British Journal of Radiology (2005) 78, 457-468
© 2005 British Institute of Radiology
doi: 10.1259/bjr/73355272
Imaging of pelvic injuries in athletes
J Brittenden, MRCP, FRCR
and
P Robinson, MRCP, FRCR
Department of Diagnostic Radiology, Leeds Teaching Hospitals, St James University Hospital, Beckett Street, Leeds LS9 7TF, UK
Correspondence: Dr Philip Robinson
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Introduction
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The pelvis is a complex osseous anatomical region providing the origin and insertion for a number of powerful muscle groups. It performs a pivotal role in all athletic activities and forces exceeding six to eight times body weight traverse this region during even light exercise making the pelvis particularly prone to sporting injury.
The clinical features of injury within the pelvis can be non-specific and a number of diagnoses need to be considered. The location and pattern of injury depends on the sporting activity, the maturity of the athlete and whether the injury sustained is part of an acute or chronic (overuse) process. Recovery from pelvic injury can be prolonged especially if the initial diagnosis is incorrect and appropriate treatment delayed.
This article will review the spectrum of pelvic sports injuries and the imaging strategies that can be employed to diagnose and grade such injuries.
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Stress reaction
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Stress fractures occur when abnormal repetitive stress is applied to normal bone [1]. The muscles and soft tissues of the pelvis protect the skeleton from the effects of repeated stress explaining the greater incidence of pelvic stress fracture in female athletes, with their relatively reduced muscle bulk.
Running athletes are most commonly affected with the femoral neck and the inferior pubic ramus most frequently involved although sacral fractures are not unknown [2]. Stress fracture of the femoral neck in particular has potentially serious consequences if the diagnosis is not made promptly as the injury can progress to complete fracture, non-union and osteonecrosis [3].
Radiographic assessment of stress fracture can be insensitive, especially in the early stage of the condition and follow up films may demonstrate visible abnormalities in only 50% [3]. Bone scintigraphy has a high sensitivity but lacks spatial resolution and specificity and has been largely superseded by MRI in athletes as it can also identify alternative sources of pain such as muscle tears or joint degeneration [1]. T1 weighted sequences provide good anatomical detail and define the low signal fracture line in stress fractures whilst fat suppressed T2 (spectral or short tau inversion recovery (STIR)) sequences can detect periosteal, bone marrow or muscle oedema which are the early signs of osseus stress injury [4]. In advanced injury, MRI clearly depicts the findings of cortical fracture and this ability to differentiate the early changes of stress injury (Figure 1
) and the later findings of stress fracture (Figure 2) are important in guiding therapy [5]. In the former a short period of rest is implemented but in overt stress fracture several months healing may be required before the athlete can return to full training.
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Figure 1. Sacral stress reaction in a tennis player with left sacroiliac pain and normal radiographs. Coronal short tau inversion recovery (STIR) MR image sequence shows oedema in the left sacral ala but no fracture is visible.
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Figure 2. Runner with increasing right hip pain. Coronal T2 weighted fat saturated MR image shows high signal within the right femoral neck with a low signal linear area (arrow) representing a fracture line. Conventional radiographs were normal.
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Scintigraphy is also less useful for follow up of stress injury as abnormal uptake can persist for up to 8–10 months, although intensity usually decreases within 3–6 months [6] compared with MRI which usually demonstrates a return to normal bone marrow signal on T2 weighted sequences at 3 months [7].
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Avulsion fracture
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Avulsion injuries occur in the skeletally immature athlete when forces generated within the myotendinous unit exceed the weaker attachment of the apophysis to the central skeleton [8]. During running major forces are distributed through the hip flexors and hamstrings resulting in the most frequent avulsion injuries occurring at the origin of these tendons [9, 10].
Avulsion injury of the ischial apophysis by the hamstrings is common in runners, dancers and gymnasts, with pain typically referred to the buttock region.
Avulsion injuries of the anterosuperior (sartorius) (Figure 3) and anteroinferior (rectus femoris) iliac spines are most commonly seen in the sprinting phase of running, hurdling and in kicking sports such as soccer.
