MR Imaging of Groin Pain in the AthleteEoin C. Kavanagh, M.D.,1 George Koulouris, M.D.,2 Stephanie Ford, M.D.,3

Peter McMahon, M.D.,3 Ciaran Johnson, M.D.,2 and Stephen J. Eustace, M.D.3

ABSTRACT

Groin pain is a frequently encountered symptom in the athlete. The differentialdiagnosis for an athlete presenting with groin pain is broad and diagnostic imaging plays acrucial role in reaching the correct diagnosis, allowing appropriate therapy to be instituted.In this article we present the radiological differential diagnosis of athletes presenting withgroin pain. The common mechanisms of injury, presenting symptoms, and imagingfindings for each of these entities are addressed.

KEYWORDS: Groin, MRI, pain

Groin pain is reported to account for 2 to 5% ofall sports injuries. In sports that involve excessive twist-ing and turning movements such as soccer, ice and fieldhockey, tennis, and Australian rules football, groin in-juries may rise to 5 to 7% of all injuries.1,2 In professionalsports, injuries account for chronic morbidity, and theassociated persistent pain and stiffness frequently pre-vent competitive involvement. Such injuries lead topersonal distress and have dramatic economic conse-quences for professional sporting organizations.

Despite the prevalence and importance, the pat-tern and nature of injuries accounting for groin pain insports remain unclear and hence approaches to manage-ment are varied and poorly constructed and outcomesunpredictable.3–6 In clinical practice, the term ‘‘athleticpubalgia’’ is used to describe exertional pubic or groinpain,7 and although many causes of pubalgia are de-scribed ranging from labral tear of the hip, sacroiliitis, andlower lumbar disc disease to pelvic soft tissue derange-ment in females, most authors conclude that adductordysfunction, osteitis pubis, and prehernia complex (alsotermed sportsman’s hernia, conjoint tendon tear, externaloblique tear, and rectus abdominis sheath tears) are the

commonest causes.8–11 Whether or not these entities aremechanically related is currently unclear.

This article reviews causes and imaging appear-ances of athletic pubalgia occurring in sports, rangingfrom derangement of the hip and its associated muscu-lature through to the commonest causes, osteitis pubis,sportsman’s hernia, and adductor dysfunction, wherebiomechanical dysfunction is primarily centered on thesymphysis pubis.

HIP LABRAL TEARLabral tear in the hip can occur following significantinjury, especially after posterior hip subluxation or dis-location. Acute traumatic labral tears are more commonin patients who play sports that involve extreme hiprotation and flexion. Therefore, runners and athletesinvolved in sports that involve repeated twisting aremost at risk. Patients with preexisting hip dysplasiaand with femoroacetabular dysplasia are more suscepti-ble to labral tears secondary to altered biomechanics.Patients with labral tears often give a history of a sharp,‘‘catching’’ pain. The pain can also be poorly localized,

1Department of Radiology, University of Pittsburgh Medical Center,Pittsburgh, Pennsylvania; 2Department of Radiology, Thomas Jeffer-son University Hospital, Philadelphia, Pennsylvania; 3Department ofRadiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin,Ireland.

Address for correspondence and reprint requests: Eoin C. Kavanagh,M.D., Department of Radiology, University of Pittsburgh MedicalCenter, 200 Lothrop Street, Pittsburgh, PA 15213.

Hot Topics in Orthopedic Imaging; Editors in Chief, David Karasick,M.D., Mark E. Schweitzer, M.D.; Guest Editor, Adam C. Zoga, M.D.

Semin Musculoskelet Radiol 2006;10:197–207. Copyright # 2006by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York,NY 10001 USA. Tel: + 1(212) 584-4662.DOI 10.1055/s-2006-957173. ISSN 1089-7860.

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radiating to the groin, where it may be the only area ofreported symptoms.

