ARS syndrome

Hip adductor muscle syndrome or ARS syndrome (Adductor Rectus Symphysis) is a pathology accompanied by the development of an inflammatory process as a reaction to regular overloading of the musculature and tendon apparatus. Such a disease is often diagnosed in professional athletes and dancers, or occurs in patients suffering from hip arthrosis. Less frequently, ARS syndrome appears as an underlying pathology. Treatment involves the use of physical therapy. The outcome of the disease is favorable.

Epidemiology

ARS syndrome proper is a pathological condition affecting the tendon-muscle complex of the long and short adductor muscles of the thigh, the thin thigh muscle, the distal part of the rectus abdominis muscle, and the anterior part of the large adductor muscle in the areas of attachment to the brow or sciatic bone. The problem occurs as a result of overstraining of the musculoskeletal mechanism due to a mismatch between the physical load performed by a person and the compensatory capabilities of the body.

Pathological ARS syndrome was first studied and described by Bulgarian Dr. M. Bankov in the 1950s. At that time, the pathology was considered as one of the symptoms of chronic instability of the anterior pelvic floor. Prolonged monotypic loads accompanied by asymmetric contractions of the adductor femoral muscles, oblique and rectus abdominis muscles provoke microtraumas of the ligamentous system of the bosom articulation. As a result, an inflammatory and degenerative process develops.

In most cases, ARS syndrome is formed during the peak season of sports competitions and demonstrations, against the background of intense physical activity. Professional athletes (soccer players, hockey players, gymnasts), as well as ballerunners and dancers are predominantly affected. The most common age of the diseased is 20-24 years old. ARS syndrome in the elderly is practically not observed. Men and women get sick with approximately the same frequency.

The leading clinical symptomatology is pain in the groin area, with localization in the area of attachment of the rectus abdominis and the adductor thigh muscles to the pelvic bones. The pain appears during physical activity, with intensification against acceleration, sharp hip lunges, kicking (on the ball).

In more than 60% of cases, the problem is found in professional soccer players.

Causes ARS syndrome

The primary cause of ARS syndrome is a mismatch between the physical load experienced by the musculoskeletal system and its adaptive abilities. The situation is "spurred" by the unstable state of soft and dense tissue structures of the pelvis and lower extremities.

ARS syndrome develops against the background of the same asymmetric overloads of the musculo-ligamentous mechanism of the thigh, lower abdomen, groin area. For example, in soccer players, the problem is often caused by the intense movement of the leg when hitting the ball. A special unfavorable role is played by an improper training regime, illiterate selection and performance of exercises, premature return to training after traumatic injuries to muscles and ligaments.

The lack of a necessary and sufficient recovery period after exertion leads to tissue damage and further destruction. The surface of the articular musculature is covered with a network of microcracks. After some time in the damaged areas starts a response inflammatory reaction, which is accompanied by pain. The process of formation of ARS-syndrome is aggravated by pathological degenerative and dystrophic changes.

Among the most common risk factors are increasing diseases of the pelvic ring structures. [1]

Risk factors

The highest rates of ARS syndrome are characterized by playing sports. A typical feature of such sports games is frequent and regular jumping, sprinting, sudden lunges and limb movements.

The risks of forming ARS syndrome are significantly increased:

• in professional sports compared to amateur sports;
• with increased athletic exertion;
• during a competition or demonstration, compared to normal training and exercise;
• during matches and performances indoors or on substandard surfaces.

In some cases, the triggering factors for ARS syndrome can be:

• weakened pelvic and femoral ligaments;
• reduced flexibility (especially plays a role in gymnastics, figure skating, ballet);
• The state of cumulative fatigue of the musculoskeletal system;
• Reduced physical capacity of the musculo-ligamentous mechanism due to improperly distributed or absent physical activity prior to competition or performance;
• Reducing the number of trainings and classes during off-season periods.

Additional risk factors can be called nutritional disorders, improper work and rest, psychosocial moments (chronic stress, uncomfortable living conditions, etc.).

Pathogenesis

The term ARS syndrome refers to the development of a secondary inflammatory process involving soft joint structures, including muscles and tendons. Inflammation occurs as a reaction to prolonged (regular) traumatization, including microcracks and microtears. Damage occurs when musculoskeletal mechanisms cease to cope with intense overload, due to their mismatch with the compensatory capabilities of the body. As a consequence, degenerative and dystrophic changes develop.

In ARS syndrome, the predominantly affected are:

• areas of tendon and muscle attachment to the hip articulation;
• of the ligaments of the rectus abdominis;
• the ligamentous apparatus of the bosom articulation.

