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learning courses across all key radiology subspecialties. Learn more at

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MRI mrionline.com. Today we're honored to welcome Dr. Mini Pathria for a

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lecture on MRI imaging of pelvic tendons, Dr. Pathria completed her medical

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training in Hamilton in Montreal, Canada, an MSK fellowship at UCSD.

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She is currently a professor of radiology and the division chief of MSK

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imaging, where she specializes in trauma and MRM imaging. At the end of

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the lecture. Please join us in the Q&A session where she will address

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questions you may have on today's topic. Please use the Q&A chat feature

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to submit your question and we will get to as many as we

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can before our time is up. With that being said, we welcome you,

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Dr. Pathria please take it from here. Thank you so much and thank

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you for this very kind invitation. I'll start my screen sharing.

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It's nice to see some familiar names in the participants, especially some

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of our old fellows from UC San Diego.

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I am going to be discussing the topic today of pelvic tendons.

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I want to make sure you can see my screen. Can somebody respond

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yes. Yes, we can. Okay, good. Thank you. So, the reason I picked

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this topic is it's something that I always found very challenging when I

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started reading MRI just because of the daunting anatomy, and the number

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of tendons in this location. The pelvis serves as the origin and insertion

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of numerous very powerful tendons. And what I've learned over the years

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is that using a systematic approach dividing these into five groups according

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to their function lets me get through the interpretation of these tendons

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fairly efficiently. So I want to go through that with you.

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And the five basic functions that we have to deal with with the

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pelvic tendons are listed on this slide. You can see the corresponding positions

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in the graphics above. And I'm going to go through these five different

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functional groups with you today. So the basic approach that I have to

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these is to start on the axial images and work through the superficial

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groups first. These include the adductors anteriorly, flexors in front of

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the hip, abductors over the greater over the greater trochanter at the lateral

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side, and the extensors posteriorly. Those are the superficial groups, and

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then I finish up by looking at the deep group of the external

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rotators and I do that right after the extensors, because pathology in those

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two groups commonly coexist. I've highlighted the tendons color, coded them

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a little bit here, just to show you that approach and that's the

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way that we're going to go through the tendons today. And we will start

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at the area of the adductors. There are several adductor tendons that lie

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in a semicircle at the pubic ramus and body adjacent to the symphysis. Of

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these the most important is going to be the adductor longus which inserts

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on this prominent tubercle at the anterior pubic symphysis. It is very far

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anterior so when you're looking at this on your coronal images you want

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to be sure you are way out in the front, where you see

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an appearance that's been likened to a mustache. And as we go further

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posteriorly we're going to be seeing the tendons of the brevis gracilis,

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and ultimately the adductor magnus. On the sagittal images here, you can

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see that the adductor longus is located anteriorly, and has a common aponeurosis

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with the rectus abdominis which we'll come back to a little bit later

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with the other adductors located more posteriorly. Now we do see acute injuries

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in the adductors though these are relatively uncommon,

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and they're often related to a sporting injury in middle aged athletes.

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Often with a little bit of underlying tendinosis or chronic problem in the

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tendon. These are easy to recognize and using that anatomic approach that

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I showed you earlier from front to back. It's quite easy to sort

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out which tendons are affected in these acute injuries. Here's just another

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example, showing an adductor longus avulsion. Just to point out again that

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these tendon avulsions are going to be far anterior, you may just appreciate

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the muscle strain when you first look at the patient's MR,

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you need to work yourself way out to the front in order to

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be able to see the retracted tendon. So while these are easy they're less

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common than the more than the insidious subacute injuries we see at the

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adductor insertion. And these go by a variety of names, the subacute complex

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of chronic groin pain has been referred to as a sportsman's hernia.

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Commonly in the US it's referred to as athletic pubalgia. And over the

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past several years there's been a shift towards calling this a core muscle

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injury in recognition of the importance of the abdominal musculature in

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creating the damage in this area. And there are a number of different

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sports associated with it. These are often cutting sports where there's

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twisting between the torso and the leg. So particularly in soccer and hockey

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and football, we're going to see these kinds of injuries. I really like

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this approach by Folman, where he's described the appearance of the

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pathology in terms of the pubic clock. So the center of the clock

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is that adductor tubercle that I already mentioned to you, and then we

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could use a clock face to divide the pathologies as to whether they

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involve the joint which means they are centrally located, whether they involve

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the tendons where they are inferiorly located involve the inguinal ligament

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which my experience is rare, which is the lateral group of the abdominal

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muscles, which is superior. I've just added to keep in mind that the

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pain may actually be referred from the hip joint, so that you want

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to always be careful that you include a large enough field of at

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least one of your sequences that you image adequately the posterior pelvis

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and the hip in patients who present with groin pain.

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Now the injuries of the pubis are often referred to as ostitis pubis. This

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is really a stress injury of the pubis created by...