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Sports Hernia and MRI: How does the "Gold Standard"? correlate?
John Bonadies*1, Daryle J. Lamonica2, Evan Fear3
1PACT, Hartford Healthcare, North Haven, CT; 2Quinnipiac Medical School, Hamden, CT; 3Biochemistry, Northeastern University, Boston, MA

Objective: MRI is widely thought to be the diagnostic modality of choice in patients presenting with injuries suspicious for sports hernias. Our most recent study found that only 53% of patients with clinically diagnosed hernias had positive MRI. The goal of this study is to determine if the MRI result correlates with the treatment outcome and what other factors might impact the outcome of the MRI, such as time interval from injury and mechanism of injury (MOI).
Design: Retrospective cohort analysis.

Setting: Single general surgeon private practice.

Patients: Patients presenting with a chief complaint of "groin pain" between 12/3/2013 and 3/16/2021 were selected for review. Inclusion criteria was physical exam suspicious for sports hernia, negative for inguinal hernia, and 1+ follow-up visit. 741 patient records were reviewed, 230 met the inclusion criteria. The majority of patients were male (86%) and non-athletes (68%). The mean age was 43 years.

Interventions: Physical exams included straight leg raise, sit up test, and adductor and hip flexor findings. 93% of the cohort underwent non-contrast pelvic MRI. +MRI was defined as any of the following: osteitis pubis, cleft sign, parasymphyseal or pubic bone edema, rectus/adductor aponeurotic tear. Subsequent treatments included minimally invasive mesh repairs, open Munich repairs, adductor longus surgical lengthening/tendon release and injection therapy.
Main Outcome Measures: MRI results compared across the following: age, gender, MOI, sports hernia type, time interval from injury, and final treatment outcome.

Results: 53% of the cohort had +MRI. Of the 3 types of sports hernia, 60% of posterior wall dominant, 50% of adductor dominant and 46% of combined type had +MRI (p =.13). The odds of obtaining a positive MRI decreased exponentially from time of injury (1 month -1.5%, 1 year -17% [OR 1.15]). Regarding MOI, 77% of sports related injuries had +MRI while all other mechanisms averaged 46% (p = .011). Demographically, 74% of athletes had +MRI while only 43% of non-athletes had +MRI (p = <.001).
Conclusions: These results reflect our bias that sports hernia remains a clinical diagnosis. While roughly half of our cohort had +MRI, 97% of the patients benefited from treatment, 84% which was surgical. Had treatment decisions been solely based on MRI results, 47% of patients would have been denied beneficial treatment. Timing of imaging following injury seems to be critical with MRIs obtained >1 year being statistically less accurate. Injuries incurred by athletes participating in sports showed the highest positivity rates on MRI. This could be a function of earlier imaging.

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