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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, sportsman’s hernia, athletic pubalgia, Gilmore groin, hockey goalie syndrome, adductor dysfunction, and osteitis pubis
- Sportsman’s 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:
- 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.
- 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.
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