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Figure 3. (a) Rugby player presenting with acute pain after kicking. Plain film shows an avulsed fragment (arrow) of bone from the anterior superior iliac spine at the site of the sartorius tendon insertion. (b) Longitudinal ultrasound in the same patient shows the avulsed fragment (arrowhead) and intact tendon and muscle (arrows).
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The clinical findings in avulsion fractures of the pelvis are loss of function and severe localized tenderness. The diagnosis can be confirmed on plain radiographs (Figure 3a
) but MRI is less specific in diagnosis because low signal cortical fragments may not contain bone marrow and can be difficult to identify. In the acute setting MRI and ultrasound may demonstrate haematoma and periosteal stripping but their main role in management is to rule out high-grade injury of the tendon (Figure 3b). Avulsion injuries should be regarded as a more serious injury than a straightforward muscle or tendon injury as it has the same implications as a fracture. Recovery from anterior pelvic avulsion typically takes approximately 5–6 weeks compared with hamstring avulsion, which may take twice as long [10]. Avulsions, if diagnosed early usually heal with conservative treatment and modification of activities. Surgical repair is undertaken if dislocation of the apophysis or bony avulsion is more than 2 cm [11]. Hamstring avulsions are also more prone to complications, because of potential involvement of the sciatic nerve by direct compression from the avulsed fragment or by abundant callous formation during the healing process [12].
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Muscle injury
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Myotendinous strain is the most common sports related injury of the pelvis with the surrounding muscle groups performing a pivotal function in all athletic activities. The forces generated within these muscle groups exceed multiples of body weight during light jogging with major forces produced during explosive athletic activity.
The site of injury within the functional muscle unit depends on the maturity of the athlete. In young, skeletally mature athletes the main area of weakness is the myotendinous junction as well as the muscular aponeurosis [13, 14]. Conversely a similar mechanism of an injury in a skeletally immature patient will cause apophyseal avulsion (see above) while in a more mature athlete the degenerate tendon can tear.
During normal muscle contraction, the muscle belly contracts whilst the myotendinous unit lengthens. Myotendinous strain injuries typically occur in muscles that cross two joints and have a high proportion of fast twitch fibres while undergoing eccentric contraction (stretch during contraction) [14]. Specific muscles are more commonly affected than others within a synergistic group, especially rectus femoris (quadriceps), biceps femoris (hamstrings) (Figure 4), adductor longus (adductors), with less frequent involvement of the iliopsoas, gluteal and abdominal muscles.
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Figure 4. 100 metre sprinter with acute right thigh pain. Axial T2 weighted fat saturated MR image of both thighs shows a normal left biceps femoris tendon (arrow). The right biceps femoris tendon can be seen as a low signal structure, but with surrounding oedema and haemorrhage (arrowheads), consistent with a grade I injury.
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Rectus femoris is most commonly injured at the distal myotendinous junction but proximal injuries are recognized when eccentrically resisting hip extension (e.g. extending the leg prior to kicking). This mechanism particularly affects the tendon of the reflected head at its junction with the straight head at the level of the acetabulum (Figure 5). The hamstrings are commonly injured in sprinting when they undergo eccentric contraction controlling knee extension. Proximal and distal myotendinous injuries occur in almost equal incidence, with biceps femoris predominantly involved [14, 15] (Figures 4 and 6).
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Figure 5. (a) Female discus thrower with normal proximal rectus femoris. Longitudinal ultrasound shows the origin of rectus femoris (RF) from the anterior inferior iliac spine (AI) lying anterior to the acetabulum and femoral head (F). (b) Corresponding image in a symptomatic soccer player with chronic pain on taking goal kicks. Anterior to the anterior inferior iliac spine (AI) and femoral head (F), there is an ill-defined area of chronic haematoma (arrowheads) containing echogenic scar tissue within rectus femoris, consistent with a chronic proximal tear of rectus femoris.
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Figure 6. Male long jumper with sudden thigh pain in competition. (a) Longitudinal extended field of view ultrasound shows a grade 2 tear within biceps femoris (BF). There is a large haematoma (arrowheads) with mixed echogenicity occupying approximately 50% of the muscle and indenting the adjacent semitendinosus (S) muscle. (b) Transverse ultrasound shows the haematoma (arrowheads) extending along the aponeurosis of biceps femoris (BF) with associated mass effect indenting semitendinosus (S).
