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

18Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides)

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

20Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides)

Same patient next slice

21Devon Klein MD "The Clinical Utility of Vasalva Imaging When Evaluating for Athletic Pubalgia" (27 slides)

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