0:02

Hello and welcome to Noon Conference, hosted by Modality

0:05

Noon Conference connects the global radiology community

0:07

through free live educational webinars that are accessible

0:11

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

Today we are honored to welcome Dr.

0:17

Tatian Canelli

0:18

for a lecture entitled Common Mistakes in Groin Pain.

0:22

Dr. Canelli is an MSK radiologist based

0:25

in Sao Paulo, Brazil.

0:26

She completed a research fellowship at NYU

0:29

and received her clinical MSK fellowship training at HOR

0:32

where she currently practices.

0:34

She's a member of several radiology societies

0:36

and has authored or co-authored numerous articles in

0:38

the MSK field.

0:40

She's dedicated to education

0:42

and lectured in many Brazilian radiology meetings,

0:45

international meetings,

0:46

and is very active in training future MSK radiologist.

0:50

At the end of the lecture, please join her in a q

0:52

and a session where she will address questions you

0:54

may have on today's topic.

0:56

Please remember to use that q

0:57

and a feature to submit your questions so we can get to

0:59

as many as we can before our time is up.

1:02

With that, we're ready to begin today's lecture. Dr.

1:05

Canelli, please take it from here.

1:07

So first I'd like to thank everyone for your attendance.

1:11

So today, the lecture, uh, we're gonna discuss, uh,

1:14

about the common mistakes in growing pain.

1:17

So, uh, look forward to sharing my insights

1:20

with you in this, uh, tough, uh, topic,

1:24

and let's get it started.

1:31

I don't have any disclosures.

1:33

So in the next minutes, uh,

1:35

we'll be reviewing the anatomy terminology mimics

1:38

of growing pain.

1:40

So focusing on clarifying misconceptions

1:42

and highlight the importance

1:43

of precise terminology when we are describing pathologists

1:47

in this particular region.

1:49

So, growth injuries are common

1:51

and potentially disabled

1:52

among professional recreational athletes account up for

1:56

to 23% of all sports injuries.

2:00

So these injuries, uh, can result for a single acute episode

2:04

or repetitive microtrauma, especially in court.

2:08

The sport involves lower limb and abdominal twisting, ity

2:11

and kicking such as football, soccer, hockey, and hug.

2:16

So according to welfare statistics, which is the union

2:19

of European Football Association, there are 1.12,

2:22

2.1 growth injuries per 1000 game hours with 50%

2:27

of cases leading to more than one week of time loss.

2:30

So on average, one of average, uh,

2:33

five players is absent from gains

2:36

during growing injuries per season.

2:40

So men have have a significantly great incidence

2:43

of growing injuries than women.

2:45

Some outers propose different region reasons, such

2:48

as an anatomical difference like the white female pelvis,

2:52

uh, which produce a more OBL angle of action

2:55

for the short adoptions in female males,

2:58

which may reduce the traction of force

3:00

as there at the origins.

3:02

Another point is the, that we have

3:05

to know the diagnosing management

3:07

of chronic athlete growing pain can be challenged since pain

3:11

may not be well localized.

3:13

We can have, uh, overlap symptoms

3:15

and also, uh, coexisting injuries may occur,

3:19

and also the complex anatomy, uh, of this region.

3:25

So good communication is the bridge

3:27

between confusion and clarity.

3:29

So, uh, this quote underscores the transformative power

3:32

or additive communication.

3:35

So it's important to know

3:36

what we got right now might not not be exactly

3:39

what we are aiming for.

3:41

So, unfortunately, about communication, there's a lot

3:44

of confusion when it comes to the terms used

3:47

for growing pain in athletes.

3:48

So this review of 72 Stu founded 30 33, uh,

3:53

separat terms we're used

3:54

to describe growing pain in the athletes.

3:56

Here we have some few terms.

3:58

Some examples there are, uh,

3:59

very famous include growing strain, strain, athletic coia,

4:04

or states bubble sports.

4:06

Nia Sportsman's growing humor, growing hot goalie syndrome.

4:10

So people often use these terms, uh, interchangeably, uh,

4:14

whether they're talking about the examination fines,

4:17

clinical diagnosis, or features in x-rays.

4:21

But, um, the thing is, there are several pathologies

4:24

inside the same umbrella.

4:26

For example, author tendinopathy isn't a sports n the terms

4:30

sportsman earnings misleading

4:32

because there are actually no Nia involved.

4:36

So additionally definitions frequently exhibit

4:38

significant overlap.

4:40

For example, Allstate's pubs is a widely used diagnosed

4:43

terms, yet there is no consensus on it,

4:46

it's exact definition,

4:47

or whether it's represent if it's a radiological finding,

4:51

a clinical entity or, or both.

4:55

So this table, um, there, uh, uh, from this, uh,

4:58

study shows several example of the use of osteo pubs, uh,

5:02

term the literature highlighting the considerable variation

5:05

in how this term is employed.

5:08

So this heterogeneous taxonomy

5:10

of growing injuries adds more confusion

5:13

to this complicated area.

5:14

This this area has a, a, a very complicated anatomy

5:19

and a very delicate anatomy that we need to be, uh, aware.

5:25

So in 2014, uh, expert panel company Doha, with the aim

5:30

of standardized clinical terminology.

5:33

In 2015, they released the Doha consensus,

5:35

which include recommended terms

5:37

for clinical terminology related to growing pain athletes.

5:42

So the panel reached a consensus on taxonomy based on

5:45

history and examination findings,

5:48

and the classification systems comprised three measures

5:51

to be had for growing pain in athletes.