Direct magnetic resonance arthrography (MRA)is the ‘‘gold standard’’ imaging technique for assessmentof the hip labrum (Fig. 1). Direct signs of labral tear onMRA include altered morphology of the labrum anddirect contrast imbibement into the labral tear.12–14

Using conventional noncontrast magnetic resonanceimaging (MRI), fluid may also extend into a labral tearon T2-weighted sequences. Paralabral cysts are a secon-dary sign of a labral tear and should provoke a carefulsearch for a tear (Fig. 2). In cases where the tear is occulton noncontrast imaging, it may be necessary to proceedto direct MRA to diagnose and to evaluate accurately the

exact site and extent of the labral tear. Other ancillaryfindings, such as subchondral marrow edema and sub-chondral cystic change, should highlight the need toscrutinize the labrum for the presence of a tear.

The presence of a labral tear, particularly in theyoung adult, requires evaluation of the femoral head-neck junction. An abnormal femoral head-neck junctionmorphology may be seen in femoroacetabular impinge-ment (cam type), which is diagnosed by the directmeasurement of the a angle.15 It is important to identifythese patients with impingement as they benefit fromsurgical intervention to prevent further impingement,ultimately preserving the labrum. Conservative therapiesinclude rest, rehabilitation, and image-guided intra-articular corticosteroid injection. Surgical techniquesfor the correction of femoroacetabular impingementare currently under development, ranging from open toarthroscopic decompression.

SNAPPING HIP SYNDROMEThe snapping hip syndrome is a descriptive term thatshould alert the radiologist to several possible differentialdiagnostic possibilities. Many subtypes of snapping hipsyndrome exist, with a variety of mechanisms havingbeen described in the literature.16 Clinically, this con-dition is characterized by the complaint of painfulsnapping at the hip joint, caused by motion, often withan audible click. The causes of this condition can bebroadly divided into intra-articular and extra-articularcauses. Intra-articular causes include labral tears, intra-articular bodies, and synovial osteochondromatosis. Allthese causes are easily assessed on MRI or by directMRA (Fig. 3). Extra-articular causes of snapping hipsyndrome are usually secondary to tendon pathologyand, as such, can be further divided into internal (me-dial), external (lateral), and posterior causes (dependingon the site of the implicated tendon pathology). Theinternal form is the most frequently encountered; it ischaracterized by a snapping sensation as the iliopsoastendon passes over and catches on the iliopectinealeminence of the pubis and is usually associated withiliopsoas bursal inflammation. Infrequently, the snap-ping hip syndrome is attributed to a catching of theiliofemoral ligaments as they slide over the femoral headin flexion and extension (external) or to a snapping of thelong head of the biceps as it slides over the ischialtuberosity on flexion and extension (posterior).

Dynamic imaging with ultrasonography is oftenuseful in the investigation of the snapping hip syndrome.17

The patient is asked to reproduce the symptoms, anddynamic scanning is then focused upon the underlyingtendon closest towhere the patient complains of pain. Thediagnosis is made by abnormal gliding of the involvedtendon, which coincides with a palpable or audible click,or both. MRI is also useful in the evaluation of snapping

Figure 1 Direct MRA of the right hip in a 24-year-old gymnastwith hip pain. This coronal image shows direct contrast imbibe-ment (arrow) into a surgically confirmed hip labral tear.

Figure 2 Axial T2-weighted image of the left hip in a 35-year-old soccer player with left groin pain shows a large multilobulatedanterior para-labral cyst (arrow). An associated hip labral tear wasconfirmed at surgery.

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hip and allows the exclusion of internal derangement ofthe hip. Management typically involves conservativemeasures including rest, reassurance, activity modifica-tion, and ultrasound-guided corticosteroid injection.

