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Athletic Groin Pain

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Imaging of Orthopedic Sports Injuries

Part of the book series: Medical Radiology ((Med Radiol Diagn Imaging))

Abstract

Groin injury and pain account for a significant proportion of all athletic injuries particularly in sports involving kicking and sudden change of direction. Acute adductor and hip flexor muscle injuries are only second in incidence to hamstring injury. Non-acute or long-standing groin pain is also a complex clinical and radiological area with confusing terminology often being used. Research has largely focused on long-standing groin pain but increasing studies are now appearing on acute injury and prevention.

This chapter reviews the anatomy of the anterior pelvis and groin and illustrates the normal anatomy and normal variation seen in athletes. Imaging strategies will be discussed emphasising the use of MRI to evaluate the symphysis pubis and surrounding rectus abdominis-adductor longus aponeurosis. Clinical and imaging findings in athletes with acute and long-standing groin pain are described and illustrated. The evidence for the specificity of imaging findings in the context of asymptomatic athletes is also presented.

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References

  • Arendt EA, Griffiths HJ (1997) The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med 16:291–306

    Article  CAS  PubMed  Google Scholar 

  • Arnason A, Sigurdsson SB, Gudmundsson A et al (2004) Risk factors for injuries in football. Am J Sports Med 32:5–16

    Article  Google Scholar 

  • Behrens SB, Deren ME, Matson A et al (2013) Stress fractures of the pelvis and legs in athletes: a review. Sports Health 5:165–174

    Article  PubMed  PubMed Central  Google Scholar 

  • Branci S, Robinson P (2014) Imaging in long-standing groin pain in athletes. Aspetar Sports Med J 3:316–324

    Google Scholar 

  • Branci S, Thorborg K, Bech BH et al (2015a) MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med 49:681

    Article  PubMed  Google Scholar 

  • Branci S, Thorborg K, Bech BH et al (2015b) The Copenhagen standardised MRI protocol to assess the pubic symphysis and adductor regions of athletes: outline and intratester and intertester reliability. Br J Sports Med 49:692

    Article  PubMed  Google Scholar 

  • Brennan D, O’Connell MJ, Ryan M et al (2005) Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology 235:162–167

    Article  PubMed  Google Scholar 

  • Calderazzi F, Nosenzo A, Galavotti C et al (2018) Apophyseal avulsion fractures of the pelvis. A review. Acta Biomed 89:470–476

    PubMed  Google Scholar 

  • Chan O, Del Buono A, Best TM, Maffulli N (2012) Acute muscle strain injuries: a proposed new classification system. Knee Surg Sports Traumatol Arthrosc 20:2356–2362

    Article  PubMed  Google Scholar 

  • Chopra A, Robinson P (2016) Imaging athletic groin pain. Radiol Clin N Am 54(5):865–873

    Google Scholar 

  • Cunningham PM, Brennan D, O’Connell M et al (2007) Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol 188:291–296

    Article  Google Scholar 

  • Ekstrand J, Hägglund M, Waldén M (2011) Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 39:1226–1232

    Article  PubMed  Google Scholar 

  • Ekstrand J, Healy JC, Waldén M et al (2012) Hamstring muscle injuries in professional football: the correlation of MRI findings with return to play. Br J Sports Med 46:112–117

    Article  PubMed  Google Scholar 

  • Elattar O, Choi H, Dills VD, Busconi B (2016) Groin injuries (athletic pubalgia) and return to play. Sports Health 8:313–323

    Article  PubMed  PubMed Central  Google Scholar 

  • Engebretsen AH, Myklebust G, Holme I et al (2010) Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. Am J Sports Med 38:2051–2057

    Article  PubMed  Google Scholar 

  • Giza E, Mithöfer K, Farrell L et al (2005) Injuries in women’s professional soccer. Br J Sports Med 39:212–216

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Guillin R, Cardinal É, Bureau NJ (2009) Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction. Eur Radiol 19:995–1001

    Article  PubMed  Google Scholar 

  • Hardi M, Robinson P (2019) Top-Ten Tips for Imaging Groin Injury in Athletes. Semin Musculoskelet Radiol 23(4):361–75.

    Article  Google Scholar 

  • Harøy J, Clarsen B, Thorborg K et al (2017a) Groin problems in male soccer players are more common than previously reported. Am J Sports Med 45:1304–1308

    Article  PubMed  Google Scholar 

  • Harøy J, Thorborg K, Serner A et al (2017b) Including the Copenhagen adduction exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players: a randomized controlled trial. Am J Sports Med 45:3052–3059

    Article  PubMed  Google Scholar 

  • Hölmich P (2007) Long-standing groin pain in sports people falls into three primary patterns, a ‘clinical entity’ approach: a prospective study of 207 patients. Br J Sports Med 41:247–252

    Article  PubMed  PubMed Central  Google Scholar 

  • Hölmich P, Uhrskou P, Ulnits L et al (1999) Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 353:439–443

    Article  PubMed  Google Scholar 

  • Ishøi L, Sørensen CN, Kaae NM et al (2016) Large eccentric strength increase using the Copenhagen Adduction exercise in football: a randomized controlled trial. Scand J Med Sci Sports 26:1334–1342