5:53

So the first group defining clinical entities

5:56

for growing pain, uh, doctor related I related,

6:00

immuno related and pelvic related gro pain.

6:03

They found that auditor related gro pain was the most common

6:06

clinical entity present, uh, more than, uh, 6% of the case

6:10

with multiple cause following 44%,

6:15

uh, Hip related growing pain

6:20

was grouped in another obsession.

6:22

They also create a group for other causes of growing pain

6:26

and fleets such as rheumatological, urological origins.

6:29

However, uh, there's a problem.

6:31

Core muscles, which can also be related

6:34

to growing pain were not included.

6:36

But one positive aspect

6:38

of the specific causative entities is that the way, uh,

6:42

they better capture the anato anatomical locations,

6:45

injured patterns

6:46

and clinical presentations associate

6:49

with long standing athlete related groin pain.

6:53

So it's important, uh, to know that we have

6:55

to make an anatomic diagnosis.

7:00

So the role of image also has not been fully clarified.

7:04

So the definition, uh,

7:07

and diagnosed criteria established in 2000, uh, 20,

7:11

uh, 2000, uh, 12 in, in Manchester's conference

7:15

and updating the Doha conference do not include image.

7:19

Uh, some studies have reported the excellent diagnosis value

7:22

of dynamic ultrasound for the diagnosed, but

7:26

although MRI remains the reference technique for

7:29

investigating bone pain in athletes, so MRI

7:32

is is the actual, uh, gold standard for evaluation

7:37

the wound pain.

7:40

So to ensure accurate evaluation,

7:43

we need a dedicated MRI protocol for assessing wound pain

7:46

with a small field of review in the region, also is crucial

7:50

to note the high prevalence

7:52

of findings in a symptomatic patients

7:56

and specific chronic pain findings such

7:59

as degenerative joint changes of the synthesis pathologist

8:02

of, uh, the auditor bone edema in the pubs

8:05

and the secondary cleft side.

8:08

We need to assess this in these exams.

8:13

So one more quote. Uh, you only see what you look for

8:16

and you recognize only what you know.

8:19

So I choose this one just to emphasize the importance

8:22

of reviewing the anatomy

8:24

because of perceptions limited, uh, for

8:26

what we actually will see and understand,

8:29

and we need to, uh, uh,

8:33

understand better this region.

8:36

So understanding the intricate anatomy

8:38

of the growing public synthesis crucial.

8:41

So the public synthesis of firo car regional joint composed

8:45

of two, uh, public bones and a fbri disc.

8:50

So, uh, it's supported by the ligaments that act

8:54

as a shock absorbed

8:55

and are capable of a small amount of movement

8:58

of under physiological conditions.

9:01

There are four OIC ligaments, the anterior, the posterior,

9:06

the superior, and the inferior OIC ligaments that blend

9:10

with the disc centrally.

9:12

So this resists, uh, she torsional force across the joint

9:16

and the inferior pubic,

9:17

or also called the arco ligament,

9:19

is the most important ligament providing stability, uh,

9:23

across, uh, the symphysis.

9:26

The public sym also receives further structural support from

9:30

closely related overlapping muscular attachment.

9:33

So the muscle groups that attach

9:35

to the SSIS pubs includes the anterior, uh,

9:37

and anterolateral abdominal muscles

9:40

and the tight attor muscle group.

9:42

So the, this includes theor, brevis

9:45

and longus, uh, reus, uh, rest ados,

9:50

uh, peris and P bacteria of all these muscles,

9:54

the most important stabilizes are rectus abdominal

9:58

andor longos theor Longo tendus the most anterior

10:01

of theor muscle groups

10:03

and blends with the inferior fibers of the head.

10:06

Ados more superiorly for intricate

10:10

apon neurotic relationships.

10:12

Uh, and it functions in conjunction

10:15

with the remain adual group to abuc the hip

10:18

and stabilize the pelvic ga

10:20

during the swing phase of the movement.

10:24

Here we have another plane, uh,

10:25

the Axi plane showing the pelvic bones, ligaments disc,

10:29

and the muscles include the abnormal muscle attaching the

10:33

synthesis, the external internal OBLs, additional

10:37

thereor muscular arising from the synthesis such

10:39

as the pectins.

10:42

So learn how to see, realize

10:44

that everything connects to everything else.

10:47

So this is to show the study in the public Synthes review

10:50

that everything is intricate connecting,

10:52

highlighting the complexity of this particular joints.

10:57

So let's see, uh, more detailed anatomy.

11:00

So exploring this connections further in the left image,

11:04

located one centimeter from the midline, uh,

11:07

cannot reserve the anterior apon neurotic apon neurosis

11:10

between the rectus abdominals

11:11

and the aor longus in this blue arrow.

11:15

The posterior apon neuros is less visible at this level,

11:18

is a small part of the perus muscle located posterior

11:22

to the recals abdominals muscle.

11:25

So, uh, moving towards the midline image on the right

11:28

shoulder, the perimeter musculus is anterior

11:30

to the public surface.

11:32

At the anterior posis is continuing more distally.

11:36

So the posterior posis merged

11:38

with the anterior superior symphysis public ligament.

11:45

It's not so, the connection

11:49

between the rectus ados

11:51

and the lung adapter is only characterized at the level

11:54

of the anterior apon roses

11:56

and extremely thin less than two millimeters.

11:59

So this is search for European radiologist.

12:01

Shows, uh, that connections

12:03

between the abdo abdominal muscles

12:05

and theor lungs do not correspond to a thick apon roses

12:09

as thickly stopped, but to thin, anterior

12:11

and posterior upon theosis.

