Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes

Groin pain in soccer players: anatomy, clinical presentation, biomechanics, pathology and imaging findings

Groin pain is extremely common in soccer players, especially male soccer players, with nearly a third experiencing groin pain over the course of their careers. Despite its high prevalence, there continues to be some confusion and controversy regarding the detailed anatomy and recommended terminology related to groin pain in athletes. This article will review the anatomy, clinical presentation, biomechanics, pathology and imaging findings most commonly associated with groin pain in soccer players.

The Role of MRI in Groin Pain Syndrome in Athletes

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Groin Pain Syndrome Italian Consensus Conference update 2023

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Acute Adductor Muscle Injury: A Systematic Review on Diagnostic Imaging, Treatment, and Prevention

BACKGROUND

Controversies remain regarding the diagnosis, imaging, and treatment of acute adductor injuries in athletes.

PURPOSE

To investigate the diagnostic imaging, treatment, and prevention of acute adductor injuries based on the most recent and relevant scientific evidence.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed and Web of Science databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles studying acute adductor injury in athletes. Inclusion criteria were original publication on acute adductor injury in amateur or professional athletes, level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or the methodological index for non-randomized studies criteria. Articles were grouped as imaging, treatment, prevention focused, or mixed.

RESULTS

A total of 30 studies published between 2001 and 2021 were selected, involving 594 male patients with a mean age 26.2 years (range, 16-68 years). The most frequent sports were soccer (62%), basketball (14%), futsal (6%), American football (3%), and ice hockey and handball (2%). Risk factors for acute adductor injury were previous acute groin injury, adductor weakness compared with the uninjured side, any injury in the previous season, and reduced rotational hip range of motion. The frequency of complete adductor muscle tears on magnetic resonance imaging was 21% to 25%. For complete adductor tears, the average time to return to play was 8.9 weeks in patients treated nonoperatively and 14.2 weeks for patients treated surgically. Greater stump retraction was observed in individuals treated surgically. Partial acute adductor tears were treated nonoperatively with physical therapy in all studies in the present systematic review. The average time to return to play was 1 to 6.9 weeks depending on the injury grade. The efficacy of adductor strengthening on preventing acute adductor tears has controversial results in the literature.

CONCLUSION

Athletes with partial adductor injuries returned to play 1 to 7 weeks after injury with physical therapy treatment. Nonoperative or surgical treatment is an acceptable option for complete adductor longus tendon tear.

Comparison between dedicated MRI and symphyseal fluoroscopic guided contrast agent injection in the diagnosis of cleft sign in athletic groin pain and association with pelvic ring instability

OBJECTIVE

To compare dedicated MRI with targeted fluoroscopic guided symphyseal contrast agent injection regarding the assessment of symphyseal cleft signs in men with athletic groin pain and assessment of radiographic pelvic ring instability.

METHODS

Sixty-six athletic men were prospectively included after an initial clinical examination by an experienced surgeon using a standardized procedure. Diagnostic fluoroscopic symphyseal injection of a contrast agent was performed. Additionally, standing single-leg stance radiography and dedicated 3-Tesla MRI protocol were employed. The presence of cleft injuries (superior, secondary, combined, atypical) and osteitis pubis was recorded.

RESULTS

Symphyseal bone marrow edema (BME) was present in 50 patients, bilaterally in 41 patients and in 28 with an asymmetrical distribution. Comparison of MRI and symphysography was as followed: no clefts: 14 cases (MRI) vs. 24 cases (symphysography), isolated superior cleft sign: 13 vs. 10, isolated secondary cleft sign: 15 vs. 21 cases and combined injuries: 18 vs. 11 cases. In 7 cases a combined cleft sign was observed in MRI but only an isolated secondary cleft sign was visible in symphysography. Anterior pelvic ring instability was observed in 25 patients and was linked to a cleft sign in 23 cases (7 superior cleft sign, 8 secondary cleft signs, 6 combined clefts, 2 atypical cleft injuries). Additional BME could be diagnosed in 18 of those 23.

