Sportsman's groin: importance of a multidisciplinary approach Poster No.:

P-0139

Congress:

ESSR 2013

Type:

Scientific Exhibit

Authors:

S. G. Cross, A. Rastogi, M. Ahmad, E. Carapeti, S. Marsh, R. Jalan; London/UK

Keywords:

Athletic injuries, Education, MR, Musculoskeletal system, Musculoskeletal soft tissue

DOI:

10.1594/essr2013/P-0139

Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.essr.org

Page 1 of 44

Purpose Purpose: • • •

Define a diagnostic and management algorithm for the "sportsman's groin". Evaluate the need for a multidisciplinary approach involving the surgeon, radiologist, physiotherapist and sport's physician. Assess the role of 3T MRI imaging as a comprehensive early diagnostic tool.

Methods and Materials • • •

Definition of Sportsman's Groin remains controversial. No clear agreement on either the name or exact underlying problem Although common and debilitating it remains a challenging diagnostic and management dilemma

We present our experience of managing groin pain in the context of a Tertiary Referral Centre. Eliciting the true cause of groin pain from a wide differential requires a multidisciplinary approach in both diagnosis and subsequent treatment. We will demonstrate the importance of 3 Tesla MRI in diagnosing true "Sportman's Groin" from other conditions that may be contributing to symptoms. Images for this section:

Page 2 of 44

Fig. 1: Sportsman's Groin and other mimicking conditions

Page 3 of 44

Results True Sportman's Groin: Traditionally, "Athletic Pubalgia" has encompassed a broad range of conditions, figure 2, anyone of which may be contributing to the patient's symptoms. This, combined with non specific signs on clinical examination, may result in inaccurate diagnosis and treatment. Rectus Abdominis/Adductor Longus Aponeurotic tears have been found to be a significant cause of pain in the "sportman's groin"(figure 3 blue arrow)[1, 2]. We have found that thorough clinical examination by experienced clinicians, together with evaluation of the groin with 3 Tesla MRI produces a comprehensive differential of diagnoses. Further re -evaluation of the patient following imaging allows a targeted and individualized approach to further management

Initial Consultation: Detailed clinical history and examination by experienced Surgeon/Sports Medicine Physician. Investigations for further evaluation of Groin pain include Plain Radiographs, 3T Tesla MRI and Ultrasound. Clinical Symptoms of the "Sportman's Groin": • • •

Groin pain which may be aggravated by running, sprinting, twisting, turning, coughing or sneezing Rarely history of sudden pain, usually a more gradual onset secondary to overuse injury Stiffness or pain in groin following exercise, which persists despite periods of rest or lay-off

Clinical Examination: • • • •

Objective physical findings often sparse Often no clinically detectable lump or hernia Dilated superficial inguinal ring may be visible Tenderness of adductor longus origin and/or positive adductor 'squeeze' test (pain and inhibition when asked to squeeze the legs together against resistance

Page 4 of 44

•

Reduced range of movement in lumbar spine, pelvis or hip

Investigations: 3 Tesla MRI of Groin and Pelvis Sequence

Voxel size (mm)

TE (ms)/TR (ms) / Flip Angle (°)

Coronal T1W TSE Large pelvis

0.9 x 0.7 x 4

10/639/150

Coronal STIR pelvis Large

1.3 x 1 x 4

33/4290/141

Axial T1 TSE pelvis Large

1 x 0.8 x 4

21/612/132

Axial STIR pelvis

1.1 x 0.9 x 4

33/4440/123

1.4 x 1 x 4

99/4880/140

Axial PD oblique Small TSE right and left

0.8 x 0.6 x 4

31/2290/150

Axial oblique T2 fat Small saturation TSE

0.8 x 0.6 x 4

97/3810/140

Sagittal T2 saturation TSE

0.8 x 0.6 x 4

97/3050/140

Axial T2 saturation TSE

FOV

Large fat Large

fat Small

We have found that the key sequences that yield the most information are shown in figure 4. Treatment of Rectus Abdominis/Adductor Longus Aponeurotic Tears: Groin Reconstruction Surgery: "The surgery itself relies on identifying pathology, releasing tension and restoring anatomy" International Hernia Conference 2012 Surgical Technique - Marsh Modification of the Gilmore Technique (Reference 3): Key steps in groin reconstruction with tension release:

Page 5 of 44

• • • • • • •

Inguinal ligament tenolysis Plication of posterior wall Resuturing conjoint tendon to inguinal ligament 2/0 prolene darn (permanent) Closure of Scarpa's fascia Skin closure NB: the use of artificial mesh is NOT indicated

