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

Associations Between Hip Pathology, Hip and Groin Pain, and Injuries in Hockey Athletes: A Clinical Commentary

Femoroacetabular impingement (FAI), particularly cam morphology, is highly prevalent among elite hockey athletes. Moreover, hip and groin pain has become a common issue in hockey, with approximately 50% of European professional athletes reported to experience a hip or groin problem during a season. While most athletes will not miss training or competition due to this, restricted competitive performance and increased risk of reduced physical and psychological well-being are likely. Recent research suggests that the development of cam morphology is related to the repetitive shear stresses experienced at the hip joint during adolescence from skating. This condition likely increases the potential for intra-articular and extra-articular injuries in these athletes later in their careers. Research also indicates that the hip joint mechanics during forward skating substantially increase the possibility of sustaining a labral tear compared to other sports. Such an injury can increase femoral head movement within the joint, potentially causing secondary damage to the iliofemoral ligament, ligamentum teres and joint capsule. These injuries and the high density of nociceptors in the affected structures may explain the high prevalence of hip and groin pain in hockey athletes. Compensatory adaptations, such as reduced hip strength, stability, and range-of-motion (ROM) likely increase the opportunity for core muscle injuries and hip flexor and adductor injuries. Specifically, the limited hip ROM associated with cam morphology appears to exacerbate the risk of these injuries as there will be an increase in pubic symphysis stress and transverse strain during rotational movements. It is hoped that this article will assist practitioners currently working with hockey athletes to develop evidence-informed monitoring strategies and training interventions, aimed at reducing the incidence and severity of hip and groin problems, ultimately enhancing athlete performance and well-being. Therefore, the purpose of this clinical commentary was to examine current evidence on common hip pathologies in hockey athletes, exploring potential associations between hip and groin pain and the biomechanics of hockey activities.

Level of Evidence

5.

Dynamic Magnetic Resonance Imaging (MRI) in Inguinal-Related Chronic Groin Pain (CGP): Comparison With Systematic Surgical Assessment

Objective This study aimed to assess the performance of dynamic MRI in Chronic Groin Pain (CGP) related to the inguinal region, comparing it with surgery as the gold standard. Materials and methods A cohort of 25 consecutive patients exhibiting persistent clinical inguinal-related CGP underwent a pre-surgical pelvis MRI. Imaging encompassed strictly axial Fast Spin Echo (FSE) T1 sequences, both without (static sequence) and with Valsalva Maneuver (VM, dynamic sequence), alongside axial-oblique Proton Density weighted with Fat Saturation (PDFS). Evaluation of these sequences focused on identifying Abdominal Wall (AW) injuries. A consistent surgical approach was employed by the same surgeon across all patients (34 AW injuries in 25 patients). Specificity (Sp), Sensitivity (Se), Negative Predictive Value (NPV), Positive Predictive Value (PPV), and overall accuracy of MRI sequences and their combinations for detecting AW injuries were computed by comparing them to surgical findings. Results Ninety sequences were obtained, revealing that the axial PDFS oblique sequence emerged as the most singularly reliable (Accuracy: 58.82%). The optimal sequence combination was found to be axial T1 combined with axial T1 VM, exhibiting an accuracy of 75.00% (Se: 85.71%, Sp: 70.59%, PPV: 54.55%, NPV: 92.31%, with an average duration of 4 minutes and 31 seconds). Conclusion Based on our findings, we advocate for the adoption of the axial FSE T1 combined with Valsalva Maneuver as a dependable protocol for inguinal-related CGP, characterized by a highly reasonable examination duration.

Clinical outcomes of different muscle flap reconstruction after inguinal tumor resection: A case series

PURPOSE

To introduce the clinical outcomes of adductor longus and sartorius muscle transfer alone and combined application for reconstruction of the inguinal region.

METHODS

This is a retrospective study of patients between January 2019 and December 2022 who underwent adductor longus flap transfer, sartorius muscle flap transfer, and combined transfer of adductor longus and sartorius muscle. The demographic data and surgical details were recorded.

RESULTS

Sixteen patients were included, with a mean age of 57.5 years. Nine patients performed adductor longus flap transfers, three patients performed sartorius muscle flap transfers, and four patients performed combined transfers. The average operation time was 238 min. The average length of stay was 6.7 days. The average follow-up period was 9.6 months (range 6-16). The overall early postoperative complication rate was 12.5% (one patient had excessive wound exudation and one patient had a wound infection). No delayed postoperative complications occurred during the follow-up.