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In our experience however, proximal myotendinous tears of the hamstrings and adductor longus (Figure 7) are more common in experienced athletes presumably due to the relative weakness produced by the presence of underlying proximal tendinopathy.
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Figure 7. Professional soccer player with acute thigh pain during tackling. Longitudinal extended field of view ultrasound shows a grade 3 adductor longus (AL) tear retracted from the pubis (P) with heterogeneous but intact proximal tendon (arrowheads). Note the intervening acute hypoechoic haematoma (*).
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Clinically, muscle strain or tear is characterized by immediate focal pain and decreased function that can be due to muscle disruption or associated muscle spasm in adjoining muscles. There is a well-established clinical grading system that has three components. Grade one injury is less than 5% loss of function, grade two injury is more severe but with some function preserved and grade three strains are complete muscle tears [16]. It is well recognized that differentiation of these clinical grades can be difficult and thus imaging has a potentially important role in these situations [17]. On ultrasound and MRI grade one muscle injuries can show normal appearances or a small area of focal disruption (less than 5% of the muscle volume) with haematoma and perifascial fluid relatively common (Figure 4) [17, 18]. Grade two injuries correspond to a partial tear with muscle fibre disruption seen (over 5%) but not affecting the whole muscle belly (Figures 6, 8 and 9). Grade three injuries (Figure 7) are complete muscle tears with frayed margins and bunching of the muscle on dynamic ultrasound assessment. Although the evaluation of muscle injury by MRI has been extensively described, ultrasound now allows demonstration of muscular architecture at a higher resolution than can currently be obtained on routine MRI. Ultrasound has a number of other advantages over MRI including dynamic muscle assessment, speed of examination, cost and the ability to perform real time intervention. However, the large muscle bulk often present in athletes means that the depth of resolution and field of view offered by ultrasound can be limiting in the pelvic area requiring familiarity with both imaging techniques (Figures 8 and 9).
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Figure 8. 110 metre hurdler with acute right groin pain during competition. Axial T2 weighted fat saturated MR image of the pelvis shows oedema (arrowheads) within the proximal myotendinous region of right adductor brevis (AB) consistent with a grade 2 tear. (AL, adductor longus; AM, adductor magnus).
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Figure 9. Professional soccer player with acute posterior thigh pain on volleying. Axial T2 weighted fat saturated MR image of the buttock and upper thigh shows an acute grade 2 right piriformis muscle tear (large arrows). Note the low signal, intact left piriformis (large arrowheads) and the posterior sacrum (small arrows) which, along with the large buttock musculature, did not allow adequate visualization with ultrasound.
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During healing, ultrasound can show the development of more normal appearing muscle architecture over the following weeks (Figure 10). Once this is the predominant finding, it is suggested that more rigorous rehabilitation can occur [17]. The MRI features of healing muscle tears have not been shown to be as clinically helpful with marked signal abnormality persisting throughout the different stages of healing [15].
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Figure 10. Soccer player with proximal thigh haematoma secondary to muscle tear. (a) On day 5, there is a predominantly hypoechoic haematoma (*) with an echogenic periphery. (b) By week 2, the hypoechoic haematoma has now resolved and been replaced by connective tissue (arrowheads) which has a similar appearance to muscle (compare with intact superficial muscle (*)).
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Another consideration in athletes is steroid misuse and this should be suspected when the extent of injury is not in keeping with the proposed mechanism or forces involved for the injury. On imaging, if the tendons seem to be predominantly involved (especially in young athletes) it should be considered unusual because steroid abuse stimulates sudden muscle growth leading to stripping of the tendons when the muscle is strained (Figure 11).
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Figure 11. Professional rugby player with sudden, severe thigh pain. (a) Longitudinal extended field of view ultrasound shows a proximal grade 3 semimembranosus (S) tear with a bunched up muscle belly and adjacent haematoma (arrows). The free edge of the torn muscle produces acoustic shadowing (*). (Note adjacent semitendinosus (St)). The large muscle bulk precluded complete visualization at ultrasound. (b) Sagittal short tau inversion recovery (STIR) MR image of the thigh confirms a grade 3 tear of semimembranosis with marked retraction of the muscle (arrowheads) and accompanying tendon (arrow). Because the tear occurred within the tendon and not at the myotendinous junction, with an unusual mechanism of injury, steroid abuse was suspected (see text).
