Top-Ten Tips for Imaging Groin Injury in Athletes

Abstract

Athletic groin injury remains a challenging prospect for sports clinicians and radiologists because of the closely related anatomical structures and overlapping clinical presentations. Recent consensus work designated four causative clinical entities, with the adductor/rectus aponeurosis and pubic symphysis capsule emphasized as key areas. This article highlights these key aspects of athletic groin injury with tips on anatomy, potential abnormalities, acronyms, and imaging appearances in this complex but common and potentially incapacitating entity. Many clinical and radiologic terms are in use such as cleft, enthesitis, plate injury, or defect that can cause confusion, and thus anatomical descriptions are preferable.

Detailed clinical assessment is necessary but remains challenging because of the nonspecific presentations. Imaging, and in particular magnetic resonance imaging, plays an essential role in the evaluation process. But only when the two are used in combination can an accurate diagnosis be reached because several studies in asymptomatic athletes show that reactive changes are common.

Keywords

athletic groin pain - symphysis pubis - MRI - ultrasound - muscle injury

• References

• 1 Lee SC, Endo Y, Potter HG. Imaging of groin pain: magnetic resonance and ultrasound imaging features. Sports Health 2017; 9 (05) 428-435
• 2 Omar IM, Zoga AC, Kavanagh EC. , et al. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics 2008; 28 (05) 1415-1438
• 3 Robinson P, Bhat V, English B. Imaging in the assessment and management of athletic pubalgia. Semin Musculoskelet Radiol 2011; 15 (01) 14-26
• 4 Koulouris G. Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. AJR Am J Roentgenol 2008; 191 (04) 962-972
• 5 Werner J, Hägglund M, Waldén M, Ekstrand J. UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 2009; 43 (13) 1036-1040
• 6 Mosler AB, Weir A, Eirale C. , et al. Epidemiology of time loss groin injuries in a men's professional football league: a 2-year prospective study of 17 clubs and 606 players. Br J Sports Med 2018; 52 (05) 292-297
• 7 Waldén M, Hägglund M, Ekstrand J. The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med 2015; 49 (12) 792-797
• 8 Weir A, Robinson P, Hogan B, Franklyn-Miller A. MRI investigation for groin pain in athletes: is radiological terminology clarifying or confusing?. Br J Sports Med 2017; 51 (16) 1185-1186
• 9 Chopra A, Robinson P. Imaging athletic groin pain. Radiol Clin North Am 2016; 54 (05) 865-873
• 10 Weir A, Brukner P, Delahunt E. , et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49 (12) 768-774
• 11 Agten CA, Sutter R, Buck FM, Pfirrmann CWA. Hip imaging in athletes: sports imaging series. Radiology 2016; 280 (02) 351-369
• 12 Rankin AT, Bleakley CM, Cullen M. Hip joint pathology as a leading cause of groin pain in the sporting population: A 6-year review of 894 cases. Am J Sports Med 2015; 43 (07) 1698-1703
• 13 O'Sullivan K, Darlow B, O'Sullivan P, Forster BB, Reiman MP, Weir A. Imaging for hip-related groin pain: don't be hip-notised by the findings. Br J Sports Med 2018; 52 (09) 551-552
• 14 Robinson P, Salehi F, Grainger A. , et al. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol 2007; 188 (05) W440-5
• 15 Norton-Old KJ, Schache AG, Barker PJ, Clark RA, Harrison SM, Briggs CA. Anatomical and mechanical relationship between the proximal attachment of adductor longus and the distal rectus sheath. Clin Anat 2013; 26 (04) 522-530
• 16 Schilders E, Bharam S, Golan E. , et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc 2017; 25 (12) 3969-3977
