Imaging in Groin Pain - IOC WORLD CONFERENCE...Ischiofemoral impingement 18 yo F, gymnast in national team with right groin pain. Ischiofemoral impingement Videos courtesy of Kentaro

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

[email protected]

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






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







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



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





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


Case courtesy of Zeynep Maraş Özdemir, MDMalatya, Turkey


Case courtesy of Zeynep Maraş Özdemir, MDMalatya, Turkey

LeftRight


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







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







• 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







• 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


Acetabular version within normal limits

iliopsoas


iliopsoas


Iliopsoas impingement background17 yo M, kickboxer

42°

Iliopsoas impingement background17 yo M, kickboxer

42°

Nomenclature for groin painCurrent classification





• Hip-related groin pain

• Other causes of groin pain


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

[email protected]

No conflicts of interest relevant to this topic

Documents

Imaging in Groin Pain - IOC WORLD CONFERENCE...Ischiofemoral impingement 18 yo F, gymnast in national team with right groin pain. Ischiofemoral impingement Videos courtesy of Kentaro