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Acute complications of muscle strain include nerve irritation, especially the sciatic nerve in hamstring injury by adjacent haematoma or muscle swelling (Figure 12a). Imaging can play an important role in these cases as the referred pain can make it difficult to clinically grade and localize the injury essential for planning rehabilitation. Chronic complications such as scar tissue (Figure 12b) can be particularly debilitating in the pelvic region as the adhesions can involve adjacent nerves and limit full joint movement. Scar tissue can start to form as soon as 2 weeks post injury and as well as restricting function can reduce the contractile strength of the muscle making it more susceptible to re-injury [19].
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Figure 12. (a). Acute hamstring tear in a runner. Transverse ultrasound image of a grade 2 semitendinosus tear with an acute haematoma (arrowheads) impinging on the sciatic nerve (arrow). (b) Professional soccer player with recurrent posterior thigh pain on sprinting. Transverse ultrasound of the proximal thigh shows the sciatic nerve (arrows) with a large adherent nodule of echogenic scar tissue (arrowheads).
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Acetabular labral injury
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The acetabular labrum is a fibrocartilaginous structure which enlarges the overall surface area for articulation with the femoral head. Until recently, labral abnormalities were thought to be only associated with major hip trauma but it is now recognized that labral tears can result from twisting injuries in athletes [20]. Labral tears in athletes can initiate or accelerate degenerative changes as the damaged labrum results in unevenly distributed loading forces over the cartilage surface, leading to development of chondral defects and osteoarthritis [21].
Labral tears can be difficult to clinically diagnose with non-specific symptoms including clicking and anterior inguinal pain. Conventional MRI and ultrasound are not sensitive for diagnosing this condition, unless an associated paralabral cyst is present. The imaging investigation of choice is MR arthrography, because the diluted paramagnetic contrast agent injected into the hip joint distends the capsule outlining the labrum and any associated abnormality (Figure 13). Studies of MR arthrography have indicated close correlation between imaging and surgical findings [22, 23]. Tears are described in relation to the four acetabular quadrants (anterior, anterosuperior, posterior and posterosuperior) with the anterior and anterosuperior components most commonly involved.
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Figure 13. Acetabular labral tear in a professional footballer with right hip pain. (a) Sagittal T1 weighted fat saturated MR arthrogram image shows a deformed anterosuperior acetabular labrum (arrow) with a proximal tear (arrowhead). (b) Coronal T1 weighted fat saturated MR arthrogram image shows a deformed superior labrum (arrow) indented by an adjacent paralabral cyst (black arrowheads).
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MR arthrography can also allow therapeutic injection of additional anaesthetic or steroid, which can give considerable extended symptom relief to the athlete. However ultimately, if the pain is persistent arthroscopic resection of the torn labrum relieves symptoms and may slow down the associated degenerative process [24].
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Snapping hip syndrome
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The "snapping hip" is a clinical entity that refers to an audible "snap" or "click" that occurs in the region of the hip joint. Internal snapping of the hip is classically associated with labral tears (see above) while external snapping occurs with the surrounding tendons. The most common cause is movement of the iliotibial band over the greater trochanter, but it is also associated with snapping of the iliopsoas tendon and gluteus maximus tendons in the region of the iliopectineal eminence and greater trochanter, respectively. It is thought that laxity of the ligaments around the hip joint allows relatively excessive movement, with subsequent local tendinous irritation [25]. Snapping usually occurs in runners and gymnasts during hip flexion and lateral rotation but is not always painful.
Imaging in this condition can be difficult, with ultrasound the method of choice for demonstrating the flicking tendon as long as the manoeuvre to reproduce symptoms allows probe contact to be maintained [26]. MRI may demonstrate fluid along the iliopsoas tendon on T2 weighted sequences, but this is not sensitive or specific also occurring in iliopsoas tendinopathy and bursitis (Figure 14). Ultrasound can also be useful for image-guided injection of corticosteroid into any associated peritendinous inflammatory tissue if rehabilitation is unsuccessful. If non-surgical treatment is unsuccessful surgical tendon lengthening procedures can be performed [27].