QUADRICEPS MUSCLE STRAINSStrains of the quadriceps muscle are common injuries inathletes.18,19 In most cases of quadriceps muscle strain,the injury follows minor trauma such as stretching oroveruse. Injuries to the quadriceps muscle are frequentlyseen in soccer players and in those involved in kickingsports. Radiological grading of muscle strains has yet tobe correlated with clinical grading of muscle injuries;however, a grading system of 1 to 3 is still routinelyemployed in clinical practice.20 A grade 1 strain ischaracterized by local hemorrhage and edema with anintact musculotendinous unit and, hence, is withoutsignificant morphologic change. A grade 2 muscle strainis a partial tear, which involves up to 50% of muscle fiberwidth. A grade 3 muscle strain is characterized bycomplete or near-complete rupture of the myotendinousunit, with or without retraction. The proximal andcentral myotendinous unit of the rectus femoris is themost common site involved, with accurate location of thetear imperative, as those involving the central aponeur-otic tendon have been associated with a prolongedconvalescence period compared with tears located pe-ripherally within the myotendinous unit.19

The MRI features of muscle strain are char-acteristic, typically showing edema as areas of T2

hyperintensity (Fig. 4). The extent of edema is bestappreciated on coronal and axial imaging (Fig. 5).Susceptibility artifact on gradient echo imaging canoccur secondary to hemorrhage within the musculo-tendinous unit.21 Occasionally, the hemorrhage andedema can become localized and encapsulated byfibrous tissue causing a pseudotumor appearance, with-out evidence of internal enhancement (Fig. 6).

Management of these injuries is almost alwaysconservative, with surgery reserved for grade 3 disrup-tion, particularly in the setting of tendon avulsion. Theanterior superior iliac spine may be avulsed in the

Figure 4 Axial fat-suppressed T2-weighted image shows agrade 1 strain of the rectus femoris muscle, as manifest by T2hyperintensity within the muscle belly.

Figure 3 (A) Coronal fat-suppressed T2-weighted image shows fluid around the iliopsoas tendon (arrow) within the associated bursa.(B) Axial fat- suppressed T2-weighted image in the same patient shows the iliopsoas tendon (arrow) limited by a focal bone overgrowth(arrowhead) over which the tendon subluxes to produce a snapping sound during hip flexion and extension.

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skeletally immature athlete, where physeal developmentlags behind the strength of the powerful lower limbmuscles.22 In such cases, the injury heals typically as afracture (although it may require surgical reduction) andthe prognosis is better than with a purely tendonavulsion.

HAMSTRING TEARSThe hamstring muscle group consists of three muscles:semimembranosus and semitendinosus medially and thebiceps femoris muscle laterally. These muscles span thehip and knee joints, assisting with hip extension andknee flexion. As the hamstring muscles span two joints,they are more susceptible to injury. Injuries to the ham-string muscles are the most common sporting musclestrain injury and are often recurrent, presentingtherapeutic challenges. Given their high incidence,

Figure 5 (A) Sagittal and (B) axial fat-suppressed T2- weighted images show a grade 2 tear of the midbelly of the rectus femorismuscle (arrows) with local hemorrhage (hyperintensity) and edema (isointensity).

Figure 6 Axial T1- weighted image of a 20-year-old soccerplayer after direct trauma shows a localized hematomawithin therectus femoris muscle, causing a pseudotumor appearance.

Figure 7 Coronal fat-suppressed MR image shows an undis-placed avulsion at the attachment of the hamstring to the ischialapophysis on the right (arrow).

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familiarity with their imaging findings is paramount.As with the quadriceps muscle, partial tearing of thesemuscles is the most typical form of injury and mostoften occurs at the myotendinous complex, which is theweakest part of the muscle-tendon unit.23,24

MRI of acute injuries to the hamstring musclegroup shows areas of marked T2 hyperintensity,representing local hemorrhage and edema (Figs. 7–10).As injuries become more subacute, areas of T1 and T2hyperintensity are seen, representing foci of subacutehemorrhage. Typically, the management of injuries tothe hamstring muscles involves conservative therapy,but in severe injuries avulsion of the ischial tuberositycan be seen, often requiring surgical fixation. Investiga-tors have demonstrated that the volume of injured musclein acute hamstring injuries is proportional to rehabilita-tion time needed, allowing prediction of the expectedrecovery time.25

