sports hernia
TRANSCRIPT
Devon Klein MD, MPH,
Raj Shah MD, Matthew Maeder MD,
and Mark Zoland, MD
Lenox Hill Hospital, NS-LIJ Healthcare
New York, NY 10075
Disclosures No conflicts of interest to disclose
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 2
Goals and Objectives To describe the utility of employing T2 weighted
SSFSE imaging with and without Valsalva during MRI evaluation of athletic pubalgia
1. Report the incidence of symptomatic groin injuries in our study population
2. Educate the MSK radiologist about other sources of groin pain in the athlete
3. Describe a protocol to facilitate the detection of other symptom inducing groin pathology which will guide treatment
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 3
What is athletic pubalgia?We define it as any abnormal signal or
morphology of the rectus abdominis tendon, adductor longus tendon, or the pre-pubic aponeurosis connecting the two
Findings on physical exam [8]
Point tenderness on the pubis at the insertion of the rectus abdominis
Reproducible pain of the adductor longus with resisted adduction of thigh
The following slides are examples ofMR-positive cases of athletic pubalgia
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 4
Athletic pubalgia
abnormal hyperintensities abnormal hyperintensities
Athletic pubalgia
pubic symphysis
rectus abdominis
pubis
5Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides)
abnormal hyperintensity abnormal hyperintensity
Athletic pubalgia
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 6
abnormal hyperintensitiesabnormal hyperintensity
Athletic pubalgia
Increased signal in pubic bone
7Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides)
symphysis pubis
abnormal hyperintensityabnormal hyperintensity
Athletic pubalgia, bilateral
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 8
Materials and Methods IRB approval was obtained
64 consecutive MRI studies performed for the diagnosis of “athletic pubalgia” from March 2011 -2013
All studies reviewed by a single MSK fellowship trained radiologist
Examinations were performed on a Philips 3T scanner utilizing modification of a published pubalgia protocol
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 9
Materials and Methods 38 studies employed axial T2 weighted
SSFSE sequencing with Valsalva breath holding
Valsalva imaging added less than 2 minutes to exam time
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 10
Materials and MethodsPresence of imaging findings consistent
with the following were noted
Athletic pubalgia
Inguinal hernia
Gilmore’s groin as defined by abnormal bulging of the transversalis fascia/preperitoneal fat with mass effect
Laterality was documented for all findings
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 11
Materials and Methods For examinations employing the
SSFSE Valsalva SequencesAny change in diagnosis based upon the
study sequence was recorded
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 12
ResultsN= 61 Age range 16-71 (mean 37.6) 49 males, 12
females
3 patients were excluded
1 patient incorrect protocol was utilized
2 patients indicated on questionnaire that study was being performed for other clinical indication
37 examinations performed with Valsalva
24 examinations without ValsalvaDevon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 13
Results 38/61 (63%) patient examinations
demonstrated imaging findings consistent with athletic pubalgia
22/61 (36%) demonstrated findings of inguinal hernia
5/61 (8%) demonstrated findings of Gilmore’s groin
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 14
Results - Concomitant FindingsAthletic pubalgia and inguinal hernias
14/61 (23%)
Inguinal hernia and Gilmore’s groin
2/61 (3%)
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 15
Results without Valsalva
Inguinal hernia and/or Gilmore’s groin 6/24 (25%)
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 16
Results with Valsalva 37 cases (32 males, 5 females)
16/37 (43%) demonstrated inguinal hernia and/or Gilmore’s groin
8/16 (50%) of cases non athletic pubalgia findings were observed only on the Valsalva sequences
7 inguinal hernias with 1 concomitant Gilmore’s Groin
1 isolated Gilmore’s groin
