10/17/17 Lower Extremity Lower ExtremityImaging Imaging Considerations Adam C. Zoga, MD Thomas Jefferson University Sydney Kimmel Medical College Philadelphia, PA, USA Professor of Radiology Vice Chair for Clinical Practice Musculoskeletal Fellowship Program Director Director of Musculoskeletal MRI OMED Philadelphia, October 09, 2017 Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Athletic Pubalgia / Core Injury • Clinical spectrum of disease associated with lower abdominal and groin injuries [1]. • Commonly referred to in the media as “sports hernia” • Affects both high performance and recreational athletes. 1. Zoga AC et al. Athletic Pubalgia and the “Sports hernia”: MR Imaging Findings. Radiology 2008 Jun:247(3): 797-807. Adam C. Zoga, MD www..jefferson.edu/msk 1 10/17/17 Lower Extremity Imaging American footballer chronic bilateral groin pain and a more acute right sided adductor strain Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Incipient Breech Adam C. Zoga, MD www..jefferson.edu/msk 2 10/17/17 Lower Extremity Imaging Treated conservatively, continued to play with pain: MRI 12 months later Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Core stabilization discussed: opted for conservative treatment Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging 3 weeks later, debilitating pain post game Adam C. Zoga, MD www..jefferson.edu/msk 3 10/17/17 Lower Extremity Imaging Adam C. Zoga, MD Aponeurosis rupture! www.. jefferson.edu/msk Lower Extremity Imaging Much larger teammate with “abdominal strain” in same game Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Midline aponeurotic plate rupture! SurgicalAdam C. Zoga, MD Core Repair: playing again in www..6 weeksjefferson.edu /msk 4 10/17/17 Lower Extremity Imaging Objectives: •Be comfortable with an imaging algorithm for the adolescent and young adult with hip and/ or groin pain. •Develop expectations for the value of imaging in creating treatment plans. •Understand the anatomy and pathophysiology of core muscle injury. •Be comfortable ordering and reviewing a dedicated athletic pubalgia imaging protocol. Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging What is “The CORE” www.bodyworlds.com Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Professional football (NFL) linebacker with acute, debilitating right sided groin pain after extending and twisting at waist Adam C. Zoga, MD www..jefferson.edu/msk 5 10/17/17 Lower Extremity Imaging PD FSE T2 FSE Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging LeftRight T2 FSE Fatsat (TE = 55) Adam C. Zoga, MD www..jefferson.edu/msk Rectus abdominis Lower/ adductorExtremity Imaging aponeurosis tear Rectus abdominis torn at attachment Adductor longus torn and retracted Entire rectus / adductor aponeurosis disrupted from pubic periosteum Adam C. Zoga, MD www..jefferson.edu/msk 6 10/17/17 Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Rectus Abdominis Lat/Sag AP Pubic Symphysis Common Adductor origin Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Rectus Abdominus Common Adductor Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Robinson P, Salehi F, Grainger A, Clemence M, Schilders E, O'Connor P, Agur A. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol. 2007 May;188(5) Adam C. Zoga, MD www..jefferson.edu/msk 7 10/17/17 Lower Extremity Imaging Fibrocartilage Plate The fibrocartilage extends the symphysis and forms a “disc” or plate, covering the bone Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Fibrocartilage Plate FIBROCARTILAGE FIBROCARTILAGE FIBROCARTILAGE Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Adam C. Zoga, MD www..jefferson.edu/msk 8 10/17/17 Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Anterior ‘ ’ AsymetricT2Anteroinferior hyperintense BME soft secondary tissue edema cleft RectusAponeurotic defect injury Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Right LeftSymphLeft RightSymphLeft Aponeurosis Tear Normal Aponeurosis Adam C. Zoga, MD www..jefferson.edu/msk 9 10/17/17 Lower Extremity Imaging Rectus Abdominis / Adductor Aponeurosis Tear: Pathoetiology: .Disruption of the rectus abdominis insertion and common adductor origin on the anterior / inferior pubis adjacent to symphysis .Likely reflects the injury commonly referred to as “Sports Hernia” .Most commonly an acute injury on chronic, degenerative tendinosis .RA tendinopathy may predispose to acute aponeurosis disruption. As the adductor longus opposes the rectus abdominis, a RA tear may lead to unopposed contraction of the AL, leading to a painful compartment syndrome and ultimately an AL tear. Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Groin pain from the pubic symphysis: •The importance of the secondary cleft •Associated with osteitis pubis symptoms in ‘footballers’ ―Brennan et al. AJR, 2005 •Associated with adductor tendon origin injury Adam C. Zoga, MD ―Cunningham et al. AJR , 2007 www.. jefferson.edu/msk Lower Extremity Imaging MR arthrographic secondary cleft Adam C. Zoga, MD www..jefferson.edu/msk 10 10/17/17 Lower Extremity Imaging The rectus abdominis / adductor aponeurosis Rectus Abdominis Pubic Symphysis Adductor Longus Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging William C. Meyers has dedicated 25 years to pioneering the diagnosis, treatment, rehabilitation and prevention of core muscle injuries (also known as athletic pubalgia or sports hernia). Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Adam C. Zoga, MD www..jefferson.edu/msk 11 10/17/17 Lower Extremity Imaging Force Studies Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Core Muscle/Hip Interaction Dividing portions of the rectus abdominis caused severe pressure changes in the adductor compartments and in the hip joints. Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging AnatomyOsseous and Anatomy: Function: Adam C. Zoga, MD www..jefferson.edu/msk 12 10/17/17 Lower Extremity Imaging Superior Pubic Ramus: Lateral Border Medial Border PubicPubicAngle Tubercle Crest Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Interpubic Disk: Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Arcuate Ligament: Adam C. Zoga, MD www..jefferson.edu/msk 13 10/17/17 Lower Extremity Imaging Muscle Attachments: Rectus Abdominis • Origin- Pubic symphysis/crest • Insertion- Xiphoid process/lower costal cartilages • Action- Flexes trunk Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Muscle Attachments: Pectineus • Origin- Broad attachment at superior pubic ramus • Insertion- Pectineal line of femur • Action- Primary thigh adductor and secondary hip flexor Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Muscle Attachments: Adductor Longus • Origin- Anterior superior pubic ramus at level of pubic angle, most superficial of the three thigh adductor muscles • Insertion- Linea aspera of femur • Action- Primary adductor of thigh and secondary external rotator and hip flexor Adam C. Zoga, MD www..jefferson.edu/msk 14 10/17/17 Lower Extremity Imaging Muscle Attachments: Adductor Brevis • Origin- Anterior pubis at the junction of the superior and inferior pubic rami, deep to adductor longus • Insertion- Upper linea aspera and between the linea aspera and lesser trochanter • Action- Primary thigh adductor, secondary hip flexor and external rotator Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Muscle Attachments: Adductor Magnus • Origin- Broad origin from the inferior pubic and ischial rami, as well as the ischial tuberosity • Insertion- Broad insertion on femoral linea aspera as well as adductor tubercle of the medial femoral condyle • Action- Primary thigh adductor and thigh flexor/ extensor Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Muscle Attachments: Gracilis • Origin- Lower half of anterior symphysis pubis and upper half of pubic arch • Insertion- Upper, medial tibial body • Action- Thigh adductor, hip flexor and internal rotator Adam C. Zoga, MD www..jefferson.edu/msk 15 10/17/17 Lower Extremity Imaging Muscle Attachments: Obturator Externus • Origin- Outer aspect of the pubic rami, inferior ischial ramus and obturator membrane • Insertion- Trochanteric fossa of femur • Action- Hip external rotator Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Accessory Muscles: Hip Flexors • Iliopsoas and Sartorius muscles Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Biomechanics: RA AL Adam C. Zoga, MD www..jefferson.edu/msk 16 10/17/17 Lower Extremity Imaging Pathology : Collegiate soccer player noncompliant with prescribed therapy Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Pathology : Osteitis pubis is functionally an arthritis Adam C. Zoga, MD www..jefferson.edu/msk Lower Extremity Imaging Pathology : Professional hockey goalie with acute on chronic, recurrent groin pain preferential to one side and exacerbated with hip