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Gabriele Mattiussi1
Pietro Tobia Baldassi1
Giulio Pasta2
Aldo Burani3
Carlos Moreno1
1 Medical Services, Udinese Football Club, Udine, Italy
2 Imaging Services, Parma Football Club, Parma, Italy
3 Department of Radiodiagnostics, Ospedale di Sas-
suolo, Modena, Italy
Corresponding author:
Carlos Moreno
Medical Services,
Udinese Football Club
Stadio Friuli, Dacia Arena
Viale A. Candolini 2
33100 Udine, Italy
E-mail: Carlos.Moreno@udinesespa.it
Summary
Background: Muscle injuries affecting the Adduc-
tor Longus are not all localised at the level of the
proximal myotendinous junction and enthesis.
Thus, the main purpose of this article was to raise
awareness of the imaging features of the Perivas-
cular Adductor Longus muscle injury, which cur-
rently remains widely under-recognised.
Methods: The ultrasound (US) and Magnetic Res-
onance imaging (MRI) images of five professional
football players were retrospectively reassessed
to identify distinctive imaging details of the
Perivascular Adductor Longus muscle injury.
Complementary information regarding the trau-
matic mechanics is presented as well.
Results: All the players presented similar US im-
ages in the first seventy-two hours: loss of eco-
structural integrity of the lateral epimysium, in
proximity to the femoral vessels, and perilesional
oedema were the main pathological findings. The
injury lead to the formation of a hypoechoic, intra-
muscular haematoma in three of the subjects. Any-
way, this was detectable only after five days, or lat-
er. Moreover, MRI sequences showed long-stand-
ing haematoma-related signal alterations which
were also observable at three months after trauma.
Typically, kicking was the traumatic motor task.
Conclusions: The main practical value of this
technical note is to compensate for the lack of
studies concerning the Perivascular Adductor
Longus muscle injury. Promptly identifying its
typical imaging features is crucial in order to es-
tablish the correct diagnosis and to implement a
highly specific rehabilitative program.
Level of evidence: V.
KEY WORDS: magnetic resonance imaging, soft tis-
sue injuries, sports injuries, thigh, ultrasonography.
Introduction
Adductor Longus (AL) muscle injuries, caused by in-
direct trauma, predominantly involve the proximal my-
otendinous junction and enthesis1-3. These injuries
are suspected when the patients refer the acute on-
set of pain in the pubic or inguinal area, particularly
during sporting activities that involve motor tasks
such as kicking or twisting movements3-4. Hyper-
trophic scarring (fibrosis) and calcifications are the
most common complications of the healing process2,
as well as a possible cause of long-standing groin
pain1,5,6. It is worth noting that these abnormalities
occur more frequently when both the direct tendon
and/or the intramuscular tendon are directly involved,
same as for the Quadriceps and Hamstring muscles7.
However, despite the fact that researchers tend to fo-
cus on injuries of the proximal aspects, there are oth-
er muscle injury, in other sites, that may affect the
AL. Nevertheless, these injuries are still poorly and
sparsely documented in literature8-10. For this reason,
they may remain widely under-recognised and, there-
fore, inadequately treated. Further studies are need-
ed to raise awareness of the clinical and imaging fea-
tures of the Perivascular Adductor Longus muscle in-
jury.
Thus, the aims of this article were: I) to present a
case series of professional football (soccer) players
with a history of AL muscle injury that we have identi-
fied as having Perivascular Adductor Longus muscle
injury, without any concomitant lesion of the proximal
portions of the muscle and II) to define the Ultra-
sound (US) and Magnetic Resonance Imaging (MRI)
features of this peculiar muscle injury, offering practi-
cal guidance on how to effectively investigate it. The
opinion of the Authors is that the structural abnormali-
ties of the Perivascular Adductor Longus muscle in-
jury are very complicated to detect during US investi-
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
376
Perivascular Adductor Longus muscle injury:
Ultrasound and Magnetic Resonance Imaging
findings
Original article
© CIC Edizioni Internazionali
gation, as the lesion is localised very close to the
femoral vessels (posterior acoustic enhancement arti-
fact-related issue). As regards MRI, instead, the sig-
nal alterations can be visualised clearly in just a few
sections, in particular, using fat-suppressed fluid sen-
sitive techniques.
