What is a strain?

A strain results from a pull or overuse of a muscle and entails some level of damage to the fibers of the muscle itself or to the tendon that attaches the muscle to bone.  A Grade I strain, such as the one Pettitte’s MRI confirmed, is the least involved, and implies only mild disruption of the tissue.  In a Grade II injury, some of the fibers of the muscle or musculo-tendinous unit have been torn.  The most severe strain, a Grade III, is actually a complete rupture of the structure.

What are some of the signs and symptoms of a strain?

The first and most noticeable issue, of course, is pain.   The injured area also becomes inflamed, with the signs of inflammation being swelling, redness of the skin and warmth to touch.  Bruising may follow as the internal bleed of the muscle (in grades II and III strains) becomes more superficial.  Not only is there likely to be pain with use of the involved muscle, but pain may be present at rest as well.  A consequence of this swelling and pain is the inhibition of the muscle, resulting in weakness.

What muscles are involved in a groin strain?

The most commonly implicated muscles are the adductors, which is a group of four muscles comprising the inner thigh.  These muscles are the primary movers of the hip into adduction, or toward the midline, thus bringing one thigh in toward the other.  To help you remember that this is the action of the ADDuctors, it might help to know that the ABDuctors are those hip muscles that move the thigh away from midline.  Think ABDuct, to take away (from your other leg) versus ADDuct, to add to…

Note that issues with the abdominal wall, at the attachment of the abdominals to the pubic bone, may also be involved in a groin strain.  The adductor muscles are not the only ones that may be at fault.  I have alluded to this type of injury in a prior post and will dedicate a future column to this fairly common athletic injury, known as a sports hernia.

Andy Pettitte’s issue however, was reportedly one that is exclusive to the adductors.
The four adductor muscles are:

1. Adductor Brevis:  The word “brevis” implies that this muscle is shorter than its counterpart (longus).  In addition to adducting the thigh, this muscle laterally (outwardly) rotates the thigh as it adducts.  Its less significant role is to assists with flexing the hip.

2. Adductor Longus:  This is the longer muscle, and it originates at a different region of the pubic bone than does Brevis.  It functions in much the same way however.  Longus inserts further down the femur than Brevis, with both attaching to a ridge on the back region of the bone.

3. Adductor Magnus:  Magnus, as the root word implies, is the largest or broadest adductor muscle.  It originates both at the pubic bone and the lower portion of the pelvic girdle in front as well as at the sit bone (ischial tuberosity) in back.  It has a broad area of attachment at its distal (far) end, extending as far as the very end of the femur, just above the medial (inner) aspect of the knee joint.

In addition to this muscle acting to adduct the hip/thigh, its front (anterior) fibers assist in flexing the hip while the rear fibers assist in extending the hip.  Like Adductor Brevis and Longus, Adductor Magnus also plays a small role in lateral rotation.

4. Gracilis:  The most unique of the adductor muscles, gracilis is the only one of the four that crosses both the hip and knee joint.  It too originates at the pubic bone but inserts at the tibia (of the lower leg) below the inner aspect of the knee joint.  Two of the three hamstring muscles – the medial (inner) ones – also attach at this same area.

Because of its orientation, when it contracts drawing its lower portion toward the upper, Gracilis serves primarily as a hip adductor muscle.  However, because it inserts below the knee, it also assists the hamstrings in flexing (bending) that joint.  Unlike the other adductor muscles, Gracilis assists in rotating the femur (and tibia) medially (inward).  If the leg is stationary, the Gracilis acts as a hip flexor when it contracts, bringing the upper portion of the muscle toward the lower rather than the other way around.

What does treatment entail?

As for any inflammatory condition, ice and electric stimulation are initially used to minimize swelling and other complications of inflammation.  Certain types of massage are generally performed to promote healing and control the formation of scar tissue.  Gentle, pain-free stretching is also employed.  After the acute period, it is likely that heat followed by ice is utilized.  Controlled and progressive strengthening is instituted in a pain-free fashion and return to activity is promoted gradually.  Toward that end, Pettitte has reportedly begun a throwing program from increasing distances before attempting to pitch.  By doing so, he initially avoids the long stride length, ballistic motion and extreme follow-through that would aggravate his condition and would be required of him to pitch effectively.

There are many reported cases where the patient co-pay is $50 and the allowable charges by contract with the provider were actually less ($45); the actual insurance cost for the visit is $0 and the patient pays the full amount. This impacts the patient by limiting access due to the excessive financial burden placed on them, and challenges the therapist with unrealistic expectations for optimal outcomes as a result of too few treatment sessions.

While recognizing the unfairness of this practice, Legislators have been encouraged to eliminate the “specialist co-pay” loophole and bills have been introduced in both the NYS Assembly (Kevin Cahill- A8171) and Senate (Neil Breslin- S4321). In fact, on Lobby Day this past May, Legislators themselves shared their own stories about family and friends who have been adversely affected by high co-pays; limiting access to care. Both bills sit in committee, not considered the most pressing issue before the Legislature, and we need continued pressure to push the issue to the forefront and demand action.

We’d like these bills passed on or before 2010. Please contact your legislator and let them know you want this change, of an unfair insurance practice, to happen.