Proximal Adductor Injury

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The imaging finding of myotendinous strain of the adductor muscle have characteristics similar to muscle injury elsewhere in the body (Fig. 14B). Adductor strains have been listed as one of the most commonly injured groups of muscles

[12,18]. In a nonconsecutive series of adductor muscle injuries (13) all involved the adductor longus [12]. The adductor longus seems to be the most commonly injured muscle but other adductors such as adductor brevis, pectineus, and gracilis may be injured [56-58].

Routine myotendinous muscle strains of adductor complex should be differentiated from acute or chronic bone-tendon interface injuries (ie, insertional avulsion) or tenoperiosteal injuries (Figs. 15, 16). These latter type injuries are probably sources of chronic pain that do not resolve and more likely associated with chronic groin pain or athletic pubalgia [16].

Acute insertional tears are infrequently reported in the literature but are probably more common. These injuries have been surgically repaired in professional footballers (two cases) with full return to play and no manual loss of strength. Repair was the chosen method as adductor tenotomy has shown to result in loss of muscle strength and decreased activity [59,60]. Clinically, many others treat these injuries conservatively and some partial entheseal tears are lysed to alleviate symptoms.

MR has been used to identify adductor-related groin pain manifesting primarily as increased T2 signal near the pubic insertion [61]. In a study of 52 athletes with chronic groin pain abnormal increased postcontrast enhancement was seen with MR, and there was significant correlation with athlete's side of symptoms [16]. The authors felt this finding was related to enhancing active tenoperiosteal granulation tissue related to chronic injury and partial healing. Anecdotally we have noticed that minor gray signal changes on unenhanced short echo time sequences representing disorganized collagen of the adductor insertion may predispose to subsequent injury as well. Other authors have described a parasymphyseal cleft sign seen on conventional MRI (and confirmed with fluoroscopic guided symphyseal cleft injection), which correlated well with athletes' symptomatic side. This finding had high sensitivity and specificity and appears to be related to adductor insertional partial tears [62].

Fig. 15. Partial insertional or entheseal tear of the adductor longus on the left (white arrow) on fluid-sensitive axial images. Note the loss of cross-sectional volume of the tendon insertion and subjacent bone marrow edema. For anatomic purposes, p = pectineus and oe = obturator externus. Black arrow shows normal insertion on the right.

Obturator Externus Tear Mri

Fig. 16. Coronal IR image showing complete acute avulsion of the left adductor longus insertion on the pubic symphysis in a professional football defensive lineman (A). Football linebacker with chronic injury of the right adductor tendon that has healed but develops intermittent pain. Note irregularity and enlargement of the tendon without surrounding edema (arrow) as compared with the opposite side (B).

Fig. 16. Coronal IR image showing complete acute avulsion of the left adductor longus insertion on the pubic symphysis in a professional football defensive lineman (A). Football linebacker with chronic injury of the right adductor tendon that has healed but develops intermittent pain. Note irregularity and enlargement of the tendon without surrounding edema (arrow) as compared with the opposite side (B).

Ultrasound has also been used to assess tendon insertional abnormalities of the groin [63]. In a recent review article by a group of musculoskeletal radiologists with significant ultrasound experience, they anecdotally favored MRI in this region because of the difficulty in differentiating the tendons at their origin

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