Methods
Participants
We completed a retrospective reanalysis of a series
of eleven footballers, members of the same profes-
sional club, who suffered from acute AL muscle in-
jury, caused by indirect trauma, during the three pre-
vious sporting seasons (period: July 2013-May 2016).
This was done in order to identify individuals who
were affected by isolated Perivascular Adductor
Longus muscle injury. Five of these athletes were di-
agnosed with the latter injury and thus included in this
research.
This study was conducted in accordance with the eth-
ical standards of the Muscles, Ligaments and Ten-
dons Journal11. In addition, it was designed taking in-
to consideration the guidelines for the writing of a
technical note12.
Review of the cases
The US and MRI images of the five participants were
re trospect ively rea sse ssed to identify dis tinct ive
imaging details of the Perivascular Adductor Longus
muscle injury. The latter mainly involves the lateral
peripheral aspects of the muscle, in the middle third
level of its belly, or those in direct contact with the
Vastus Medialis and femoral blood vessels -hence
the “perivascular” prefix- without any concomitant le-
sion of the proximal portions (myotendinous junction
and enthesis) of the muscle.
Complementary information regarding the injury
mechanism was noted as well. On the contrary, since
the participants of this study were professional foot-
ball players, basic anthropometric and sport-related
details have not been collected in order to ensure
maximum anonymization. The US images were cap-
tured in the club facilities, using the Logiq S7 Expert
(GE Healthcare) device, equipped with a 50 mm lin-
ear probe (6-15 MHz), by an operator with more than
ten years of experience in the US assessment of
muscle injuries in professional football players. On
the other hand, the MRI images were obtained using
the HDe 1.5T Signa device (GE Healthcare) in a pri-
vate clinic. All the US and MRI figures presented in
this article have been revised and selected by the Au-
thors for their educational value.
Ultrasound examination: anatomical considera-
tions, Push-to-View tip and guidelines
A thorough knowledge of the US-specific anatomy of
the AL is essential to properly complete the investiga-
tion. The muscle belly of the AL is easily observable
already at 1-2 cm below its insertion on the pubic tu-
bercle, where its short intramuscular tendon is also
discernible13,14. At this level, between the AL and the
adductor canal, also called Hunter’s or subsartorial
canal, the Pectineus muscle is interposed (Fig. 1)15-17.
By moving the probe distally, almost to the level of
the femoral insertion to the Pectineus, the AL comes
into direct anatomical contact with the Vastus Medi-
alis and the femoral vessels15. Considering the trans-
verse section, the neurovascular bundle is located
377
Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
Figure 1. Cross-sectional ultrasound anatomy of the Adductor Longus (AL), proximal third, in a 25-year-old male healthy vol-
unteer. The muscle is easily recognizable as its intramuscular tendon (hyperechoic structure indicated by the arrow) runs
through the muscle belly; this has a wavy shape and runs substantially in the coronal plane of AL, almost parallel to the long
axis of the muscle. At this level, the AL is still divided from the femoral vessels (asterisk) by the Pectineus muscle (PE). Vir-
tual Convex technology was used to capture this image. AB = Adductor Brevis.
© CIC Edizioni Internazionali
latero-superiorly to the muscle: usually, the lateral pe-
ripheral aspects of the AL are not simple to investi-
gate due to the posterior acoustic enhancement arti-
fact induced by the blood vessels1 8 and due to the
depth at which they are situated (Fig. 2). In addition
to this, even the deep femoral vessels and the obtu-
rator nerve cannot be seen clearly using high ultra-
sonic frequencies.
Typically, during the US examination, no pressure
must be exerted on the patient’s skin with the probe.