TROCHANTERIC BURSITISTrochanteric bursitis is also a potential cause of groinand hip pain in the athlete.26 There are two importantbursae in the trochanteric region, one between thetensor fascia lata (the so-called trochanteric bursa)and a deeper one between the gluteus medius tendonand the posterior surface of the greater trochanter (thesubgluteus medius bursa).27,28 Either or both of thesebursae can become inflamed and distended. Trochan-teric bursitis typically occurs in athletes who are

involved with repeated flexion at the hip joint. It isthought that excess friction between the tensor fascialata and its underlying bursa gives rise to bursitis. Inchronic cases the bursae can become massively enlarged.This condition is frequently bilateral and can also bepost-traumatic in etiology, often the result of directcontusion in contact sports, resulting in a hemobursa.Typically, patients complain of lateral groin and hippain, exacerbated by adduction and external rotation ofthe hip.

Figure 8 Coronal fat-suppressed MR image shows 3-cmretraction at the site of a hamstring avulsion on the right (arrow).

Figure 9 Coronal fat-suppressed T2-weighted image of a Na-tional Football League kicker shows a grade 2 strain of the righthamstring muscles.

Figure 10 Coronal fat-suppressed T2-weighted image of aprofessional skater shows a high-grade injury to the right ham-string complex with complete rupture of the myotendinous unit.

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Utilizing fluid-sensitive sequences, the inflamedfluid-filled trochanteric bursa is best appreciated oncoronal images of the pelvis and hips, lateral andparallel to the greater trochanter of the hip(Fig. 11). Management is usually conservative andmay require radiologically guided corticosteroid in-jection, best achieved with real-time sonography.Surgical bursectomy and removal of loose bodies arereserved for refractory cases.

STRESS FRACTURESStress fractures in athletes mostly occur about the pubicsymphysis and proximal femur. Stress fractures areeither fatigue fractures, occurring as a result of abnor-mal stress on normal bone, or insufficiency fractures as aresult of normal stress on abnormal bone. In general,the term stress fracture is used to describe fatiguefractures rather than insufficiency, and although theyoccur as a result of chronic stress, they often arise as anacute fracture to a site previously weakened over time.Insufficiency fractures can occur in athletes with osteo-porotic or osteomalacic bone, typically seen in youngfemale athletes with nutritional or hormonal deficiency,or both.

Radiologic evaluation of stress fractures usuallyinvolves MRI as plain films and computed tomographyexaminations are often normal.29 Stress fractures of thepubic symphysis on MRI are seen as a low-signal bandperpendicular to and continuous with the cortex on allpulse sequences, secondary to increased osteoblasticactivity and bone sclerosis. Within 3 weeks of the onsetof symptoms, note is often made of adjacent edema andhemorrhage, manifest as signal hyperintensity on fluid-sensitive sequences (Fig. 12). After 3 weeks, followingresolution of edema, hypointense sclerosis at the sites offracture may be obscured adjacent to hypointense fat onboth inversion recovery and frequency-selective sequen-ces. Evaluation of suspected stress fracture is thereforebest achieved using a T1-weighted spin echo sequence in

which the hypointense line is contrasted against normalhyperintense marrow fat.

Rest is usually advised until complete healing hasoccurred, which usually takes 5 to 8 weeks, but thisprocess may take longer. For those with insufficiencyfractures, dietary review regarding calcium intake andthe need for supplementation is also necessary. Surgicalfixation is indicated for superior (tension) side fracturesof the femoral neck.