12:17

There's another ality about these connections,

12:19

and from a histological perspective, the fibrous

12:22

of the adult Longo tenders inserts perpendicular into

12:26

to the bone through a fibro cardiologist anis.

12:28

However, a significant discover was made by, in this study

12:32

by the Meer and colleagues,

12:35

which is this fibrous interconnect across the anterior

12:38

pelvic ligament and linked with the opposite side tendon.

12:43

So this fights might shed light on why usually the symptoms

12:46

are, uh, occur, uh, by light.

12:51

There are some new concepts

12:53

regarding the anatomical connections

12:55

between the adult tendons and the pelvic bone.

12:58

They are introducing recent studies, including the role

13:01

of the premal muscle, the insertion

13:03

of the adult Longo standal fibers in the pelvic bone,

13:06

like which we saw,

13:07

and the integration of other abdominal muscle

13:11

with theor complex.

13:12

We are gonna see, uh, something about the pyramid.

13:17

So recent interest was focused on the peris muscles role

13:20

and the pelvic, uh, uh, plate, the,

13:25

the ubic epi complex with some outers proposing that Aries

13:30

and not the rectus ados connect

13:32

to the auditor lung was forming the pyramid anterior pubic

13:36

ligament adult complex, which called black, which is easier

13:41

to to pronounce the, the whole name.

13:44

So, uh, and nothing, uh,

13:46

not significance in auditor j uh, injuries.

13:50

So this finds r light, a direct to anatomical connection

13:53

between the peral muscle and theor long tenders.

13:56

That is crucial for understanding injury patterns

13:59

and treatment, particularly in case

14:00

of proximal auditor lungs tion.

14:04

So it's also know that this, uh, the presence

14:08

of these connections helps to interpret MRI particularly

14:12

as image when, where you can see the pyramid,

14:14

the retro abdominal, and the plaque.

14:21

So, uh, in these studies, they, they

14:24

suggest the classifications.

14:26

When we have injuries of the plaque.

14:28

Here we have illustrations of the six height of the pre

14:33

anterior public ligaments Longo complex.

14:36

According to the shooters, the outer

14:39

gonna assist in more detail.

14:45

So the type one black injury, it's a complete, uh,

14:48

fibro cast tion, uh,

14:51

pyramidal separate from AAL lungs intact pectins.

14:56

So we see the, the pectins is, is normal.

14:59

Uh, uh, here in this, uh, a version

15:04

of the adual lungs, fe cast due to retraction

15:07

and lateral displacement, the type two,

15:11

we have a complete fibro casts tion Ali,

15:15

separate from auditor lung ster,

15:18

we have a par partial actin tear

15:20

and tion of the, the auditor ongo.

15:24

The type three, we have a complete tion, uh, of the,

15:29

the fibro cast, uh, mase connected

15:32

to AOL lungs intact pectin.

15:35

So we see here the fibro cast, uh, displace it.

15:39

And here we have a tear

15:41

of the anterior pelvic ligament, the type four.

15:45

We have a complete, uh, fibrocartilage ul, uh,

15:49

of mase connect to editorial longs and partial pectin.

15:53

There the type four,

15:57

we have the type five.

15:59

We have, uh, complete, uh, fibrocartilage ul, partially

16:03

separated from lungs

16:04

and partial pectin, uh, uh, tear.

16:09

And the type six we have, uh, a partial, uh,

16:13

fibro cast tion.

16:15

And you can see there is no displacement of the, the,

16:17

the fibro casto with the pre is connected to ab lung, uh,

16:22

inact continuous.

16:25

So, uh, wrapping up the anatomy session, uh, let's see,

16:28

some cases, uh, most of the cases are from soccer players

16:34

since I'm from Brazil.

16:37

So the first case is a case involving 26-year-old

16:40

professional football players experienced

16:42

chronic growing pain.

16:44

These are surveyed by acute Abso episode

16:47

of Right Growing Pain.

16:48

So the MRI reviews an extensive tear with partial detachment

16:53

of the right Longo standard near the symphysis pelvis.

16:57

You can see here indicate by this blue arrow, I think bundle

17:00

of superficial fiber remain normal in insertion

17:03

with interposed, uh, lamina fluid

17:06

and edema, uh, in the per layer.

17:10

Additionally, there is small exte extension

17:12

of the tear near the origin of the A revis,

17:18

uh, marked by the purple arrow, uh, company by edema

17:22

of the muscle fibers at the,

17:24

my transition of the percutaneous.

17:27

Additionally, a small partial detachment of the head

17:29

neuro place near the Phis boobs on the right side.

17:33

So these cases is a opper to ablution, uh, if the AOR lungs

17:37

and coul rectus abdominal apon neurosis.

17:41

On the left side, there is a, a tendinopathy, uh,

17:44

of theu lungs with thickening on green,

17:48

and also we can see there's a linear area

17:51

of, uh, high signal.

17:54

I'll show you again, which should not be mistaken

17:57

for art TenDot Terran.

17:58

This line is located inside the bone, indicates sub, uh,

18:02

resorptive bone change, doing chronic stress is not a

18:06

tear in this other case.

18:09

Also involve a professional football player with acute pain.

18:13

The right groin, there is a complete tear

18:15

with partial detachment of the, uh, right, uh, Dr.

18:19

Longo stand near the syn fist pub is exhibits a distal

18:23

retraction with interposed lamina fluid and edema.

18:27

Additionally, there is a extension

18:28

of the tear near the original of the ado ado revis

18:33

accompanied, uh, uh, by, uh,

18:38

interpose lamina fluid, uh, also edema the muscles fibers

18:42

and the myo tenus transitions.

