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Imaging in Groin PainWhat the Team Physician Needs to Know
Üstün Aydıngöz, MD
Professor of RadiologyHacettepe University School of Medicine
Ankara, Turkey
International Olympic CommitteeAdvanced Team Physician Course
Tokyo, Japan 3 July 2019
ustunaydingoz@yahoo.com
No conflicts of interest relevant to this topic
Imaging groin pain in athletesBackground
• Complex anatomy
• Multiple groin pathologic conditions may coexist
• Variable nerve supply of the groin referred pain
• Clinical and imaging findings often do not point to a discrete entity
Imaging groin pain in athletesChallenge
A targeted approach may not be initially possible
Nomenclature for groin painCurrent classification (Doha Consensus, 2014)
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
• Hip-related groin pain
• Other causes of groin pain
Weir A et al.Br J Sports Med 2015
Clinical entities defined for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
Weir A et al.Br J Sports Med 2015
Based on history and clinical examination—NOT imaging findings
PRINCIPAL
Imaging modalities for groin painPrincipal and adjunct
• Magnetic resonance (MR) imaging
• Plain radiographs
• Ultrasonography
ADJUNCT
ADJUNCT
Clinical entities defined for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
Weir A et al.Br J Sports Med 2015
Adductor-related groin painKey features
• In any sports that requires fast changes in direction and rapid leg movements against resistance
• Adductor longus is chiefly implicated
• Typically medial thigh pain
• Tenderness at the adductor enthesis
• Reproducible pain on passive adductor stretching and resisted adduction of the thigh
Adductor-related groin pain25 yo M, basketball player
Courtesy of Vicky Earle, McGraw-Hill Education
Adductor-related groin pain25 yo M, basketball player
Adductor-related groin pain25 yo M, basketball player
LeftRight
Adductor-related groin pain25 yo M, basketball player Adductor longus
Adductor-related groin pain25 yo M, basketball player Rectus abdominis
Adductor longus
Adductor-related groin pain22 yo M, football player, sudden groin pain after kicking the ball
Adductor-related groin pain22 yo M, football player, sudden groin pain after kicking the ball Adductor longus
Adductor-related groin pain22 yo M, football player, sudden groin pain after kicking the ball Adductor longus
Adductor-related groin pain35 yo M, football player
LeftRight
Right groin injury 5 months earlier; felt pain during game 2 days ago
Adductor-related groin pain35 yo M, football player
Right groin injury 5 months earlier; felt pain during game 2 days ago
Adductor-related groin pain35 yo M, football player
Right groin injury 5 months earlier; felt pain during game 2 days ago
I.v. contrast
Adductor-related groin painMR imaging findings
• Diffuse high signal intensity at the adductor enthesis
• Focal fluid signal areas representing tears
• Contrast enhancement of the enthesis and anterior pubic region
• Central disc protrusion
• Pubic bone marrow edema
• Degenerative changes of the pubic symphysis
Adductor-related groin pain24 yo M, football player
Case courtesy of Zeynep Maraş Özdemir, MDMalatya, Turkey
Adductor-related groin pain24 yo M, football player
Case courtesy of Zeynep Maraş Özdemir, MDMalatya, Turkey
LeftRight
Adductor-related groin pain24 yo M, football player
Central disc protrusion
Branci S et al. Br J Sports Med 2015
Central disc protrusion andhigher grades of pubic BME significantly more common in symptomatic (versusasymptomatic) football players
Clinical entities defined for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
Weir A et al.Br J Sports Med 2015
Pubic-related groin painKey features
• In athletes where the pubic symphysis is repetitively subjected to high torsional and shear loads (soccer players)
• Local tenderness of the pubic symphysis and the immediately adjacent bone
• Previously called “osteitis pubis”
Pubic-related groin pain19 yo M, football player
Pubic bone marrow edema
Pubic-related groin painMR imaging
• Pubic bone marrow and parasymphyseal findings (cleft, capsule/tendon edema) are frequently found in asymptomaticathletes
• MRI findings do not predict injury or symptom development
Robinson P et al. Br J Sports Med 2015
➢ A 4-year prospective study
➢ Elite academy soccer players
➢ Started with 34 and ended with 22 male participants
Pubic-related groin pain19 yo M, professional football player
Pubic bone marrow edema
Pubic-related groin painMR imaging findings
• Pubic bone edema, more extensive in symptomatic athletes
• Degree of edema more pronounced in more symptomatic athletes
• If the history of pain <6 months: >6 months:
Subchondral pubic marrow edema Subchondral sclerosis
