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CASE REPORT
Year : 2013  |  Volume : 13  |  Issue : 1  |  Page : 42-44

Thigh splints presenting as groin pain: A case with whole body bone scan findings


Department of Nuclear Medicine, Saral Diagnositics, E-1073, Saraswati Vihar, Pitampura, Delhi, India

Date of Web Publication28-May-2013

Correspondence Address:
Madhuri Shimpi Mahajan
Consultant, Department of Nuclear Medicine, Saral Diagnositics, E-1073, Saraswati Vihar, Pitampura, Delhi - 110 034
India
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DOI: 10.4103/1319-6308.112227

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  Abstract 

A thigh splint (adductor insertion avulsion syndrome) is a relatively uncommon diagnosis analogous to shin splints. This article reports a case of 19-year-old female NOT a regular athlete who presented with groin pain. Physical examination was nonspecific, MRI pelvis did not reveal any abnormality. Patient referred for whole body bone scan, especially to locate any abnormality in the spine. This study highlights the role of whole body bone scan in the evaluation of groin pain and importance of evaluation of whole lower extremity.

Keywords: Bone scan, groin pain, thigh splints


How to cite this article:
Mahajan MS, Digamber NS, Sharma R. Thigh splints presenting as groin pain: A case with whole body bone scan findings. Saudi J Sports Med 2013;13:42-4

How to cite this URL:
Mahajan MS, Digamber NS, Sharma R. Thigh splints presenting as groin pain: A case with whole body bone scan findings. Saudi J Sports Med [serial online] 2013 [cited 2022 Jan 24];13:42-4. Available from: https://www.sjosm.org/text.asp?2013/13/1/42/112227


  Introduction Top


Groin pain usually presents due to a condition of the genitals or reproductive organs. Pain can also radiate into the groin from a condition of the hip, lower spine, pelvis, kidney, bladder, or colon. Another cause of groin pain is a groin pull; a strain on the inner thigh muscles often occurs due to an activities that involves running, skating, jumping or swimming.

Acute sport injuries are often easily recognized as there is a sudden onset of symptoms following a traumatic event, such as a direct force applied to the bones or joints. However, acute soft-tissue injuries, tendon ruptures or ligamentous injury, are not so familiar and may therefore be more difficult to diagnose. In athletic individuals, the lower extremity is often the site of musculoskeletal trauma. Commonly seen conditions include enthesopathies, stress fractures, shin splints, plantar fasciitis and rarely thigh splints. [1] Physicians usually concentrate more on imaging of spine, pelvis or tibia region. Here we are emphasizing the role of whole body bone scan in the evaluation of groin pain.


  Case Report Top


A 19 year old, averagely built female presented with groin pain since last 15-20 days. On enquiry patient gave history of playing foot ball for a week one month ago. MRI of the pelvis was within normal limits. Roentgenograms of the tibia and femurs were normal. Local examination was negative for tenderness, redness and swelling. Patient referred for whole body bone scan, especially to locate any abnormality in the spine.

The whole body bone scan was performed using a large field-of-view gamma camera and a parallel hole low energy high-resolution collimator, 3 hour following iv injection of 20 mCi technetium-99m methylene diphosphonate. The scans routinely included whole body sweep along with anterior-posterior spot images of the pelvis and lower extremities. For each view 500 K counts were collected.

The scinitigraphic findings showed low to moderate grade linear tracer uptake along anteromedial and, to a lesser degree along lateral aspect of the proximal to mid shaft of both femurs [Figure 1] and [Figure 2], which correspond to the insertion of adductor muscle groups. In addition to that, foci of abnormal tracer uptake seen in the distal diaphysis of left ulna [Figure 1] and right tibia [Figure 3]. SPECT of spine and pelvis did not show any abnormality in the lumbar vertebrae, pelvic bones and hip joints. Thus overall scan findings were suggestive of bilateral thigh splints with stress fractures in the left ulna and right tibia, which were subsequently confirmed on radiological imaging [Figure 4].
Figure 1: Whole body Tc-99m-MDP Bone scan images: showing linear increased tracer uptake along the corticies of both femurs and focal increased tracer uptake in the distal shaft of left ulna and right tibia

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Figure 2: Static images of the femurs showing linear increased tracer uptake along the corticies of both femurs consistent with thigh splints

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Figure 3: Static images of the tibias showing increased tracer uptake in the distal shaft of right tibia consistent with stress fracture

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Figure 4: Coronal turbo spin-echo inversion recovery image reveals high signal intensity along periosteum of proximal to mid femur

