MRI of Athletic Pubalgia Christopher Beaulieu, M.D., Ph.D. Stanford University Medical Center Groin Pain Hip joint Arthritis Femoracetabular impingement (FAI) Osseous stress injuries AVN Tendinopathy or tear $0<4>09/49:?=49I,88,>4:9:<-?<=4>4= SCFE Inguinal or femoral hernia (traditional) “Sports or sportsman’s hernia” “Sports Hernia” Originally, described as a weakness in the abdominal wall without true herniation of bowel. “incipient hernia” Later, a variety of predominantly musculotendinous disorders about the pubis recognized and lumped under this term, having nothing to do with hernia whatsoever A somewhat better term the syndrome of groin pain in athletes is athletic pubalgia Athletic Pubalgia Groin pain in an individual that cannot be attributed to hip joint or hip tendon pathology, often in competitive athletes May be acute, but is more often chronic Encompasses osseous, myotendinous, as well as abdominal wall disorders Current terminology in fashion is “core (muscle) injury” Etiology Sports with rapid change in direction and twisting or kicking American football Soccer Rugby Australian rules football Hockey Trail running (?) Anatomic Structures Involved Bones - pubic symphysis Tendons and muscles Rectus abdominis Adductors, long and short Inguinal ligament and abdominal wall muscles Modified from Falvey et al. Br J Sports Med 2016;50:423-430 Injury Patterns Osteitis pubis - bone marrow edema Rectus-adductor “pubic plate” injury Adductor longus tendinopathy/tear Short adductor tendinopathy/tear Muscle tear Pubic bone marrow edema, Osteitis Pubis Radiographic Signs Primary (symphyseal) cleft Normal physiologic cleft between pubic bones, closed superiorly and inferiorly by cartilage and ligaments Secondary cleft Fluid extending from the primary cleft and tracking parallel to the inferior margin of inferior pubic rams. Related to tears of the short adductors (adductor brevis, gracilis, pectineus) Superior cleft Fluid tracking parallel to the inferior margin of the superior pubic ramus. A marker of tear of the adductor longus or rectus-adductor aponeurosis. Symphyseal Cleft Injection Radiographic Signs Becker et al, J Anat. 2010 Nov; 217(5): 475–487. Byrne, C.A., et al, AJR 209:380-388, 2017 Large FOV Cor T1 and T2FS Central Pubic Plate Disruption 22 y.o. Running Back 29 y.o. Quarterback with 2 weeks of Groin Pain 56 y.o. Runner with RT Groin Pain Incipient Hernia = Gilmore’s Groin Minnich, JM et al, Am J Sports Med 39, 1341-1349. 78 y.o. Man with Prostate Ca and XRT Take Home Points Athletic pubalgia is an important clinical syndrome with complex anatomy Primarily involves myotendinous structures about the pubic symphysis Some interaction with inguinal canal injury and traditional hernia exists At least 4 injury areas need to be assessed: Osteitis pubis - bone marrow edema Rectus-adductor “pubic plate” injury Adductor longus tendinopathy/tear Short adductor tendinopathy/tear 1. Meyers WC. Editorial Commentary: Core Muscle Injuries or Athle�c Pubalgia-Finally the Real Sausage, Not Just the Same Ole Baloney. Arthroscopy. 2017; 33(5):1050-2. 2. Knapik DM, Gebhart JJ, Nho SJ, Tanenbaum JE, Voos JE, Salata MJ. Prevalence of Surgical Repair for Athle�c Pubalgia and Impact on Performance in Football Athletes Par�cipa�ng in the Na�onal Football League Combine. Arthroscopy. 2017; 33(5):1044-9. 3. Jack RA, Evans DC, Echo A, et al. Performance and Return to Sport A�er Sports Hernia Surgery in NFL Players. Orthop J Sports Med. 2017; 5(4): 2325967117699590. 4. Harr JN, Brody F. Sports hernia repair with adductor tenotomy. Hernia. 2017; 21(1):139-47. 5. Morley N, Grant T, Blount K, Omar I. Sonographic evalua�on of athle�c pubalgia. Skeletal Radiol. 2016; 45(5):689-99. 6. Ela�ar O, Choi HR, Dills VD, Busconi B. Groin Injuries (Athle�c Pubalgia) and Return to Play. Sports Health. 2016; 8(4):313-23. 7. Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athle�c Pubalgia: A Review. R I Med J (2013). 2016; 99(10):31-5. 8. Ross JR, Stone RM, Larson CM. Core Muscle Injury/Sports Hernia/Athle�c Pubalgia, and Femoroacetabular Impingement. Sports Med Arthrosc. 2015; 23(4):213-20. 9. Coker DJ, Zoga AC. The Role of Magne�c Resonance Imaging in Athle�c Pubalgia and Core Muscle Injury. Top Magn Reson Imaging. 2015; 24(4):183-91. 10. Garvey JF, Hazard H. Sports hernia or groin disrup�on injury? Chronic athle�c groin pain: a retrospec�ve study of 100 pa�ents with long-term follow-up. Hernia. 2014; 18(6):815-23. 11. Palisch A, Zoga AC, Meyers WC. Imaging of athle�c pubalgia and core muscle injuries: clinical and therapeu�c correla�ons. Clin Sports Med. 2013; 32(3): 427-47. 12. Khan W, Zoga AC, Meyers WC. Magne�c resonance imaging of athle�c pubalgia and the sports hernia: current understanding and prac�ce. Magn Reson Imaging Clin N Am. 2013; 21(1):97-110. 13. Mullens FE, Zoga AC, Morrison WB, Meyers WC. Review of MRI technique and imaging findings in athle�c pubalgia and the "sports hernia". Eur J Radiol. 2012; 81(12):3780-92. 14. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athle�c pubalgia symptoms in professional athletes with symptoma�c femoroacetabular impingement. Arthroscopy. 2012; 28(10):1388-95. 15. Litwin DE, Sneider EB, McEnaney PM, Busconi BD. Athle�c pubalgia (sports hernia). Clin Sports Med. 2011; 30(2):417-34. 16. Zoga AC, Mullens FE, Meyers WC. The spectrum of MR imaging in athle�c pubalgia. Radiol Clin North Am. 2010; 48(6):1179-97. 17. Campanelli G. Pubic inguinal pain syndrome: the so-called sports hernia. Hernia. 2010; 14(1):1-4. 18. Zajick DC, Zoga AC, Omar IM, Meyers WC. Spectrum of MRI findings in clinical athle�c pubalgia. Semin Musculoskelet Radiol. 2008; 12(1):3-12. 19. Shor� CP, Zoga AC, Kavanagh EC, Meyers WC. Anatomy, pathology, and MRI findings in the sports hernia. Semin Musculoskelet Radiol. 2008; 12(1): 54-61. 20. Omar IM, Zoga AC, Kavanagh EC, et al. Athle�c pubalgia and "sports hernia": op�mal MR imaging technique and findings. Radiographics. 2008; 28(5): 1415-38. 21. Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON. Experience with "sports hernia" spanning two decades. Ann Surg. 2008; 248(4):656-65. 22. Akita K, Niga S, Yamato Y, Muneta T, Sato T. Anatomic basis of chronic groin pain with special reference to sports hernia. Surg Radiol Anat. 1999; 21(1): 1-5. 23. Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med. 1993; 27(1):58-62. .