CONCLUSION

The sartorius muscle flap, the adductor longus flap, and the combined application are suitable techniques for inguinal region reconstruction under different conditions. The combined application of the two flaps can fill the dead space and cover the neurovascular bundle efficaciously.

Novel Use of Botulinum Toxin in Long-Standing Adductor-Related Groin Pain: A Case Series

BACKGROUND

Adductor-related groin pain (ARGP) is the most common groin injury in athletes. If conservative treatment fails, then adductor tenotomy to relieve tension can be considered. The use of botulinum toxin A (BoNT-A) has shown good results in other musculoskeletal pathologies.

OBJECTIVE

Assess the effectiveness of BoNT-A injections in ARGP in cases where usual treatment has failed.

DESIGN

Retrospective cohort study.

SETTING

Orthopedic Medicine and Rehabilitation Unit, University of Bordeaux.

PARTICIPANTS

Fifty patients treated by BoNT-A injection in ARGP after failure of medical and/or surgical treatment were included in this study.

INTERVENTIONS

One or several adductor muscles were injected with BoNT-A, according to clinical evaluation using ultrasound and electrical stimulation guidance. Patients were followed up at 1, 3, 6, and 12 months.

MAIN OUTCOME MEASURES

The primary assessment criterion was the improvement of Hip and Groin Outcome Score subscales at day 30. Secondary outcomes included pain intensity and impact on sport, work, and quality of life (QoL), the Blazina scale, and side effects.

RESULTS

All the first 50 injected patients (45 male and 5 female patients) were included. A significant improvement was noted regarding the majority of Hip and Groin Outcome Score subscales at day 30 ( P < 0.05). Pain intensity and its impacts were both significantly reduced ( P < 0.001): less sport and professional disability and lower impact on QoL. Severity of symptoms assessed by the Blazina scale was significantly reduced ( P < 0.001). The improvements remained significant until 1-year postinjection.

CONCLUSIONS

BoNT-A is promising as a new treatment for ARGP but should be fully assessed in a randomized controlled trial.

Ultrasound feature variants of the adductor longus tendon in asymptomatic sportive subjects: Management implications

OBJECTIVES

The potential contribution of ultrasound (US) to diagnose adductor longus (AL) tendinopathy in athletic pubalgia requires clarification. We investigate US findings from AL tendons of asymptomatic participants to identify the range and prevalence of common US features not associated with groin pain.

METHODS

We consecutively enrolled 45 volunteers physically active participants with no history of groin pain. US features of bilateral AL tendons were investigated and recorded by two experienced musculoskeletal radiologists (MSKR) in accordance with a defined ultrasound protocol. Two other MSKRs retrospectively and independently analyzed all US images.

RESULTS

Ninety AL tendons from 45 participants (4/45 women) were imaged (average age: 35 years ±14.6; dominant side: 37/45 (82.2%) right, 8/45 (17.8%) left). Abnormalities on US were found in all 45 (100%) AL tendons, including: abnormal echogenicity (98.9%/100% respectively according to reader), loss of fibrillar structure (92.2%/97.8%), irregularities of the superficial paratendon (23.3%/30%), calcifications (22.2%/25.5%), and cortical erosion (52%/55.5%), with excellent inter-observer assessment. No AL tears or hyperemia at color Doppler were detectable.

CONCLUSIONS

AL tendon abnormalities were identified via US in 100% of our asymptomatic athletes. The significance of these US findings should be interpreted cautiously with respect to clinical presentation. On the other hand, there is a need for supplemental investigation into the clinical relevance of US AL tendon tears not present in the present asymptomatic athlete population.

Hamstring autograft and anatomical footprint evaluation for anterior talofibular ligament reconstruction: Cadaveric study

PURPOSE

The aim of the study was to evaluate whether or not there was any incompatibility between two-strand hamstring tendons taken from the same knee and the ATFL and it was the determination of suitable footprint points in the fibula and talus for anatomical ATFL reconstruction.