18:45

So in this case, particular case we stand the Corona view.

18:48

You can see the, the, the, the bottom image on the right,

18:52

uh, to observe the extension

18:53

of the fluid collection into the tide.

18:56

So sometimes, uh, usually starts the exam

18:59

with uhm small field of view of the pelvic syn,

19:02

but sometimes you may need to adapt the protocol depend

19:05

of this tension of the injuries.

19:07

So you need to cap everything.

19:10

So this is the same case, the same patient

19:13

of the MRI demonstrate the injuries aspects in ultrasound

19:16

during the follow up with hypo coic fluid has been replaced

19:20

by cogenic tissues, uh, exam a week

19:23

by week represented carrying of the, the lesion.

19:29

This is another case, uh, involving a 32,

19:32

a 33 old professional football player

19:35

who experienced the left groin pain during a match.

19:38

So, uh, the MRI reviews extensive injury, uh,

19:42

with tion of the auditor tenders at the level

19:45

of the pelvic surface marked by this blue arrows, along

19:48

with the fluid collection and also eda.

19:51

There is also a disruption

19:53

of the rectus abdo auditor along those, uh, plate,

19:57

this connection, the image, uh, in this yellow arrow.

20:01

So, uh, additionally there are, uh,

20:05

injuries in the abdominal wall involving the, uh,

20:09

oblique muscles, as we can see here, with signs

20:13

of posterior wall insufficiency leading to lateralization

20:17

of the spermatic cord.

20:19

So, uh, the rectus abdominals

20:22

and the abdominal objects form the posterior

20:25

and medial walls of the superficial endocrinal ring.

20:28

So, extensive injuries to the rectus abdominal

20:31

can lead to hernia.

20:33

So this is actually a true hernia knot.

20:35

We, we can usually call as i sports hernia.

20:43

Uh, this shows the evolution also the the last case, uh, uh,

20:48

by ultrasound we can evaluate

20:49

by sequential image the progression of the injuries

20:52

during the follow up.

20:53

We can observe the entire healing process of the injury.

20:57

Initially, we can see the hypo called fluid observed, uh,

21:00

the injury site around the first week, uh,

21:04

which has been replaced by echogenic tissues,

21:07

which indicates the scaring late.

21:09

Uh, this had led to the formation of a heterotopic, uh,

21:13

calcifications as we can see here

21:16

around the eighth and 10th weeks.

21:20

The, the same athlete under the right surgery using a MA

21:23

to prepare the defect.

21:24

Unfortunately, he suffered another injury involving

21:28

thedo stern, so we can observe muscle edema

21:31

and a partial detachment of the muscle ac combin

21:34

by a fluid field collect.

21:37

Here's another case, uh, showing full thickness there

21:40

of the left adual long tendon with detachment from insertion

21:44

of the phos pubis

21:45

and substantial distal retraction, uh,

21:49

extensive A heterogene, uh, uh, ima

21:53

around the torn tend represent the torn muscle fibers

21:57

and also the hematoma.

21:59

Uh, there is hematoma edema, inflammatory reaction

22:02

around all the muscles of the medial compartment

22:04

of the left eye, as always, all uh, uh, as well as edema

22:08

of the remaining, uh, auditor and continues.

22:13

Another case is a case of, uh, 29-year-old football player,

22:17

experienced chronic pain in the left groin.

22:20

So the MRI image on Axi

22:22

and coronal T two shows this linear high signal area

22:27

correspond the partial detachment of the ado

22:30

of Revis Sili Standal.

22:32

So, uh, this line represent the secondary cleft sign,

22:37

but what means the secondary cleft sign?

22:41

So let's see, to have the secondary,

22:44

it must have the primary.

22:46

So the primary cleft sign

22:48

marking this yellow arrow is physiological.

22:51

Uh, in, in contrast, the secondary cleft sign

22:55

that is showing the previous case

22:56

and which is marking here in blue, uh,

22:59

was primarily describing astro graphic study

23:01

and represents the lower extension

23:03

of the contrast material in the primary cleft.

23:07

So it originates in theis and revis muscle standards

23:11

and is associated with tenal tion

23:14

and material skeletal structures.

23:17

We saw the primary and the secondary cleft sign,

23:20

but we also have the superior cleft sign.

23:22

So the superior cleft sign serves as an indicator

23:26

of hector's abdominal or lungs attachment injuries.

23:29

So it's characterized by the extension of contrast parallel

23:33

to the lower margin of the superior pelvic haus

23:37

and the insertion of the rectal abdo, uh, adductor aosis.

23:41

So it's frequently found in conjunction

23:43

with the secondary cleft sign.

23:46

So we can see together the superior

23:49

and the secondary cleft sign.

23:51

Remember that the primary is physiological.

23:54

Here we have a case of 4-year-old men

23:56

with ongoing medial lung pain.

23:58

We can observe the left cleft sign, uh,

24:01

left superior cleft sign with, uh, a fluid cleft,

24:05

partially standing between the APO neurotic bone interface

24:09

of the combining retinal abdominal long aosis anterial

24:13

to the left superior pelvic hamus.

24:18

This is another case, uh, now involving, uh,

24:22

ter foal professional football player

24:25

with clinical auditor related wound pain.

24:27

So the MRI reviews extensive tear

24:30

with partial detachment at the origin of the adult

24:33

of Revis Brazil, which is related

24:36

to the secondary cleft sign.

24:38

As I said before, the secondary CLE signs frequently found

24:41

in conjunction with the superior cleft side.