However, pressure can be applied to compress (or
move) a vein. When examining the AL, to better visu-
alise the lateral peripheral aspects of the muscle, it is
useful to implement the following tip which, for conve-
nience, the Authors named Push-to-View: the posteri-
or acoustic enhancement induced by the femoral vein
may be substantially reduced, occluding its blood
flow. This can be obtained by applying a moderately
high pressure with the probe. In this way, the artifact
is reduced sufficiently so as to make the epimysium
of the AL, the deep femoral vessels and the obturator
nerve ideally observable. At this point, the operator is
able to adequately observe the site where the
Perivascular Adductor Longus muscle injury is locat-
ed, or the anatomical region interposed between the
superficial and the deep femoral vessels (Fig. 3). As-
sessing also all other portions of the muscle, in par-
ticular the proximal myotendinous junctions and en-
thesis, is mandatory to rule out other injuries.
The ISMuLT guid elines for the U S ass essment o f
muscle injuries19 and those presented by other Au-
thors20-22 have been taken into high consideration
during the acquisition and the revision of the US im-
ages, in order to be consistent with the most recent
and widely used classification systems and with the
related nomenclature. All the participants of this study
were evaluated every day during the first week post
trauma and (at least) twice a week during the follow-
ing period, up to three months after the traumatic
event.
MRI investigation: routine protocol, specific re-
quirements and guidelines
MRI was considered the gold standard to confirm the
presence of muscle injuries that were clinically and
ultrasonographically suspected19, 21-24. The protocol
included traversal (axial), sagittal and coronal T1-
weighted spin-echo (T1w), fat-suppressed T2-weight-
ed spin-echo (T2w) and short tau inversion recovery
(STIR) sequences20. According to the most recent
MRI-based classification systems22,23, the presence
of isolated intramuscular oedema was indicative of a
minor lesion, while the presence of perifascial liquid
and/or intramuscular haematoma typically indicated a
more severe injury. MRI was especially useful to ac-
cur ately identify t he site of injury (myofascial, my-
otendinous junction, intratendinous or a combination
of these)20,22,23.
In order to accomplish these aims, transverse MRI
sequences were also acquired at the level of the AL
muscle belly and not “concentrated” only in the proxi-
mal third, as usually done when an Adductor Longus
muscle injury is suspected. This was essential to rule
out or confirm the presence of Perivascular Adductor
Longus muscle injury.
According with the most known and considered
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
378
G. Mattiussi et al.
Figure 2. Cross-sectional ultrasound anatomy of the Adductor Longus (AL), middle third, in a 25-year-old male healthy vol-
unteer. The muscle makes anatomical contact with the Vastus Medialis (VM), the femoral vein (v) and the femoral artery (a).
Even the saphenous nerve (s), the final branch of the femoral nerve, can be observed. The Sartorious muscle (SA) acts as
a “roof” to the neurovascular bundle. It can be seen how the lateral aspects of the AL (inside the dashed rectangle) are not
easily observable; this is because the artifact induced by the femoral vein limits their visualisation and due to the fact that
they are already at about four centimetres of depth (see parameters of the device on the right).
© CIC Edizioni Internazionali
guidelines19, 20, 22, 23, the first MRI was preferably per-
formed within 72 hours after the trauma and, typical-
ly, following ultrasound evaluation, while the following
two acquisitions were carried out at 3 weeks/1 month
and at 2/3 months post-trauma, in all the five foot-
ballers.
Results
Ultrasound
In the first seventy-two hours, the Perivascular Ad-
ductor Longus muscle injury was characterised by: I)
loss of eco-structural integrity of the AL lateral epimy-
sium, which appeared hypo-echogenic; II) intramus-
cular, perilesional oedema, corresponding to the ar-
eas of increased echogenicity within the muscle belly
and III) difficulty seeing the perilesional perimysium,
due to the intramuscular oedema. All the five players
presented comparable images in this phase (Fig. 4,
Tab. I).
The difference in the image quality captured by apply-
ing the Push-to-View tip, or not, was critical for diag-
nos is in all the cases (Fig . 5). D espi te this, those
signs were challenging to detect or of controversial
analysis and interpretation in two footballers (Fig. 6,
Tab. I). It is worth noting that, in this first phase, the
US signs were similar even among injuries that have
proven to be, afterward, of different severity.
The muscle injury led to the local formation of intra-
muscular haematoma in three of five cases (Figs. 7,
8). This was defined by the presence of hypo-
echogenic or anechoic areas within the muscle belly.
Interestingly, intramuscular haematoma was not evi-
dent before day five following the traumatic event, in
all of these three cases (Tab. I).
