PREVIEW ONLY 3/04/2013. Andrew Ellis. Dr John Read IMAGING OF GROIN PAIN. Click to minimize panel and see whole screen

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Osborne Powell
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Be sure to convert to your own time zone at Andrew Ellis BSc (Ex. Sci), M.

(Australia/NZ) Host Presented by: Dr John Read Will commence LIVE from Sydney,

Completed post-graduate radiology training at Westmead Hospital, Sydney 1985.

the end MB BS, FRANZCR, DDU Diagnostic Radiologist Over the past 20 years has been

become a popular reference used in daily clinical practice by many radiologists,

1 Be sure to convert to your own time zone at Andrew Ellis BSc (Ex. Sci), M. Phty IMAGING OF GROIN PAIN World Health Webinars CEO World Health Webinars (Australia/NZ) Host Presented by: Dr John Read Will commence LIVE from Sydney, Australia at 7pm AEDT Be sure to convert to your own time zone at Dr John Read Completed post-graduate radiology training at Westmead Hospital, Sydney Click to minimize panel and see whole screen Type questions to be answered live at the end MB BS, FRANZCR, DDU Diagnostic Radiologist Over the past 20 years has been involved with musculoskeletal ultrasound development & education in Australia and New Zealand. Co-author of Atlas of Imaging in Sports Medicine, an international textbook that has become a popular reference used in daily clinical practice by many radiologists, sports physicians and physiotherapists. Over the last 10 years John has practised exclusively at Castlereagh Imaging as a subspecialised musculoskeletal radiologist working with all imaging modalities. 1

2 IMAGING OF GROIN PAIN PELVIC FORCES hip joint rectus abdominis inguinal hernia adductor origin osteitis pubis conjoint tendon SACRO-ILIAC JOINT GAIT CYCLE SYMPHYSIS PUBIS ORIENTATION SYMPHYSIS PUBIS 2

PUBIC PLATE PUBIC PLATE SUPERFICIAL TENDON LAYER

Traditional text superficial crossing fibres (Gray

and AL joined through symphysial capsular tissues

transmission possible from AL to contralateral rectus

3 PUBIC PLATE PUBIC PLATE SUPERFICIAL TENDON LAYER Courtesy: Isaac Lui, Dzung Huu Vu (UNSW 2012) Traditional text superficial crossing fibres (Gray 1859, Testut 1904, Netter 2003) Distal rectus sheath and AL joined through symphysial capsular tissues (Robinson et al 2007, Norton-Old et al 2012) Force transmission possible from AL to contralateral rectus sheath (Clark 2010, Norton-Old et al 2012) Courtesy: Isaac Lui, Dzung Huu Vu (UNSW

4 PUBIC PLATE DEEP TENDON LAYER 4

5 PYRAMIDALIS PYRAMIDALIS 5

6 PYRAMIDALIS VARIANTS GRACILIS & FASCIA LATA Unilateral absence Bilateral absence Dzung Vu (UNSW 2012) ADDUCTOR BREVIS Gracilis & medial thickening excised 6

7 CAPSULAR LAYER CONJOINT TENDON 7

8 CONJOINT TENDON PUBIC STABILITY passive stabilisers articular disc, symphysial ligaments dynamic stabilisers cross-brace of anterior myofascial sling neuromotor control POSTERIOR MYOFASCIAL SLING ANTERIOR MYOFASCIAL SLING Courtesy: Isaac Lui, Dzung Huu Vu (UNSW) self-bracing mechanism Pubic cross-brace FORCES ACTING ACROSS THE PUBIC PLATE Ossification of the Pelvis Mullens et al (2011) Lui and Vu (UNSW 2012) 8

9 Normal Pubic Apophysis Normal Pubic Apophysis almost closed Asymptomatic Patient M21 Normal Apophysis CAUSES OF CHRONIC GROIN PAIN PATHWAYS TO CHRONIC GROIN PAIN 1. ACUTE INJURY Isolated tendon tear Multi-tendon/plate tear Symphysis subluxation Apophyseal avulsion MUSCLE IMBALANCE PELVIC INSTABILITY From: Brukner & Khan s Clinical Sports Medicine 4e, McGraw-Hill, Sydney (2012) 9

10 M45 Pubic Apophysitis & Apophyseal Avulsion PATHWAYS TO CHRONIC GROIN PAIN 2. CHRONIC MICRO-TRAUMA Symphysis disk degeneration Para-symphysial tendonitis Pubic apophysitis ACUTE INJURY PELVIC INSTABILITY 10

