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Imaging Review of Groin Pain in Elite Athletes: An Anatomic Approach to Imaging Findings

¹ Victoria House Medical Imaging, 316 Malvern Rd., Prahran, Victoria 3181, Australia.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Healthy 28-year-old male athlete. Coronal proton density–weighted MR image shows medial (asterisk) and lateral (solid arrow) heads of rectus abdominis muscle. Also note inguinal ligament (open arrow), superior to which spermatic cord courses through inguinal canal (arrowhead).

View larger version (163K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Healthy 28-year-old male athlete. Coronal proton density–weighted MR image slightly more posterior than A shows lateral (solid arrow) and medial (asterisk) heads of rectus abdominis continue to be visualized. Inguinal ligament (open arrow) attaches onto pubic tubercle medially, with contralateral spermatic cord (S) visualized superior to ligament. Note triangular tendon (arrowhead) that provides origin for left adductor longus tendon, which is essentially continuous superiorly as tendon of origin for rectus abdominis. Immediately lateral to pubic tubercle, pectineus muscle (P) gains origin from superior pubic ramus, which is slightly posterior and thus not seen on this image.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —Healthy 28-year-old male athlete. Diagrammatic representation of relationship between abdominal musculature and adductor longus muscle. On left of image, external oblique muscle is most superficial layer, inferiorly forming external oblique fascia. This structure splits medially to form external (superficial) inguinal ring through which cut end of spermatic cord exits canal. Anterior rectus sheath covers rectus abdominis muscle on this side, and adductor longus inferiorly has been cut away. On right side of image, external oblique muscle and fascia have been removed to reveal internal oblique and deeper transversus abdominis muscles. These two muscles at level of inguinal ligament laterally form internal (deep) inguinal ring, through which spermatic cord enters inguinal canal. These two structures medially form "conjoint tendon," which is posterior inguinal wall, and blend with anterior rectus sheath (not shown on this side) and, in essence, attach anterior rectus sheath to rectus abdominis as depicted.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Series of axial proton density–weighted MR images in asymptomatic 28-year-old male athlete depict anatomy pertinent to assessment of groin pain. Note anterior (arrow) and posterior (arrowhead) walls of inguinal canal, as well as pectineus (P) and obturator internus (OI) muscles.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Series of axial proton density–weighted MR images in asymptomatic 28-year-old male athlete depict anatomy pertinent to assessment of groin pain. Further inferiorly, anterior (arrow) and posterior (arrowhead) walls of inguinal canal are again noted, and spermatic cord (S) is best visualized on this image. Observe how posterior inguinal wall, composed of the two closely apposed internal oblique and transversus abdominis muscles, appears to merge with rectus abdominis, best seen on left side of image.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —Series of axial proton density–weighted MR images in asymptomatic 28-year-old male athlete depict anatomy pertinent to assessment of groin pain. On next image inferiorly, linear hypointense structure (arrow) represents inguinal ligament, which is inferior margin of external oblique aponeurosis. Note its attachment onto pubic tubercle. P = pectineus, OE = obturator externus, QF = quadratus femoris.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2D —Series of axial proton density–weighted MR images in asymptomatic 28-year-old male athlete depict anatomy pertinent to assessment of groin pain. On final image, adductor longus tendon (circle) is shown, deep in relation to which lies belly of adductor brevis (AB). Inferior pubic (arcuate) ligament (arrow) is important stabilizer of pubic symphysis. P = pectineus, OE = obturator externus, QF = quadratus femoris.

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Sagittal image from reformatted MDCT image in 21-year-old male soccer player shows continuity of rectus abdominis tendon superiorly (arrow) with adductor longus tendon inferiorly (asterisk).

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —26-year-old man with normal anatomy. Lateral scout view on CT shows two options for imaging pubic symphysis in axial plane, either along true anatomic plane (dashed line) or obliquely, in plane with pubic symphysis (solid line).

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —26-year-old man with normal anatomy. Figures B and C will result, respectively, and serve as basis for planning coronal images. Note pubic tubercle (arrow), pubic body (B), and superior (S, C) and inferior (I, C) pubic rami.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —26-year-old man with normal anatomy. Figures B and C will result, respectively, and serve as basis for planning coronal images. Note pubic tubercle (arrow), pubic body (B), and superior (S, C) and inferior (I, C) pubic rami.

View larger version (180K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —Coronal T1-weighted image of groin in 26-year-old male professional football player shows chronic full-thickness disruption of lateral head of right rectus abdominis muscle (asterisk) with ill definition, decreased bulk, and early fatty replacement of medial head (arrowhead). Note normal contralateral left rectus abdominis muscle.