Referral for Rehabilitation: Traditional 4 week program (3-4 weeks for Professionals and 6-8 weeks for Amateurs). 4 Key Stages in rehabilitation are as follows: Stage 1: Mobility Stage 2: Flexibility Stage 3: Strength Stage 4: Sport specific -------------------------------------------------------------------------------We present a number of case studies that illustrate the importance of a Multidisciplinary team approach to the diagnosis, imaging and treatment of the "sportsman's groin" and other mimicking conditions. CASE STUDY 1: History: 35 yr old male presents with bilateral groin pain. Past medical history of bilateral inguinal hernia mesh repairs in 2006. Pain similar to previously, with gradual onset and aggravated by all types of exercise. Examination: Dilated superficial inguinal rings bilaterally, with a bulge posteriorly Working Diagnosis:

Page 6 of 44

Persistent groin disruption inadequately treated by Inguinal mesh repairs Investigations: 3T MRI of pelvis and groins fig. 5-7

Fig. 5: Coronal T1W image of pelvis: Demonstrates bilateral mesh repairs from previous bilateral inguinal hernia repairs (white arrows). These are intact. References: The Gilmore Groin & Hernia Clinic

Page 7 of 44

Fig. 6: Coronal STIR image of pelvis slightly more posteriorly Demonstrates hyperintense signal extending along the midline at the symphysis pubis in keeping with bilateral rectus abdominis/adductor longus aponeurotic tears (white arrows). References: The Gilmore Groin & Hernia Clinic

Page 8 of 44

Fig. 7: Sagittal T2 fat saturated image of pelvis: demonstrates linear hyperintensity in keeping with rectus abdominis - adductor longus aponeurotic tear (white arrow). The adductor tendon is thickened but intact (blue arrow).

Page 9 of 44

References: The Gilmore Groin & Hernia Clinic Diagnosis: Bilateral rectus abdominis-adductor longus aponeurotic tears, which correlated with symptoms of bilateral groin pain. No migration of mesh repairs. Treatment: Bilateral Groin Reconstruction Surgery (as described previously). Physiotherapy Teaching/Discussion Points from Case study 1: Illustrates the importance of the use of high resolution 3T MRI in identification of aponeurotic tears -----------------------------------------------------------------------------CASE STUDY 2: History: 47 yr old male complaining of right groin pain. History of previous Inguinal Hernia Mesh Repair in 2010. Pain aggravated by exercise and coughing. Examination: Nil of note, scar from previous hernia repair on right but no significant bulge. Working Diagnosis: Possible displaced Mesh with persistent groin disruption? Investigations: 3T MRI, fig 8,9

Page 10 of 44

Fig. 8: Axial T2W image of pelvis- demonstrates disruption of the right mesh repair (black arrow). Note the increased stranding in the surrounding soft tissues compared to normal left side References: The Gilmore Groin & Hernia Clinic

Page 11 of 44

Fig. 9: Axial T2 Fatsaturated image of pelvis during Valsalva maneouvre - Confirms disruption of the right mesh repair with inflammatory soft tissue stranding (white arrow) References: The Gilmore Groin & Hernia Clinic Diagnosis: Right inguinal Mesh Repair Disruption Treatment: Right sided Groin Reconstruction following Mesh Removal Physiotherapy Teaching/Discussion Points from Case Study 2:

Page 12 of 44

Dynamic MRI scanning as well as post contrast scanning are useful in detection of primary hernia and post operative complications ------------------------------------------------------------------------------CASE STUDY 3: History: 52 yr old male with bilateral groin pain, worse on the right than the left. Had undergone bilateral inguinal hernia mesh repair 6 weeks with no improvement in symptoms. Examination: Scars over both inguinal ligaments. Postive impingement test for FAI. Nil else of note. Working Diagnosis: Possible Groin Disruption, Osteoarthritis/FAI Investigation: 3T MRI Figures 10, 11

Page 13 of 44

Fig. 10: Axial STIR image of pelvis: Note the marker capsule placed at site of maximal symptoms (red arrow) There is Femoroacetabular Impingment (FAI) with secondary Osteoarthritis. Note the right hip joint effusion with fluid extension into the right iliopsoas bursa (blue arrow). Abnormal signal hyperintensity at the site of the recent bilateral mesh hernia repairs in keeping with post operative change (white arrow) References: The Gilmore Groin & Hernia Clinic