• 17 Tsifountoudis I, Kraniotis P, Karantanas AH. Hip and pelvis: MRI of musculotendinous trauma and mimickers. Semin Musculoskelet Radiol 2017; 21 (03) 218-239
• 18 Sailly M, Whiteley R, Read JW, Giuffre B, Johnson A, Hölmich P. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br J Sports Med 2015; 49 (12) 828-834
• 19 Cunningham PM, Brennan D, O'Connell M, MacMahon P, O'Neill P, Eustace S. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol 2007; 188 (03) W291-W296
• 20 Serner A, Weir A, Tol JL. , et al. Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes. Scand J Med Sci Sports 2018; 28 (02) 667-676
• 21 Zajick DC, Zoga AC, Omar IM, Meyers WC. Spectrum of MRI findings in clinical athletic pubalgia. Semin Musculoskelet Radiol 2008; 12 (01) 3-12
• 22 Zoga AC, Kavanagh EC, Omar IM. , et al. Athletic pubalgia and the “sports hernia”: MR imaging findings. Radiology 2008; 247 (03) 797-807
• 23 Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 2001; 35 (01) 28-33
• 24 Taylor R, Vuckovic Z, Mosler A. , et al. Multidisciplinary assessment of 100 athletes with groin pain using the Doha agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clin J Sport Med 2018; 28 (04) 364-369
• 25 Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A, Gibbon WW, Bismil Q. Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2009; 91 (10) 2455-2460
• 26 Sheen AJ, Stephenson BM, Lloyd DM. , et al. ‘Treatment of the sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014; 48 (14) 1079-1087
• 27 Branci S, Thorborg K, Nielsen MB, Hölmich P. Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature. Br J Sports Med 2013; 47 (10) 611-619
• 28 Brandon CJ, Jacobson JA, Fessell D. , et al. Groin pain beyond the hip: how anatomy predisposes to injury as visualized by musculoskeletal ultrasound and MRI. AJR Am J Roentgenol 2011; 197 (05) 1190-1197
• 29 Thorborg K, Branci S, Nielsen MP, Langelund MT, Hölmich P. Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function. Br J Sports Med 2017; 51 (07) 594-599
• 30 Falvey ÉC, King E, Kinsella S, Franklyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients—clinical findings, MRI findings, and patient-reported outcome measures at baseline. Br J Sports Med 2016; 50 (07) 423-430
• 31 Elattar O, Choi H-R, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health 2016; 8 (04) 313-323
• 32 Vasileff WK, Nekhline M, Kolowich PA, Talpos GB, Eyler WR, van Holsbeeck M. Inguinal hernia in athletes: role of dynamic ultrasound. Sports Health 2017; 9 (05) 414-421
• 33 Steele P, Annear P, Grove JR. Surgery for posterior inguinal wall deficiency in athletes. J Sci Med Sport 2004; 7 (04) 415-421 ; discussion 422–423
• 34 Robinson P, Grainger AJ, Hensor EMA, Batt ME, O'Connor PJ. Do MRI and ultrasound of the anterior pelvis correlate with, or predict, young football players' clinical findings? A 4-year prospective study of elite academy soccer players. Br J Sports Med 2015; 49 (03) 176-182
• 35 Campbell R. Ultrasound of the athletic groin. Semin Musculoskelet Radiol 2013; 17 (01) 34-42
• 36 Robinson P, Barron DA, Parsons W, Grainger AJ, Schilders EM, O'Connor PJ. Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings. Skeletal Radiol 2004; 33 (08) 451-457
• 37 Broadley P, Offiah AC. Hip and groin pain in the child athlete. Semin Musculoskelet Radiol 2014; 18 (05) 478-488
• 38 Serner A, Roemer FW, Hölmich P. , et al. Reliability of MRI assessment of acute musculotendinous groin injuries in athletes. Eur Radiol 2017; 27 (04) 1486-1495
