George Koulouris

Athletic pubalgia and the "sports hernia": MR imaging findings

PURPOSE To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard. MATERIALS AND METHODS Institutional review board approval was granted for this HIPAA-compliant study, and informed consent was waived. MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17-71 years) who had been referred to a subspecialist because of groin pain were reviewed for findings including hernia, pubic bone marrow edema, secondary cleft sign, and rectus abdominis and adductor tendon injury. MR imaging findings were compared with surgical findings for 102 patients, physical examination findings for all 141 patients, and MR imaging findings in an asymptomatic control group of 25 men (mean age, 29.8 years; range, 18-39 years). Sensitivity and specificity of MR imaging for rectus abdominis and adductor tendon injury were determined by using a chi(2) analysis, and significance of the findings was analyzed with an unpaired Student t test. Disease patterns seen at MR imaging were compared with those reported in the surgical and sports medicine literature. RESULTS One hundred thirty-eight (98%) of 141 patients had findings at MR imaging that could cause groin pain. Compared with surgery, MR imaging had a sensitivity and specificity, respectively, of 68% and 100% for rectus abdominis tendon injury and 86% and 89% for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group (P < .001). Only two patients had hernias at surgery. At MR imaging, injury or disease could be fit into distinct groups, including osteitis pubis, adductor compartment injury, rectus abdominis tendon injury, and injury or disease remote from the pubic symphysis. Patients with injury involving the rectus abdominis insertion were most likely to go on to surgical pelvic floor repair. CONCLUSION MR imaging depicts patterns of findings in patients with athletic pubalgia, including rectus abdominis insertional injury, thigh adductor injury, and articular diseases at the pubic symphysis (osteitis pubis).

Magnetic Resonance Imaging Parameters for Assessing Risk of Recurrent Hamstring Injuries in Elite Athletes

Background Magnetic resonance (MR) imaging has established its usefulness in diagnosing hamstring muscle strain and identifying features correlating with the duration of rehabilitation in athletes; however, data are currently lacking that may predict which imaging parameters may be predictive of a repeat strain. Purpose This study was conducted to identify whether any MR imaging-identifiable parameters are predictive of athletes at risk of sustaining a recurrent hamstring strain in the same playing season. Study Design Cohort study; Level of evidence, 3. Methods Forty-one players of the Australian Football League who sustained a hamstring injury underwent MR examination within 3 days of injury between February and August 2002. The imaging parameters measured were the length of injury, cross-sectional area, the specific muscle involved, and the location of the injury within the muscle-tendon unit. Players who suffered a repeat injury during the same season were reimaged, and baseline and repeat injury measurements were compared. Comparison was also made between this group and those who sustained a single strain. Results Forty-one players sustained hamstring strains that were positive on MR imaging, with 31 injured once and 10 suffering a second injury. The mean length of hamstring muscle injury for the isolated group was 83.4 mm, compared with 98.7 mm for the reinjury group (P = .35). In the reinjury group, the second strain was also of greater length than the original (mean, 107.5 mm; P = .07). Ninety percent of players sustaining a repeat injury demonstrated an injury length greater than 60 mm, compared with only 58% in the single strain group (P = .01). Only 7% of players (1 of 14) with a strain <60 mm suffered a repeat injury. Of the 27 players sustaining a hamstring strain >60 mm, 33% (9 of 27) suffered a repeat injury. Of all the parameters assessed, only a history of anterior cruciate ligament sprain was a statistically significant predictor for suffering a second strain during the same season of competition. Conclusion A history of anterior cruciate ligament injury was the only statistically significant risk factor for a recurrent hamstring strain in our study. Of the imaging parameters, the MR length of a strain had the strongest correlation association with a repeat hamstring strain and therefore may assist in identifying which athletes are more likely to suffer further reinjury.

Imaging Review of Groin Pain in Elite Athletes: An Anatomic Approach to Imaging Findings

OBJECTIVE Groin pain in elite athletes is a common yet challenging diagnostic and management dilemma for the sports clinician, accounting for a significant proportion of athletic injuries. It is often debilitating and, if severe enough, may compromise an athletes career. Traditionally, groin pain has been poorly understood by radiologists. CONCLUSION A major reason groin pain has been misunderstood is the complexity of the anatomy of this region, which this article discusses in detail in an effort to inform the reader.

Posterior Tibiotalar Ligament Injury Resulting in Posteromedial Impingement

Objective: To describe the imaging features of the normal anatomy and injury of the posterior tibiotalar ligament (PTTL) of the ankle in a group of patients presenting with posteromedial impingement. Materials and Methods: Twenty-five consecutive patients underwent imaging for posteromedial ankle pain following injury. All 25 patients were investigated with MR imaging, 17 with ultrasound and 5 with radionuclide bone scanning. Clinical data and surgical findings were correlated with the results of radiological investigation. Results: The PTTL demonstrated scar formation and a hypertrophic response consistent with previous injury in all 25 patients. Displacement or encasement of the surrounding tendons and their sheaths was often encountered (12/25). Bony avulsion was demonstrated in 5/25 occasions with ultrasound and 2/25 with MR imaging. Twelve patients underwent surgery, confirming the radiological findings. Conclusion: Imaging can effectively evaluate the integrity of the PTTL in the context of ongoing posteromedial ankle pain.