24:44

So there is also a pressure there with the detachment

24:48

of the right adult long stand near, uh,

24:53

the phy pub indicate by this green arrow

24:56

with interposed lamina fluid edema,

24:59

and the per which call it the superior cleft sign.

25:03

So on the right image, the ality two weight,

25:06

we can see both the superior cleft on the green

25:09

and the secondary cleft on blue,

25:13

we now have a case involving a younger patient at

25:16

22-year-old professional football place suffering

25:19

from chronic pain.

25:20

The MRI show abdo long tendinopathy with partial,

25:25

uh, tears of both sides associated

25:29

with the tenal abolition between theor longus

25:33

and the bilateral coul rectus abdominal

25:36

aosis forming the superior left side.

25:40

Additionally, uh,

25:41

we can see there is edema at the left upper, upper, uh,

25:44

pelvic hemos with adjacent dark

25:46

uh, signal line.

25:50

We can see in this blue arrow, this is not a fracture,

25:54

but rather the superior hypothesis at the level

25:56

of the rectus ab alu upper neurosis.

25:59

So this case shows also a superior pelvic hypothesis.

26:05

So before talk about the apophysis, uh,

26:08

let's review more anatomy

26:09

of the pelvic synthesis hypothesis.

26:12

Uh, the synthesis has two hypothesis standing from arterial,

26:16

uh, medial margin of the pubis to the lateral margin

26:19

to the arterial pub ligament.

26:21

So, uh, these hypotheses are enclosed relationship

26:24

with fibro disc

26:26

and ligaments instructors under

26:28

underlying the subc chondral bone.

26:29

So the upper process originated originate from the long

26:33

abutter and come upon theosis with the rectus

26:36

with the lower process,

26:37

the inferior hypothesis originates from

26:39

avatar vis and breast.

26:44

The public safety secondary ossifications center centers

26:48

appear around the late poverty.

26:50

So the maturations of the aposty starts, uh, 16-year-old

26:54

and continues up to 21 years old.

26:57

And the version it's around 20 to 25 years old age.

27:02

However, in some states, foreclosure of the public, uh,

27:06

uhis does not occur until approximately at the 35 years old.

27:10

So the maturation of the, the,

27:12

the public sense is a complex process which depends on age,

27:16

gender, race, and environment factors, including, uh, the,

27:21

the athlete, uh, background of the patient.

27:24

So the complete formation usually happen

27:27

during the immediate post phase at 36

27:30

to four years old of age.

27:33

So we can still see this hypothesis in older patients, uh,

27:38

with almost 4-year-old.

27:41

So we need to understand this process of maturations

27:44

to prevent misinterpretations of mimicking injuries.

27:49

So there are four types, uh, for different stage

27:52

of maturation, describes the stage one,

27:54

which we have the opium profusion plate without a secondary

27:58

ification center, as we can see in the MRI and ct.

28:02

This stage two, we can see the open up of visual plate

28:05

with a secondary ification center.

28:07

It starts to the secondary ification center,

28:11

the stage three A, the close

28:13

above your plate without a secondary ification center.

28:17

And finally, close up official plate

28:19

with a remain second divers ification center represented

28:22

by this cortical irregularity

28:26

only 2015.

28:28

The pelvic stem IDE was described for the first times

28:31

as a cause of Cobo in athletes with I amateur skeleton.

28:35

There are some image finds when zaza mine,

28:38

uh, image results.

28:39

Key indications include widening, uh,

28:42

symmetry bone me edema, soic nds erosions and sclerosis.

28:48

So this is a case involved a 16-year-old juvenile football

28:50

play with adult related bone pain.

28:52

There is edema at the superior hypothesis at the level

28:55

of rector OSI standing to the public hemos.

28:59

So this is a case of, uh, superior public hypophysitis.

29:05

Uh, this is a case above a 16-year-old juvenile football

29:08

play with public related growing pain.

29:10

There is bone edema at the pelvic rams.

29:13

We can see also irregularities

29:16

and edema at the, uh, inferior hypothesis of both sides,

29:20

mostly on the right

29:21

or occurring at the level of the gracilis.

29:23

And a rib region is standing, uh,

29:27

to the lower pelvic, uh, hemos.

29:29

So this is a case of, uh, inferior public hypophysitis.

29:34

Another entity that can affect the public synthesis,

29:37

the phys, which can be observed as a, you define

29:40

or well-defined intermediate signal between the low signal,

29:44

uh, superficial hypothesis and sify superficial bone.

29:48

So intermediate, uh, signal erosion

29:50

and seelike chain seems continuity with the hypothesis often

29:54

as if signal charact is of the matter, uh, uh, he metal

29:59

or on routine sequence.

30:01

Uh, there are not typically in continuity

30:03

with the syn physio cleft

30:05

or shoal fluid signal, uh, indicated there is no, uh,

30:09

synovial, uh, cyst.

30:13

Another find is the sequela of pelvic apophysis due

30:17

to chronic stress and leads can lead to delay, uh,

30:20

maturation and incomplete fusion.

30:23

As we can see in those CT image, we can see on first

30:26

hypothesis in, in this patient.

30:28

So we can see, uh, in this, uh, 23-year-old patient

30:32

with UHS sclerosis and irregularity of this hypothesis.

30:39

In this case, we can observe, uh,

30:41

the high signal linear alteration

30:44

on two fat suppressed MRI sequence.

30:47

At first glance, it might resemble the superior cleft sign.

30:52

However, this is actually a sequela of superior pelvic xi,

30:56

which may mimic the superior cleft sign

31:01

for comparison the left with the sequela of, uh,

31:04

superior pelvic phy eye alongside the superior cleft sign.