    Article  PubMed  Google Scholar 

  • Kiel J, Kaiser K (2018) Adductor strain. StatPearls Publishing. Available via DIALOG. https://www.ncbi.nlm.nih.gov/books/NBK493166/. Accessed 19 Jan 2020

  • Kluin J, Den Hoed PT, Van Linschoten R et al (2004) Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 32:944–949

    Article  PubMed  Google Scholar 

  • Koulouris G (2008) Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. AJR Am J Roentgenol 191:962–972

    Article  PubMed  Google Scholar 

  • Kunduracioglu B, Yilmaz C, Yorubulut M, Kudas S (2007) Magnetic resonance findings of osteitis pubis. J Magn Reson Imaging 25:535–539

    Article  PubMed  Google Scholar 

  • Lee SC, Endo Y, Potter HG (2017) Imaging of groin pain: magnetic resonance and ultrasound imaging features. Sports Health 9:428–435

    Article  PubMed  PubMed Central  Google Scholar 

  • Liong SY, Whitehouse RW (2012) Lower extremity and pelvic stress fractures in athletes. Br J Radiol 85:1148–1156

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Mascarenhas VV, Castro MO, Diana Afonso P (2020) Hip, pelvis and sacro-iliac joints. Med Radiol. https://doi.org/10.1007/174_2020_256

  • Madani H, Robinson P (2019) Top-ten tips for imaging groin injury in athletes. Semin Musculoskelet Radiol 23:361–375

    Article  PubMed  Google Scholar 

  • Meindl RS, Lovejoy CO, Mensforth RP, Walker RA (1985) A revised method of age determination using the os pubis, with a review and tests of accuracy of other current methods of pubic symphyseal aging. Am J Phys Anthropol 68:29–45

    Article  CAS  PubMed  Google Scholar 

  • Morelli V, Weaver V (2005) Groin injuries and groin pain in athletes: part 1. Prim Care 32:163–183

    Article  PubMed  Google Scholar 

  • Omar IM, Zoga AC, Kavanagh EC et al (2008) Athletic pubalgia and “Sports Hernia”: optimal MR imaging technique and findings. Radiographics 28:1415–1438

    Article  PubMed  Google Scholar 

  • Peetrons P (2002) Ultrasound of muscles. Eur Radiol 12:35–43

    Article  CAS  PubMed  Google Scholar 

  • Pogliacomi F, Calderazzi F, Paterlini M, Ceccarelli F (2014) Surgical treatment of anterior iliac spines fractures: our experience. Acta Biomed 85:52–58

    PubMed  Google Scholar 

  • Pollock N, James S, Lee J, Chakraverty R (2014) British athletics muscle injury classification: a new grading system. Br J Sports Med 48:1347–1351

    Article  PubMed  Google Scholar 

  • Robinson P, Barron D, Parsons W et al (2004) Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings. Skelet Radiol 33:451–457

    Article  CAS  Google Scholar 

  • Robinson P, Hensor E, Lansdown M et al (2006) Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol 187:1168–1178

    Article  PubMed  Google Scholar 

  • Robinson P, Salehi F, Grainger A et al (2007) Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol 188:440–445

    Article  Google Scholar 

  • Robinson P, Bhat V, English B (2011) Imaging in the assessment and management of athletic pubalgia. Semin Musculoskelet Radiol 15:14–26

    Article  PubMed  Google Scholar 

  • Robinson P, Grainger AJ, Hensor EMA (2016) Do MRI and ultrasound of the anterior pelvis correlate with, or predict, young football players’ clinical findings? A 4-year prospective study of elite academy soccer players. Br J Sports Med 49:176–182

    Article  Google Scholar 

  • Sailly M, Whiteley R, Read JW (2015) Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br J Sports Med 49:828–834

    Article  PubMed  Google Scholar 

  • Schilders E, Bharam S, Golan E et al (2007) The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc 25:3969–3977

    Article  Google Scholar 

  • Schilders E, Talbot J, Robinson P (2009) Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 91:2455–2460

    Article  PubMed  Google Scholar 

  • Sedaghati P, Alizadeh M, Shirzad E, Ardjmand A (2013) Review of sport-induced groin injuries. Trauma Mon 18:107–112

    Article  PubMed  PubMed Central  Google Scholar 

  • Serner A, Jakobsen MD, Andersen LL et al (2014) EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. Br J Sports Med 48:1108–11014

    Article  PubMed  Google Scholar 

  • Serner A, Tol JL, Jomaah N et al (2015a) Diagnosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med 43:1857–1864

    Article  PubMed  Google Scholar 

  • Serner A, Van Eijck C, Beumer BR et al (2015b) Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med 49:813

    Article  PubMed  Google Scholar 

  • Serner A, Weir A, Tol JL et al (2016) Can standardised clinical examination of athletes with acute groin injuries predict the presence and location of MRI findings? Br J Sports Med 50:1541–1547