Page 14 of 44

Fig. 11: Coronal STIR image of pelvis: Demonstrates secondary degenerative changes within the right hip joint as evidenced by the joint effusion, loss of joint space, subchondral sclerosis and cyst formation. Note the underlying CAM deformity at the right femoral head/neck junction (black arrow). References: The Gilmore Groin & Hernia Clinic Diagnosis: Intact Bilateral Mesh Repairs. Bilateral CAM type Femoro-acetabular impingement with established secondary osteoarthritis of both hip joints, worse on the right Treatment: Referral for Further evaluation and Treatment of FAI

Page 15 of 44

TEACHING/DISCUSSION POINTS FROM CASE STUDY 3: Referred pain from hips mimicking groin pain from hernia origin. This case illustrates the importance of accurate clinical history and examination together with MRI identifying the true cause for this patient's original symptoms -------------------------------------------------------------------------------CASE STUDY 4: History: 30 yr old male footballer with right groin pain. Initially brought on by stretching but no specific triggering incident. Now pain on sneezing, coughing and turning in bed. Limited to low intensity footballing only. Examination: Tenderness at right adductor origin on squeezing. Wide dilation of the tender right superficial inguinal ring Working diagnosis: Right Groin disruption and possible additional Adductor tear Investigation: 3T MRI of pelvis and Right Groin Figure 12

Page 16 of 44

Fig. 12: Sagittal oblique T2 fat saturated image of pelvis just parasagittal to symphyseal midline: Demonstrates a right sided rectus abdominis -adductor longus aponeurotic tear. Note the linear high signal defect at the anterior aspect of the pubis (white arrow). The adductor tendon was intact

Page 17 of 44

References: The Gilmore Groin & Hernia Clinic Diagnosis: Right Rectus Abdominus/Adductor Longus Aponeurotic Tear Intact right Adductor Origin Treatment: Right Groin reconstruction Surgery Physiotherapy Teaching Points of Case study 4: Illustrates how MRI can be instrumental in shaping the decision making process regarding Operative or Non operative management in these patients. -------------------------------------------------------------------------------CASE STUDY 5: History: 45 yr old male International Ironman Competitor with right groin pain. Persistent tightness in right groin. Past history of bilateral Sportsman's Groin repair in 2009 Examination: Both groins intact. Nil of note Working Diagnosis: Right Adductor Strain Investigation: 3T MRI of pelvis and Groin Figure 13-15

Page 18 of 44

Fig. 13: Coronal STIR of pelvis: Demonstrates hyperintense signal insinuating between the left pubic bone and the retracted left adductor longus tendon (white arrow). Features are in keeping with Left adductor origin avulsion. Note however the normal, but symptomatic right adductor origin References: The Gilmore Groin & Hernia Clinic

Page 19 of 44

Fig. 14: Sagittal T2W Fat saturated image of pelvis: Demonstrates the left adductor origin tear with retraction of fibres (black arrow). This differs from an aponeurotic tear in both its position (more medial to symphyseal midline) and the orientation of the linear hyperintensity(more oblique than an aponeurotic tear). References: The Gilmore Groin & Hernia Clinic

Page 20 of 44

Fig. 15: Coronal STIR image more posteriorly in pelvis: Note the marked dessication of L5/S1 intervertebral disc with reactive oedematous end plate changes (red arrow) References: The Gilmore Groin & Hernia Clinic Diagnosis: Left adductor tear but intact Right adductor origin. No recurrence of Sportsman's Groin. Degenerative changes of the lumbosacral spine. Treatment: Physiotherapy PRP (Plasma rich Protein) injections to left adductor origin.

Page 21 of 44

Teaching points from Case Study 5: MRI often demonstrates a number of potential sources of groin pain which then require re-evaluation clinically to help further identify the cause of the patient's symptoms. Distinction can be made between tear of the Rectus Abdominis-Adductor Longus Aponeurosis and tear of the Adductor Longus origin. This has implications in subsequent management as Aponeurotic tears often require Surgical approach whilst Adductor Longus tears can often be managed conservatively. We have found that the Sagittal Oblique T2W fat saturated sequences are very useful in differentiating the two. Figures 16 [1].