METHODS

16 fresh frozen cadaver specimens were dissected to gracilis and semitendinosus tendons and the anterior talofibular ligament. The origins, insertions, distances from osseous landmarks of fibular talus of ATFL were determined. The diameters of gracilis, semitendinosus and ATFL were calculated. There was a moderate correlation between body height and the distance between the distal of inferior lateral malleolus and the fibular adhesion site of ATFL (r: 36.5 p: 0.036). There was a weak correlation between body height and the distance between the apex of the lateral talar process and the talus adhesion site of ATFL in a single bundle (r: 28.4 p: 0.002). There was no correlation between the distance from proximal and distal adhesion side of ATFL and body height in the double bundle (p: 0.241).

RESULTS

There was no significant relationship between ATFL diameter and gracilis, semitendinosus and both hamstring in women. A significant relationship at 80.5% was determined between the ATFL and the gracilis diameter in man. A significant relationship at 92.6% was determined between the ATFL and the semitendinosus diameter in man.

CONCLUSION

It was determined that there is not compatibility between the gracilis tendons, the semitendinosus tendon and ATFL in women. It should be supported by biomechanical and clinical studies whether this incompatibility has a clinical effect or not.

Hip Adductor Longus Tendon Origin Anatomy Is Consistent and May Inform Surgical Reattachment

Purpose

To define the topographic anatomy of the footprint of the adductor longus origin on the pubis and its underlying bony morphology to better inform surgical repair of adductor longus tendon injuries.

Methods

Five cadaveric pelvis specimens were dissected, making 10 adductor footprints available for analysis. The adductor longus tendon origin was isolated and the surrounding tissue debrided. The circumference of the tendinous attachment to the pubic crest was marked before excising the tendon and fibrocartilage enthesis from the pubis. Radiopaque paint was prepared by mixing 30 mL of all-purpose acrylic paint (Anita’s no. 11150 Island Blue; Rust-Oleum Corp, Vernon Hills, IL) with 15g of E-Z-HD 98% w/w barium sulfate (Bracco Diagnostics Inc., Anjou Quebec, Canada) and applied to the marked footprint. The specimens underwent a 1.0-mm slice computed tomographic scan with 3-dimensional reconstructions. Synapse PACS (FujiFilm, Valhalla, NY) software for measurements of the tendon footprint and underlying bone.

Results

Average age and weight of the specimens at the time of death was 37 years and 204.6 ± 48.7 lbs, respectively. The width and length of the tendon origin was 12.0 ± 1.1 mm and 10.9 ± 1.1 mm, respectively. The distance of the center of the footprint from the center of the pubic tubercle was 8.5 ± 1.4 mm lateral and 12.2 ± 0.4 mm caudal. The osseous thickness underlying the footprint was 18.7 ± 3.7 mm at an angle of 34.5 ± 1.5° in relation to the sagittal plane. The correlation between specimen body weight and the thickness of the bone underlying the footprint was strongly positive (r = 0.92).

Conclusions

We found that there is a consistent angle from the center of the adductor longus tendon footprint to the point of maximal underlying bony thickness, as well as a positive correlation between body mass index and osseous thickness, which may inform anatomic reattachment of this tendon.

Clinical Relevance

Our findings will assist surgeons in identifying the footprint of the adductor longus tendon and safely perform anatomic repair of adductor longus tendon avulsions.

Cross-Sectional Area Measurement Techniques of Soft Tissue: A Literature Review

Evaluation of the biomechanical properties of soft tissues by measuring the stress-strain relationships has been the focus of numerous investigations. The accuracy of stress depends, in part, upon the determination of the cross-sectional area (CSA). However, the complex geometry and pliability of soft tissues, especially ligaments and tendons, make it difficult to obtain accurate CSA, and the development of CSA measurement methods of soft tissues continues. Early attempts to determine the CSA of soft tissues include gravimetric method, geometric approximation technique, area micrometer method, and microtomy technique. Since 1990, a series of new methods have emerged, including medical imaging techniques (e.g. magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound imaging (USI)), laser techniques (e.g. the laser micrometer method, the linear laser scanner (LLS) technique, and the laser reflection system (LRS) method), molding techniques, and three-dimensional (3D) scanning techniques.