View larger version (181K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —Coronal proton density–weighted image through right groin in 22-year-old male soccer player with acute severe groin pain and loss of adduction shows full-thickness tear of adductor longus tendon from its origin with distal retraction (arrow). Tear occurs on background of preexisting pubic overload, where chronic changes of osseous spurring and capsular hypertrophy of superior aspect of pubic symphysis (arrowhead) are noted. P = pectineus, I = iliopsoas.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —Coronal proton density–weighted image of 30-year-old male athlete shows absence of left adductor longus tendon (asterisk), which is consistent with full-thickness disruption and simultaneous partial-thickness tear of medial aspect of pectineus muscle (arrow) as it arises from superior pubic ramus.

View larger version (178K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —Coronal proton density–weighted image of 33-year-old male recreational triathlete shows partial-thickness tear isolated to right pectineus muscle (arrow).

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Axial T2-weighted fat-saturated sequences through left groin in 28-year-old male recreational soccer player. Image shows subtle edema at lateral head of rectus abdominis muscle (circle) consistent with partial strain. P = pectineus.

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Axial T2-weighted fat-saturated sequences through left groin in 28-year-old male recreational soccer player. Further distally (B), bone marrow edema involves pubic body (asterisk, B), with partial disruption of medial aspect of origin of pectineus (P) as well as obturator externus (solid arrow, B) muscles. Hypointense focus medial to pectineus represents common adductor origin complex (arrowhead), which is confirmed further distally (C) to have avulsed anteriorly from pubis, with fluid undermining its osseous attachment (open arrow, C).

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —Axial T2-weighted fat-saturated sequences through left groin in 28-year-old male recreational soccer player. Further distally (B), bone marrow edema involves pubic body (asterisk, B), with partial disruption of medial aspect of origin of pectineus (P) as well as obturator externus (solid arrow, B) muscles. Hypointense focus medial to pectineus represents common adductor origin complex (arrowhead), which is confirmed further distally (C) to have avulsed anteriorly from pubis, with fluid undermining its osseous attachment (open arrow, C).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —Anteroposterior radiograph of pelvis with left leg raised (flamingo view) in 27-year-old female recreational athlete shows widening of pubic symphysis and slight superior migration of left pubic bone when compared with right.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —Spot film from fluoroscopically guided injection of pubic symphysis in 23-year-old male soccer player with severe groin pain shows primary central cleft and contrast material extending inferolaterally on right side (arrow), away from joint, in keeping with "secondary cleft" sign.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —28-year-old male soccer player with intractable groin pain. Axial (A) and coronal (B) T2-weighted fat-saturated MR images through groin show fluid (arrowhead) in symphysis and extending beyond confines of joint on left side, consistent with "secondary cleft" sign.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —28-year-old male soccer player with intractable groin pain. Axial (A) and coronal (B) T2-weighted fat-saturated MR images through groin show fluid (arrowhead) in symphysis and extending beyond confines of joint on left side, consistent with "secondary cleft" sign.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —18-year-old male football player with pubic bone marrow edema. Axial (A) and coronal (B) T2-weighted fat-saturated sequences through groin show presence of asymmetric pubic bone marrow edema, left-side predominant (asterisk), and edema at origin of left pectineus muscle (arrow).

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —18-year-old male football player with pubic bone marrow edema. Axial (A) and coronal (B) T2-weighted fat-saturated sequences through groin show presence of asymmetric pubic bone marrow edema, left-side predominant (asterisk), and edema at origin of left pectineus muscle (arrow).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —Oblique coronal (tilted gantry) CT image through pubic symphysis of 17-year-old male football player shows changes of subchondral cyst formation, erosions, and ill-defined osseous margins, particularly on right side (arrowhead), all compatible with erosive osteitis pubis.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15 —Coronal proton density–weighted image of pubic symphysis in 32-year-old male football player shows osseous spurring and capsular hypertrophy, particularly superiorly (arrowhead), consistent with premature symphyseal degeneration.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16 —Oblique axial (tilted gantry) CT image in 35-year-old retired professional football player with chronic groin pain shows subchondral sclerosis, irregularity, and decrease in joint space height, which are compatible with premature symphyseal degeneration.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17 —Delayed phase nuclear medicine technetium-99m methylene diphosphonate (MDP) bone scintigraphy (axial view) in 25-year-old male soccer player shows increased uptake on either side of pubic symphysis (arrowhead), compatible with osteitis pubis.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18 —Coronal T2-weighted fat-saturated image through anterior abdominal wall of elite 28-year-old male Australian-rules football player shows area of increased hyperintensity of left external inguinal ring, consistent with traumatic disruption of most medial fibers of external oblique aponeurosis (arrowhead) and thus in keeping with acute disruption of anterior inguinal wall.

View larger version (150K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19 —Axial proton density–weighted image in 26-year-old male recreational soccer player with left-sided groin pain shows anterior bulging of posterior inguinal wall on left side (arrow), consistent with posterior inguinal wall deficiency. This results in more anteriorly positioned spermatic cord (S) when compared with right side.

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