0:00

<v ->This next difficult case is a 47-year-old man.

0:04

So older than you see with sports hernia

0:06

or sportsman's hernia syndrome,

0:08

typically 35 and under.

0:11

One criteria for a sports hernia is

0:14

they should not have an inguinal hernia.

0:17

In other words, they should not have a hernia,

0:18

but especially an inguinal hernia.

0:21

That virtually excludes the diagnosis

0:24

of sports hernia syndrome,

0:26

or you should be looking at the other diagnosis

0:30

Next, when someone has groin pain,

0:33

you wanna look at their activity.

0:36

Certain sports are very prone to this entity.

0:39

One sport, if you know the sport of soccer

0:42

or European football, the way they kick,

0:44

there's a tremendous amount of adduction that goes into it.

0:47

13% of all soccer injuries are gonna be groin related.

0:51

The classic sport is going to be hockey,

0:54

so-called slapshot groin.

0:56

Whereas, we've said before, tennis players,

0:59

more likely to have pre-pubic plate

1:01

and abdominal wall abnormalities.

1:03

American football, rugby, Australian rules football,

1:06

they have the most heterogeneous collection of pathologies

1:10

and you've gotta really be on your guard.

1:12

And this is one example.

1:13

This is an athletic guy.

1:14

You can see he's pretty muscular for his age.

1:16

He's also a pretty big guy,

1:18

but what other types of things can they get?

1:21

Inguinal ligament tears.

1:23

The wall of the inguinal canal can tear.

1:25

Iliopsoas strain, iliac strain, lig teres injuries,

1:30

rectus femoris injuries, abdominal oblique tears,

1:34

osteitis pubis may masquerade as sports hernia syndrome,

1:38

labral tears, sartorius strains, the hip capsule,

1:42

iliac bone avulsions, stress injuries, and apophysitis.

1:47

These are all things that I check off

1:51

as I'm looking for a sports hernia syndrome,

1:53

especially when I haven't found the root cause

1:57

in the middle of the body towards the midline.

2:00

Now, in this case, I've got an axial T1 on the left,

2:02

anatomy, skeleton, articular surface.

2:06

Look at the erosions that are present in the synthesis pubis

2:10

that probably has caught your eye.

2:13

I'll blow them up a little bit.

2:13

I'll point to it.

2:15

Let's take a look at the MR in this patient.

2:18

We've got an unusual look to the symphysis pubis.

2:22

First, you can see this erosion right here.

2:25

There's some irregularity and some swelling

2:27

or edema in the symphysis pubis.

2:29

Now I don't like to see anything more than

2:32

10 millimeters of fluid-like signal A to P.

2:35

So that usually means that the capsule is damaged.

2:38

'Cause this is more than 10 millimeters.

2:40

This is the entire length, 15, 20 millimeters.

2:44

And let's scroll a little bit now.

2:47

I want you to focus on this spot right here.

2:50

Let's scroll.

2:51

And that little spot catches your eye.

2:55

Let's scroll up.

2:59

And now let's scroll down.

3:02

Keep looking.

3:05

Nothing else too impressive.

3:07

Now you might be interested

3:10

in the small effusions in the testicular region,

3:14

because this is a place where you might have

3:17

inguinal or groin pain.

3:18

So I'm looking for varicoceles and hydroceles

3:21

and testicular abnormalities as a sidelight.

3:24

Let's go over to the coronal T2.

3:27

I think you're gonna be relatively unimpressed

3:30

with the coronal T2.

3:32

T2 is water weighted, but not that water sensitive.

3:35

And it's good for gauging the chronicity of something.

3:38

Once again, we see an irregular symphysis pubis,

3:42

the superior pubic ligament, a very irregularly shaped,

3:46

scarred, thickened, arcuate ligament,

3:50

and really not a lot else, except for one thing.

3:53

Now I'm really gonna blow it up,

3:55

'cause this is how subtle it can get.

3:57

You're starting to get some signal outside of the joint.

4:04

Ooh, that's nasty, isn't it?

4:06

Right there.

4:07

Could that produce the kind of symptoms

4:10

of sports hernia syndrome?

4:12

You bet.

4:13

When you're contracting and adducting, that will do it.

4:17

But we're not done yet.

4:18

Let's keep going.

4:19

Let's pull down something that's even more water weighted,

4:23

and I'm gonna pull down my sagittal

4:25

so you can see what kind of projection we've got.

4:27

We've got an axial oblique

4:29

perpendicular to the symphysis pubis.

4:32

Something like this.

4:36

Now let's go back to the axial and scroll it.

4:42

Now we've got this extra little tiny cleft here anteriorly.

4:46

That is not in the joint.

4:48

That may be the only thing you will see

4:51

in sports hernia syndrome.

4:53

But let's keep going.

4:54

Let's go down.

4:56

Let's go up, and look at the space

5:00

between the normally secure,

5:03

flat, abutted, attached pre-pubic plate.

5:07

It's starting to peel from the degenerated pubic bone.

5:12

So the mast, the central portion of our sailboat analogy,

5:16

is separating away from the hull of the boat.

5:21

So we've got a typical unilateral cleft sign,

5:25

small on the left,

5:26

and then we've got a large cleft running side to side

5:30

with pre-pubic plate separated from

5:32

an edematous pubic bone and pubic joint

5:36

with rupture or insufficiency of the midline pubic capsule.

5:41

Oh yeah, this patient, at age 47,

5:43

has sports hernia syndrome.