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Figure 14. Triathlete with hip pain and clinically suspected snapping hip. Axial T2 weighted fat saturated MR image at the level of the ileopectineal eminence demonstrates the normal iliopsoas tendon (arrowhead) with surrounding oedema (arrow).
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Chronic groin pain
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Chronic groin pain is a complex clinical problem both in diagnosis and successful management [28]. There are four main differential diagnoses to consider, namely inguinal hernias, pre-hernia complex (Sportsman's hernia), osteitis pubis and adductor dysfunction. The incidence and proposed pathology varies between different sports and clinician experience but are common to sports involving repetitive kicking or frequent change of direction (e.g. soccer, ice hockey, rugby and Australian rules football) [28, 29]. Accurate clinical diagnosis can be difficult because there is considerable overlap in symptoms and signs with conditions often coexisting.
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Inguinal hernia
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Herniography has been extensively evaluated in athletes with equivocal clinical features and studies have shown this technique to be very sensitive but relatively non-specific technique demonstrating a large number of asymptomatic hernias [30]. Although herniography has been shown to have a low complication rate the procedure is still invasive and requires ionizing radiation [30].
In our institution clinically suspected hernias in athletes are assessed with ultrasound using the inferior epigastric vessels as a landmark (as they arise from the external iliac vessels) near the deep inguinal ring. Therefore if the hernia sac arises lateral to the vessels it is indirect (passing through the deep ring) (Figure 15), but if it lies medial to the vessels it is a direct hernia (bulging through the posterior wall).
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Figure 15. Professional soccer player with right groin pain. (a) Sagittal ultrasound of the right groin shows the short axis of the inguinal canal (arrowheads) with a number of hypoechoic vessels and tubules (*). (b) On straining, the contents are obliterated and the canal expanded by an indirect hernia of bowel and fat (arrowheads).
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Sportsman's hernia
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This is a controversial clinical area increasingly recognized as accounting for up to 5% of all groin injuries. It can be difficult to diagnose and treat effectively [31, 32] and the underlying biomechanical problem is not clearly understood but occurs more commonly in ball kicking sports [28, 29]. It is probably a chronic overuse injury, which develops insidiously with some authors postulating a chronic imbalance between the powerful adductor and the relatively weaker abdominal muscles across the symphysis pubis. The pathologies described include posterior inguinal wall weakness, aponeurosis tear and neuralgia. Although some authors [33] have proposed that posterior inguinal wall bulging on ultrasound occurs in this condition we commonly see this feature in asymptomatic athletes (Figure 16). Microtears cannot be reliably diagnosed on imaging and therefore imaging is performed to exclude other conditions that affect the groin (see above and below).
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Figure 16. Demonstration of normal left posterior inguinal wall bulging on dynamic ultrasound of a patient asymptomatic in this region. On straining, the shape of the normally oval inguinal canal becomes more crescent-like (arrowheads) with distension of the vessels within the canal and pushing in ("ballooning") of the posterior wall (arrows).
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Conservative treatment involves controlled rehabilitation which can be effective but of a long duration (>6 months), whilst a number of surgical procedures have been developed predominantly involving surgery to the posterior inguinal wall, rectus abdominis and adductor muscles alone or in combination [28].
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Chronic adductor strain
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The adductor muscle group consists of adductor longus, brevis and magnus as well as gracilis. These muscles originate from the pubic body and inferior pubic ramus and pass distally to the femur and tibia [34]. Their main action is thigh adduction with some hip flexion and are functionally important in sports where frequent changes of direction are required [29, 35]. The tendinous origins are small and are subjected to high loads during athletic activity which accounts for the prevalence of tears and chronic tenoperiosteal injury [36].
The main clinical difficulty is differentiating adductor tendinopathy from the other causes of chronic pain as it too can present with diffuse groin pain and multiple tender areas on examination [28, 29, 37]. Additionally many athletes (professional and recreational) will have chronic adductor longus tendinopathy which can be asymptomatic [29]. Therefore detecting abnormal tendon architecture on imaging does not necessarily explain the patient's current symptoms (Figure 17a).