CONCLUSION

Dedicated 3-Tesla MRI outmatches symphysography for purely diagnostic purposes of cleft injuries. Microtearing at the prepubic aponeurotic complex and the presence of BME is a prerequisite for the development of anterior pelvic ring instability.

CLINICAL RELEVANCE STATEMENT

For diagnostic of symphyseal cleft injuries dedicated 3-T MRI protocols outmatch fluoroscopic symphysography. Prior specific clinical examination is highly beneficial and additional flamingo view x-rays are recommended for assessment of pelvic ring instability in these patients.

KEY POINTS

• Assessment of symphyseal cleft injuries is more accurate by use of dedicated MRI as compared to fluoroscopic symphysography. • Additional fluoroscopy may be important for therapeutic injections. • The presence of cleft injury might be a prerequisite for the development of pelvic ring instability.

Surgical Reattachment of Rare Proximal Adductor Avulsion Injury in a Female Athlete: A Case Report

CASE

A 54-year-old female professional equestrian sustained a traumatic right groin injury with disabling groin pain. Magnetic resonance images indicated a proximal adductor avulsion injury with a 3.2-cm tendon retraction. Surgical reattachment of the fibrocartilage avulsion with suture anchor repair was subsequently performed.

CONCLUSION

Adductor avulsion injuries have been rarely reported in female athletes. Patient-reported outcomes demonstrate a successful return to preinjury levels of daily function and sports performance after surgery for a female athlete. Surgical reattachment should be considered for the management of proximal adductor avulsion injuries in elite female athletes.

Current Clinical Concepts: Exercise and Load Management of Adductor Strains, Adductor Ruptures, and Long-Standing Adductor-Related Groin Pain

Adductor-related groin pain is a common problem in sports. Evidence-based management of athletes with adductor strains, adductor ruptures, and long-standing adductor-related groin pain can be approached in a simple yet effective and individualized manner. In most cases, managing adductor-related pain in athletes should be based on specific exercises and loading strategies. In this article, I provide an overview of the different types of adductor injuries, from acute to overuse, including their underlying pathology, functional anatomy, diagnosis, prognosis, mechanisms, and risk factors. This information leads to optimal assessment and management of acute to long-standing adductor-related problems and includes primary, secondary, and tertiary prevention strategies that focus on exercise and load-based strategies. In addition, information on different options and contexts for exercise selection and execution for athletes, athletic trainers, and sports physical therapists in adductor injury rehabilitation is provided.

Contemporary imaging of inguinal hernia and pain

Inguinal hernias are the commonest type of hernia, and are frequently encountered by general, abdominal and musculoskeletal radiologists. Such hernias may cause discomfort or pain; but many other conditions may cause pain in a similar location, meaning it is not always straightforward to determine the underlying cause of a particular patient’s symptoms. Although surgical fixation of hernia has high success rates with low recurrence, ongoing symptoms are common after apparently uncomplicated surgery. In particular, post-surgical chronic groin pain can be highly problematic in some patients. In this review, we highlight the relevant surgical and imaging anatomy, common modes of clinical presentation, contemporary surgical approaches to the repair of inguinal hernia, imaging techniques to diagnose such hernias in both unoperated and operated groins and mimics of hernia-related pain.

New Insights into the Musculotendinous and Ligamentous attachments at the Pubic Symphysis: a systematic review

OBJECTIVE

Collection and meta-analysis of all relevant anatomical studies related to the pubic symphysis to provide a state of the art review of its musculotendinous and ligamentous attachments from 2010 to date.

METHODS

A systematic search of published literature databases (PubMed, Web of Science and Embase) was conducted according to the PRISMA guidelines from January 2010 up until now. All papers investigating the anatomy of the musculotendinous attachments of the pubis and the pubic ligaments were eligible. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS scale). A narrative analysis approach was adopted to synthesise the findings.