1 case where an equivocal findings was made more apparent and a diagnosis was made
Devon Klein MD "The Clinical Utility of VasalvaImaging When Evaluating for Athletic Pubalgia" (27 slides) 17
Without Valsalva:
No left inguinal hernia
With Valsalva:Left inguinal hernia
Valsalva maneuver
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40 y.o. male, bulging of preperitonealfat/transversalis fascia (Gilmore) seen with Valsalva
Ax PD no Valsalva AX T2 Valsalva
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 19
24 y.o. soccer playerAX PD No Valsalva AX T2 with Valsalva
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Same patient next slice
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Conclusion: Symptomatic Groin Injuries Symptoms and clinical findings of athletic
pubalgia often overlap with those of other groin injuries such as Gilmore’s groin and inguinal hernia
In our population who presented for MRI evaluation of athletic pubalgia
8/61 (13%) of MRI’s depicted ipsilateral inguinal hernias in the absence of athletic pubalgia
2/61 (3%) of MRI’s depicted findings consistent with Gilmore’s groin in the absence of athletic pubalgia Devon Klein MD "The Clinical Utility of Vasalva
Imaging When Evaluating for Athletic Pubalgia" (27 slides) 22
Conclusion: Valsalva ImagingEmploying T2 weighted SSFSE Valsalva
sequencing increased the diagnostic yield in the detection of hernias and Gilmore’s groin
Observation of these pathologies increased from 25% to 43% when employing the Valsalva sequence
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 23
Conclusion: Valsalva Sequence Valsalva imaging for evaluation of hernias has been
established
Our preliminary data utilizing SSFSE Valsalva sequences when performing MRI of the pelvis for athletic pubalgia has revealed many unsuspected inguinal hernias in patients referred for athletic pubalgia
We have modified our athletic pubalgia protocol for all patients to include T2 weighted SSFSE with and without Valsalva
Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides) 24
ConclusionMusculoskeletal Radiologists interpreting athletic pubalgia examinations must be well versed and vigilant in the detection of other groin injuries traditionally not within the scope of musculoskeletal imaging.
Utilizing Valsalva sequences in the athletic pubalgia protocol will assist in the detection of other groin injuries
Devon Klein MD "The Clinical Utility of VasalvaImaging When Evaluating for Athletic Pubalgia" (27 slides) 25
Conclusion: We are continuing our study and now have over 125
patients with similar trends developing
Post surgical evaluation is forthcoming
The authors recognize that hip and other pathologies may also present with groin pain but these etiologies have not been included in the scope of this study
Devon Klein MD "The Clinical Utility of VasalvaImaging When Evaluating for Athletic Pubalgia" (27 slides) 26
References1. Omar et al. Athletic pubalgia and "sports hernia": optimal MR imaging
technique and findings. Radiographics. 2008 Sep-Oct;28(5):1415-38. doi: 10.1148/rg.285075217. Review.
2. Hackney, Roger G. "The sports hernia: a cause of chronic groin pain." British journal of sports medicine 27.1 (1993): 58-62.
3. Malycha P, Lovell G. Inguinal surgery in athletes with chronic groin pain: the ‘sportsman’s’ hernia. Aust N Z J Surg 1992;62:123–5.
4. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. ClinSports Med 1998;17:787–93, vii.
5. Omar et al. Athletic Pubalgia and the "Sports Hernia":Optimal MR Imaging of the Pubic Symphysis Region and Pictorial Review of MR Technique and Findings. RSNA presentation Nov 26 –Dec 1, 2006
6. Kavanagh EC, Koulouris G, Ford S, et al. MR imaging of groin pain in the athlete. Semin Musculoskelet Radiol 2006;10:197–207.
7. Meyers et al. Experience with "sports hernia" spanning two decades. Ann Surg. 2008 Oct;248(4):656-65. doi: 10.1097/SLA.0b013e318187a770.
8. Ahumada, Leonik A., et al. "Athletic pubalgia: definition and surgical treatment." Annals of plastic surgery 55.4 (2005): 393-396.
9. Jaffe, Tracy A., et al. "MDCT of abdominal wall hernias: Is there a role for Valsalva's maneuver?." American Journal of Roentgenology 184.3 (2005): 847-851. 27