Magnetic resonance imaging
In the first seventy-two hours, the Perivascular Ad-
ductor Longus muscle injury was characterised by: I)
altered signal of the lateral fascial aspects of the AL;
II) altered signal of the lateral muscle fibres and III)
presence of inter-fascial liquid infiltrations, even de-
tectable distally to the lesion.
Transversal sequences acquired using fat-sup-
pressed fluid sensitive techniques were basically
used to assess the signs listed above. In T2w
transversal sequences the signal alteration, albeit
possibly moderate, mimics a pseudo-thickening of the
lateral fascial aspects, making it possible to locate
the site of injury, in two cases (Fig. 9). STIR se-
quences instead offered better visualisation of intra-
muscular oedema and perifascial fluid collection (Fig.
10), which were observable in all the cases assessed
(Tab. I). We underline the fact that these signs were
clearly observable in just a few sections. On the other
hand, signal alterations in T1w sequences were mini-
mal and offered little contribution for the diagnosis.
No haematoma was detected in the first MRI acquisi-
tions (Tab. I).
The muscle injury led to the local formation of intra-
muscular haematoma in 3 of 5 cases (Figs. 11, 12),
as well as it was observed using ultrasound (see
above). In such cases, haematoma-related signal al-
379
Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
Figure 3. The “Push-to-View” tip, performed in a 25-year-old male healthy volunteer. The ultrasonographer applies pressure
to the muscle belly of the Sartorius (SA), using the probe; note the evident flattening of the muscle belly onto the femoral
artery (a). In doing so, the blood flow of the femoral vein (asterisk) is almost interrupted, as well as the resulting posterior
acoustic enhancement artifact. As a result, the epimysium and perimysium in the lateral portions of the Adductor Longus
(AL) become easily observable. In addition to this, thanks to the compression of tissues, even the deep femoral vessels
(small circles) and the obturator nerve (large circle) are visible deeper. Therefore, the “perivascular” portion of the AL is now
completely observable.
© CIC Edizioni Internazionali
terations were also visible in T1w sequences (Fig.
13). Interestingly, comparable findings were observed
between the MRI performed at 3 weeks/1 month and
at 2/3 months post trauma. For this reason, long-
standing oedema and haematoma have been consid-
ered the main long-term complications. In the
perivascular Adductor Longus muscle injury, being
classified as isolated “myofascial”, there were no in-
volvement of tendon structures, for which the forma-
tion of extensive fibrotic areas or perilesional calcifi-
cations did not occur in any of the cases.
Injury mechanism
Relevant information concerning the primary traumat-
ic event is reported in Table II. Four footballers in-
jured during an official or a friendly match. Three
players experienced sudden and stabbing pain in
their medial thigh region, which forced them to imme-
diately suspend the sporting activity.
Three footballers reported that kicking was the trau-
matic gesture, while the other two players felt in-
creasing soreness in the adductor region, without be-
ing able to identify the precise motor task that led to
the injury. These two did not suspend the sporting ac-
tivities due to the thigh pain; anyway, they sought
medical attention and the first screening tests surpris-
ingly revealed the muscle injury.
Discussion
The main purpose of this technical note was to raise
awareness of the US and MRI features of the
Perivascular Adductor Longus muscle injury. The ma-
jor function of this article is to compensate for the
lack of studies concerning the Perivascular Adductor
Longus muscle injury, offering practical guidance on
how to effectively investigate it via US and MRI. This
article may be considered the point of reference for
the imaging of this injury and for future related inves-
tigations.
Ultrasound findings
US was helpful as a first screening test and all the
cases presented comparable findings in acute phase.
