MR Imaging of Sports-Related Groin Pain

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.

ACR Appropriateness Criteria® Chronic Hip Pain: 2022 Update

Chronic hip pain is a frequent chief complaint for adult patients who present for evaluation in a variety of clinical practice settings. Following a targeted history and physical examination, imaging plays a vital role in elucidating the etiologies of a patient's symptoms, as a wide spectrum of pathological entities may cause chronic hip pain. Radiography is usually the appropriate initial imaging test following a clinical examination. Depending on the clinical picture, advanced cross-sectional imaging may be subsequently performed for further evaluation. This documents provides best practice for the imaging workup of chronic hip pain in patients presenting with a variety of clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Magnetic resonance imaging of muscle injury in elite American football players: Predictors for return to play and performance

Muscle injury accounts for about one-third of total sports-related injuries. The lower limb muscles have one of the highest predisposition for injury in high-level professional athletic sports, such as the National Football League. The commonest group of muscles injured among football players include the hamstrings, followed by the quadriceps. Muscle injuries lead to significant time, off the field and affect return to play. Sports physicians and teams have been keen on assessing such injuries and also relying on multiple tools to safely return the player back to the field. MRI plays a key role in evaluation, follow-up, and assessment for return to play (RTP). In this review, we will discuss details of muscle anatomy, incidence of muscle injuries, injury mechanisms, and use of MRI in assessment, grading, follow-up and in predicting the natural course of muscle injuries in the high-end athletic players. While the use of MRI is clear in diagnosis, and for follow up of muscle injuries, there is some limitation in its ability to predict RTP, based on current MRI classification systems. Footballers who have clinical injuries without MRI evidence of significant muscle injury (grade 0 and 1) have a shorter period of RTP. Injuries classified as high grade (3 and 4) on MRI do not correlate well with time to RTP. Further trials are required to improve the capability of MRI in its prediction of RTP.

Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management

Synopsis Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.

Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27 years (range 18-37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo-tendinous junction (MTJ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI, with avulsion injuries accounting for three-quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine

PURPOSE

To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine.

METHODS

Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI).

RESULTS

AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI.

CONCLUSIONS

Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis.

LEVEL OF EVIDENCE

Level IV, prognostic study-case series.

The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain

Context:

In active individuals with femoroacetabular impingement (FAI), the resultant reduction in functional range of motion leads to high impaction loads at terminal ranges. These increased forces result in compensatory effects on bony and soft tissue structures within the hip joint and hemipelvis. An algorithm is useful in evaluating athletes with pre-arthritic, mechanical hip pain and associated compensatory disorders.

Evidence Acquisition:

A literature search was performed by a review of PubMed articles published from 1976 to 2013.

Level of Evidence:

Level 4.

Results:

Increased stresses across the bony hemipelvis result when athletes with FAI attempt to achieve supraphysiologic, terminal ranges of motion (ROM) through the hip joint required for athletic competition. This can manifest as pain within the pubic joint (osteitis pubis), sacroiliac joint, and lumbosacral spine. Subclinical posterior hip instability may result when attempts to increase hip flexion and internal rotation are not compensated for by increased motion through the hemipelvis. Prominence of the anterior inferior iliac spine (AIIS) at the level of the acetabular rim can result in impingement of the anterior hip joint capsule or iliocapsularis muscle origin against the femoral head-neck junction, resulting in a distinct form of mechanical hip impingement (AIIS subspine impingement). Iliopsoas impingement (IPI) has also been described as an etiology for anterior hip pain. IPI results in a typical 3-o’clock labral tear as well as an inflamed capsule in close proximity to the overlying iliopsoas tendon. Injury in athletic pubalgia occurs during high-energy twisting activities in which abnormal hip ROM and resultant pelvic motion lead to shearing across the pubic symphysis.

