High insertion of conjoint tendon is associated with inguinal-related groin pain: a MRI study

  • Myriame Bou Antoun
  • Maxime Ronot
  • Amandine Crombe
  • Marie-Hélène Moreau-Durieux
  • Gilles Reboul
  • Lionel PesquerEmail author



To compare the insertions of the conjoint tendon (CT) on MRI in athletes with and without symptoms and to assess their relationship to groin pain with surgery as a reference.

Materials and methods

Between January and May 2017, patients with inguinal-related groin pain undergoing Shouldice repair were prospectively enrolled and underwent MRI. Exams were independently reviewed by two radiologists blinded to surgical results to assess types of CT insertion as high muscular without (type 1) or with tendinous expansion (type 2) or low muscular (type 3). Radiological and surgical results were compared. Patients were compared with a gender- and age-matched control group of asymptomatic athletes.


One hundred twenty-eight walls (64 in patients, 64 in controls) in 64 subjects (32 patients and 32 controls, only men; mean age, 31.7 ± 10 years; range, 15.0–54.8) were analyzed. CT insertion was defined as types 1, 2, and 3 in 32/128 (25%), 35/128 (27%), and 61/128 (48%) walls, respectively, with 22/64 (34%), 27/64 (42%), and 15/64 (23%) in patients and 10/64 (16%), 8/64 (12.5%), and 46/64 (72%) in controls. Type s1+2 were significantly more frequent in patients compared with that in controls (p < 0.01). MRI predicted a high CT insertion with a sensitivity and specificity of 97% (95%CI 85–99) and 62% (95%CI 36–82). The intra- and inter-reader agreement for the prediction of the type of insertion was excellent (k > 0.75).


A high CT insertion is more frequent in athletes with groin pain and may be a predisposing factor. MRI could help predict the type of CT insertion.

Key Points

• MR imaging should be included in the initial workup of patients with inguinal-related groin pain.

• MR imaging can be used to visualize the type of insertion with acceptable results.

• High insertion of the conjoint tendon may be a predisposing factor for inguinal-related groin pain.


Hip Tendons Inguinal canal Groin Abdominal wall 



Body mass index


Confidence interval


Conjoint tendon

MR imaging

Magnetic resonance imaging


Negative predictive value


Positive predictive value


Funding information

The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Lionel Pesquer.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

Maxime Ronot kindly provided statistical advice for this manuscript.

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• prospective

• case-control study

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology, HEGP Hospital, Assistance publique- hôpitaux de Paris (AP-HP)University of Paris VParisFrance
  2. 2.Department of Radiology, Beaujon Hospital, Assistance publique- hôpitaux de Paris (AP-HP)University of Paris VIIParisFrance
  3. 3.Department of RadiologyInstitut BergoniéBordeauxFrance
  4. 4.MSK Imaging DepartmentClinique du sportBordeaux-MérignacFrance
  5. 5.Hernia CenterClinique du sportBordeaux-MérignacFrance

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