These were consistent with those presented in the ar-
ticles describing the US characteristics of muscle in-
juries19-21. Despite this, misdiagnosis was a distinct
possibility, particularly if the examination was carried
out in the first seventy-two hours post-trauma; in fact
the eco-structural abnormalities were of controversial
analysis and interpretation in two of the five cases. In
this sense, the Push-to-view tip has shown to have
relevant practical value as it allowed to thoroughly
evaluate the lateral peripheral portions of the AL
muscle belly, during the investigations; without apply-
ing this tip, the image quality decreased substantially,
likely leading to misinterpretation. On the other hand,
in the three cases in which an intramuscular
haematoma formed, the associated US abnormalities
were visible only at day 5 post-injury, or later, while,
typically, their presence should be previously de-
tectable19-21. Contrary to what is currently known
about the evolution of the US features of the intra-
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
380
G. Mattiussi et al.
Figure 4. Cross-sectional ultrasound performed 48 hours post trauma showing the ultrasonographical features of the
Perivascular Adductor Longus muscle injury in the acute phase. The eco-destructuration of the Adductor Longus (AL)
epimysium, which appears hypoechogenic, is indicated by the solid arrows and extends from the compressed femoral vein
(asterisk) to the deep femoral vessels (circles). Oedema of AL within the muscle belly is visible in the vicinity of the lesion
(dashed arrow). Due to this, the perimysium is not locally distinguishable from the muscle fibres. The hyperechoic region be-
low the vessels and facing the Vastus Medialis (VM) is likely due to the posterior acoustic enhancement artifact induced by
the femoral artery. Accordingly, at this site, the presence of interfascial liquid should not be confirmed using ultrasound.
© CIC Edizioni Internazionali
381
Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
! !
!
Table I. List of included studies presenting different methods for assessment of tunnel widening on radiographs.
Measured
value
Measured points Tunnels
measured
!
Study!
Diameter
!
Proximal, middle, distal
!
Tibial
!
Peyrache et al. (1996)
!
Diameter
!
Widest
!
Tibial + femoral
!
L’Insalata at al. (1997)
!
Diameter
!
Femoral entrance, tibial entrance, tibial exit
!
Tibial + femoral
!
Nebelung et al. (1998)
!
Diameter!Widest of 5 mm from tibial entrance,
5 mm from tibial exit
!
Tibial!Murty et al. (2001)!
Diameter!Widest point + 1 cm from the apertures of the tibial
and femoral tunnels at the joint
!
Tibial + femoral!Baumfeld et al. (2008)!
Area!Tibial: AP + lateral – 1 cm distal of ACL attachment!
Femoral: AP – 1 cm proximal to physeal line, lateral –
1 cm proximal to Blumensatt’s line.
!
Tibial + femoral!Clatworthy et al. (1999)!
Diameter!At 1 cm below the tibial plateau, 1 cm above
the femoral entrance
!
Tibial + femoral!Fauno and Kaalund
(2005)
!
Diameter!Intra-articular outlet!Femoral!Kawaguchi et al. (2011)!
© CIC Edizioni Internazionali
muscular haematomas19, in no case we observed iso-
or hyperechoic areas within the muscle belly. This
does not exclude that blood was present, at least, in
the intra-fascial region. However, when clearly ob-
servable, the haematomas had clear hypoechogenic
or anechoic appearance. According with the above,
the final ultrasound diagnosis should not be estab-
lished prior to one week post-trauma. Doing the op-
posite, entails the main risk of underestimating the
actual severity of the injury.
Magnetic Resonance Imaging findings
Fat-suppressed fluid sensitive MRI techniques were
the most useful to detect structural abnormalities in
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
382
G. Mattiussi et al.
Figure 5 a, b. Practical value of the Push-to-View tip. Cross-sectional ultrasound images acquired in acute phase with (a) or
without (b) the use of the tip. In (a), the eco-destructuration of the epimysium is well displayed (indicated by the solid arrows)
as well as the intramuscular oedema (dashed arrow). In (b), the posterior acoustic enhancement artifact induced by the
femoral vein (asterisk) significantly impairs the visualisation of the lesion; even the signs of the intramuscular oedema
(dashed arrow), though present, are very weak in comparison. In this case, the possibility of misdiagnosis is certainly sub-
stantial.
