I took this off of the new ANSM curriculum, and I would encourage everybody to take a look at that, as I think it's exceptionally helpful in terms of describing protocols that one should think about when evaluating these anatomic regions. But one point to note here is that this is not at all meant to be comprehensive, nor prescriptive for clinical practice, it's more of a guideline, which then you should tailor, we all should tailor to our specific patient and the specific clinical question. And so for me, when I have an anteromedial hip patient, I tend to focus on these highlighted structures every single time. As part of my basic scan, this also again satisfies the requirement for a complete sonographic evaluation, and then these other structures that are not highlighted, you know, I'll add these in as I find indicated. So just a couple points about anatomy and definitions here, I think this is exceptionally important. You know, a lot of folks, you know, myself included, before I really had a great understanding of what the heck I was talking about, you know, we throw around athletic pubalgia, sports hernia, core muscle injury, osteitis pubis, and I think for the most part, everybody is referencing an aponeurotic injury, but I think it's important to understand the anatomy and understand that these are not really all the exact same thing. And there are some nuances and involvement of different anatomic structures. And so I just wanted to briefly touch on this. So this top left picture, I really like this picture, I think it's really helpful for me anatomically to understand the complex interrelated anatomy in this region. And so, you know, when we talk about athletic pubalgia or rectus adductor aponeurosis injury, it's this structure that we're talking about right here that courses over the pubic tubercle. So it's the confluence of the proximal adductor longus and the distal rectus abdominis tendon. And again, they kind of form together to form this aponeurosis right in this region. And this little kind of clock picture up here helps me orient myself with the far three o'clock, if we're talking about the right side here, the three o'clock position correlating to the pubic symphysis, and then the surrounding structures, as described up in this kind of like I said, top clock looking picture. Just a bit superior or cephalad and lateral, that's where you're going to find your superficial inguinal ring, your conjoint tendon, and so on and so forth. So I can certainly send this article to folks if you're interested, this is a great reference for the anatomy in this region. If you look over here on the right side of the screen at this right picture here, now we're looking at the anatomy of the inguinal canal. Just briefly speaking, the inguinal canal for the most part is formed by four walls. The anterior wall tends to be described as being comprised of the aponeurosis of the external oblique and the superficial inguinal ring. The superficial wall or the roof is really a combination of the aponeurosis from the internal and external obliques as well as the transversalis fascia. The posterior wall is formed by the transversalis fascia and the deep inguinal ring and then the inferior wall, the floor is primarily composed of the inguinal ligament. And so there are two types of inguinal hernias that we talk about, direct and indirect, which are really defined as a relationship to the inferior epigastric vessels. That's what I'll look for if I'm doing an inguinal hernia scan. Direct inguinal hernias occur medial to these vessels where abdominal contents essentially herniate through a weak spot in the fascia of the posterior wall, whereas an indirect hernia occurs when these abdominal contents course and protrude directly to the deep inguinal ring, which is lateral to these vessels. I bring this up to contrast this to what's described as a sports hernia for the most part or posterior wall insufficiency. So that essentially is weakness of the posterior wall through which abdominal contents may bulge into the canal, but there's no actual wall defect. So the abdominal contents don't completely enter the canal. So it's more of a pseudo hernia, excuse me, and not a true hernia. So a sports hernia or a posterior wall insufficiency really isn't a true hernia. And then lastly, a femoral hernia, you know, all of this, again, is in relatively close proximity here, but a femoral hernia occurs below the inguinal ligament where contents will enter the femoral canal here. So again, just a couple of points of anatomic definition here, which I think are important. And all this to say that when I describe these injuries, for the most part, I try and get away from these buzzwords, you know, such as sports hernia and the title of my talk and all that, and really describe the structures that are involved in the pathology I'm seeing. All right, so we'll rock and roll with this patient here. So all of these slides are going to have my sonographic images on, for the most part, on the left here with the bony pelvis top right, and then the transducer orientation to help show folks how we're doing the scan here. So in this patient, we're looking at his anterior hip joint, we've got nice rounded femoral head as seen here, capsule coursing over the top here, and we're