A pathologically active role in the formation of the disorder - ARS syndrome - is played by regular and intensive (frequently occurring) overloading of the hip joint, after which the thigh and rectus abdominis muscles do not have time to recover. As a result, the adductor muscle is traumatized, the fibers are gradually destroyed, and microcracks are formed on their surface. Over time, the damaged areas are affected by an inflammatory process, which is accompanied by pain. Degeneration and dystrophy of tissues develops. An additional damaging factor can become a pathological change in the pelvic ring.

Symptoms ARS syndrome

ARS-syndrome is represented, first of all, by such a symptom as pain: it is localized in the buttocks, radiating to the posterior surface of the thigh. Increased pain is noted with muscle tension, with prolonged sitting. In addition, pain sensation appears when probing the sciatic tubercle, during massive hip flexion or extension of the lower leg, during intense knee flexion against the background of reverse resistance.

The pain in ARS syndrome is usually sharp and begins to bother the patient during (and immediately after) physical activity associated with intense movements (swings, lunges, etc.) of the hip joint. For example, such a phenomenon is often noted during vigorous dancing, running with sudden turns, jumping, kicking. The pain is more often localized:

• in the lower abdomen (along the course of the rectus abdominis muscles);
• in the inguinal area (with irradiation downward along the inner thigh surface);
• in the area of the bosom articulation (pulling discomfort).

The pain usually ceases to bother you at rest, but with the onset of exertion it resumes with even greater intensity.

Complications and consequences

If ARS syndrome persists without appropriate treatment, it leads to the development of a pronounced degenerative process in the tendon tissue. As a result, the risk of major trauma to the joint structures - in particular, multiple tears and ruptures - is significantly increased.

The clinical picture in ARS syndrome worsens and expands with time. Pains become regular, their intensity increases. In most cases, the patient is forced to refuse physical activity and participation in performances or competitions. Sports and dancing careers of such people end prematurely.

Adverse effects and complications are often provoked not only by the lack of treatment of ARS syndrome, but also by the ongoing intensive drug therapy. For example, frequent blockades with corticosteroid drugs can aggravate the development of degeneration in pathologically altered tissues, and prolonged administration of nonsteroidal anti-inflammatory drugs adversely affects the gastrointestinal tract.

Diagnostics ARS syndrome

In the process of examining a patient with ARS-syndrome, an increase in pain is noted when probing the thigh area, closer to the pubis. In addition, for diagnostic purposes, physiological stress tests are performed: the patient should make a few simple movements at the request of the doctor.

Clinical tests are aimed at detecting abnormalities in the hip joints and sacral spine. Special attention is paid to the condition of the musculature involved in the formation of ARS syndrome.

Laboratory tests are ordered to determine the inflammatory process and possible pathologies that accompany ARS syndrome directly:

• general blood test with determination of erythrocyte sedimentation rate;
• assessment of creatine kinase levels (levels are elevated against a background of marked ongoing muscle breakdown);
• determination of rheumatoid factor or antibodies to cyclic citrullinated peptide;
• autoantibody detection.

To make a diagnosis of ARS syndrome, instrumental diagnostics is necessarily prescribed:

• hip radiography (anterior and posterior projection);
• ultrasound of the symphysis with muscle attachment sites.

MRI is prescribed if the patient has symptomatology of an inflammatory process developing in the area of muscle insertion. Magnetic resonance imaging visualizes the presence of degenerative changes in the hip joint and sacroiliac spine.

MRI is an indispensable procedure for the examination of muscles, ligamentous and tendon apparatus. The method is also relevant when ARS syndrome has to be differentiated from severe soft tissue pathology (rupture of a large ligament or tendon, damage to important structures in the hip joint).

Differential diagnosis

Adequately conducted diagnostic measures allow not only to determine the development of ARS-syndrome in the patient, but also to distinguish it from other pathologies with similar symptomatology:

• pelvic bone fractures;
• osteoarthritis;
• myositis of the adductor muscles of the thigh;
• Rheumatoid arthritis;
• inguinal hernia;
• tumor processes;
• prostate inflammation.

Differentiation of ARS syndrome is performed in stages, after all standard investigations (including instrumental studies) have been performed.

Very often pain localized in the groin area is detected along with dilation of the inguinal ring, weakness of the posterior wall of the inguinal canal. This situation can occur in many pathological conditions:

• ARS syndrome and inguinal ring syndrome;
• internal hernia;
• pubic asthenitis, Gilmore's groin.