Surface Mapping of the Musculotendinous Attachments at the Pubic Symphysis in Cadaveric Specimens: Implications for the Treatment of Core Muscle Injury

PURPOSE

To characterize the 3-dimensional muscular, musculotendinous, and neurovascular anatomy about the pubic symphysis relevant to core muscle injury (CMI).

METHODS

Ten cadaveric hips were dissected to characterize the musculotendinous insertion of the rectus abdominis and inguinal ligament, origins of the adductor longus and adductor brevis, and the pubic cartilage plate. A 3-dimensional coordinate measuring system and data acquisition software were used to calculate structure cross-sectional area, and the landmark anatomical relationships to 1 another and relevant neurovascular structures.

RESULTS

All specimens were male with an average age of 62 ± 2 years. The mean footprints of the rectus abdominis, inguinal ligament, adductor longus, and adductor brevis were 8.4 ± 3.1, 1.2 ± 0.5, 3.8 ± 1.6, and 2.9 ± 1.3 cm², respectively. The mean pectineus and gracilis footprints were 6.3 ± 2.4 and 3.4 ± 0.9 cm², respectively. The mean cross-sectional area of the cartilage plate was 24.8 ± 5.6 cm². The adductor longus was an average 1.5 ± 0.25 cm from the adductor brevis and 0.69 ± 0.52 cm from the rectus abdominis. The genital branch of the genitofemoral nerve was an average of 4.3 cm (range, 2.8-6.4) lateral to the insertion of the inguinal ligament. The femoral vein and artery were 3.0 cm (range, 2.5-3.6) and 3.7 cm (range, 2.5-5.9) lateral to the inguinal ligament footprint. The obturator nerve was 2.5 cm (range, 1.6-3.4) lateral to the adductor longus.

CONCLUSIONS

Familiarity with the anatomy of the pubic symphysis is essential for surgeons treating patients with CMI. We have shown that this relatively small area is the site of many muscular, musculotendinous, and neurovascular structures with various sized footprints and described the 3-dimensional anatomy of the anterior pubic symphysis. The origin of the adductor longus lies in close proximity to other structures, such as the adductor brevis, the insertion of the rectus abdominis, and the obturator nerve. These findings should be considered when operating in this region and treating patients with chronic groin pain.

CLINICAL RELEVANCE

The anatomy of the pelvic region and pubic symphysis has not been well characterized. Intimate knowledge of relevant anatomy is essential to treating CMI, also known as athletic pubalgia or sports hernia.

Editorial Commentary: Core Muscle Injury: The Anatomy Is Enlightening

Core muscle injuries are being diagnosed with increasing frequency in athletes. Knowledge of the anatomy is key to understanding the pathology. Notably, the origin on the pubis of the majority of adductor long muscles is via direct insertion of the muscle to the bone and not via a tendon, thus making direct repair difficult.

Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings

Background

Muscle injuries affecting the Adductor Longus are not all localised at the level of the proximal myotendinous junction and enthesis. Thus, the main purpose of this article was to raise awareness of the imaging features of the Perivascular Adductor Longus muscle injury, which currently remains widely under-recognised.

Methods

The ultrasound (US) and Magnetic Resonance imaging (MRI) images of five professional football players were retrospectively reassessed to identify distinctive imaging details of the Perivascular Adductor Longus muscle injury. Complementary information regarding the traumatic mechanics is presented as well.

Results

All the players presented similar US images in the first seventy-two hours: loss of ecostructural integrity of the lateral epimysium, in proximity to the femoral vessels, and perilesional oedema were the main pathological findings. The injury lead to the formation of a hypoechoic, intramuscular haematoma in three of the subjects. Anyway, this was detectable only after five days, or later. Moreover, MRI sequences showed long-standing haematoma-related signal alterations which were also observable at three months after trauma. Typically, kicking was the traumatic motor task.

Conclusions

The main practical value of this technical note is to compensate for the lack of studies concerning the Perivascular Adductor Longus muscle injury. Promptly identifying its typical imaging features is crucial in order to establish the correct diagnosis and to implement a highly specific rehabilitative program.

Level of evidence

V.

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.

Magnetic Resonance Imaging of Nonneoplastic Musculoskeletal Pathologies in the Pelvis

Musculoskeletal pathologies in the pelvis encompass a wide variety of lesions including femoroacetabular impingement, athletic pubalgia, ischiofemoral impingement, and apophyseal avulsion injuries. Magnetic resonance imaging is the noninvasive imaging modality of choice for the diagnosis and management of these lesions. In this article, the authors discuss the nonneoplastic musculoskeletal lesions in the pelvis, with illustrations and relevant case examples.

