Ultrasound of Groin Pain in the Athlete

Abstract

Groin pain is a common cause of disability in athletes. Imaging is crucial in a clinical diagnosis, given the multiple associated etiologies. The main sites of groin pain are the adductors, iliopsoas muscles, inguinal ring, hip joint, and pubic symphysis. Although magnetic resonance imaging is the gold standard to image groin pain, ultrasound (US) offers excellent accuracy in pinpointing muscle injuries, inguinal disruption, and hernias. US requires a detailed knowledge of anatomical landmarks; imaging pitfalls, and pathologic patterns. We review the complex anatomy of the groin region, the sonographic appearance of the involved structures, and the strengths and weaknesses of US.

Keywords

groin - hip - ultrasound - magnetic resonance imaging

Publication History

Article published online:
19 November 2024

• References

• 1 Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001; 29 (04) 521-533
• 2 Fon LJ, Spence RA. Sportsman's hernia. Br J Surg 2000; 87 (05) 545-552
• 3 Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med 1993; 27 (01) 58-62
• 4 Lloyd DM. Sportsman's groin and the inguinal ligament release procedure. In: Diduch DR, Brunt LM. eds. Sports Hernia and Athletic Pubalgia. Boston, MA: Springer; 163-172
• 5 Weir A, Brukner P, Delahunt E. et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49 (12) 768-774
• 6 Bisciotti GN, Di Pietto F, Rusconi G. et al. The role of MRI in groin pain syndrome in athletes. Diagnostics (Basel) 2024; 14 (08) 814
• 7 Bisciotti GN, Zini R, Aluigi M. et al. Groin Pain Syndrome Italian Consensus Conference update 2023. J Sports Med Phys Fitness 2024; 64 (04) 402-414
• 8 Sheen AJ, Stephenson BM, Lloyd DM. et al. ‘Treatment of the sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014; 48 (14) 1079-1087
• 9 Rennie WJ, Lloyd DM. Sportsman's groin: the inguinal ligament and the Lloyd technique. J Belg Soc Radiol 2017; 101 (Suppl. 02) 16
• 10 Robinson P, Grainger AJ, Hensor EM, Batt ME, O'Connor PJ. Do MRI and ultrasound of the anterior pelvis correlate with, or predict, young football players' clinical findings? A 4-year prospective study of elite academy soccer players. Br J Sports Med 2015; 49 (03) 176-182
• 11 Dallaudiere B, Sans H, Reboul G. et al. Dynamic magnetic resonance imaging (MRI) in inguinal-related chronic groin pain (CGP): comparison with systematic surgical assessment. Cureus 2024; 16 (03) e55947
• 12 Ducouret E, Reboul G, Dalmay F. et al. MRI in chronic groin pain: sequence diagnostic reliability compared to systematic surgical assessment. Skeletal Radiol 2018; 47 (05) 649-660
• 13 Lungu E, Michaud J, Bureau NJ. US assessment of sports-related hip injuries. Radiographics 2018; 38 (03) 867-889
• 14 Jacobson JA, Khoury V, Brandon CJ. Ultrasound of the groin: techniques, pathology and pitfalls. AJR Am J Roentgenol 2015; 205 (03) 513-523
• 15 Koski JM, Anttila PJ, Isomäki HA. Ultrasonography of the adult hip joint. Scand J Rheumatol 1989; 18 (02) 113-117
• 16 Briggs K, Philippon M, Ho C, McNamara S. Prevalence of acetabular labral tears in asymptomatic young athletes. Br J Sports Med 2017; 51 (04) 303
• 17 Jin W, Kim KI, Rhyu KH. et al. Sonographic evaluation of anterosuperior hip labral tears with magnetic resonance arthrographic and surgical correlation. J Ultrasound Med 2012; 31 (03) 439-447
• 18 Agricola R, Heijboer MP, Ginai AZ. et al. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: a prospective study with minimum 2-year follow-up. Am J Sports Med 2014; 42 (04) 798-806
