Hi Bikerphys.

Have you considered his joints? You probably have but you do not mention them, only his muscles.

Adductor Longus has fascial attachments to the contralateral external oblique (EO). Overactive EO can cause pain and overactivity in the adductors. I had one lady who had >6 month progressively declining ROM in her right hip which another physio couldn't help. In the end, it was an overactive EO that was the culprit and simple oblique cruches improved her ROM (by teaching EO to become phasic again). Maybe the same is happening to your guy.

What about his pubic symphysis? Is it symmetrical? Does his Active SLR test show one leg heavy? If so, he has a load transfer problem and it is probably the cause of the overactive piriformis which is trying to stabilise the pelvis. The same would go for the L/S and Wikipedia reference-linkSIJ. I only add these since you did not mention them, only muscles...

Lastly, please don't write your patients off with psychosoial problems unless there are clear yellow flags. I feel that too many physios go down this route when they can't get their patients better - better to blame the patient than improve their own knowledge. I am not saying that you are doing this. It is just a pet hate of mine! A good yellow flag screening can be found on the NSW Workcover Site, Appendix 1. It also has the Orebero Questionnaire in it. It is publication Number 4402 and the link is www.workcover.nsw.gov.au/...ctprog.htm

I find the FACTORWEB acronym helpful and the list is in a particular order.

In summary, I believe that this guy - based on such limited information and not actually seeing him - has a load transfer problem through his pelvis or L/S and it is shown up through harder work. If untreated, i would expect it will begin to take less strenuous training to bring on the pain. In my experience, triathletes are not wimps and don't fake things to get out of training - I find it hard to stop them overtraining!

Hope this helps!