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  Discussion Top


In general osseous fatigue-related injuries are relatively common and are thought to result from abnormal stresses to bone, repetitive axial loading, abnormal biomechanics or excessive muscular forces. Initially, such injuries consist of areas of asymptomatic stress reaction, which may eventually become symptomatic; shins splints are a classic example. Stress fractures involving the posteromedial aspect of the femoral diaphysis are less common

than tibial and proximal femoral stress fractures and are thought to be on the continuum of osseous fatigue-/stress-related injuries. Another specific, albeit much less common, type of osseous fatigue injury is the adductor insertion avulsion syndrome, also known as "thigh splints." The syndrome was felt to be related to an overly long marching step in a short-statured individual. It occurs when there are repetitive anteromedially directed vector pull upon the linea aspera. A lengthened stride would cause excessive adductor contraction and tend to strip the femoral periosteum in the vector plane. [2]

Thigh splints, is a rare cause of groin pain. Patients may also have a palpable mass due to periostitis, ossification of the injured muscle, or both, often confusing the clinical picture. The osseous changes from traction injury on the adductor magnus can be considerable, especially in children in whom florid periostitis can occur, occasionally appearing as an aggressive growth, and should not be mistaken for a neoplasm. [3] Occasionally serial imaging follow-up is needed to exclude other diagnoses such as infection, [4] femoral stress fracture or articular hip disease.

Early in the course of the adductor insertion avulsion syndrome, radiographs may appear normal or may show subtle periosteal reaction in the characteristic location on the medial margin of the proximal-to-mid portion of the femoral diaphysis. Bone scintigraphy may show corresponding areas of linear abnormal radiotracer uptake and no evidence of stress fracture. In 1981, Ozburn and Nichols [5] found that bone scans to be the most sensitive and effective diagnostic aids in differentiating the adductor syndrome from stress fracture, but no scans were published. Hyperperfusion and hyperemia are typically present in acute stress fracture whereas angiograms and blood pool images are usually normal in periostitis (thigh and shin splints). The differentiation of stress fracture from periostitis is important because their treatments are very different. At early stage of thigh splints, MR may show periosteal fluid/edema as the only abnormality. In others more severe and/or more advanced cases, additional MR signal abnormalities in the underlying medullary cavity and cortex may be seen, indicating the presence of a more severe stress reaction and a frank stress fracture, respectively. In contradiction to the stress fractures that occur in other locations, these femoral shaft stress fractures are often oblique and may therefore appear subtle or even occult radiologically.

Treatment of adductor insertion avulsion syndrome is one of planned and gradually increased physical therapy and anti-inflammatory medication, with surgery (tenotomy) reserved only for failures of conservative therapy. [6],[7] If the patient's clinical symptoms persist, short term imaging follow-up is advised to assess for the interval development of a radiologically evident fracture line. If conservative measures fail and the abnormal imaging findings persist, other entities on the short list of differential diagnostic possibilities could be entertained and assessed for via biopsy.

In conclusion, doctors should carefully evaluate the patients of groin pain before advising any imaging modality. Whole body bone scan is relatively low-cost imaging modality that can be used not only to evaluate the presence of thigh splints but also to visualize the stress fractures elsewhere in the skeleton and to see any active osseous pathology of hip joints. Thus its exquisite sensitivity makes it a useful screening procedure. Moreover, some conditions that are not evident on anatomic images can be diagnosed with radionuclide bone imaging. The adductor insertion avulsion syndrome is thought to represent the early stage of an evolving osseous stress reaction on the continuum to frank stress fracture; therefore, the importance of early detection is emphasized.


  Acknowledgment Top


I would like to thank Dr. Ravi Gupta, CEO, Saral diagnostics, Delhi, India and Dr. Chandrashekhar Debnath, anesthetist, Saral diagnostics, Delhi, India for their continuous encouragement.

 
  References Top

1.Murray IP. Bone scintigraphy in trauma. In: Murray IP, Ell PJ, editors. Nuclear medicine in clinical diagnosis and treatment. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 1998. p. 1241-67.  Back to cited text no. 1
    
2.Charkes ND, Bone Scanning in the Adductor Insertion Avulsion Syndrome (Thigh Shplints). J Nucl Med 1987;28:1835-8.  Back to cited text no. 2
    
3.Anderson SE, Johnston JO, O'Donnell R, Steinbach LS. MR imaging of sports-related pseudotumor in children: Mid femoral diaphyseal periostitis at insertion site of adductor musculature. AJR Am J Roentgenol 2001;176:1227-31.  Back to cited text no. 3
    
4.Tshering-Vogel D, Waldherr C, Schindera ST, Steinbach LS, Stauffer E, Anderson SE. Adductor insertion avulsion syndrome, "thigh splints": Relevance of radiologic follow up. Skeletal Radiol 2005;34:355-8.  Back to cited text no. 4
    
5.Ozburn MS. Hichols DW. Pubicramusand adductor insertion stress fractures in female basic trainees. Milit Med 1981;146:332-3.  Back to cited text no. 5
    
6.Karlsson J, Sward L, Kalebo P, Thomee R. Chronic groin injuries in athletes: Recommendations for treatment and rehabilitation. Sports Med 1994;17:141-8.  Back to cited text no. 6
    
7.Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med 1992;20:640-3.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Acknowledgment
References
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