Fig. 16: Sagittal oblique T2W fat sat images through midline (right image)and approx 1 cm lateral to symphyseal midline (left image): Note how the linear hyperintensity of a true rectus abdominis-adductor longus tear is 1cm lateral to the midline and more horizontally orientated (white arrow). The adductor longus tendon origin is more oblique (Red arrow). Often there is a high incidence of co-existence degree of these findings. References: The Gilmore Groin & Hernia Clinic -------------------------------------------------------------------------------CASE STUDY 6: History:

Page 22 of 44

27 yr old male rugby player presenting with 10 month history of right groin pain. Started after being struck in groin during a game when he sustained a significant amount of bruising. Pain in groin intermittent since then and aggravated by decelerating from a fast run and on hip flexion. No groin lump at anytime. Examination: No adductor origin tenderness, no pain with adductor squeeze test. Both hips slightly tight on internal rotation. Working Diagnosis: Pain referred from back and hip rather than groin. Investigation: 3T MRI of pelvis and groins. Figure 17-20

Page 23 of 44

Fig. 17: Coronal STIR image: Demonstrates hyperintense linear signal at the right rectus abdominis/adductor longus aponeurosis in keeping with an aponeurotic tear (white arrow) References: The Gilmore Groin & Hernia Clinic

Page 24 of 44

Fig. 18: Axial oblique T2Fat saturated image of pelvis: Confirms hyperintense signal at the right rectus abdominis/adductor longus aponeurosis in keeping with an aponeurotic tear (white arrow) References: The Gilmore Groin & Hernia Clinic, UK

Page 25 of 44

Fig. 19: Coronal STIR image of pelvis: Demonstrates coexisting Femoro-acetabular impingment (FAI) with bilateral femoral head/neck osseous bumps (blue arrows) with underling fibrocystic change on the right (white arrow). There is established secondary degenerate change in both hips, particularly on the right ,with lateral acetabular rim osteophytic lipping (black arrow) References: The Gilmore Groin & Hernia Clinic, UK

Page 26 of 44

Fig. 20: Coronal STIR image of pelvis: Note the extensive acetabular subchondral cyst formation bilaterally (red arrows) in keeping with secondary osteoarthritis on a background of FAI References: The Gilmore Groin & Hernia Clinic Diagnosis: Significant secondary osteoarthritis on a background of CAM type deformity FAI. Right rectus abdominis/adductor longus aponeurotic tear Treatment:

Page 27 of 44

As clinical symptoms and signs were more in keeping with the FAI and degenerative changes of both hip joints, Orthopaedic referral for further evaluation and treatment of the FAI was made. Learning points for Case Study 6: MRI will often demonstrate a number of "pathologies" which prompt further re evaluation within the clinical setting to clarify which of these are clinically significant. -------------------------------------------------------------------------------CASE STUDY 7: History: 32 yr old male with bilateral groin pain aggravated by running. Examination: Tenderness in the right adductor origin. No clinical evidence of groin disruption on either side Working Diagnosis: Right adductor strain Investigation: 3T MRI of Pelvis Figure 21-23

Page 28 of 44

Fig. 21: Coronal STIR image pelvis anteriorly- Note the marker capsules placed on patient to demonstrate sites of maximal clinical symptoms of patient (blue arrows) References: The Gilmore Groin & Hernia Clinic

Page 29 of 44

Fig. 22: Coronal STIR image of pelvis: Linear hyperintense signal extending across the midline at the symphysis pubis, in keeping with bilateral tears of the rectus abdominis-adductor longus aponeurosis (blue arrows) References: The Gilmore Groin & Hernia Clinic

Page 30 of 44

Fig. 23: Coronal STIR (left) and Axial T2 fat saturation (right)images of pelvis: Demonstrates marked marrow oedema at the symphysis pubis in keeping with osteitis pubis (white arrows) References: The Gilmore Groin & Hernia Clinic Diagnosis: Bilateral Rectus Abdominis-Adductor Longus Aponeurotic Tears Osteitis Pubis Both Adductor tendons intact Treatment: Physiotherapy Groin Reconstruction Surgery (the decision to treat the patient using a surgical rather than conservative approach was reached in a more timely manner) Teaching/Discussion Points for Case Study 7: The use of MRI in further evaluating and often changing the initial expert clinical diagnosis. -------------------------------------------------------------------------------Case Study 8 History: 22 yr old male with bilateral groin pain. Pain is constant and aggravated by exercise. Examination: Both groins intact, nil else of note Working Diagnosis: Possible Groin disruption

Page 31 of 44

Investigation: 3 Tesla MRI Figures 24-26

Fig. 24: Coronal T1W image of pelvis: Demonstrates symphyseal degeneration with hypertrophy and displacement of the disc (white arrow) References: The Gilmore Groin & Hernia Clinic