    Article  PubMed  Google Scholar 

  • Serner A, Weir A, Tol JL et al (2018a) Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes. Scand J Med Sci Sports 28:667–676

    Article  CAS  PubMed  Google Scholar 

  • Serner A, Weir A, Tol JL et al (2018b) Characteristics of acute groin injuries in the hip flexor muscles—a detailed MRI study in athletes. Scand J Med Sci Sports 28:677–685

    Article  CAS  PubMed  Google Scholar 

  • Serner A, Mosler AB, Tol JL et al (2019) Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis. Br J Sports Med 53:158–164

    Article  PubMed  Google Scholar 

  • Sheen AJ, Stephenson BM, Lloyd DM et al (2014) “Treatment of the sportsman’s groin”: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 48:1079–1087

    Article  PubMed  Google Scholar 

  • Shortt CP, Zoga AC, Kavanagh EC, Meyers WC (2008) Anatomy, pathology, and MRI findings in the sports hernia. Semin Musculoskelet Radiol 12:54–61

    Article  PubMed  Google Scholar 

  • Stevens MA, El-Khoury G, KATHOL MH et al (1999) Imaging features of avulsion injuries. Radiographics 19:655–672

    Article  CAS  PubMed  Google Scholar 

  • Tansey RJ, Benjamin-Laing H, Jassim S et al (2015) Successful return to high-level sports following early surgical repair of combined adductor complex and rectus abdominis avulsion. Bone Joint J 97-B:1488–1492

    Article  CAS  PubMed  Google Scholar 

  • Thorborg K, Branci S, Nielsen MP et al (2014) Eccentric and isometric hip adduction strength in male soccer players with and without adductor-related groin pain: an assessor-blinded comparison. Orthop J Sports Med 2:2325967114521778

    Article  PubMed  PubMed Central  Google Scholar 

  • Tuite DJ, Finegan PJ, Saliaris AP et al (1998) Anatomy of the proximal musculotendinous junction of the adductor longus muscle. Knee Surg Sports Traumatol Arthrosc 6:134–137

    Article  CAS  PubMed  Google Scholar 

  • Vanhoenacker FM (2021) Bone marrow edema in sports injuries/general concept. Med Radiol. https://doi.org/10.1007/174_2020_241

  • Vasileff WK, Nekhline M, Kolowich PA et al (2017) Inguinal hernia in athletes: role of dynamic ultrasound. Sports Health 9:414–421

    Google Scholar 

  • Verrall GM, Slavotinek JP, Fon GT (2001) Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 35:28–33

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Vitale K, Smitaman E, Huang BK (2019) Medial iliac stress fractures in athletes: report of two rare cases: review of literature and clinical recommendations. Skelet Radiol 48:1119–1123

    Article  Google Scholar 

  • Waldén M, Hägglund M, Ekstrand J (2015) The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med 49:792–797

    Article  PubMed  Google Scholar 

  • Wangensteen A, Guermazi A, TOL JL et al (2018) New MRI muscle classification systems and associations with return to sport after acute hamstring injuries: a prospective study. Eur Radiol 28:3532–3541

    Article  PubMed  Google Scholar 

  • Weir A, Brukner P, Delahunt E (2015) Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 49:768–774

    Article  PubMed  Google Scholar 

  • Weir A, Robinson P, Hogan B, Franklyn-Miller A (2017) MRI investigation for groin pain in athletes: is radiological terminology clarifying or confusing? Br J Sports Med 51:1185–1186

    Article  PubMed  Google Scholar 

  • Werner J, Hägglund M, Waldén NM, Ekstrand J (2009) UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 43:1036–1040

    Article  CAS  PubMed  Google Scholar 

  • Wunderbaldinger P, Bremer C, Schellenberger E (2002) Imaging features of iliopsoas bursitis. Eur Radiol 12:409–415

    Article  CAS  PubMed  Google Scholar 

  • Zajick D, Zoga A, Omar I, Meyers W (2008) Spectrum of MRI findings in clinical athletic pubalgia. Semin Musculoskelet Radiol 12:3–12

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK

    Radhika Prasad, Omar Abdulla & Philip Robinson

  2. Leeds Musculoskeletal Biomedical Research Centre, University of Leeds, Leeds, UK

    Philip Robinson

Authors
  1. Radhika Prasad
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  2. Omar Abdulla
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  3. Philip Robinson
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Correspondence to Philip Robinson .

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Editors and Affiliations

  1. Department of Radiology, Antwerp University Hospital, Edegem, Belgium

    Filip M. Vanhoenacker

  2. Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, The Netherlands

    Mario Maas

  3. Department of Radiology, Antwerp University Hospital, Edegem, Belgium

    Jan L.M.A. Gielen

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Prasad, R., Abdulla, O., Robinson, P. (2021). Athletic Groin Pain. In: Vanhoenacker, F.M., Maas, M., Gielen, J.L. (eds) Imaging of Orthopedic Sports Injuries. Medical Radiology(). Springer, Cham. https://doi.org/10.1007/174_2020_254

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  • DOI: https://doi.org/10.1007/174_2020_254

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  • Print ISBN: 978-3-030-75361-0

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