31:08

Both appears at the origin of theor longs

31:11

and the common aosis with the rectus abdominals

31:14

and should not be misinterpreted

31:19

in another case, involve a 22-year-old soccer play.

31:23

MRI reviews a high signal linear, uh,

31:25

band near the conjoint insertion

31:28

of the a adult brevis and silis.

31:31

Also, this might initial suggest the classic secondary cleft

31:35

side, which simply indicates detachment of theor revisal.

31:40

However, this is a sequela of inferior OB hypotheses.

31:45

We can see that there is also a cortical regularity

31:48

of the synthesis and the sub visual bone.

31:57

For comparison. On the left, we, we see a sequela

32:00

of the inferior public hypotheses alongside, uh, uh,

32:05

the secondary CLE sign.

32:06

Both are observed at the original of the privacy andis, uh,

32:10

and we need to be familiarized with both

32:12

to not misinterpret the image

32:17

as, uh, we discussed in the dohan consensus.

32:22

Besides ute

32:23

and pelvic related groin pain,

32:25

there are other causes of growing pain.

32:28

So we saw that the most common is adductor related,

32:31

but the second most common EEU source related.

32:34

We also have related gro pain.

32:38

We have the public related, uh, hip related growing pain.

32:42

To evaluate it, we cannot use the, the same protocol

32:46

of the, the pelvic synthes.

32:49

So we usually have to extend the protocol.

32:51

We are doing, uh, dedicate MRI to the hip

32:56

and, uh, let's see some other causes of, of,

33:01

um, growing pain, uh, based on this classification

33:06

of the health consensus.

33:08

So the prevalence of source related gro pain based on

33:12

physical examination has been reported to range from, uh,

33:16

12% to 36% among athletes.

33:20

So instead of iluso disorders in athletes with growing pain,

33:24

uh, MRI signal intensity change in the loop.

33:27

So were observed

33:28

and 21% of the athletes, so this might correlate, uh, uh,

33:33

with the number of patients were reported disorder

33:36

complainant in the study.

33:39

So the this first case is a case of 30 5-year-old, uh, man

33:43

with right rib pain.

33:45

Uh, the pain was exacerbated by active flexion for 20 days,

33:49

and there's no, uh, history of trauma, direct trauma,

33:54

uh, nothing related.

33:56

So this MRI on sagittal

33:58

and axial plane reveal this flu field set surrounding the

34:02

ilio source, uh, tender at the hip joint level,

34:06

Indic indicative of ilio source, bures,

34:08

which is a very common pathologist.

34:11

So the I source bura, also known as the iin.

34:14

Bura is the largest bur in the human body

34:17

and may extend, uh, from the pelvis to the ral counter

34:22

communication of the hip joint occurs in, uh, up

34:24

to 15% of the cases.

34:26

Uh, ilio source bura is characterized by inflammation

34:30

of this birth and the most commonly linked

34:32

to severe underlying, uh, uh, hip, uh, arthropathies

34:38

such as osteoarthritis,

34:39

rapid disruptive auto osteoarthritis, osteonecrosis

34:42

of the femoral head or, uh, uh, humanoid arthritis.

34:47

However, we also can see in at leads

34:50

and it, it can also rise from mechanical, uh,

34:53

origins, uh, by friction.

34:54

For example, this is a case of a 20-year-old man

34:59

with sharp anterial, uh, heart growing pain, uh, especially,

35:04

uh, reflection.

35:06

And also there's snapping in the groin during,

35:09

during hip flexion.

35:10

So there is edema in the muscles around both

35:13

of the tend components of the lip.

35:15

So the lips

35:16

and the sores corresponded to the side

35:19

of the patient's pain indicative of tendinopathy

35:22

and adjacent muscle inflammation.

35:24

So the presence of separate medial

35:26

and lateral tendons of IUP sos uh, could be a cause

35:30

of the napping, uh, tendons where the medial SOS

35:34

and lateral ILE components cross over

35:36

and pinch of the i bacterial implant

35:38

during the hip flexion and extension.

35:41

So this caused the sensation of asthma.

35:44

So this is a case of ASU napping.

35:48

Uh, this is another case of a 44-year-old woman

35:51

with anterior hip and right gro pain,

35:54

the MR MRI show ins surrounding so tendon

35:57

and anterior superior labor tear.

36:00

So, uh, slides are consistent

36:02

with central ilio source impingement.

36:04

So, uh, what does it mean?

36:07

So central ilio source impingement is different from the

36:09

typical napping ilio source, which includes audible napping

36:13

of the tendon

36:14

and pain with electron abduction, abduction,

36:18

external rotation and extension of the hip.

36:20

So the clinical diagnosis

36:22

of central OSA imp patients more difficult

36:24

because there's no audible snapping

36:26

and the clinical fines of anterior hip pain, uh,

36:29

for example, positive impingement test

36:31

and focal tenderness of the anterior hip.

36:34

And he tend are common with labo pathology

36:37

and not specific to this diagnosis,

36:40

but usually when we don't see a cause of the, the,

36:44

the anterior, uh, labor tear with this edema as

36:48

around the loop source, it's the combination that,

36:51

that we can use to make the diagnosis some case

36:57

that we should pay attention to, which can lead

36:59

to an evaluation for going pain or laboratory are fractures.

37:03

So these are commons, uh, common,

37:05

especially in other patients,

37:07

but also we can see frequently in

37:09

athletes like stress factors, uh, at the public, uh, hemos.

37:14

This, this case, we can see two different on the, uh,

37:17

the anterior, uh, portion of the ace table

37:20

to the superior pubic hemos.