Figure 6 a, b. Ultrasound diagnostic difficulties in the analysis of the Perivascular Adductor Longus muscle injury, in acute
phase. In (a), the compression of the femoral vein causes the formation of a wide echogenic area just under it (black aster-
isk), which prevents ideal visualisation of the injury. Despite this, the deepest part of the epymsium is still visible and ap-
pears hypoechogenic (solid arrows). The ultrasonographer must rule out that it is not from a horizontal blood vessel, origi-
nating from the deep femoral vessels (circles). In (b), while the eco-destructuration of the epymisium is quite evident, the in-
tramuscular perilesional oedema (dotted arrow) is barely visible. There is also the possibility that this sign is mistaken for the
posterior acoustic enhancement artifact caused by vessels.
a b
a b
© CIC Edizioni Internazionali
all phases of the healing process2 0. However, only
the STIR sequences were positive in all the five cas-
es, in the acute phase. Consequently, in case of sus-
pected Perivascular Adductor Longus muscle injury, it
is advisable to specifically review the sequences ob-
tained using this technique. Despite this, haema -
tomas-associated signal alterations were visible only
in the MRI carried out after seventy-two hours, con-
firming the tendency to delayed formation of intra-
muscular haematomas of the Perivascular Adductor
Longus muscle injury. It is worth noting that these
signs were also visible at three months post-injury,
even considering the T1-sequences, which typically
have modest role in the assessment of muscle in-
juries2 0. Long-standing haematoma (and related
oedema) should be therefore considered the main
complication of the Perivascular Adductor Longus
muscle injury. Other structural abnormalities (large fi-
brotic areas and/or calcification) have not been ob-
served in any of the cases. However, considering the
low number of participants of this study, we did not
definitely exclude that those may form.
383
Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
Figure 7. Cross-sectional ultrasound performed 7 days post trauma showing a high grade Perivascular Adductor Longus
(AL) muscle injury. A wide anechoic region (solid arrow) is visible within the AL muscle belly. The sign is compatible with the
presence of fluid, most likely blood, resulting from local lesion of the muscle fibres.
Figure 8. Elastosonography of an intramuscular haematoma within the lateral peripheral aspects of the Adductor Longus
(AL). The fluid collection (full arrow) appears easily circumscribed as corresponding to the blue region, surrounded by
green/red areas. Such collection is considered hard, i.e., with high mechanical resistance, potentially interpretable as a
dense and not compressible liquid.
© CIC Edizioni Internazionali
Injury mechanism and limitations of the study
Kicking was reported to be the traumatic motor task
in three cases. This gesture is already known to be
implicated in the etiopathogenesis of AL muscle in-
juries4. Interestingly, the other two players were not
able to identify the gesture that led to the injury and,
moreover, the onset of the symptoms was gradual.
This suggests that clinical history may be misleading
in case of Perivascular Adductor Longus muscle in-
jury. In fact, when AL muscle injuries occur, the onset
is usually sudden and the pain not compatible with
the sporting activities1-3.
Participants’ anthropometric characteristics and
sport-related information are not provided to ensure
maximum anonymization, while relevant clinical find-
ings, treatment protocol and return-to-play time infor-
mation was not collected due to the fact that different
physicians used different clinical assessment proto-
cols to evaluate the footballers and inconsistent
nomenclature to describe the clinical findings. The
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
384
G. Mattiussi et al.
Figure 9 a-e. Fat-suppressed T2-weight-
ed transversal consecutive sections
showing the MRI features of Perivascu-
lar Adductor Longus (AL) muscle injury,
in the acute phase. In a and c the intra-
muscular oedema, while in b and d the
interfascial fluid, are observable. In c
and d the portions of interest of sections
a and b (white squares) are magnified.
In c it is worth noting how the oedema-
tous area, corresponding to the region of
increased intramuscular signal, does not
extend to the Vastus Medialis, excluding
lesions affecting this muscle. In d the in-
crease signal of the lateral epymisium
mimics a pseudo-thickening of the fas-
cia, which can be better assessed if
compared with the same healthy portion
of the contralateral limb (e).