OSTEITIS PUBISThe pubic symphysis is a midline joint that consists of afibrocartilaginous disc situated between the bodies of thetwo pubic bones. The pubic symphysis is a poorlyunderstood joint that is susceptible to injury in athletes,probably secondary to abnormal forces encounteredduring exercise. Osteitis pubis is a painful conditionaffecting the pubic symphysis that is considered likelyto represent a stress response, secondary to abnormalshearing forces. It is most frequently seen in athletesinvolved in kicking sports such as soccer and Australianfootball. Osteitis pubis can occur as an isolated entity butis commonly associated with other pathological entitiesaround the pubic symphysis such as adductor and rectusabdominis muscle strains. Clinically, patients typicallycomplain of pain localized to the symphysis, radiating tothe medial thigh, lower abdomen, and perineum. Thepain is exacerbated by exercise, kicking, and running.

Radiographic findings include subchondral cysticchange, subchondral resorption, fragmentation, joint ir-regularity and in chronic cases sclerosis (Fig. 13), andosteophytic bridging. Flamingo views may reveal jointlaxity manifest as the development of step off in superiorsymphyseal alignment in the flamingo weight-bearing

Figure 11 Coronal fat suppressed T2 weighted image showsfocal inflammation over the greater trochanter (arrow) in a patientwith left trochanteric bursitis.

Figure 12 Coronal fat-suppressed T2-weighted image of a 30-year-old female runner shows a stress fracture of the inferioraspect of the right femoral neck (arrow). Note the florid surround-ing bone marrow edema.

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position. Radioisotope bone scans show increased uptakeof radiotracer about the pubic symphysis (Fig. 14).30

MRI reveals perisymphyseal hyperintensity on fluid-sen-sitive sequences, presumably reflecting edema related toincreased stress response and areas of trabecular micro-trauma (Fig. 15).31 T1-weighted images can show wid-ening of the symphyseal cleft in chronic cases. If stressfractures are also present, these are often manifest asvertically oriented subchondral areas of T1 hypointensityadjacent to the pubic symphysis. Nonsurgical manage-ment includes rest, oral anti-inflammatory medications,physical rehabilitation, and image-guided injection ofcorticosteroid and local anesthetic directly into thejoint.32,33 Surgical management includes curettage, andin the setting of instability, arthrodesis may be performedto stabilize the pelvis. Wedge resection of the pubicsymphysis is rarely performed in cases that are refractory

to nonoperative measures; however, this can be eventuallycomplicated by pelvic instability.

ADDUCTOR DYSFUNCTIONInjury to the adductor muscles represents one of themost common causes of groin pain in athletes. Adductordysfunction is especially common in soccer, Australianfootball, and ice hockey players. The hip adductormuscles include adductors longus, adductor brevis, ad-ductor magnus, pectineus, and the gracilis muscles. Theorigins of the adductor longus and brevis muscles areintimately related and reinforce the inferior joint capsuleof the pubic symphysis.34 The pectineus muscle arisesfrom the superior pubic ramus and its most medial fibersalso blend with the superolateral joint capsule of thepubic symphysis. It is therefore not surprising that injurywith subsequent weakening and alteration of biome-chanics of the adductor muscles can lead to instability atthe pubic symphysis. The adductor muscles all insert onthe posteromedial aspect of the femur (linea aspera),with adductor magnus having the largest area of inser-tion. The range and manifestations of injury that mayoccur to the adductor muscles are analogous to those inthe preceding discussion related to quadriceps and ham-string muscle strains.

Patients typically present with groin pain, exacer-bated by exercise and kicking. Clinical examination mayreveal local muscle tenderness or tenderness over thepubic symphysis, or both, exacerbated by resisted adduc-tion of the thighs. The adductor longus muscle is themost frequently injured adductor muscle and may coexistwith osteitis pubis. Fat-saturated fluid-sensitive MRsequences in the axial oblique plain best demonstrateadductor muscle injuries, and coronal sequences are idealfor the detection of any simultaneous pathology at thepubic symphysis, particularly the ‘‘secondary cleft’’ sign.The secondary cleft sign is manifest as extension of fluid-bright signal outside the pubic symphysis to one or both

Figure 15 Axial fat-suppressed T2-weighted image of thepelvis in a 22-year-old male ice hockey player. Note the floridbone marrow edema in the bilateral pubic bones (arrows), con-sistent with osteitis pubis.Figure 13 Anteroposterior radiograph shows focal sclerosis

due to excess traction at the adductor attachments bilaterally(arrows) in a soccer player with bilateral groin pain.

