Adductor tendonitis is a clinical syndrome characterized by sharp, constant, and severe pain on adduction of the affected musculotendinous units. Patients suffering from adductor tendonitis will often shift their trunk over the affected lower extremity when walking, adopting a lurch type gait in an effort to reduce the pain. This dysfunctional gait may cause a secondary bursitis and tendonitis around the hip and groin, which may serve to confuse the clinical picture and further increase the patient’s pain and disability. Pain on palpation of the insertions of the adductor tendon is a consistent finding in patients with adductor tendonitis as is exacerbation of pain with active resisted abduction. Patients suffering from adductor tendonitis will also exhibit a positive Waldman knee squeeze test. This test is performed by having the patient sit on the edge of the examination table. The examiner places a tennis ball between the patient’s knees and asks the patient to gently hold it there with gentle pressure from the knees (Fig. 120.1A). The patient is then instructed to quickly squeeze the ball between the knees as hard as possible. Patients suffering from adductor tendonitis will reflexly abduct the affected extremity due to the pain of forced adduction, thereby causing the ball to drop to the floor (see Fig. 120.1B). Untreated, adductor tendonitis will result in increasing pain and functional disability with patients complaining of an inability to get in and out of a car.

Plain radiographs of the hip and pelvis are indicated in all patients who present with pain thought to be secondary to adductor tendonitis (Fig. 120.2). Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging of the pelvis is indicated if occult mass or tumor is suggested as well as to confirm the diagnosis. Radionuclide bone scanning may be useful in ruling out pelvic stress fractures not seen on plain radiographs. Ultrasound-guided injection of adductor tendonitis serves as both a diagnostic and a therapeutic maneuver.

The adductor muscles of the hip include the adductor longus, adductor brevis, and adductor magnus muscles as well as the gracilis, pectineus, and obturator externus muscles (Fig. 120.3). The adductor function of these muscles is innervated by the obturator nerve, which is susceptible to trauma from pelvic fractures and compression by tumor. The tendons of the adductor muscles of the hip have their origin along the pubis and ischial ramus, and it is at this point that tendonitis frequently occurs.

The benefits, risks, and alternative treatments are explained to the patient, and informed consent is obtained. The patient is then placed in the supine position with the patient’s arms crossed over the chest (Fig. 120.4). With the patient in the above position, a high-frequency linear ultrasound transducer is placed in a transverse plane over the pubic prominence, which lies just above the penis in males and the clitoris in females, and an ultrasound survey scan is taken (Figs. 120.5 and 120.6). The bright hyperechoic pubic bodies are identified with the hypoechoic interpubic fibroelastic cartilage in between (Fig. 120.7). The interpubic fibroelastic cartilage is wider anteriorly, narrowing toward the back of the joint space (see Fig. 119.6). It is this asymmetrical shape that gives the joint space and its adjacent pubic bodies their characteristic heart-shaped appearance on transverse ultrasound scan (see Fig. 120.7). After the pubic symphysis is identified, the transversely placed ultrasound transducer is slowly moved laterally following the superior pubic ramus until the insertions of the adductor muscles are identified (Fig. 120.8). When the insertions of the adductor muscles are identified, the skin overlying the area above the ultrasound transducer is prepped with antiseptic solution. A sterile syringe containing 3.0 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 3½-inch, 22-gauge needle using strict aseptic technique. The needle is placed through the skin ˜1 cm above the superior
border of the ultrasound transducer and is then advanced using an out-of-plane approach with the needle trajectory adjusted under real-time ultrasound guidance so that the needle tip rests against the site of tendinous insertion (Fig. 120.9). When the tip of the needle is thought to be in satisfactory position, after careful aspiration, the contents of the syringe are slowly injected. There should be minimal resistance to injection. The patient may note an exacerbation of his or her pain during the injection.