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Figure 17. Abnormal adductor tendon architecture in asymptomatic and symptomatic patients. (a) Professional footballer with left hip pain. Longitudinal ultrasound of the asymptomatic proximal right adductor longus (AL) (performed during assessment of the symptomatic left groin) shows the proximal tendon (arrowheads) and the pubis (small arrows). Note the tendon does not have a structured, homogeneous internal appearance consistent with chronic tendinopathy but does have a smooth defined contour. (b) Professional footballer with acute on chronic right groin pain. Longitudinal ultrasound (dual screen to extend field of view) shows marked distortion of the right adductor longus tendon which is swollen and hypoechoic (arrowheads) adjacent to the symphysis pubis (SP). The adductor longus muscle (AL) appears normal.
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Ultrasound examination can evaluate the tendons looking for any specific area of focal tenderness that reproduces the patients' symptoms and evidence of superimposed acute changes within the tendon including haematoma or oedema (Figure 17b) [38]. In our institution we believe gadolinium enhanced MRI is more sensitive in detecting acute on chronic adductor enthesis changes important in athletes [39] (Figure 18). Controlled rehabilitation can successfully treat this condition but surgery involving tenotomy has been advocated in resistant cases [40].
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Figure 18. Professional soccer player with chronic left-sided adductor pain. Axial T1 weighted fat saturated post-gadolinium image of the inferior symphysis pubis shows marked enhancement of the left adductor longus enthesis and adjacent myotendon (arrowheads). There is also some enhancement of the anterior subchondral bone (small arrow). Minor changes are present on the right.
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Osteitis pubis
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The symphysis pubis is a fibrocartilaginous joint of the anterior pelvis and is also the confluence for the adductors, rectus abdominis and the medial aspect of the inguinal ligament [34]. Osteitis pubis is probably a biomechanical inflammatory arthropathy across the symphysis pubis produced by an imbalance in strengths of the pelvic and abdominal muscles [32]. Again there is controversy over definition of this condition and whether this is a single entity or due to a spectrum of the processes described above. Radiographs and scintigraphy may show sclerosis and increased activity but these are non-specific features and can be seen in asymptomatic athletes.
MRI is the technique of choice in osteitis pubis demonstrating generalized and often, symmetrical symphyseal bone marrow oedema which classically extends into the soft tissues with intact adjacent muscle and tendons (Figure 19). Although oedema can be seen in asymptomatic athletes more marked changes appear to correlate with symptoms [39, 41].
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Figure 19. Professional soccer player with a clinical diagnosis of osteitis pubis. Coronal short tau inversion recovery (STIR) MR image shows diffuse symmetrical oedema throughout the pubic bodies and distal rami (large arrowheads) as well as within the adjacent soft tissues (small arrowheads). There is also fluid within the symphysis pubis (arrow).
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Active rehabilitation used in the treatment of osteitis pubis includes a reduction in the athlete's activity level, an emphasis on strengthening the surrounding muscles and the use of non-steroidal anti-inflammatory drugs. However complete recovery can take over 6 months and an earlier return to full activity has been anecdotally reported following intra-articular corticosteroid injection [42].
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Conclusion
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The diagnosis of pelvic injuries in athletes can be difficult owing to the degree of overlap of symptoms between different injuries. Early diagnosis and injury grading is important for athletes so that appropriate treatment can be commenced to prevent the development of chronic pain or other complications. MRI and ultrasound are accurate for grading most soft tissue injuries while bone injury (the most common being stress reaction and avulsion injury) can be assessed with MRI and conventional radiographs. Chronic groin pain is a controversial clinical area and is especially difficult to diagnose and manage. In these cases we use a combination of ultrasound and MRI to try and define the origin of pain, as conventional radiographs and scintigraphy are relatively non-specific.
Received for publication April 27, 2004.
Revision received September 14, 2004.
Accepted for publication November 25, 2004.
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I. M. Omar, A. C. Zoga, E. C. Kavanagh, G. Koulouris, D. Bergin, A. G Gopez, W. B. Morrison, and W. C. Meyers
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RadioGraphics,
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Introduction
Stress reaction