Fluid within the pubic symphysis Subchondral resorption
Periarticular edema Pubic osteophytes
Chopra A, Robinson P. Radiol Clin N Am 2016
Pubic bone marrow edema with active sacroiliitis33 yo M
Most likely represents axial spondyloarthritis
Pubic bone marrow edema with active sacroiliitis33 yo M
Clinical entities defined for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
Weir A et al.Br J Sports Med 2015
• Groin pain and tenderness in the inguinal canal region in the absence of a palpable hernia
• More likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze
• Patients do not have a true inguinal hernia, but instead an acquired inguinal wall deficiency/dysfunction through overuse
Inguinal-related groin painKey features
PRINCIPAL
Imaging modalities for groin painPrincipal and adjunct
ADJUNCT
ADJUNCT
• Magnetic resonance (MR) imaging
• Plain radiographs
• Ultrasonography
Inguinal-related groin painImaging
• Best assessed initially with ultrasonography (US) to exclude true inguinal or femoral hernia
• US allows dynamic assesment of the posterior inguinal wall for incompetence and disruption
• Main role of MR imaging: to exclude an alternative diagnosis such as inguinal canal masses
• MR imaging can also show occasional injury to the aponeurotic structures
• Best assessed initially with ultrasonography (US) to exclude true inguinal or femoral hernia
• US allows dynamic assesment of the posterior inguinal wall for incompetence and disruption
Inguinal-related groin painImaging
Revzin MV et al. Radiographics 2016
Clinical entities defined for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
Weir A et al.Br J Sports Med 2015
• Acute injuries in athletes typically involve an eccentric contraction or direct trauma
• Overuse injuries occur in activities involving rapid hip flexion or external rotation of the thigh (running, soccer, and gymnastics)
• More likely if there is pain on resisted hip flexion and/or pain on stretching of the hip flexors
Iliopsoas-related groin painKey features
Iliopsoas-related groin painImaging
• Iliopsoas bursitis, caused by overuse and friction as the iliopsoas tendon rides over the iliopectineal eminence of the pubis, is best assessed with MR imaging
• MR imaging also shows iliopsoas tears and iliopsoas impingement
• Ultrasonography can be used to assess snapping iliopsoas tendon syndrome
Iliopsoas-related groin pain47 yo MIliopsoas bursitis
Iliopsoas-related groin painIliopsoas impingement
• First described in 2007
• In patients with close proximity of the iliopsoas tendon to the acetabular labrum
• Isolated anterior tear (at 9 o’clock)
• Labral tear/injury does not characteristically extend to an anterosuperior location (which is usually the site of injury with femoroacetabular impingement)
Heyworth BE et al. Arthroscopy 2007
Iliopsoas impingement15 yo M, football player
IP RF
Iliopsoas impingement15 yo M, football player
Iliopsoas impingement29 yo M
iliopsoas
IP
Iliopsoas impingement29 yo M
Acetabular version within normal limits
iliopsoas
Iliopsoas impingement29 yo M
iliopsoas
Iliopsoas impingement29 yo M
Iliopsoas impingement background17 yo M, kickboxer
42°
Iliopsoas impingement background17 yo M, kickboxer
42°
Nomenclature for groin painCurrent classification
• Adductor-related groin pain
• Pubic-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
• Hip-related groin pain
• Other causes of groin pain
Weir A et al.Br J Sports Med 2015
Stress fx, right femoral neck, left acetabulum34 yo M
MRI is the best modality
to show acute occult fractures
Synovial chondromatosis18 yo F with left hip pain
Ischiofemoral impingement18 yo F, gymnast in national team with right groin pain
lesser
trochanterischium
q. femoris
Sussman WI et al. Surg Radiol Anat 2013
External rotation, extension, adduction
Ischiofemoral impingement18 yo F, gymnast in national teamwith right groin pain
Ischiofemoral impingement
Videos courtesy of Kentaro Onishi, DOUPMC, Pittsburgh, USA
q. femoris
QF
IT
LT
HAM
Imaging groin pain in athletesTake home points
• MR imaging is the principal imaging modality—although a targetedapproach may not be initially possible
• MR imaging may be positive in asymptomatic persons
• Radiologists should describe their findings—and do not attempt tomake the clinical diagnosis
• Radiologists can provide relevant differential diagnosticconsiderations
Imaging in Groin PainWhat the Team Physician Needs to Know
Üstün Aydıngöz, MD
Professor of RadiologyHacettepe University School of Medicine
Ankara, Turkey
International Olympic CommitteeAdvanced Team Physician Course
Tokyo, Japan 3 July 2019
ustunaydingoz@yahoo.com
No conflicts of interest relevant to this topic
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