37:22

The other one, the inferior pubic hemos.

37:24

So we need to look for this fracture sometimes is minimal,

37:27

especially ct there is no displacement.

37:30

And MRI is a little bit easy

37:32

because we can see the edema, the bone edema.

37:35

For example, in this case, we have a case

37:38

of stress fracture in, uh, female with distance athletes.

37:43

So there is, uh, a stress fracture

37:46

of the left inferior, inferior pelvic hamos.

37:49

And also are you defined area of me edema, maybe

37:51

what we find complete, uh,

37:54

fracture line on the anterior aspect of the ascent tableau.

37:58

Uh, so we can see, uh, for example, this, um,

38:03

case of the stress factor fractures in athletes.

38:09

So, uh, here we have some key points of this presentation.

38:13

So during this presentation, we, uh, diving into, uh,

38:18

the particular particularity of the end

38:21

of this regions explor various scale causes of growing pain,

38:25

especially in athletes.

38:27

I'd like to highlight some key finds that we discuss it,

38:31

which may be commonly mistaken diagnose abductor

38:33

and public related wound pain.

38:36

So, uh, first, uh, the superior cleft sign,

38:40

which indicates a chair at the origin of the longs

38:44

and comma poly neurosis with the rectus.

38:47

We also dis discuss, discuss it, discuss it.

38:50

The secondary class sign represents a tear at, at the origin

38:54

of the OID revis and braus.

38:57

Additionally with thematic bone reabsorption due

39:00

to chronic bone stress,

39:01

which can sometimes be mistaken from a there.

39:05

Uh, also we discussed the superior apophysis

39:09

where sequela may mimic the superior cleft sign

39:14

and the inferior hypophysitis

39:16

where sequela may mimic the secondary cleft sign at the

39:19

origin of the adult vis and the les,

39:22

and also not forgetting the other causal such as I source

39:26

and re related cause.

39:27

So when we cannot find some, uh, explanation

39:32

of the, the why the patient has pain, we need to

39:35

study the other causes of the, the groin pain, right?

39:39

Sores and group related causes.

39:41

So we can see here there's, uh, we need to be, uh,

39:45

very comfortable with the anatomy of the re region to,

39:48

to make, uh, accurate diagnosis.

39:51

So here are some common mistakes.

39:54

So as we can already talk, the primary cleft,

39:57

which is a development cleft in the

39:59

posterior superior central portion.

40:01

So it's physiological is not associated with pathology.

40:05

So it's a midline fluid fill cleft on MRI

40:08

or doing syn physiography,

40:10

and usually some, some, uh, who can be, uh, mistaken

40:14

or misinterpreted as a pathological finding.

40:17

The superior cleft, uh, the cleft run parallel

40:20

to the inferior margin of the superior pelvic hemos

40:23

represented there in the, the, the prep pelvic, uh, complex.

40:27

Uh, so we can see on MRI a linear hyperintensity T weight

40:31

or ster image

40:33

or contrast leak during physiography at the level

40:36

of the superior pelvic hemos.

40:38

We also, we can misdiagnosis the cleft as a tendinopathy

40:41

or other muscle related injuries.

40:43

The secondary, the cleft inferior from the synthesis

40:46

and parallel to the inferior margin

40:48

of the inferior pelvic hemos represented a tear in the

40:51

poster inferior adult such as the abdo revis.

40:54

So we see an MRI as a linear hyperintense on two or see

40:59

or contrast leak, uh, during synography at the level

41:03

of the inferior oric hemo.

41:06

So we can confuse with the superior CLE pathology

41:08

or mistake for adult tendinopathy.

41:11

And also we cannot forget the, also the hypothesis,

41:15

the superior inferior pathy.

41:18

So, uh, my last words talk about, uh, some current stage

41:22

of the radiology, uh, evaluating the growing region

41:25

and the recommendations.

41:27

First, we got the importance

41:29

of consistent radiology reporting.

41:31

So we need to, to precise, uh,

41:33

the terminology when described.

41:35

Injuries making this anatomic diagnosis

41:38

also cannot forget about bridging the communication gap

41:41

between radiologists and clinicians or surgeons.

41:43

So we need, uh, to standardize terminology in radiology.

41:47

We need to use the same terms of the surgeons

41:51

and clinical as well between the radiologists.

41:55

And also, uh, if one is interested in read, uh,

42:00

more, know more about the common mistakes in growing pain.

42:03

Uh, I published

42:04

with my colleagues this recent article on the last, uh,

42:08

additional of seminars.

42:10

One, you want the rest, you can download it.

42:15

And thank you everyone for the attendance.

42:20

Thank you so much Dr. Canelli for this lecture.

42:22

It was awesome. We will now open the floor

42:26

for some questions.

42:28

Oh, so the first questions about, uh, the Gado

42:32

question Mark Case of Apophysis.

42:35

Uh, usually we don't use a contrast for evaluating the,

42:39

the, the synthesis.

42:40

So, uh, the description of apophysis is very recent.

42:45

There is no studies about in the, uh, the use

42:49

of contrast to evaluations.

42:50

The bone is sclerotic,

42:52

is is not viable or nothing like that.

42:54

So we usually don't use in routine.

42:57

We usually evaluate by, since there's surrounding edema,

43:01

like, and also the presence of cyst and more irregularity,

43:06

and also if it's coincidence, coincidence with the, the,

43:10

the region of the pain of the patient.

43:16

So, uh, there are other questions, how to differentiate.

43:18

I source bura versus Ola cyst.

43:22

So I source bura.