11 What is Osteitis Pubis? Marrow oedema 91/100 cases central groin pain; 0/100 controls Articular irregularity 50/100 cases central groin pain; 27/100 controls Disk herniation 82/100 cases central groin pain; 73/100 controls Cunningham et al, AJR 2007 Secondary clefts tear of one or more of the capsular ligaments of the symphysis 88/100 cases central groin pain (correlating with the side of pain in 100%) 0/100 controls Cunningham et al, AJR Degenerative Changes 11

12 FLAMINGO STRESS RADIOGRAPHS Merrill s Atlas of Radiographic Positions 8e, 1995 alternative technique dynamic stabilisers on the non-wb side must be switched off > 2mm vertical displacement abnormal Superior Pubic Ligament Tear Enthesopathy Superior Pubic Ligament 12

13 M44 Pubic Stress Fracture PUBIC APOPHYSITIS M22 Rugby player with 2yr bilateral groin pain M20 Soccer player with 6 months central groin pain (running, jumping, twisting) M25 Right - Sided Groin Pain 13

14 M18 Groin Pain 12 Months M22 Chronic Exercise-Related Right-Sided Groin Pain CONJOINT TENDONITIS Conjoint tendonitis focal tender hypoechoic swelling Conjoint tendonitis 14

CONJOINT TENDON TEAR INCIPIENT DIRECT INGUINAL HERNIA

posterior inguinal wall definition = anterior bulge

regard this as normal, as can be often seen in

lateral abdominal wall weakness or conjoint tendon

tendon in a young symptomatic athlete SPORTS HERNIA

Sports with pivoting on one leg predispose to labral

15 CONJOINT TENDON TEAR INCIPIENT DIRECT INGUINAL HERNIA Normal straight posterior inguinal wall Bulge of posterior inguinal wall definition = anterior bulge of the posterior inguinal wall when straining many regard this as normal, as can be often seen in asymptomatic individuals functionally denotes either lateral abdominal wall weakness or conjoint tendon dysfunction if combined with an abnormal conjoint tendon in a young symptomatic athlete SPORTS HERNIA ADDUCTOR TENDON LESIONS ASSOCIATION WITH HIP LABRAL TEARS Why the Association? Do the same forces overload 2 separate anatomical regions independently? VS Does one pathology lead to the other? Sports with pivoting on one leg predispose to labral tears predispose to osteitis pubis Limited range of hip motion increases stress at symphysis Symphysis dysfunction increased shock load at hip 15

16 Leg Length Discrepancy, Pubic Malalignment 16

WB R Flamingo Stress Views WB L GROIN DISRUPTION INJURY 2.

tendons intact failure of load transfer micro-instability INSTABILITY dynamic stabilisers

physical therapy Rx = surgery 1/200 chance to win an ipad Coming up next week Part 3 / 6 in

Biomechanics and Management" Review anatomy and understand pelvic biomechanics Understand

Utilise objective physiotherapy tests for SIJ dysfunction Develop clinical reasoning skills

17 WB R Flamingo Stress Views WB L GROIN DISRUPTION INJURY 2.5 mm vertical displacement IMPLICATIONS DYSFUNCTION dynamic stabilisers fail ligaments & tendons intact failure of load transfer micro-instability INSTABILITY dynamic stabilisers fail ligaments fail true instability macro-instability Live Q & A With Dr John Read Rx = physical therapy Rx = surgery 1/200 chance to win an ipad Coming up next week Part 3 / 6 in our Hip & Groin Series Understanding the Dysfunctional Pelvis: Review of Anatomy, Biomechanics and Management" Review anatomy and understand pelvic biomechanics Understand concept of failed load transfer at the SIJ and potential consequences to other areas of body Utilise objective physiotherapy tests for SIJ dysfunction Develop clinical reasoning skills surrounding core stability & pelvic motor control exercises Understanding of special population groups including pregnancy related pelvic pain Nichole Hamilton 17

18 Live Q & A With Dr John Read Thank you From Dr John Read & World Health Webinars Australia / NZ 18

Imaging in Groin Pain What the Team Physician Needs to Know

Imaging in Groin Pain What the Team Physician Needs to Know Üstün Aydıngöz, MD Professor of Radiology Hacettepe University School of Medicine Ankara, Turkey ustunaydingoz@yahoo.com No conflicts of interest