0:00

So with that, let's start with the adductor.

0:03

So our first stop that we're gonna look at is in the area

0:06

of the pubic synthesis.

0:08

And I've listed

0:13

that we encounter in the,

0:15

the adductor longus inserting on the adductor tubercle,

0:19

the smaller brevis

0:21

and sillus inferiorly

0:27

and the adductor magnus at the bottom of the es skim.

0:34

As you look at these adductors,

0:35

and we look at longest, it's the most anterior

0:38

of the tendons, and it is continuous with the rectus

0:42

abdominous muscle, uh, and APA neurosis superiorly.

0:47

So this is the area of the adductor tubercle over here.

0:50

And then notice how far anterior it is.

0:53

So if you start in the middle of the pubis,

0:56

you will have missed the adductor longus insertion,

0:58

and that's the most important part.

0:59

So make sure you look at the far anterior images when you're

1:04

evaluating the structure,

1:06

because all of these structures attach

1:09

as a sheet onto a common fibrous plate

1:12

anterior to the synthesis.

1:14

These structures are subjected

1:16

to traction forces in multiple directions,

1:19

and we will often see injuries in this area

1:23

in patients who are involved in sports.

1:28

Now, this is an acute injury, and this is straightforward.

1:31

The history is not of a single episode event.

1:33

We have an ul of the adductor longus,

1:38

and that's where we will typically see single tendon

1:41

avulsions or muscle strains from an acute trauma.

1:45

What I wanna show you though, are the injuries

1:47

that we see from repetitive injury.

1:49

These are more insidious

1:50

and the symptoms can be somewhat vague.

1:53

The definition of these repetitive injuries,

1:56

and they go by a number of different names,

1:59

is chronic pain centered near the synthesis

2:05

generally in an athlete in the United States.

2:08

The term athletic, the term sportsman's hernia is popular,

2:12

and it's been suggested

2:14

that we use the term core muscle injury rather than these

2:17

imprecise terms to refer to, uh, the type of pathology

2:22

that we see around the area of the pubic, uh, synthesis.

2:26

So we can see this related to a number of, uh, different,

2:30

uh, different, uh, sports that are, are practiced.

2:34

I like this, uh, image, which is modified from an article

2:38

by Falvey looking at the structures in terms

2:41

of a pubic clock with the abdominal musculature superiorly,

2:46

the adductor musculature inferiorly,

2:49

the joint itself located centrally,

2:53

and then the inua ligament

2:55

and the p located a little more sup laterally.

3:00

So if you look at this, we can think

3:02

of disease either involving the joint

3:05

or the soft tissue structures that insert in this area

3:09

and work on this.

3:11

Now, don't forget that central pain can be referred from the

3:15

hip, so you don't want to just focus in on this area.

3:18

You also want to look at the adjacent structures

3:21

to make sure you're not looking at referred pain.

3:23

These images are taken from a very nice website

3:26

by Dr. Reed from Australia showing the normal anatomy

3:30

of the pubic synthesis.

3:31

With this thick fibrous tissue anteriorly

3:34

and the joint in the center,

3:36

we typically don't see much fluid, uh, in

3:40

our articulation.

3:42

Uh, sometimes in, in women who are postpartum,

3:45

you're gonna get fluid, but generally in males,

3:48

there's really a paucity of fluid in this, uh, region.

3:51

This is a case of early Osteitis pubis.

3:54

It's can be unilateral or bilateral.

3:58

The whole market is gonna be bone marrow edema,

4:01

which is seen far

4:03

before any radiographic abnormalities develop

4:06

and subc chondral cyst formation.

4:09

Now, the the concept of how this happens is thought

4:12

to be repetitive instability of the pubic synthesis,

4:16

and a well-known example to all of us is postpartum osteo

4:21

pubis in the female,

4:22

and that can be associated with vertical offset as well

4:27

as the and sclerosis indicating

4:31

chronicity, uh, of this process.

4:33

But don't think that this always has to be bilateral.

4:36

The changes can be unilateral,

4:38

and often in athletes we see relatively unilateral cystic

4:42

changes in sclerosis from chronic osteo pubis

4:47

in terms of the athletic pubal or core muscle injuries.

4:52

Soft tissue components we wanna look at is the area

4:55

of the adductor tubercle at the confluence

4:58

of the rectus abdominis and the adductor uh, musculature.

5:02

So you can see this patient has disease of two types.

5:06

There is joint disease with the fusion

5:08

and edema, pubic synthesis.