RESULTS

After screening and review of 1313 papers, a total of six studies investigating the anatomy of the pubic ligaments and tendons were included. Of the six articles included in this systematic review, five articles performed a macroscopic anatomical dissection, three articles performed a microscopic (histological) study, and one article combined microscopic examination with an MRI imaging examination. The anatomy of the pubic symphysis was examined in 76 anatomical cadavers (60 embalmed, 16 fresh frozen). In total 44 male cadavers (58%), 28 female cadavers (37%) and four cadavers whose gender was not stated were dissected.

CONCLUSION

The age-old accepted concept of the fusion of the rectus abdominis with the adductor longus via the aponeurotic plate is outdated. New anatomical concepts like the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC), recto-gracilis tendon, fusion of adductor brevis with gracilis, etc. are recently introduced. The awareness of anatomy and morphology of the pubic ligaments plays a significant role in understanding the diagnosis and treatment of groin pain.

Proximal Adductor Longus Tendon Repair With a Concomitant Distal Fascial Release for Complete Hip Adductor Tendon Tears: Surgical Technique and Outcomes in 40 Male Athletes

Background:

The optimal treatment for complete avulsions of the proximal adductor longus (AL) is still debatable, and different operative and nonoperative treatment options have been suggested.

Purpose:

To report surgical techniques and functional outcomes of a series of athletes who were treated operatively for proximal AL tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective evaluation of patients who underwent surgical repair of complete proximal AL tear with concomitant distal fascial release with or without lesions of the neighboring soft tissue structures was performed. This included preinjury Tegner score, age, number of tendons involved, time interval from injury to surgery, and postoperative complications. Self-reported outcomes were defined based on the ability to regain sports activities (excellent, good, moderate, fair, or poor). Between-group comparisons were performed to identify factors associated with improved outcomes. The Mann-Whitney nonparametric test was used for comparing continuous variables, and the Fisher exact test was used for comparing nominal variables.

Results:

A total of 40 male athletes were included in the evaluation, with an average follow-up of 11 months (range, 6 months-8 years). Self-reported outcome was excellent in 23 (57.5%), good in 13 (32.5%), and moderate in 4 (10%) patients. Comparisons between patients with excellent versus good/moderate outcomes revealed nonsignificant differences regarding age at injury and preinjury Tegner score. Athletes with excellent outcomes received surgery sooner after the injury compared with athletes with good/moderate outcomes (2.4 ± 1.8 vs 11.4 ± 11.0 weeks, respectively; P < .01).

Conclusion:

Surgical repair for complete proximal AL tears with a concomitant distal fascial release resulted in outcomes rated as good or excellent in 90% of the cases. This treatment should be considered particularly in high-level athletes with a clear tendon retraction and within the first month after the injury. Further research is nevertheless needed to compare these outcomes with other treatment alternatives to better define criteria advocating surgery.

One-Year Clinical and Imaging Follow-up After Exercise-Based Treatment for Acute Complete Adductor Longus Tendon Avulsions in Athletes: A Prospective Case Series

BACKGROUND

Complete avulsions of the adductor longus tendon are serious injuries, yet we have few data to inform clinical decisions on management. Previous studies are limited by a lack of detailed follow-up.

PURPOSE

To describe detailed clinical and imaging measures 1 year after complete proximal adductor longus avulsion injuries in athletes who received exercise-based treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 16 adult male competitive athletes were included in this study <7 days after an acute adductor longus tendon avulsion injury. All athletes were advised to complete a supervised standardized criterion-based rehabilitation protocol. Standardized clinical examination, a modified Copenhagen Hip and Groin Outcome Score (HAGOS), the Oslo Sports Trauma Research Centre Overuse Injury Questionnaire (OSTRC-O), and detailed magnetic resonance imaging (MRI) assessment were performed after inclusion, on the day of completion of the treatment protocol (return to sport), and at 1-year follow-up after injury.