Figure 14 Isotope bone scan shows concentration of radio-tracer activity at the symphysis pubis with increased marginalosteoblastic activity in a 27-year-old soccer player with osteitispubis.

MR IMAGING OF GROIN PAIN IN THE ATHLETE/KAVANAGH ET AL 203

sides (the side of extension has been shown to correlatewith symptoms).35 The exact anatomy of this sign has notyet been elucidated, but it is thought likely to representcapsular injury to the pubic symphysis secondary toadductor avulsion, be it partial or complete. Coronalshort-TI inversion recovery (STIR) and fat-saturatedT2-weighted sequences are most useful for looking forthe secondary cleft sign (Figs. 16 and 17). MRI alsoshows symphyseal irregularity and para-articular boneedema if there is coexistent osteitis pubis (Figs. 18–20).

Nonoperative management is the rule in adductorstrain, with surgical intervention, such as reattachmentof an avulsion injury in the acute setting. In the contextof chronic groin pain, adductor tenotomy can be per-formed, with surgical excision of granulation tissue.36

ILIOPSOAS BURSITISThe iliopsoas bursa is the single largest bursa in thehuman body, lying deep to the distal iliopsoas musclecomplex and anterior to the superior hip joint. Thisbursa communicates with the hip joint in �15% of thepopulation; thus, pathology in the iliopsoas bursa canalso affect the hip joint. Iliopsoas bursitis is an inflam-matory condition seen in athletes secondary to overusewith repetitive hip flexion and extension.37 The condition

Figure 16 Contrast injection to the symphysis (symphysogra-phy) in a 17-year-old soccer player shows contrast filling of anaccessory cleft on the right at a site of microtear at the rightadductor attachment accounting for right groin pain. Symptomrelief in this patient was achieved by subsequent injection ofsteroid and bupivacaine (Marcaine) to the symphysis and sec-ondary accessory cleft.

Figure 17 Coronal fat-suppressed T2-weighted image of a23-year-old professional ice hockey player with groin pain. Notethe secondary cleft sign on the left (arrow) representing capsularinjury to the pubic symphysis secondary to adductor avulsion.

Figure 19 Coronal fat-suppressed T2-weighted image of a19-year-old soccer player with groin pain shows a right-sidedsecondary cleft sign (arrow) with focal bone edema in the rightpubic bone (arrowhead).

Figure 18 Coronal fat-suppressed T2-weighted image of a22-year-old soccer player with groin pain shows fluid filling of aright-sided secondary cleft (arrow) due to microtear at the rightadductor attachment, with focal distraction-induced bone edemaon the right at the site of tear (arrowhead).

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causes groin pain in gymnasts, dancers, and runners.Rarely, patients present with a groin mass secondary togross bursal distention. Iliopsoas bursitis can also beseen in association with inflammatory arthropathies,and concomitant exclusion of these conditions may bewarranted.

MRI is the investigation of choice for this con-dition as it more accurately defines the size and extent ofthe distended bursa and also allows evaluation of asso-ciated hip pathology.38,39 Fat-suppressed fluid-sensitivesequences typically show a rounded high-signal fluidcollection posteromedial to the iliopsoas muscle(Fig. 21). Management is most often nonoperative,consisting of rest, rehabilitation therapy, and rarelytherapeutic injection of the bursa with steroids and localanesthetic using sonographic guidance.

SPORTS HERNIAThe term sports hernia has resulted in confusion as it hasbeen used interchangeably in the literature for twosimilar, although distinct clinical entities.