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.

Distal rupture of the adductor longus in a skier

Acute adductor longus ruptures occur infrequently and have been rarely described in the literature. Schlegel et al. reviewed a series of adductor longus tendon ruptures and found that all ruptured proximally. A 42-year-old man with right hip pain 3 weeks following a skiing injury underwent magnetic resonance imaging (MRI), which demonstrated a distal adductor longus avulsion. The diagnosis of acute adductor longus injury can be difficult on physical examination alone, but MRI can accurately depict the site of injury. Surgery may be indicated for a proximal avulsion, but a distal injury may heal with nonoperative treatment, as in our case.

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Current concepts of inguinal-related and adductor-related groin pain

Groin pain encompasses a number of conditions from the lower abdomen, inguinal region, proximal adductors, hip joint, upper anterior thigh and perineum. The complexity of the anatomy, the heterogeneous terminology and the overlapping symptoms of different conditions that may co-exist epitomise the challenges in diagnosis and treatment. Inguinal-related and adductor-related pain is the most common cause of groin pain and will be discussed in this article.

Imaging of adductor-related groin pain

Groin pain is a common condition in athletes and results from various causes. Osteitis pubis, adductor dysfunction, inguinal hernia, or a combination of all three entities, generally explains the onset of symptoms. Adductor longus tendinopathy is the main cause of adductor-related groin pain. It leads to a significant reduction of sports participation and can require surgical management. Diagnosis is based on ultrasonography and magnetic resonance imaging. Asymptomatic findings (tendinosis, calcifications, cortical erosions) are common in athletes and care should be taken when assessing groin pain. The most specific sign of tendinopathy is an intratendinous tear of the adductor longus.

"Superior cleft sign" as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman's hernia

OBJECTIVE

We describe a new imaging sign, the "superior cleft sign", identified at both symphysography and MRI, which should be used as a marker of rectus abdominis/adductor longus attachment tearing.

MATERIALS AND METHODS

A study population of 25 patients presenting with clinically suspected sportsman's hernia, who had undergone both symphysography and MRI of the groin were included for study. In each case, images were reviewed to determine the presence of a superior cleft, secondary cleft, and or both abnormalities.

RESULTS

Images of all patients complaining of groin crease discomfort similar to sportsman's hernia revealed the presence of a superior cleft at the rectus abdominis/adductor longus attachment. This "superior cleft sign" correlated with the side of symptoms in each case, and, in contrast to the previously described secondary cleft along the inferior margin of the inferior pubic ramus, occurred parallel to the inferior margin of the superior pubic ramus.

CONCLUSIONS

The presence of the "superior cleft sign" should be sought in addition to the previously described secondary cleft sign in sportspeople presenting with exercise-related groin pain or pubalgia. It should specifically be sought in patients referred with suspected sportsman's hernia.

Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes

BACKGROUND

Chronic adductor enthesopathy is a well-known cause of groin pain in athletes. Currently, percutaneous nonselective adductor tenotomies give mixed results and not always predictable outcomes.

HYPOTHESIS

A selective partial adductor longus release as treatment for recalcitrant chronic adductor longus enthesopathy provides excellent pain relief with a prompt and consistent return to preinjury levels of sport.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All athletes were assessed in a standard way for adductor dysfunction. They received radiographs and a specifically designed magnetic resonance imaging groin study protocol. Only professional athletes who received a selective partial adductor release were included. Pain and functional improvement were assessed with the visual analog scale (VAS) pain score and time to return to sport.

RESULTS

Forty-three professional athletes (39 soccer and 4 rugby) with chronic adductor-related groin pain were treated with a selective partial adductor release. The average follow-up time was 40.2 months (range, 25-72 months). Forty-two of 43 athletes returned to their preinjury level of sport after an average of  9.21 weeks (range, 4-24 weeks; SD, 4.68 weeks). The preoperative VAS score improved significantly (Wilcoxon signed-rank test, P < .001) from 5.76 ± 1.08 (range, 3-8) to 0.23 ± 0.61 (range, 0-3) postoperatively.