• 39 Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med 1998; 32 (02) 134-139
• 40 Ostrom E, Joseph A. The use of musculoskeletal ultrasound for the diagnosis of groin and hip pain in athletes. Curr Sports Med Rep 2016; 15 (02) 86-90
• 41 Brennan D, O'Connell MJ, Ryan M. , et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology 2005; 235 (01) 162-167
• 42 Murphy G, Foran P, Murphy D, Tobin O, Moynagh M, Eustace S. “Superior cleft sign” as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman's hernia. Skeletal Radiol 2013; 42 (06) 819-825
• 43 Zoga AC, Meyers WC. Magnetic resonance imaging for pain after surgical treatment for athletic pubalgia and the “sports hernia.”. Semin Musculoskelet Radiol 2011; 15 (04) 372-382
• 44 Slavotinek JP, Verrall GM, Fon GT, Sage MR. Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome. Am J Sports Med 2005; 33 (06) 894-899
• 45 Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med 2007; 35 (03) 467-474
• 46 Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol 2006; 187 (05) 1168-1178
• 47 Bou Antoun M, Reboul G, Ronot M, Crombe A, Poussange N, Pesquer L. Imaging of inguinal-related groin pain in athletes. Br J Radiol 2018; 91 (1092): 20170856-20170858
• 48 Morley N, Grant T, Blount K, Omar I. Sonographic evaluation of athletic pubalgia. Skeletal Radiol 2016; 45 (05) 689-699
• 49 Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol 2008; 190 (03) 576-581
• 50 Hölmich P, Uhrskou P, Ulnits L. , et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999; 353 (9151): 439-443
• 51 Hölmich P, Larsen K, Krogsgaard K, Gluud C. Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Scand J Med Sci Sports 2010; 20 (06) 814-821
• 52 Yousefzadeh A, Shadmehr A, Olyaei GR, Naseri N, Khazaeipour Z. Effect of Holmich protocol exercise therapy on long-standing adductor-related groin pain in athletes: an objective evaluation. BMJ Open Sport Exerc Med 2018; 4 (01) e000343
• 53 Paksoy M, Sekmen Ü. Sportsman hernia; the review of current diagnosis and treatment modalities. Ulus Cerrahi Derg 2015; 32 (02) 122-129
• 54 Ostrom E, Joseph A. Percutaneous ultrasound tenotomy using the Tenex system on the adductor longus tendon: a pilot case series. MOJ Sports Med. 2018; 2 (01) 00035
• 55 McCarthy E, Hegazi TM, Zoga AC. , et al. Ultrasound-guided interventions for core and hip injuries in athletes. Radiol Clin North Am 2016; 54 (05) 875-892
• 56 Schilders E, Bismil Q, Robinson P, O'Connor PJ, Gibbon WW, Talbot JC. Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007; 89 (10) 2173-2178
• 57 Byrne CA, Bowden DJ, Alkhayat A, Kavanagh EC, Eustace SJ. Sports-related groin pain secondary to symphysis pubis disorders: correlation between MRI findings and outcome after fluoroscopy-guided injection of steroid and local anesthetic. AJR Am J Roentgenol 2017; 209 (02) 380-388
• 58 Dojčinović B, Sebečić B, Starešinić M, Janković S, Japjec M, Čuljak V. Surgical treatment of chronic groin pain in athletes. Int Orthop 2012; 36 (11) 2361-2365
• 59 de Sa D, Hölmich P, Phillips M. , et al. Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med 2016; 50 (19) 1181-1186
• 60 Mei-Dan O, Lopez V, Carmont MR. , et al. Adductor tenotomy as a treatment for groin pain in professional soccer players. Orthopedics 2013; 36 (09) e1189-e1197
• 61 Rennie WJ, Lloyd DM. Sportsmans groin: the inguinal ligament and the Lloyd technique. J Belg Soc Radiol 2017; 101 (Suppl. 02) 16
• 62 Hechtman KS, Zvijac JE, Popkin CA, Zych GA, Botto-van Bemden A. A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes. Sports Health 2010; 2 (03) 211-215