MRI of rupture of the spring ligament complex with talo-cuboid impaction.

The spring ligament complex is essential for the stability of the longitudinal arch of the foot and includes the ligaments between the calcaneus and the talus at the superomedial to inferoplantar aspect of the foot. Tears of the spring ligament complex are most commonly degenerative in etiology and secondary to concomitant abnormality of the posterior tibial tendon. We report MRI findings in a 30-year-old man who presented with traumatic rupture of the spring ligament complex, seen following dislocation of the talonavicular joint. We also describe the previously unreported MRI features of talo-cuboid impaction secondary to disruption of the spring ligament complex.

Bifid insertion of the distal biceps brachii tendon with isolated rupture: Magnetic resonance findings

Victoria House Medical Imaging Prahran, Victoria, Australia Department of Radiology, Geisinger Medical Center, Danville, PA Department of Radiology, Northwestern Memorial Hospital, Chicago, IL Department of Musculoskeletal Imaging, Thomas Jefferson University Hospital, Phialdelphia, PA The Avenue Clinic, Windsor, Victoria, Australia Department of Radiology, Mater Misericordiae Hospital, Dublin, Ireland

Multiple congenital cranial hemangiomas

Though cranial hemangiomas are second only to vertebral hemangiomas in frequency, such lesions are rarely congenital and multiple. It is probable that the true incidence of congenital calvarial hemangiomas is higher than that reported in the literature, as they are unlikely to undergo imaging, most being asymptomatic and without a significant soft tissue component. We present a case of multiple congenital calvarial and skull base cavernous-type hemangiomas, diagnosed in a 4-day-old female, involving the right zygoma, maxilla, frontal and petrous temporal bones and contralateral squamous temporal bone. Surgical biopsy confirmed the radiological diagnosis as well as the concomitant multiple subcutaneous capillary-type hemangiomas which were identified clinically. No specific clinical syndrome or chromosomal abnormality was identified and the underlying cerebral parenchyma was normal with no intra-axial involvement. With conservative treatment, two lesions completely resolved and a further two lesions subsequently decreased in both size and degree of enhancement. To the best of our knowledge, this is the first case of multiple congenital hemangiomas involving the calvarium and skull base. Despite this, the radiological features, combined with the clinical findings of multiple capillary hemangiomas, were characteristic enough to permit an accurate preoperative diagnosis. Osseous hemangiomas should feature prominently in any differential diagnosis of multiple hypervascular lesions, as they are common, more so when limited to an anatomical region, irrespective of site or age.

Does Extended-Field-of-View Sonography Improve Interrater Reliability for the Detection of Rotator Cuff Muscle Atrophy?

OBJECTIVE Assessment of rotator cuff muscle atrophy is an important component of the shoulder sonogram. We hypothesized that extended-field-of-view (EFOV) sonography would allow greater interrater reliability than conventional sonography for the evaluation of rotator cuff muscle atrophy. MATERIALS AND METHODS This retrospective study involved 50 consecutive patients who presented for shoulder sonography. All patients underwent EFOV imaging of the supraspinatus and infraspinatus muscles in addition to conventional imaging of each muscle. Five musculoskeletal radiologists first assessed 50 EFOV images of the supraspinatus and infraspinatus muscles and scored both muscles using a scale of 1-5. The reliability of each method was determined by calculating intraclass correlation coefficients (ICCs) according to a method developed by Shrout and Fleiss. The significance of the difference between reliabilities for conventional images and EFOV images was tested with a z-test. RESULTS For the EFOV images, the ICC for the supraspinatus muscle was 0.77 and for the infraspinatus, 0.75. For the conventional images, the ICC for the supraspinatus muscle was 0.52 and for the infraspinatus, 0.57. The degree of interrater reliability for the five readers in our study was significantly higher for the EFOV images than for the conventional images (p < 0.0001). CONCLUSION EFOV sonography results in greater interrater reliability than conventional sonography for the detection of rotator cuff muscle atrophy. EFOV images of the rotator cuff muscles should be obtained as part of routine shoulder sonography.

Imaging of the shoulder after surgery

Postoperative imaging of the shoulder is challenging. This article reviews the radiologic evaluation following surgery for subacromial impingment, rotator cuff lesions and glenohumeral instability, including the common surgical procedures, the expected postoperative findings and potential complications. A specific emphasis is made on magnetic resonance imaging.

Hip and Groin Pain: Radiological Assessment

Hip and groin pain are commonly encountered complaints in orthopedic practice. The diagnosis can be difficult to establish based on the complex interconnected anatomy at the pubic symphysis and around the hip. In addition patients can present with varied pathology, such as labral and cartilaginous injuries, surrounding soft tissue derangement involving muscles or tendons and osseous abnormalities. The differential diagnosis is therefore broad and diagnostic imaging is crucial in reaching the correct diagnosis, thus allowing appropriate therapy to be instituted. This article will review the relevant anatomy, differential diagnoses and important imaging findings encountered in chronic hip pain and overuse injuries of the groin.