**8. Adductor muscle**

A lesion at the proximal end of the abductor complex is not a common injury. There are few articles in literature about it, and those few are of a low level of evidence and with a few selected cases. An eccentric contraction during a movement of forced abduction of the lower limb may cause this type of acute injury. The most common mechanism is bilateral abduction of the lower limbs with a hip flexion and internal rotation of the other hip [45]. Usually the acute injury is preceded by painful symptoms previous to the accident that express an acute injury on a chronic disease in the area. In fact, histological studies [46, 47] have shown that in the area near the lesion there are degenerative tissue alterations. For this reason the first therapeutic approach to acute injuries of proximal abductor insertion was based on the results of treatment of the chronic lesion. Tenotomy, often used for chronic pain resistant to conservative therapies, had not guaranteed excellent results: 40% of patients were unable to return to competitive activity after surgery and the strength of the adductors reported a significant decrease at the isokinetic test [48]. These results led to the surgical reconstruction of the injured tendon / muscle to prevent the loss of strength and try to increase the percentage of athletes who could return to their previous level of competitive activity [46].

It was later shown that about 60% of the athletes complained of an aspecific symptom, especially abdominal or inguinal pain in the period prior to the injury [49]. However, the importance of the integrity of these anatomical structures has decreased. Studies on the conservative treatment of these lesions have shown that the anatomical continuity of these structures is not essential for a high athletic performance and electromyographical studies support the idea that the abductor muscles do not play a key role in sprinting and cutting movements [50, 51].

The most recent study with the largest series includes 19 players of the American National Football League (NFL) [49], 14 were treated conservatively and 5 surgically. The authors conclude that although all the players returned to play in the top league, those who received conservative treatment returned to the field sooner (6.1 + / - 3.1 weeks) than those treated surgically (12.0 + / - 2.5 weeks). Moreover, besides the risk of complications with surgery, the operation is not easy to perform if the lesion is at the level of the muscle-tendon junction [45].

The information available in the literature on this subject is scarce, with a low level of evidence and often conflicting. Some authors recommend surgery to suture / reinsert in the case of acute injuries occurring in athletes and excision / tenotomy in the case of inveterate injuries; other authors do not recommend surgery because it extends recovery time and does not guarantee better results than conservative treatment, considering also the non fundamental function of this muscle group in sport activities. Much still needs to be understood in this regards and future studies should be conducted with better methods and possibly with a larger number of patients.