The differentiation of these diseases is a relatively recent phenomenon. Specialists have found that a certain percentage of athletes (according to different data - from 1 to 11%) who are engaged in sports accompanied by pelvic loads, often have regular groin pain. Thus, ARS syndrome in soccer players occurs in about 3-5% of cases. At the same time, during the examination, a picture is revealed that requires differentiation: dilation of the external inguinal ring, prolabration of the posterior wall of the inguinal canal. The doctor's task should be to determine the causes of inguinal pain:

• tendon damage;
• ARS syndrome proper;
• injuries of the articular lip of the hip joint, articular cartilage of the acetabulum and femoral head, and the presence of free bone and cartilage bodies;
• stress fracture of the proximal femur or pelvis, bone tumor processes, chondritis and osteochondrosis of the vertebrae, and disc injuries;
• bosom symphysitis, hernias;
• post-traumatic neuropathy;
• prostate inflammation, epididymitis, varicocele, urethritis;
• connective tissue pathologies (ankylosing spondylitis, rheumatoid arthritis, etc.);
• Osteoarthritis, arthritis, dorsopathies (more typical of non-athletes).

Treatment ARS syndrome

Drug therapy for ARS syndrome consists of local injection of corticosteroid drugs and non-steroidal anti-inflammatory drugs. Involve various physiotherapeutic procedures - in particular, electrophoresis with anesthetics, laser therapy, Bernard currents. The success rate of such treatment is estimated at about 20%.

Unfortunately, long-term administration of corticosteroids and non-steroidal anti-inflammatory drugs in ARS syndrome often leads to gradual degenerative changes of tendons, digestive tract pathologies. Meanwhile, surgical treatment is prescribed predominantly for significant damage or disruption of the integrity of the tendons of the adductor muscles. Surgical intervention in this situation is not the "gold standard", because even after surgery, scarring changes remain in the tendons, which further prevent the patient from returning to intensive training. However, provided there are no peak loads, the pain after surgery disappears.

A good trend in the treatment of ARS syndrome is demonstrated by shockwave therapy. This method helps to eliminate the pathology without prolonged use of drugs and corticosteroid injections. Shockwave therapy is also indicated after surgical intervention for ARS-syndrome, as it helps to restore the previous physical abilities.

Specialists conditionally categorize patients with ARS syndrome into two groups:

• that don't require surgery;
• who have tendon tears that require surgery.

In many cases, both the first and the second group require elimination of scarring or degenerative changes that become sources of painful sensations. For this purpose, the shockwave technique is successfully used, supplemented with kinesiotherapy or biomechanical muscle stimulation as indicated.

Both the treatment and rehabilitation period for ARS syndrome do not require hospitalization. Upon completion of the treatment course, ultrasound and MRI follow-up diagnostics is performed to assess the elimination of degenerative processes in the tendons of the adductor muscles and tissues of the bosom articulation. Increased vascularization, lysis of fibroses, and increased local metabolic processes are also indicators of positive dynamics. [2]

Prevention

Preventive measures to prevent the development of ARS syndrome include proper selection of physical activity, competent distribution of training regimen. It is necessary to properly prepare the supporting muscles and tendon apparatus for the upcoming loads. The intensity of exercises should be increased gradually, and the activities should be interspersed with sufficient periods of muscle rest and regeneration.

The appearance of discomfort or pain in the groin area during exercise should be a reason to stop exercising and consult a specialist.

An important role in preventing the development of ARS syndrome is played by regular monitoring of physical activity by coaches, mentors and teachers. It is important to choose the right training facilities, equipment, equipment, protective devices according to the type of physical activity. A sports doctor should check the condition of the musculoskeletal system of each mentee, take into account all injuries that occurred earlier during training and competitions.

In gymnastics, acrobatics, sports dancing, warm-up plays a special role, creating a general background that allows you to successfully perform the necessary exercises in the future. During the warm-up should provide a load not only on the muscles that perform the main work in a particular activity, but also on the muscles that will not be subjected to load. Important: a well-designed warm-up should not lead to fatigue or excessive excitement.

By paying the necessary attention to preventing injury during vigorous physical activity, proper exercise and training, the risk of developing ARS syndrome can be minimized.

Forecast

The prognosis in ARS syndrome can be called unstable, but conditionally favorable. The success of drug treatment alone is doubtful, with sustained positive dynamics noted only in less than 20% of cases. The best effectiveness is observed in the implementation of a comprehensive approach, involving:

• elimination of physical activity;
• taking medications (non-steroidal anti-inflammatory drugs of general and local action, corticosteroid injections);
• use of physiotherapy (laser therapy, magnetotherapy, Bernard currents, electrophoresis with analgesics);
• chiropractic care;
• shockwave therapy.

A comprehensive approach can eliminate pain, restore mobility and the ability to perform certain physical activities.

In the absence of a positive effect, surgical intervention demonstrates a good result. However, the remote period may be accompanied by the development of recurrences of ARS syndrome.

In many cases, ARS syndrome severely limits the patient's physical capabilities and becomes the reason for the forced termination of a sports or dancing career.