RESULTS

One player was lost to follow-up. Median return-to-sport time was 69 days (interquartile range [IQR], 62-84). One player had an early reinjury and performed an additional rehabilitation period. One-year follow-up was completed a median from 405 days (IQR, 372-540) after injury. The median HAGOS score was 100 for all subscales (IQRs from 85-100 to 100-100), and the median OSTRC-O score was 0 (IQR, 0-0). The median range of motion symmetry was 100% (IQR, 97%-130%) for the bent-knee fall-out test and 102% (IQR, 99%-105%) for the side-lying abduction test. Side-lying eccentric adduction strength symmetry was 92% ± 13% (mean ± SD), and median supine eccentric adduction strength symmetry was 93% (IQR, 89%-105%). MRI results at 1-year follow-up showed that from the original complete discontinuity in all cases, 10 athletes (71%) had partial tendon continuity, and 4 (29%) had complete tendon continuity.

CONCLUSION

Nonsurgically treated athletes with a complete acute adductor longus avulsion returned to sport in 2 to 3 months. At the 1-year follow-up after injury, athletes had high self-reported function, no performance limitations, normal adductor strength and range of motion, and signs of partial or full tendon continuity as shown on MRI. This indicates that the primary treatment for athletes with acute adductor longus tendon avulsions should be nonsurgical as the time to return to sport is short, there are good long-term results, and there is no risk of surgical complications.

[Avulsion injuries of the adductors and iliopsoas]

Avulsion injuries of the tendon-bone junction of the adductor longus are rare. Avulsions of the iliopsoas tendon insertion on the lesser trochanter are even rarer. Avulsion injuries of the adductor insertion occur predominantly in active athletes. Iliopsoas tendon avulsions are described mainly in nonathletes, in old age and frequently with no triggering event. In these cases possible underlying pathologies (e.g. tumor or metastases in the lesser trochanter) must be ruled out. In the literature no generally accepted recommendations for treatment of these injuries can be found because only a few retrospective anecdotal case reports and case studies have been published. For this reason, it is mostly unclear if and when a conservative or operative approach is indicated.A PubMed/Medline literature search resulted in 86 articles for iliopsoas avulsions and 155 hits for adductor tendon avulsions. Accordingly, both injuries can basically be treated conservatively. A surgical treatment is recommended only occasionally when conservative treatment fails and when the adductor insertion or the apophysis of the lesser trochanter is dislocated more than 2 cm after avulsion. Reinsertion for adductor longus tendon avulsion injuries is usually performed by open repair using various anchor systems, while extensive avulsion injuries or non-unions of the apophysis of the lesser trochanter are treated by refixation by cannulated screw systems or resection and anchor refixation of the tendon. The postoperative outcome in most cases is described as good or very good (excellent). No major complications were reported in both groups.

Surgical versus conservative management of traumatic proximal adductor longus avulsion injuries: A systematic review

BACKGROUND

Proximal avulsion injuries of the adductor longus have been managed both conservatively and operatively with good clinical outcomes, but there is no consensus on which option yields the best results. Thus, the present study aimed to review the available literature, comparing the outcomes and the time to return to sports with different management options.

MATERIAL AND METHODS

This study was conducted according to the PRISMA statement. The literature search was conducted in September 2020. All the clinical trials investigating the management of traumatic proximal adductor longus avulsion injuries were considered for inclusion. Only studies reporting data from athletes were considered. The outcomes of interest were the time to return to sport and return to preinjury activity level.

RESULTS

Data from 46 patients were retrieved. The mean follow-up was 24.6 ± 23.8 months. The study population was represented by male athletes with a mean age of 30.0 ± 4.8. Mean stump retraction was 3.3 ± 0.6 cm in the surgical and 1.7 ± 0.6 in the conservative cohort (P = 0.07). The rate of patients returning to prior activity level was similar in the two groups, but surgically treated patients required a longer time to return to sport (3.9 ± 1.5 months vs. 2.2 ± 1.0 months, P = 0.0001).

CONCLUSION

Conservative management for traumatic avulsion of the proximal adductor longus insertion may produce shorter time to return to sport. Both conservative and operative strategies allowed to achieve similar pre-injury activity level.

LEVEL OF EVIDENCE

IV, systematic review.