Posterior Inguinal Wall DeficiencyThis condition occurs as a result of tearing and injury tothe conjoint tendon, which is formed by the medialportion of the internal oblique and transversus abdominismuscles. Injury to the conjoint tendon, which forms theposterior wall of the inguinal canal, thus results in loss ofintegrity of the canal and probably represents an earlyspectrum of injury for which direct hernia formation isthe end result. At the early stage of this spectrum ofinjury, an athlete presents with clinical symptoms similarto those of a direct hernia, but no discrete hernia isdetected. The deficiency, or incompetence, of the poste-rior inguinal wall is readily demonstrated sonographi-cally, as contraction of the anterior abdominal wall resultsin loss of the normal valve-like effect of the canal. Hence,the posterior inguinal wall is displaced anteriorly, asopposed to becoming taut. Furthermore, there is a lossof the mild physiological compression of the spermaticcord, which is normally evidenced by a decrease in size ofthe veins of the pampiniform plexus.40 In posterior walldeficiency, the pampiniform plexus paradoxically in-creases in size.

Gilmore’s Groin/Groin DisruptionThis condition currently remains a clinical diagnosis andradiological diagnosis of exclusion, as no imaging find-ings have been reported. In these athletes, the pathologyinvolves the medial aspect of the external oblique muscle,which forms the anterior wall of the inguinal canal aswell as the superficial (external) inguinal ring. Tears ofthe external oblique thus result in point tenderness at thesuperficial inguinal ring, which is dilated. Again, nohernia is present; however, patients, like those withposterior inguinal wall deficiency, benefit from surgeryused for the standard treatment of hernias, be it open orlaparoscopic.

Athletes may present simultaneously with thepreceding two conditions, as any activity sufficient tocause tearing and weakness in one wall of the inguinalcanal may do so in the other. Left untreated, theseconditions are incapacitating and may be deleterious toan athletic career, possibly resulting in premature retire-ment. Without surgery, these patents are at risk forfuture discrete direct inguinal hernia formation.

OTHER CAUSES OF GROIN PAININ THE ATHLETEThere are many other potential causes of groin pain in theathlete. Osseous, soft tissue, and urinary tract pathologycan lead to presentation with groin pain. Lumbar spon-dylosis can result in patients presenting with radiculargroin pain. In these patients, dedicated MRI of thelumbar spine may reveal a disc herniation, foraminalstenosis, facet arthropathy, or central canal narrowing.

Figure 20 Coronal fat-suppressed T2-weighted image of a24-year-old professional hockey player with groin pain shows aright-sided secondary cleft sign (arrowhead) with grade 1 strainpattern within his right adductor longus muscle (arrow).

Figure 21 Axial T2-weighted MR image shows a distendedinflamed iliopsoas bursa on the left (arrow), anterior to the lefthip.

MR IMAGING OF GROIN PAIN IN THE ATHLETE/KAVANAGH ET AL 205

Developmental osseous abnormalities such as transitionalanatomy at the lumbosacral junction and spondylolysismay lead to presentation with groin and pelvic pain.

In young female athletes, various pelvic patholo-gies such as adnexal cysts, endometriosis, and adeno-myosis can result in groin pain. In young female athletesin whom a structural cause for groin pain is seen onMRI, there are often ancillary findings seen within thepelvis organs, such as adnexal cysts. In other cases thepelvic pathology may be the sole source of groin pain.

The pelvic soft tissues should be scrutinized whenevaluating MR images of all patients presenting withgroin pain (Fig. 22).

Sacroiliitis can also arise with groin pain in theathlete (Fig. 23). If this is suspected, dedicated MRI ofthe sacroiliac joints should be performed. Full rheuma-tological work-up of these patients is recommended toevaluate for the potential presence of an underlyinginflammatory arthropathy.

CONCLUSIONThis article presents an overview of the many causes ofgroin pain or pubalgia occurring in athletes, in particularstressing the impact of osteitis pubis, adductor dysfunc-tion, and sportsman’s hernia. Appropriate use of MRIallows accurate diagnosis, appropriate management ofthe patient, and ultimately return to sporting activities.

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