getting a peek at the anterior labrum over here. So all of this looks pretty stone cold normal, no effusion, no synovitis, none of that. As I slide a bit medial here, you've got a bit of a better picture of the anterior labrum here, which in this kiddo was normal. So my report, and what we'll do is go through my wording of the report for each structure as we go through it. So at this point, I would say the anterior hip joint's normal without effusion or synovitis, the capsule is normal, the anterior labrum is normal without large peripheral tear. For me, next I'll move to the iliopsoas. We're already in the general region here, so I'll just slide just a bit cephalad or superior and medial to get this nice image of the iliopsoas tendon. So I like to look at this as it sits right here on the acetabulum, you've got nice bony cortex of the acetabulum with the, like I said, tendon in short axis over top. I will then flip my transducer more into this anatomic sagittal plane to look at a long axis view of the iliopsoas tendon as it's coursing over the hip joint. I will follow this all the way down as it enters some of the lesser, but for the most part, I tend to see a lot of pathology over the hip joint here. And then almost always, but not always, I'll do a dynamic evaluation to look for dyskinetic snapping of this tendon, I didn't include the video, but in this patient, that was not present. All right, so iliopsoas, tendon's normal without tendinosis or tear, no bursal fluid, and again, no dyskinetic motion. So from here, I will slide my transducer a bit more cephalad and lateral and begin my evaluation of the rectus femoris. So here we've got rectus femoris at the A-I-I-S, short axis here, normal looking tendon without tendinosis or tear. I'll then flip the transducer, and now I'm looking at the tendon in long axis here, so proximal left, distal to the right, here's the A-I-I-S, and you can see this nice hyperechoic fibular appearance of the direct head of the rectus femoris, and you can appreciate this hypoechoic shadow that's coursing downward in this image, but actually tends to be medial. This is the indirect head of the rectus tendon, this is not the transducer position to evaluate this, but just know that this shadow is not pathology within the direct head, this is actually the indirect head, which I will show you in a second. After this, after I evaluated the indirect head, if it was clinically relevant at that point or at this point is when I would move up to the A-S-I-S to evaluate sartorius TFL, lateral frontotaneous nerve, so on and so forth, but for this patient, it was not clinically relevant, so I did not do it. All right, so the indirect head can be challenging at first, figuring out the orientation of this tendon, and basic anatomy, the tendon essentially takes a rather oblique angle to course medially and insert on the superior S-tabular ridge here, and so this is the transducer orientation for a long axis view, which is essentially of an indirect head, which is essentially a short axis view for the most part of the direct head, and you can see here on this image, this nice, again, linear fibular hypoechoic structure coursing onto the superior S-tabular ridge here, and just quickly, this video I like to show folks as I'm sliding cephalad and caudal in a short axis plane of the direct head, you can see this hypoechoic shadow right here coursing downward on the screen, so that's the indirect head as I described previously, so in this patient, both the direct and indirect heads are normal without any tendinosis, and the proximal rectus femoris myotendinous junction was normal as well. After that, I come all the way down to the medial thigh, and this is where I start my adductor musculature scan, and you can see in this patient, so in a short axis, you have this nice stacking of all three adductor muscles, and again, transducer orientation, I start decently far down in the thigh here, but you see nice typical appearance of the longus brevis and magnus muscles here in short axis, and then flipping over into a long axis view, again, you got that nice stacked appearance of longus brevis, and then the very large magnus muscle deep to it, so at this point, my muscle evaluation is done, and I can say that the adductor longus brevis and magnus muscles are normal without fibrodisruption or muscle edema. I then move, I just learned how to do these little slidey things with the transducer picture up here, so I'm very proud of this. So next, I'll move to the proximal adductor longus tendon, and this can be a bit more challenging than I think people realize to really obtain a good image of this. When I'm evaluating the adductor tendon, the proximal adductor tendon, this is what I like to have in view, so I've got proximal left distal to the right, I've got this structure here is adductor longus muscle, you can see this nice fibrillar linear appearance of the adductor longus tendon as it courses just superficial in the region of this myotendinous junction here. This is actually a bit of a tendinopathic tendon, but regardless, these are the structures that I want to see when I'm evaluating this. Here's pubic tubercle, the rectus adductor aponeurosis sits on top, and you've got rectus muscle over to the left. You know, I bring this up