5:11

So there are findings of osteitis,

5:14

but in addition to that, there is fluid anterior

5:17

to the pubic synthesis and irregularity

5:20

and disruption of the fibrous tissues

5:24

that insert anteriorly.

5:26

So the synthesis not the only cause

5:29

of pain, uh, in this area.

5:31

Now, the cleft sign has been popularized

5:33

as an important finding in Osteitis,

5:37

and what this initially was described was

5:40

by using arthrography

5:42

and the, the finding of extravasation of fluid

5:46

beyond the central slip of the synthesis.

5:50

Now, this is really not a comfortable technique.

5:53

The patients don't like to have this done.

5:55

And now with high resolution Mr,

5:57

we can see this finding non-invasively.

5:59

And here's a nice example on an angled image

6:02

through the pubic synthesis showing fluid, undermining the,

6:06

uh, bone, uh, continuous, uh, with the, uh, with the joint.

6:12

Now, be aware that there are actually two different clefts

6:15

that are described.

6:16

They're not always easy to distinguish on imaging,

6:20

but if you look carefully, you can try

6:22

to tell whether you're dealing with a cleft

6:24

that's located more inferiorly wrapping

6:27

around the undersurface of the pubis,

6:29

or one located more superior.

6:33

Superior cleft is more strongly associated

6:37

with pectus pathology,

6:38

whereas the inferior cleft is associated

6:41

with adductor pathology.

6:43

Now, in order to see these types of clefts, well, you want

6:47

to use angled imaging.

6:49

So angled imaging is done parallel

6:51

and perpendicular to the pubis with small field of view

6:55

because some of the lesions can be quite

6:57

small and quite subtle.

6:58

Here we see focal edema

7:00

and just very low grade delamination

7:02

of the tendon from the bone.

7:05

And this, you're not going

7:06

to see clearly on large field of view imaging.

7:09

So a couple of angled high resolution images

7:13

are really worthwhile.

7:15

And this particular finding of these small lesions at the,

7:19

uh, at the anterior margin

7:21

of the adductor longus have been written up

7:24

by, uh, many authors.

7:25

But I like a little, uh, saying that, uh, George Calis, um,

7:30

talks about this with, uh, the, uh, snot on a mustache sign,

7:34

and that's an easy way to try to remember that.

7:36

It, uh, just that looks like a little bit of snot, uh,

7:40

on the, on the mustache.

7:42

This is an, uh, picture taken from an anatomic article

7:45

showing you this fibrous layer

7:49

that we have anterior to the pubis.

7:51

And notice that you have crisscrossing fibers

7:54

that have many origins.

7:56

We have fibers from the adductor longus inserting

7:59

and they blend with fibers from the rectus

8:03

ados musculature.

8:05

In many people, there's an additional small muscle in here

8:08

called the parama DAUs that contributes to these, uh,

8:11

to this, uh, this region.

8:13

But this area is known as the rectus apo neurotic plate.

8:18

And you can see here

8:19

that this rectus apo neurotic plate can become detached from

8:24

the pubic synthesis

8:25

and is thought to be the cause for the chronic groin pain,

8:29

uh, that we see in, uh, athletes.

8:32

Now in my practice, I really don't see

8:35

injuries extending into the abdominal wall

8:37

with any frequency.

8:39

I think if you do high resolution ultrasound, some

8:41

of the more minor injuries involving the para

8:44

are probably going to be seen better than they are on mr.

8:48

But when you do see AULs of that tissue,

8:52

you should always look and,

8:55

Uh, look superiorly because the fibers are continuous

8:59

and you can get extension.

9:01

Uh, c cranially here is that odalis muscle, just

9:04

so you're familiar with what it looks like.

9:07

It's a little triangular muscle, broader

9:10

inferiorly located anterior,

9:12

the distal most fibers of the rectus.

9:15

And in this, uh, patient here, we can see

9:17

that there has been an injury

9:19

with edema within the adductor musculature,

9:22

and again, injury extending up into those abdominal, uh,

9:26

wall, uh, muscles.

9:28

So look for it though.

9:29

I really don't see that, uh, very, very, uh, frequently.

9:34

The other area that you should look

9:36

for is in the inguinal canal.

9:38

And again, I rarely see injuries extending into the inguinal

9:42

region on the athletes that I image.

9:45

Uh, this is a patient, uh, who was injured playing

9:49

American football, uh,

9:51

and he has a significant injury involving his pectineus.

9:55

And in this case, we can see that the external, uh,

9:59

inguinal, uh, ring has been disrupted.

10:02

But, uh, I find this, uh, not, uh,

10:04

not a very common finding on, uh, Mr.

10:07

Uh, imaging.