Working Diagnosis:
Osseous avulsion fracture of left adductor longus.

Treatment:
Non-operative management with a progressive rehabilitation program.

Week 1: NSAIDs, intermittent ice, rest, and non-weight bearing.

Week 2: Partial-weight bearing, heat, ultrasound, strengthening exercises, and stationary bike.

Week 3: Jogging.

Week 4: Sprinting.

Week 5/6: Lateral movements and plyometrics.

Week 7: Practicing.

Week 8: Playing in games.

Outcome:
Patient returned to game activity 8 weeks after his injury and finished out the season. Patient occasionally had pain in the area that was exacerbated by changing speeds, striking the ball with his left leg, and reaching for the ball. He was still a bit hesitant about reinjuring his groin. His season ended and he took 3 months off during the off-season. Follow up MRI showed healing of avulsion fracture, decreased swelling, and minimal muscle atrophy. After resuming play for the new season his only complaint is that occasionally he feels sore in the area.

Author's Comments:
Actual MRI films could not be obtained due to professional league rules. This injury is very rare after adolescence when skeletal maturity is achieved. I could only find a handful of case reports in the literature on actual osseous avulsion fractures of the adductor longus tendon. Thus there is no consensus on operative versus non-operative treatment. Our patient did well with a non-operative approach and returned to play in 8 weeks. The size of the avulsion is very important.

Editor's Comments:
Hip apophyseal injuries are a relatively uncommon injury in adolescent patients. While in the skeletally immature patient, a strong eccentric muscle contraction can pull off the apophysis, in adults, these injuries usually involve the tendinous origins of the muscles involved. This case is very interesting in that this was an adult patient with an osseous avulsion. Common sites include the ischium, iliac crest, anterior inferior iliac spine, anterior superior iliac spine, greater and lesser trochanters, and the pubis.
Patients often complain of acute onset of pain and may experience a "pop". Examination usually involves focal tenderness to palpation over the tendinous origin or apophysis, and pain with activation of the associated muscle units. Plain radiographs are usually sufficient to diagnose an avulsion fracture in a skeletally immature patient, but as in this case an MRI may be necessary to diagnose this injury in an adult.
Most authors recommend non-operative treatment as outlined in the case. However, if the avulsed fragment is separated more than 2 cm from its origin, surgical repair may be necessary.

References:
McKinney Bl, et al. Apophyseal avulsion fractures of the hip and pelvis. Orthopedics. 2009 Jan; 32 (1):42.
Moeller JL. Pelvic and hip apophyseal avulsion injuries in young athletes. Curr Sports Med Rep. 2003 Apr; 2(2):110-5.

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