Weekly Case

Title : Case 675

Age / Sex : 60 / M


Chief complaint : right inguinal pain


What is your diagnosis?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).


Courtesy : 
박선영 (Sun-Young Park), 한림대학교 평촌성심병원 (Hallym University Sacred Heart Hospital )


Diagnosis:

Athletic pubalgia (Sports hernia)



Discussion


Findings:


[Plain radiograph]


  . Mild sclerotic change of symphysis pubis


[MRI]


  . Avulsion of the adductor brevis tendon from the right lateral margin of the pubic body with associated muscle strain.


  . Mild bone marrow edema at anterior aspect of the pubic body.


  . Partial tear of right rectus abdominis muscle at pubic attachment site with rectus abdominis-adductor longus aponeurotic plate disruption


Differential Diagnosis:


 Pubic stress fracture, osteitis pubis, adductor longus tendinosis and tenoperiostitis


 


Discussion:



  • Groin pain in athletes:  one of the most frequent complain in athletes, and is involved in up to 6% of all sports-related pathologies

  • Terminology used for groin pain in athletes remains unclear - various terms describe entities that either identical or at least close neighbors in the same spectrum of disease, including sports hernia, sportsmans hernia, athletic pubalgia, Gilmore groin, hockey goalie syndrome, adductor dysfunction, and osteitis pubis

    • Sportsmans hernia is a misleading term, since no hernia is present



  • Anatomy: pubic symphysis is the centerpoint of numerous musculotendinous attachments – including the anterolateral abdominal muscles (external and internal oblique, transverse abdominis, rectus abdominis), and the thigh adductor muscles (pectineus, gracilis, adductor longus, adductor brevis, and adductor magnus)

  • MRI findings

    • Adductor tendon injury: strain, partial-thickness, and complete tear, typically distal to the rectus abdominis-adductor longus aponeurosis, with often results in distal retraction of the avulsed tendon

    • Rectus abdominis strain

    • Aponeurotic plate injury: tear of aponeurotic plate manifests as a fluid-signal cleft lifting up the anterior periosteum at the pubis with additional fluid signal abnormality, disrupting the tendinous insertion

    • Osteitis pubis: Degenerative process of the pubic symphysis and occurs secondary to repetitive biomechanical stresses, usually associated with other adductor or hip pathology

      • Acutely : subchondral marrow edema encompass the entirety of the anterior to posterior dimension of the symphysis, and should be bilateral

      • Long-standing : subchondral irregularity and sclerosis along with osteophytes and resorption






 


 


References:



  1. Mullens FE, Zoga AC, Morrison WB et-al. Review of MRI Technique and imaging findings in athletic pubalgia and the "sports hernia" Eur J Radiol. 2011; 81(12): 3780-3792.

  2. Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G, Lopez H, et al. Athletic Pubalgia and the “Sports Hernia”: MR Imaging Findings. Radiology. 2008;247(3):797-807.



Correct Answer
Total applicants 34 Correct answers 13
Name Institution
장민영 국민건강보험공단 일산병원, 전문의
여현정 전문의
이수민 전문의
김기욱 국군수도병원, 전문의
윤유성 순천향대 부천병원, 전문의
조신영 전문의
강지희 전문의
김동언 국군양주병원, 전문의
김현진 서울성모병원, 전공의
이혜란 전문의
이민욱 충남대학교병원, 전문의
윤소진 분당서울대병원, 전문의
김성진 365병원, 전문의
Semi-Correct Answer
Total applicants 34 Semi-Correct answers 18
조영민 전문의
이진영 전문의
문경일 전남대학교병원, 전공의
이규정 국군대전병원, 전문의
조숭문 전문의
이현규 전문의
이동규 경인지방병무청, 전문의
전인환 전문의
윤선근 전공의
이성욱 군의관, 전문의
한유비 전문의
이승보 서울아산병원, 전문의
권기언 서울아산병원, 전문의
유해원 전공의
백승진 분당차병원, 전공의
심상우 서울아산병원, 전문의
안태란 길병원, 전문의
김형민 연세의대 강남세브란스병원, 전문의


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