CONCLUSION

A selective partial adductor longus release provides excellent pain relief for chronic adductor enthesopathy in professional athletes with a consistent high rate of return to the preinjury level of sport.

Hip pain from the orthopeadic point of view

The hip and its disorders represent a clinical, diagnostic and therapeutic challenge greater than any other joints. Clinical symptoms are usually non specific and provocative maneuvers are sometimes unreliable, pain might be referred even from other joints and many times accurate assessment need imaging techniques. New surgical options, especially the latest development of hip arthroscopy has open horizons for treating intraarticular disorders. In this review article we will review basic clinical assessment and what we need as orthopeadic surgeons from radiology.

Is percutaneous adductor tenotomy as effective and safe as the open procedure?

BACKGROUND

Percutaneous adductor longus tenotomy (PAT) is a frequently used procedure, yet no study has ever compared its effectiveness and safety with those of open adductor longus tenotomy (OAT). We conducted this prospective study to describe the effects of PAT and to compare them with those of OAT.

METHODS

This consisted of a cross-over randomized controlled trial including 50 consecutive hips from 27 patients with cerebral palsy scheduled for adductor tenotomy in the setting of multilevel tendon lengthening/release procedures or hip surgery (femoral or Dega osteotomy) in a university hospital. A pediatric orthopaedic surgeon conducted a PAT. Another surgeon extended the wound to explore what had been cut during the PAT, and completed the tenotomy if necessary. Hip abduction (HA) was assessed by a third surgeon immediately before PAT, after PAT, and then after OAT, using a goniometer, in a standardized reproducible manner. All 3 surgeons were blinded to the others' findings. Primary end-points included the percentage of tendon/muscle portion sectioned percutaneously, and the HA measure. Comparison between HA after PAT and OAT was done using a paired t-test with a 95% confidence interval. The influence of anatomic variants of adductor longus origin was also assessed.

RESULTS

Mean HA (hips flexed) measured 40.36 degrees preoperatively and increased to 50.04 degrees after PAT (P<0.0001). After OAT, HA averaged 53.32 degrees with no statistical gain compared with that observed after PAT (P=0.2). The tendinous portion of adductor longus was cut to an average of 98% by PAT (completely in 46 cases and more than 75% in only 4 cases). The muscular portion of adductor longus origin was cut to an average of 83.7% (completely in only 15 cases, cut to more than 75% in 26 cases, and approximately 50% in 9 cases). The gain in HA positively correlated with the extent of the tendinous portion divided (P=0.03) but not with the extent of muscular portion divided. Results were independent of the anatomic variants of adductor longus origin. Partial section of adductor brevis after PAT was encountered in 6 cases. No major iatrogenic lesion was observed (obturator nerve, major vessels).

CONCLUSIONS

This is the only prospective study concerning the effects of PAT. The anatomic factor associated with gain in HA seems to be the extent of the section of the tendinous portion of adductor longus origin, which was found to be cut to more than 90% in all cases after PAT. The extent of muscular portion section does not seem to influence the gain in HA. The researchers detail the technique of percutaneous adductor tenotomy and show that when done correctly, PAT is a fast and simple procedure, as reliable and effective as the open release and without any major risks.

LEVEL OF EVIDENCE

Level II therapeutic study-prospective comparative study.

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.

Differential diagnosis of pain around the hip joint

The differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology, and mimickers, including the joints of the pelvic ring. With the current advancements in hip arthroscopy, more patients are being evaluated for hip pain. In recent years, our understanding of the functional anatomy around the hip has improved. In addition, because of advancements in magnetic resonance imaging, the diagnosis of soft tissue causes of hip pain has improved. All of these advances have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. In this review, we discuss the causes of intra-articular hip pain that can be addressed arthroscopically: labral tears, loose bodies, femoroacetabular impingement, capsular laxity, tears of the ligamentum teres, and chondral damage. Extra-articular diagnoses that can be managed arthroscopically are also discussed, including: iliopsoas tendonitis, "internal" snapping hip, "external" snapping hip, iliotibial band and greater trochanteric bursitis, and gluteal tendon injury. Finally, we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture, adductor strain, piriformis syndrome, sacroiliac joint pain, athletic pubalgia, "sports hernia," "Gilmore's groin," and osteitis pubis.