for a reason, which I'll show in a minute. But this is what you want to see when you're scanning the proximal adductor. And this is what you don't want to see. So in this patient, so again, here's that linear fibrillar pattern of the adductor longus tendon coursing over the top here, this is again, the proximal adductor longus muscle belly, so myotendinous region here. And you can already see kind of in this region here, and maybe this is a better picture down here, but very hypoechoic heterogeneous, you completely lose that nice fibrillar architecture. And again, it becomes rather hypoechoic. So you see, you know, rather significant tendinosis in the region of the proximal adductor. Additionally, we talked about the aponeurosis, and it's critical to identify an aponeurosis injury versus purely a proximal adductor tendon injury, because they're very different animals with very different treatments, and very different prognoses. And so I will scrutinize this area and prove to myself that I don't see any sort of pathology in the aponeurosis because again, that changes management. But unfortunately, here in this athlete, again, all this adductor stuff going on here, and you can see this hypoechoic cleft that does propagate into the adductor aponeurosis, adductor rectus aponeurosis. So this will be consistent with with an aponeurotic tear here. And unfortunately, in this patient, so here's the rectus abdominis over here, proximally did not extend into the rectus. But it stayed within the aponeurosis. And this patient didn't add the images did have nice MRI correlative pictures. The last thing to mention in this view is here's a pubic tubercle. So significant cortical regularity, and everybody on here knows that that's one of the secondary signs of tendinosis with any tendon that we talk about. So all of these things, you know, kind of clue you in and there's, you know, some significant pathology in this region. So my report at this point says the adductor longus is significantly thickened hypoechoic, and heterogeneous, there's partial thickness tearing deep 25%, which extends into the aponeurosis, but does not extend in the rectus muscle. I'll comment on the cortical regularity of the pubic tubercle. And as with anything, I am a big proponent of sonopalpatory pain. And if I see pathology, I'll apply sonopalpation to see if it reproduces symptoms. And I'll always comment on that, because I think that's incredibly important. Just quickly here, so I struggled with this early on the transducer orientation to optimize your adductor longus. And I think a lot of us when we're starting, we think that the adductor tendon is in this, you know, rather oblique appearance here, excuse me, oblique orientation here. But in fact, it's actually more in a in a almost near vertical anatomic sagittal plane here. And so this is that picture that I mentioned previously, excuse the tendinopathy here. But you see this nice linear tendon over top with a bit of muscle deep to it. If you start seeing too much muscle, that means you're getting into the adductor brevis muscle, which is going to sit a bit more lateral here. And you don't see that nice tendon coursing superficially. So you're a bit oblique here, it's not an optimal picture to really scrutinize the tendon. So this is the view that you want to get here. So just a quick aside to make. Alright, moving on after I do my aponeurosis scan, I will come up into the rectus abdominis muscle. This is obviously a very thin, lean fit athlete with minimal subcutaneous tissue. So this is a nice appearance of the rectus abdominis muscle, which in this patient is stone cold normal. Lastly, from the rectus, I will move on to the pubic symphysis. And so in this athlete, you know what, what really is highlighted here. So here's his left symptomatic side. And this essentially looks like the Rocky Mountains, right? So there's all this cortical regularity at the left pubic tubercle, which is consistent with what I showed previously with the proximal adductor tendinosis, excuse me. Interestingly, and just a quick note here, so his right side doesn't look fantastic either. And in fact, we saw this kiddo think a couple weeks afterwards for right sided pain. And, and he in fact, had pretty significant right proximal adductor tendinosis, but fortunately did not have any evidence of aponeurosis um, injury on, on that side. So, so please don't use this right side as a correlative normal example is not, is there a significant cortical regularity here? And then again, I'll comment on the cortical regularities of the pubic symphysis with involvement of the left greater than right pubic tubercle. There's no Doppler within the synthesis. And then I did my best to only sonopalpate the pubic symphysis and trying to avoid either pubic tubercle here. And there was no reproduction of, of pain with sonopalpation directly over the pubic symphysis, which again, I think is helpful at least for myself when I'm reviewing my reports after the fact, as well as other physicians to, to that send me diagnostic scans to let them know that just because there's pathology, maybe the patient isn't all that symptomatic.

2nd Edition, CASE 53

2nd Edition

Thigh

ANSM curriculum

anteromedial hip

athletic pubalgia

sonographic evaluation

clinical assessment