• 19 Bisciotti GN, Di Marzo F, Auci A. et al. Cam morphology and inguinal pathologies: is there a possible connection?. J Orthop Traumatol 2017; 18 (04) 439-450
• 20 Naal FD, Dalla Riva F, Wuerz TH, Dubs B, Leunig M. Sonographic prevalence of groin hernias and adductor tendinopathy in patients with femoroacetabular impingement. Am J Sports Med 2015; 43 (09) 2146-2151
• 21 Lohan DG, Seeger LL, Motamedi K, Hame S, Sayre J. Cam-type femoral-acetabular impingement: is the alpha angle the best MR arthrography has to offer?. Skeletal Radiol 2009; 38 (09) 855-862
• 22 Tsukada S, Niga S, Nihei T, Imamura S, Saito M, Hatanaka J. Iliopsoas disorder in athletes with groin pain: prevalence in 638 consecutive patients assessed with MRI and clinical results in 134 patients with signal intensity changes in the iliopsoas. JB JS Open Access 2018; 3 (01) e0049
• 23 Blankenbaker DG, Tuite MJ. Iliopsoas musculotendinous unit. Semin Musculoskelet Radiol 2008; 12 (01) 13-27
• 24 Serner A, Tol JL, Jomaah N. et al. Diagnosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med 2015; 43 (08) 1857-1864
• 25 Bui KL, Ilaslan H, Recht M, Sundaram M. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol 2008; 37 (03) 245-249
• 26 Probyn L, Flores D, Rowbotham E, Cresswell M, Atinga A. High-resolution ultrasound in the evaluation of the adult hip. J Ultrason 2023; 23 (95) e223-e238
• 27 Bianchi S, Martinoli C, Keller A, Bianchi-Zamorani MP. Giant iliopsoas bursitis: sonographic findings with magnetic resonance correlations. J Clin Ultrasound 2002; 30 (07) 437-441
• 28 Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol 2008; 190 (03) 576-581
• 29 Pesquer L, Poussange N, Sonnery-Cottet B. et al. Imaging of rectus femoris proximal tendinopathies. Skeletal Radiol 2016; 45 (07) 889-897
• 30 Sailly M, Whiteley R, Read JW, Giuffre B, Johnson A, Hölmich P. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br J Sports Med 2015; 49 (12) 828-834
• 31 Becker I, Stringer MD, Jeffery R, Woodley SJ. Sonographic anatomy of the pubic symphysis in healthy nulliparous women. Clin Anat 2014; 27 (07) 1058-1067
• 32 Morley N, Grant T, Blount K, Omar I. Sonographic evaluation of athletic pubalgia. Skeletal Radiol 2016; 45 (05) 689-699
• 33 Robertson BA, Barker PJ, Fahrer M, Schache AG. The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes. Sports Med 2009; 39 (03) 225-234
• 34 Davis JA, Stringer MD, Woodley SJ. New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. Br J Sports Med 2012; 46 (12) 871-876
• 35 Strauss EJ, Campbell K, Bosco JA. Analysis of the cross-sectional area of the adductor longus tendon: a descriptive anatomic study. Am J Sports Med 2007; 35 (06) 996-999
• 36 Mathieu T, Van Glabbeek F, Van Nassauw L, Van Den Plas K, Denteneer L, Stassijns G. New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: a systematic review. Ann Anat 2022; 244: 151959
• 37 Schilders E, Bharam S, Golan E. et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc 2017; 25 (12) 3969-3977
• 38 Tharnmanularp S, Muro S, Nimura A, Ibara T, Akita K. Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain. Anat Sci Int 2024; 99 (02) 190-201
• 39 Mathieu T, Van Glabbeek F, Denteneer L. et al. New anatomical concepts regarding pubic-related groin pain: a dissection study. Ann Anat 2024; 254: 152238
• 40 Pesquer L, Reboul G, Silvestre A, Poussange N, Meyer P, Dallaudière B. Imaging of adductor-related groin pain. Diagn Interv Imaging 2015; 96 (09) 861-869
