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Age / Sex : 22 / M
Age / Sex : 22//M, Soccer player
Chief complaint : Inguinal pain and left upper thigh pain
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of
this case.
* Send Application Answers to In Sook Lee, MD (lis@pusan.ac.kr)
Courtesy : Soo-Jung Choi, Gangneung Asan Hospital
Diagnosis: Sports Hernia
Discussion
Findings:
MR coronal and oblique axial images show insertional detachment of rectus
abdominis-adductor longus aponeurosis in the left pubic symphysis (marked with
arrows). Bone marrow edema is noted in the symphysis pubis.
Differential Diagnosis: none
Diagnosis:
Sports Hernia (Athletic pubalgia, rectus abdominis-adductor longus aponeurosis
injury)
Discussion:
Sports Hernia- Athletic
pubalgia
•
A spectrum
of related pathologic conditions
è resulting from musculotendinous
injuries
(Rectus abdominis–adductor longus aponeurosis tear)
•
Subsequent
instability of the pubic symphysis
•
Without any
finding of inguinal hernia at physical examination
•
Athletes in
sports that rely on quick acceleration, rapid changes in direction, kicking,
and frequent side-to-side motions
•
Soccer, ice
hockey, American foot ball, fencing
•
Patients frequently
present with pain in the inguinal region which may radiate to the thigh
adductor muscle origins or to the scrotum and testicles
•
Hernia-like
symptoms may be related to the proximity of the injury site to the medial
margin of the superficial ring of the inguinal canal or to lesion extension
through the superficial ring and resultant weakening of the posterior wall of
the inguinal canal.
Rectus abdominis muscle and Adductor longus muscle
•
Relative
antagonist of one another during rotation and extension of the waist.
•
They share
common attachment in the anterior margin of the pubis, below the pubic crest,
anterior inferior aspect of pubic body
MR imaging finding of Athletic pubalgia
•
Because many
pathophysiologic processes may manifest with pubic and inguinal pain, an MR
imaging survey of the pelvis is recommended during the initial evaluation.
•
The combined
use of non–fat-suppressed T1-weighted and fat-suppressed fluid-sensitive sequences is recommended.
•
Fluid-sensitive
sequences in the three standard orthogonal planes may be helpful to improve
diagnostic accuracy.
•
An axial
oblique sequence has been described that allows visualization of the adductor
tendon origins along their long axes.
•
Direct
visualization of tears involving the rectus abdominis–adductor aponeurosis which appear as
irregular areas with signal intensity like that of fluid undermining the
aponeurosis. It may be most visible on axial and sagittal fluid-sensitive images,
approximately 1–2 cm lateral
to the pubic symphysis
• Abnormal marrow signal intensity
isolated to the anterior-inferior aspect of the pubic body and deep to the
rectus abdominis–adductor
aponeurotic attachment
• Secondary cleft sign, an apparent
inferior extension of the central symphyseal fibrocartilaginous cleft along the
anteroinferior margin of the pubic body.
References:
Omar IM,
Zoga AC, Kavanagh EC et al. Athletic Pubalgia and “Sports
Hernia”: Optimal MR Imaging Technique and
Findings. RadioGraphics 2008:
28; 1415-1438
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