versus the deeper adductor tubercle. The pes anserine involves three separate muscles that cross the inner knee joint to insert on the tibia (lower leg bone). They are the sartorious (blue line), gracilis (red line) and the semitendinosus (purple line and part of the inner hamstring muscles). This is a common area for inflammation and tendonitis. It is also easy to palpate and find. See the video below for more detailed instructions on how to differentiate between the three tendons.

Muscles

#1 Gracilis.

Of all the inner thigh muscles, the gracilis is the easiest to find. Start at the common tendon insertion at the pubic bone. Unlike the other adductor muscles which work their way in towards the femur (long thigh bone), the gracilis remains on the outside and works it’s way straight down towards the knee and it’s insertion into the pes anserine. It is a very common area for soft tissue adhesions and tension due to it’s role in stabilizing the knee joint. It is also a key area to work on due to it’s overlapping with the deeper adductors and hamstrings.

#2 Adductor Longus (AL).

This muscle is the most commonly affected in sprains/strains or “groin pulls”. To find this muscle start by finding the common origin at the pubic bone. There are two major muscle paths originating from it. The gracilis muscle will move down towards the knee while the second muscle, the AL, will move in towards the quad and femur.

#3 Adductor Brevis (AB).

This is the smallest and uppermost adductor muscle. It is located just above the AL and inside the femoral triangle.

#4 Adductor Magnus (AM).

This muscle is deep to it’s surrounding muscles. To specifically find it, you will need to find the gracilis first and then the hamstrings beneath it. To differentiate between the two, start with your fingers on the gracilis and bend/straighten your knee. You will be able to feel the hamstring contracting as you do so. From there you want to sneak your fingers in between the gracilis and hamstring muscle. Deep to the bone and between them is the AM muscle.

Soft Tissue Release

What you’ll need: stick/foam roller and tennis ball

The techniques:
1) Lengthening/elongation with the foam roller or stick.
2) Cross friction with your hand or tennis ball.
3) Sustained pressure or trigger point release with the tennis ball.

Key Areas to work on:

1) Common insertion point on pubic bone-

This area, while hard to work on, is important to think about, especially in the presence of acute sprain/strain symptoms. It will be difficult to work on with the foam roller and tennis ball due to it’s location and the surrounding bones/muscles. Cross friction using your hands will be the best technique for helping to improve soft tissue mobility and decrease tenderness over the area. Start as close to the bone as you can and work your way down the thigh. This will allow you to work on the common tendon, as well as, the muscle-tendon junction. Depending on your flexibility, you can use the tennis ball to work on the back side of this insertion point using the trigger point technique. Start in a long sit position with both knees straight in front of you. Then slide forward and spread your legs out into a V-position (maintain straight knees). Find your sit bone and position the tennis ball just below and inside of it. Then lean forward to try and touch the toes of that leg. As stated earlier, it’s a tough area to get to so you may not feel much when doing this technique depending on your flexibility. If you’re having nagging troubles near the upper insertion, you can always schedule some time with your favorite sports massage therapist or bodywork specialist.

2) Hamstring/Adductor Intersection-

This intersection is important to note because it is a common source of muscle tension and overuse injury due to the muscles role in hip extension. To find this area, start halfway between the knee and upper adductor insertion point. Palpate the rope like gracilis muscle. Then bend/straighten your knee. Directly beneath it, you will feel the hamstring muscle moving (especially as you bend your knee). This is the area you are looking for. The best way to work on it is to use the foam roller first and then move onto the deeper techniques of cross friction and trigger point (sustained pressure).

3) Common insertion point on the knee (pes anserine)-

This area should be a key area to work on regardless of symptoms. The pes anserine is home to three muscles that help stabilize the inner knee joint. Together they form a common tendon that inserts into the lower leg bone (tibia). Foam roll/stick the area first to loosen up the muscles and to decrease tenderness over the area. Cross friction with your hand works best, although, you will be able to use the tennis ball. Position the ball on the back and inside of the knee where the three tendons join together to wrap around the front. From here you will be be able to perform both the cross friction and trigger point techniques. Be careful! This area is usually very sensitive. When using the foam roller/stick, be sure to try and work deeper into the inside of the knee just above the joint line. This will allow you to work on the deeper adductor muscles where they insert onto the adductor tubercle.

Video

Here is a video demonstration of the techniques.

References:
1) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
2) Moore, Keith and Dalley, Arthur. (1999). Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, MD.