• 41 Dallaudiere B, Sylvain B, Poussange N. et al. Ultrasound feature variants of the adductor longus tendon in asymptomatic sportive subjects: Management implications. Eur J Radiol 2021; 144: 109928
• 42 Branci S, Thorborg K, Bech BH, Boesen M, Nielsen MB, Hölmich P. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med 2015; 49 (10) 681-691
• 43 Branci S, Thorborg K, Bech BH. et al. The Copenhagen standardised MRI protocol to assess the pubic symphysis and adductor regions of athletes: outline and intratester and intertester reliability. Br J Sports Med 2015; 49 (10) 692-699
• 44 Connell D, Ali K, Javid M, Bell P, Batt M, Kemp S. Sonography and MRI of rectus abdominis muscle strain in elite tennis players. AJR Am J Roentgenol 2006; 187 (06) 1457-1461
• 45 Teyhen DS, Childs JD, Stokes MJ, Wright AC, Dugan JL, George SZ. Abdominal and lumbar multifidus muscle size and symmetry at rest and during contracted states. Normative reference ranges. J Ultrasound Med 2012; 31 (07) 1099-1110
• 46 Idoate F, Calbet JA, Izquierdo M, Sanchis-Moysi J. Soccer attenuates the asymmetry of rectus abdominis muscle observed in non-athletes. PLoS One 2011; 6 (04) e19022
• 47 Kingsnorth AN, Skandalakis PN, Colborn GL, Weidman TA, Skandalakis LJ, Skandalakis JE. Embryology, anatomy, and surgical applications of the preperitoneal space. Surg Clin North Am 2000; 80 (01) 1-24
• 48 Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and treatment highlighting a minimal repair surgical technique. Am J Sports Med 2011; 39 (06) 1341-1349
• 49 Bhosale PR, Patnana M, Viswanathan C, Szklaruk J. The inguinal canal: anatomy and imaging features of common and uncommon masses. Radiographics 2008; 28 (03) 819-835 , quiz 913
• 50 Revzin MV, Ersahin D, Israel GM. et al. US of the inguinal canal: comprehensive review of pathologic processes with CT and MR imaging correlation. Radiographics 2016; 36 (07) 2028-2048
• 51 Dimitrakopoulou A, Schilders E. Sportsman's hernia? An ambiguous term. J Hip Preserv Surg 2016; 3 (01) 16-22
• 52 Thorborg K, Branci S, Stensbirk F, Jensen J, Hölmich P. Copenhagen Hip and Groin Outcome Score (HAGOS) in male soccer: reference values for hip and groin injury-free players. Br J Sports Med 2014; 48 (07) 557-559
• 53 Bou Antoun M, Reboul G, Ronot M, Crombe A, Poussange N, Pesquer L. Imaging of inguinal-related groin pain in athletes. Br J Radiol 2018; 91 (1092): 20170856
• 54 Jamadar DA, Jacobson JA, Morag Y. et al. Sonography of inguinal region hernias. AJR Am J Roentgenol 2006; 187 (01) 185-190
• 55 Santilli OL, Nardelli N, Santilli HA, Tripoloni DE. Sports hernias: experience in a sports medicine center. Hernia 2016; 20 (01) 77-84
• 56 Muschaweck U, Berger LM. Sportsmen's groin-diagnostic approach and treatment with the minimal repair technique: a single-center uncontrolled clinical review. Sports Health 2010; 2 (03) 216-221
• 57 Tagliafico A, Bignotti B, Cadoni A, Perez MM, Martinoli C. Anatomical study of the iliohypogastric, ilioinguinal, and genitofemoral nerves using high-resolution ultrasound. Muscle Nerve 2015; 51 (01) 42-48
• 58 Klaassen Z, Marshall E, Tubbs RS, Louis Jr RG, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric nerves with observations of their spinal nerve contributions. Clin Anat 2011; 24 (04) 454-461
• 59 Martinoli C, Miguel-Perez M, Padua L, Gandolfo N, Zicca A, Tagliafico A. Imaging of neuropathies about the hip. Eur J Radiol 2013; 82 (01) 17-26