MR imaging of sports-related hip disorders

Hip apophyseal injuries in soccer players: can MRI findings be useful to define when to return to play?

OBJECTIVE

To describe magnetic resonance imaging (MRI) findings in professional soccer players with acute apophyseal injury of the hip and to assess their relationship with return to sports.

MATERIAL AND METHODS

Adolescent soccer players with diagnosis of apophyseal injury in the anterosuperior and anteroinferior iliac spine were retrospectively evaluated between 2008 and 2016. All athletes underwent hip MRI examination within 4 days after onset of clinical complaint. Images were independently analyzed by two radiologists. Medical records were reviewed to obtain clinical data.

RESULTS

Mean displacement of the apophysis was 4.8 ± 4.6 mm. Bone edema was present in 82% of athletes and muscular edema in 41%. The mean time to return to sports was 37.3 ± 14.7 days. The difference between the measurements of the two radiologists was close to zero with agreement limits below 1.0 mm (p < 0.001). There was a significant correlation between displacement of the apophysis and return to sports, as well as between both and the presence of muscular edema. A displacement of the apophysis of 3.0 mm might serve as a parameter to predict return to sports/activity before 40 days, with a sensitivity of 92% and specificity of 96%, considering conservative physiotherapy treatment.

CONCLUSION

Displacement of the apophysis and presence of muscular edema evaluated by MRI showed a significant correlation with return to sports in athletes with acute apophyseal injuries of the anterosuperior and anteroinferior iliac spines.

The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept

PURPOSE

Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.

METHODS

A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.

RESULTS

The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.

CONCLUSION

The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Imaging of groin pain

Groin pain is a commonly encountered problem in musculoskeletal radiology. The diagnosis can be difficult to establish, based on the complex interconnected anatomy at the pubic symphysis and surrounding structures. The differential diagnosis is therefore broad, and diagnostic imaging is crucial in reaching the correct diagnosis, thus allowing appropriate therapy to be instituted. This article reviews the relevant anatomy and differential diagnoses encountered in overuse injuries of the groin. The common mechanisms of injury, presenting symptoms, and imaging findings for each diagnosis are addressed.

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.

Role of hip arthroscopy in the diagnosis and treatment of hip joint pathology

PURPOSE

Hip arthroscopy is growing in importance and relevance in the detection and treatment of various pathologies affecting the hip joint. There are a number of indications, including diagnosis and treatment of labral tears, extraction of loose bodies, and synovial-based diseases. Reports in the literature cite few complications arising from this minimally invasive procedure in a joint that has been difficult to access. The purpose of our study was to assess the efficacy and role of hip arthroscopy in the management of hip joint pathology.

TYPE OF STUDY

Retrospective review of a consecutive series of 22 patients over a 44-month period.

METHODS

The indications for surgery included ongoing hip pain for more than 6 months. Sixteen patients underwent contrast-enhanced magnetic resonance imaging scans, including all patients with mechanical symptoms. The procedure was performed as day surgery and all the patients were available for follow-up. They were assessed for pain, mechanical symptoms, activity levels, and sporting activities.

RESULTS

All patients were assessed by means of a questionnaire and allocated scores out of a maximum of 100 points. The most significant improvement was seen in the group of patients (n = 10) who had mechanical symptoms with definite labral pathology confirmed and treated arthroscopically. Their scores improved from an average of 64 preoperatively to 90 postoperatively. There were no complications in our series.

CONCLUSIONS

Hip arthroscopy represents an effective tool in treating hip joint pathology with reasonable expectations of success and a minimal complication rate.

LEVEL OF EVIDENCE

Level IV.

Groin injuries and groin pain in athletes: part 1

Sports injuries to the hip and groin region have been noted in 5% to 9% of high school athletes. These injuries occur most commonly in athletes participating in sports involving side-to-side cutting, quick accelerations and decelerations, and sudden directional changes.Symptoms may range from intermittent episodes of mild discomfort to severe and chronic career-ending pain. Groin injuries may result from a variety of causes. Although this article deals mainly with athletic etiologies, the physician must keep in mind that many other medical conditions may also affect the groin. Because of these overlapping medical conditions and because the anatomy of the region is so complex, a team approach is optimal. In Part 1 of this two-part series, ligament/muscle strains, nerve entrapment syndromes, and posterior abdominal wall abnormalities are reviewed as common causes of groin pain.