Conclusion:

Failure to recognize and address concomitant compensatory injury patterns associated with intra-articular hip pathology can result in significant disability and persistent symptoms in athletes with pre-arthritic, mechanical hip pain.

Strength-of-Recommendation Taxonomy (SORT):

B

Use of ultrasonography as a diagnostic and therapeutic tool in sports medicine

Ultrasonography has many important advantages over other imaging modalities and many important applications in sports medicine. This article presents an evidence-based discussion of the use of ultrasound technology to diagnose and treat common musculoskeletal disorders, with emphasis on the shoulder, elbow, hip, knee, and foot and ankle. Topics include basic principles, scan artifacts, the appearance of musculoskeletal structure characteristics and pathologies, and various diagnostic and therapeutic applications in sports medicine.

Imaging assessment of groin pain

Groin pain is a common condition in athletes, especially those who play certain sports, for instance soccer, ice hockey, fencing which request rapid acceleration and frequent changes of movement. This condition represents a diagnostic difficulty for the radiologist due to either the anatomical pubic region complexity than the many causes that can be a source of pain, because the groin pain can be determined by conditions affecting the bony structures, cartilage and muscle tendons that are part of the proper pubis but also from those involving the hip. The approach to the groin through diagnostic imaging is multidisciplinary: The study of the patient is performed by traditional radiographs, ultrasound examination, magnetic resonance imaging or computed tomography, based on clinical suspicion, and each of these methods provides different results depending on the disease in question. The purpose of this article is to examine what are the optimal imaging techniques to investigate the various diseases affecting the patient with groin pain.

Imaging of sports-related hip and groin injuries

A normally functioning hip joint is imperative for athletes who use their lower extremities with running, jumping, or kicking activities. Sports-related injuries of the hip and groin are far less frequent than injuries to the more distal aspect of the extremity, accounting for less than 10% of lower extremity injuries. Despite the lower incidence, hip and groin injuries can lead to significant clinical and diagnostic challenges related to the complex anatomy and biomechanical considerations of this region. Loads up to 8 times normal body weight have been documented in the joint in common daily activities, such as jogging, with significantly greater force expected during competitive athletics. Additionally, treatment for hip and groin injuries can obviate the participation of medical and surgical specialties, with a multidisciplinary approach frequently required. Delay in diagnosis and triage of these injuries may cause loss of time from competition and, potentially, early onset of degenerative changes. Magnetic resonance imaging (MRI) of the hip has proven to be the gold standard for the diagnosis of sports-related hip and groin injuries in the setting of negative radiographs. With its exquisite soft tissue contrast, multiplanar capabilities, and lack of ionizing radiation, MRI is unmatched in the noninvasive diagnosis of intra-articular and extra-articular pathology, as well as intraosseous processes. This review focuses on MRI of common athletic injuries of the hip and groin, including acetabular labral tears, femoral acetabular impingement syndrome, muscle injuries around the hip and groin (including athletic pubalgia), and athletic osseous injuries.

Hip and Groin Pain in the Professional Athlete

Hip and groin pain is a common condition in professional athletes and may result from an acute injury or from chronic, repetitive trauma. It is responsible for significant morbidity, which leads to time away from training and competition, and may result in a career-ending injury. The anatomic and biomechanical causes for hip and groin injuries are among the most complex and controversial in the musculoskeletal system. This makes clinical differentiation and subsequent management difficult because of the considerable overlap of symptoms and signs. This review article will evaluate several pathologic conditions of the hip and groin in athletes, divided into acute (secondary to single event) and chronic (secondary to altered biomechanical load or repetitive microtrauma) injuries, with an emphasis on imaging in the diagnosis of these injuries. Appropriate use of imaging along with clinical findings can allow accurate diagnosis and subsequent appropriate management of these patients to ultimately allow return to athletic activity.

Hip and groin pain in adolescents

A variety of disorders may result in hip or groin pain, particularly in adolescents who partake in sports. Both intra-articular and extra-articular pathologies should be considered. We will review a select group of abnormalities that are gaining recognition in this age group.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series

STUDY DESIGN

A case series of 6 athletes with a suspected sports hernia.