43:24

Uh, general, uh, we see, uh,

43:28

the format is more elongated than, uh, Olas,

43:31

and it's surrounding the tendons of the EU source.

43:35

So you're gonna see like, uh, not just, uh, isolate, uh,

43:39

uh, flute collection.

43:41

You see a, a collection, a flute collection that runs

43:44

through, uh, runs along with the, the, the, the tendon.

43:47

Usually they are largers

43:49

and there's a component inside of the pelvis,

43:52

the ILE components.

43:56

So the other questions, so superior

43:58

and secondary cleft, I think I show, show,

44:01

uh, during the lecture.

44:03

Uh, uh, and the other one please explain central

44:07

Ile impeachment.

44:08

I also show a case, uh,

44:12

but, uh, uh, about the iose impingement,

44:17

I show some case, but usually it's more, uh, diagnosed

44:20

of exclusion and also if there's no other

44:23

pathologist in the hip.

44:25

So you have, uh, edema or a bura of iose

44:29

and you have, uh, isolate injury

44:31

of the interior, uh, leg room.

44:34

So that's usually, uh, how we do the diagnosis.

44:39

Someone's asking for the article.

44:43

I think gonna, you can assess after the, the, the,

44:46

'cause this, the session is gonna be recorded,

44:48

so we're gonna access later.

44:51

How common is, uh, actual the

44:55

aate ligament disruption?

44:58

We usually don't, don't, don't describe isolated the,

45:02

the ligament, uh, disruptions.

45:04

Uh, usually this, this, uh, uh,

45:08

when it's only, uh, ligament disrupt is more traumatic,

45:12

like, uh, a car crash, something like this.

45:15

Usually in, in, in athletes we see the tendinopathy,

45:18

the motors and tion of the tendons

45:22

and not isolate the ar weight.

45:24

We don't have, uh, the numbers

45:26

of isolated, there's no studies.

45:28

So with the isolate injury of the AWAI ligament.

45:37

Another question, uh, the fascists shared by the peral

45:41

and rectus abdominal muscle.

45:42

So it, yes, the, the recent studies, they, they say

45:45

that not only Hector

45:46

but of the permease has some, some, uh, influence,

45:50

like a big influence of, of this fascia.

45:54

So, uh, significance of separation in terms

45:56

of the sports anus care.

45:58

Also, how to identify, uh, the poster constraints

46:01

of the repair, either, uh, full surgical

46:03

and endoscopic approaches, what to look for.

46:07

So, uh, the separation of sports anus, uh, is

46:10

because, uh, not in all case we have hernia.

46:15

Sometimes, uh, the pain, it's a growing pain,

46:17

so it's clinical.

46:18

The patients come with the growing pain

46:20

with a clinical entity

46:22

and go to, to, uh, under to an MRI, for example.

46:26

And they have only, uh, bone marrow edema,

46:28

like a stress fracture

46:30

or some, uh, mechanical overload of the synthesis.

46:34

So it's not a true hernia.

46:36

So, uh, uh, in the past, uh, people, uh, put in the same,

46:40

uh, uh, package.

46:42

Everything was called sports hernia.

46:44

When it, when we don't have, uh, uh, true hernia,

46:47

when we see what represents Nia is not a true nia.

46:51

So it changed the, the, the, the communication.

46:54

So everyone's calling everything of the same thing,

46:57

but inside there is no, uh, there's different pathologies.

47:01

It's more complicated, the communication

47:02

between the radiologist and the surgeon.

47:05

So the most important, uh, to know exactly

47:08

what the NTCR you describing and how to identify the posts.

47:13

Surgical change of the repair, either, uh,

47:15

for surgical endoscopic approach usually can see, uh, scary.

47:21

But we, what we have to do,

47:23

like the anatomy will not be the same after a surgery.

47:28

So you have to look, if there's a, a new tear, a new, uh,

47:32

detachment, if there's collection, if there's a version,

47:36

we gonna look, uh, this, the signs off video of the surgery.

47:42

Uh, can we evaluate it, uh, labor tear properly

47:48

without asy?

47:50

Uh, we can see laboratory, uh, without asy, uh, act,

47:55

uh, uh, asy astro, MRI of the, the, the, the, the, the hip,

48:00

it's better because it is a very compact, uh,

48:03

uh, joint.

48:06

But we can see, especially when we use, uh, uh, three TMRI,

48:10

so we can, uh, see if you have, uh, a good protocol

48:15

and, uh, equipment with, uh, high field,

48:23

no, uh, is so, uh, sports area is the same as beginner area.

48:27

No, there are different sports area was what they used

48:30

to call, uh, growing pain, uh, in the past.

48:35

Awesome. You got through all the questions. Yeah,

48:38

A lot of Questions. A

48:39

lot of questions. Thank you so much.

48:43

Yeah, thank you so much for answering 'em.

48:44

And thanks so much for being on today.

48:46

Thank you so much for invite me again, Ashley.

48:50

Absolutely. We always love having you

48:52

and thanks for everyone else for participating in today's No

48:54

conference and asking such great questions.

48:57

As a reminder, we will email out a link

48:59

to the replay later today and you'll find, uh, Dr.

49:01

Kelli's article link in that as well.

49:05

Be sure to join us in next Wednesday,

49:07

November 5th at 12:00 PM Easter,

49:08

where Dr. Daniel Souza will deliver

49:11

a lecture entitled Multimodality Imaging of Gallstones,

49:15

cholecystectomy, and Complications.

49:18

You can register for that@modality.com

49:20

and follow us on social media

49:21

for updates on future NOOM conferences.

49:23

Thanks again for learning with us, and have a great day.