Page 32 of 44

Fig. 25: Axial STIR image of pelvis: Demonstrates PRIMARY CLEFT sign of separation of chondral cartilage from pubic bone (white arrow) References: The Gilmore Groin & Hernia Clinic, UK

Page 33 of 44

Fig. 26: Coronal STIR image of pelvis: Demonstrates hyperintense signal vertically within the pubic symphysis - PRIMARY CLEFT SIGN (blue arrow). There is marrow oedema in the pubic bones. Note the oblique linear hyperintensity at the right aponeurosis - SECONDARY CLEFT SIGN (white arrow) - in keeping with a right rectus abdominis-adductor longus tear References: The Gilmore Groin & Hernia Clinic, UK Diagnosis: Right Rectus Abdominis-Adductor Longus Aponeurotic Defect Osteitis Pubis Treatment: On clinical re-examination it was felt that the salient problem was the osteitis pubis. Referral was made for Core stability exercises and Pubic Symphyseal injection.

Page 34 of 44

Teaching point for Case Study 8: Importance of clinical re-evaluation to assess the relevance of imaging findings. -------------------------------------------------------------------------------CASE STUDY 9: History: 39 yr old male presenting with left groin pain. This was precipitated by a fall 4 weeks previously. Examination: No groin disruption Working diagnosis: Left adductor strain Investigations: 3 Tesla MRI Figure 27-29

Page 35 of 44

Fig. 27: Axial oblique T2 fat saturated image of pelvis: Demonstrates a fracture of the left inferior pubic ramus with adjacent proximal adductor oedema (white arrow). This corresponds with site of maximal clinical tenderness as evidenced by marker capsule on patient anteriorly (red arrow) References: The Gilmore Groin & Hernia Clinic, UK

Page 36 of 44

Fig. 28: Coronal STIR image of pelvis posteriorly: Demonstrates linear high signal at the left common hamstring origin in keeping with a left Hamstring Origin tear (white arrow). Note also the Grade 1 left gluteal muscle strain (black arrow) References: The Gilmore Groin & Hernia Clinic, UK

Page 37 of 44

Fig. 29: Coronal STIR image of pelvis: Hyperintense signal within the left obturator externis muscle (white arrow). No discrete haematoma or significant muscle fibre disruption. Features in keeping with grade 1 muscle strain . Note also bone marrow oedema within the left acetabulum (blue arrow) References: The Gilmore Groin & Hernia Clinic, UK Diagnosis: Left inferior pubic ramus fracture Left acetabular microtrabecular fracture Adductor and hamstring muscle strain Treatment: Page 38 of 44

Pain relief and rest Teaching points for Case Study 9: Role of MRI in evaluating Trauma

Images for this section:

Fig. 2: Groin pain: True Sportsman's groin and various other causes

Page 39 of 44

Page 40 of 44

Fig. 3: A major cause of Sportsman's Groin - tear of the Rectus Abdominis/Adductor Longus Aponeurosis [3]

Page 41 of 44

Page 42 of 44

Fig. 4: useful sequences

Page 43 of 44

Conclusion The results of this study shows that • •

3T MRI is effective as an early and comprehensive imaging tool in the evaluation of groin pain Multidisciplinary approach encompassing the surgeon, sports physician, radiologist and physiotherapist is invaluable for the prompt diagnosis, treatment and management of patients with groin pain and the data highlight the importance of clinical re-evaluation in light of the initial MRI findings.

References

1.

2. 3.

Robinson P et al. Cadaveric and MRI study of the Musculotendinous Contributions to the Capsule of the Pubic Symphysis. AJR, May 2007, Volume 118, No 5 Zoga A et al. Althletic Pubalgia and the "Sports Hernia": MR imaging findings. Radiology, June 2008, Volume 247, 797 - 807 Simon Marsh. Consultant Surgeon MA MD FRCS. The Gilmore Groin and Hernia Clinic. 108 Harley Street, London, W1G 7ET

Personal Information SG Cross, A Rastogi: Department of Radiology, Royal London Hospital, Bart's Health NHS Trust. London. E Carapeti and S Marsh: The Gilmore Groin Clinic. London M Ahmad and R Jalan: Department of Radiology, Royal London Hospital, Bart's Health NHS Trust and Nuada Medical Specialist Imaging, Nuada Medical Group. London

Page 44 of 44