BACKGROUND

Groin pain in athletes is common, and 1 source of groin pain is athletic pubalgia, or a sports hernia. Description of this condition and its management is scarce in the physical therapy literature. The purpose of this case series is to describe a conservative approach to treating athletes with a likely sports hernia and to provide physical therapists with an algorithm for managing athletes with this dysfunction.

CASE DESCRIPTION

Six collegiate athletes (age range, 19-22 years; 4 males, 2 females) with a physician diagnosis of groin pain secondary to possible/probable sports hernia were referred to physical therapy. A method of evaluation was constructed and a cluster of 5 key findings indicative of a sports hernia is presented. The athletes were managed according to a proposed algorithm and received physical therapy consisting of soft tissue and joint mobilization/manipulation, neuromuscular re-education, manual stretching, and therapeutic exercise.

OUTCOMES

Three of the athletes received conservative intervention and were able to fully return to sport after a mean of 7.7 sessions of physical therapy. The other 3 athletes reached this outcome after surgical repair and a mean of 6.7 sessions of physical therapy.

DISCUSSION

Conservative management including manual therapy appears to be a viable option in the management of athletes with a sports hernia. Follow-up randomized clinical trials should be performed to further investigate the effectiveness of conservative rehabilitation compared to a homogeneous group of patients undergoing surgical repair for this condition.

LEVEL OF EVIDENCE

Therapy, level 4.

Analysis of the cross-sectional area of the adductor longus tendon: a descriptive anatomic study

BACKGROUND

Strain injury to the adductor longus muscle is a common cause of groin pain in athletes and generally occurs in the proximal portion of the muscle, near its origin from the anterior aspect of the pubis. The composition and cross-sectional anatomy of this muscle's origin has not been previously described.

HYPOTHESIS

We hypothesize that the adductor longus muscle origin is composed mainly of muscle fibers and that the tendon composes only a small part of the cross section at the origin of the muscle.

STUDY DESIGN

Descriptive laboratory study.

METHODS

We harvested 42 adductor longus muscles from 28 cadavers and measured the cross-sectional dimensions of the tendon with microcalipers. Next, we determined the relative contributions of the tendon and muscle fibers to the cross-sectional anatomy of the muscle using optical scanning. These 2 sets of measurements were obtained at 3 locations: at the muscle origin and 1.0 and 2.0 cm distal to the origin.

RESULTS

The average length and width of the tendon was 11.6 and 3.7 mm, respectively, at the origin. The average cross-sectional areas of the tendon were 49.3, 27.9, and 25.7 mm(2) at points 0.0, 1.0, and 2.0 cm from its origin, respectively. The origin of the adductor longus muscle was composed of 37.9% tendon and 62.1% muscle tissue. At 1.0 cm from the origin, the percentage of tendon decreased to 34%. At 2.0 cm from the origin, the tendon composed 26.7% of the cross section.

CONCLUSION

The cross-sectional area of the tendon of the adductor longus muscle is relatively small. The muscle origin is composed predominantly of direct attachment of muscle fibers.

CLINICAL RELEVANCE

Knowledge of the cross-sectional anatomy of the adductor longus muscle at its origin may help clinicians better understand the complex nature of injuries in this area.

Hip pain in adults: MR imaging appearance of common causes

To determine the exact origin of hip pain can be challenging. Symptoms apparently originating from the hip may arise from the pelvis, the sacroiliac joint, the lumbar spine, periarticular structures such as muscles and bursae, or from unexpected sites such as the abdominal wall, the genitourinary tract, or the retroperitoneal space. This article reviews the differential diagnosis of hip pain arising from the hip and surrounding structures and the role of different imaging methods with emphasis on magnetic resonance imaging where most recent advances have occurred.