Imaging of inguinal-related groin pain in athletes

Abstract

Inguinal canal-related groin pain is common in athletes and may involve numerous structures such as the conjoint tendon and the transversalis fascia. Ultrasound is the only dynamic tool that shows the passage of preperitoneal fat at the level of the Hesselbach triangle and allows excluding true inguinal hernias. Fascia transversalis bulging and inguinal ring dilatation may also be described. MRI assesses injuries of rectus abdominis and adductor longus enthesis and osteitis symphysis but its accuracy for the diagnosis of inguinal-related groin pain remains debated.

Figure 1.

Schematic drawing from an anterior view of the inguinal canal. The internal deep ring is superior, and located at the middle of the inguinal ligament. It is inferior and mediolateral to the conjoint tendon, and lateral to the inferior epigastric vessels. The external superficial ring is a triangular opening in the external oblique aponeurosis. The inferior epigastric artery (a) and vein (v) originate from the external iliac artery and vein and lie medial to the internal inguinal ring. CT, conjoint tendon; EO, external oblique muscle; EOA, external oblique aponeurosis; IL, inguinal ligament; IO, interne oblique muscle; RA, rectus abdominis; SC, spermatic cord; T, transverse muscle; TF, transversalis fascia; DR, deep ring.

Figure 2.

Schematic drawing from a posterior view of the Hesselbach triangle. Medial to this deep ring, the Hesselbach triangle is medial to the inferior epigastric vessels, lateral to the rectus abdominis muscles and cranial to the inguinal ligament. CT, conjoint tendon; TF, transversalis fascia; IL, inguinal ligament; RA, rectus abdominis; DR, deep ring; S, symphysis; SC, spermatic cord; T, transverse muscle; O, interne oblique muscle; E, external oblique muscle.

Figure 3.

Anterior laparoscopic view of the inguinal canal during Shouldice procedure shows dehiscence of the TF and protrusion of pre-peritoneal fat (star). CT, conjoint tendon; IL, inguinal ligament; SC, Spermatic cord; TF, transversalis fascia.

Figure 4.

Ultrasound of an asymptomatic male athlete. Dynamic ultrasound in the axial plane at rest (A) and at the beginning (B) and end (C) of Valsalva’s maneuvers shows the location of the Hesselbach triangle (double arrows) at the level of the LEV. Additionally, there is a slight convexity of the fascia transversalis (arrowheads) without protrusion of pre-peritoneal fat. LEV, lower epigastric vessels; RA, rectus abdominis.

Figure 5.

Ultrasound of a 27-year-old male soccer player with bilateral groin pain. Dynamic ultrasound at the level of Hesselbach’s triangle of the right deep inguinal ring in the transverse planes shows progressive bulging of the preperitoneal fat during Valsalva’s maneuvers (white arrow). V, vessels; RA, rectus abdominis.

Figure 6.

MRI of a 25-year-old male rugby player with bilateral groin pain. 3D-GE T₁ weighted sequence in the axial plane shows fat within the right spermatic cord (white star), anterior wall bulging and thickening of the right external oblique aponeurosis (black arrowhead), normal distal insertion of the CT (white arrowheads) and tear of the left external oblique (white arrow). 3D, threedimensional.

Figure 7.

MRI of a 27-year-old male soccer player with right groin pain. 3D-GE T₁ weighted sequence in the coronal plane shows thinning thickening of the inguinal ligament (arrowhead) and conjoint tendon (arrow). 3D, three-dimensional.

Figure 8.

MRI of a 23-year-old male soccer player with right groin pain. 3D-GE T₁ weighted sequence in the coronal plane shows fat within the right spermatic cord (white star), thinning and stretching of the inguinal ligament (arrowhead) and thinned conjoint tendon (white arrow).