Figure 10 a-e. Short tau inversion re-
covery transversal MRI consecutive
sequences (corresponding to those
presented in Figure 9). By comparing
the sequences, sections a and b clear-
ly show an increase in signal intensity
in the lateral peripheral region of the
Adductor Longus (AL). The sections
contained in the black squares are
magnified and show the oedema (c)
and the interfascial liquid (d) that
specifically extend from the superficial
femoral vessels to the deep ones
(hence the “perivascular” prefix). This
should be considered as the site to be
reassessed in the sub-acute phase in
order to evaluate the potential delayed
intramuscular haematoma formation or
interfascial fluid accumulation. The
comparison with the contralateral limb
(e) is always extremely useful as the
signal alterations may be modest at
this stage or present only in a few sin-
gle sequences. In general, whenever
possible, an MRI of both limbs should be carried out: the possible misinterpretation is that the interfascial liquid is mistaken
for a blood vessel.
a
b
c
d
e
a
b
c
d
e
© CIC Edizioni Internazionali
lack of this relevant information should be considered
the main limitations of this article.
Perivascular Adductor Longus muscle injury in
the medical literature
At the best of Authors’ knowledge, there are only two
more articles in literature that describe the clinical
and/or the imaging characteristic of the Perivascular
Adductor Longus muscle injury. In the report by Van
De Kimmenade et al.8, the case of a football player
with long-standing (three months) thigh pain is pre-
sented. Kicking was the traumatic mechanism. Inter-
estingly, the clinical tests were all substantially nega-
tive. On the contrary, the MRI images clearly showed
a distal intramuscular haematoma. Our analysis of
the transversal MRI sequences confirms it was a high
grade Perivascular Adductor Longus muscle injury,
since the signal alteration are specifically detectable
between the AL and the Vastus Medialis. Anyway,
generic diagnosis of intramuscular AL rupture was
made. No proximal injuries are reported and no addi-
tional ultrasound images or follow-up MRI are pre-
sented in the paper.
On the other hand, in the article by Orlandi et al.10, an
intramuscular Platelet-rich Plasma (PRP) injection
procedure within the AL muscle belly is presented.
Revising the US-guided interventional techniques to
treat sport-related muscle injuries was the main pur-
pose of the paper. One of the US images provided
shows an injury of the AL located just below the
385
Perivascular Adductor Longus muscle injury: Ultrasound and Magnetic Resonance Imaging findings
Muscles, Ligaments and Tendons Journal 2017;7 (2):376-387
Figure 11 a, b. Short tau inversion re-
covery sagittal MRI sequences ac-
quired 30 days after trauma. In a the
persistent and isolated intramuscular
oedema (black asterisk), which ex-
tends for the entire section of the mus-
cle, is visible. In b, the haematoma
(large bright area) can easily be spot-
ted, just slightly below the surface to
the femoral artery and in relation with
it.
Figure 12 a-c. Short tau inversion recovery axial MRI sequences acquired at 30 days after trauma, from proximal to distal.
The proximal section (a) shows the site as being likely to have been affected by the primary injury, with presence of interfas-
cial effusion and intramuscular oedema, extending for about a third of the muscle belly. In b, fluid spillage, enclosed in the
muscle belly, is clearly visible (bright area). It is situated just below the femoral vessels (two black points), possibly accumu-
lated due to gravity. Just below the plausible haematoma, only a minimum increase of signal is observable (c) at epimysial
level.
a b
a b c
© CIC Edizioni Internazionali
femoral vessels. The US features of that injury are
fully consistent with those of the Perivascular Adduc-
tor Longus muscle injury presented in our technical
note. However, figure caption is somehow confound-
ing as it indicates that the pubis, the proximal AL ten-
don and the femoral vessels would be visible in the
same (transversal) section. This description creates
an “anatomical paradox” since those structures can-
not be this close, at any anatomical level. Despite
this, the US images are overall of a high quality and
show the evolution of the healing process of the in-
jury (twenty days follow-up).
Summary
The Perivascular Adductor Longus muscle injury is
still widely under-recognised and poorly and sparsely
described in literature. Locating the presence of the
injury and quantifying its extension is of vital impor-
tance to properly establish the prognosis and to ratio-
nally orientate the rehabilitation program, possibly op-
timising the healing process and reducing the risk of
recurrence. Future studies are needed to identify the
incidence of the Perivascular Adductor Longus mus-
cle injury, which remains to this day unknown, among
all the myotendinous injuries that affect the Adductor
Longus, stating the return-to-play time depending on
the degree of severity.
Conflict of interest
The Authors declare that they have no conflict of in-
terest.
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