This document provides an overview of anatomy related to the groin region. It describes the structures in the groin including bones, muscles, nerves, blood vessels, and fascia. It discusses conditions that can cause groin or hip pain such as hernias, nerve entrapment, and Gilmore's groin. It also outlines the course of cutaneous nerves that innervate the groin and thigh including the iliohypogastric and ilioinguinal nerves which are susceptible to entrapment.
3. MOB TCD
Groin
• Lower half of anterior abdominal wall
• Proximal portion of the thigh
• Pain in the groin may be due to local
structures
• Referred from other areas e.g. the
spine or ureter
• Pain may be acute or chronic
• Quality of pain
• Rest or movement
4. MOB TCD
Hip and Groin Pain
• Spinal problems such as disc
•
•
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•
lesions
Intra-abdominal problems
Gynecological disorders
Urological problems
Urinary tract infection
Pelvic inflammatory conditions
Genital swelling or inflammation
Epididymis, hydrocele, variocele
7. MOB TCD
Inguinal Glands
• Proximal group parallel to
inguinal ligament
• Enlarged tender inguinal
glands
• Part of a generalised
lymphadenopathy
• Secondaries
8. MOB TCD
Inguinal Glands
• Proximal group
• Lesions in local structures
• Skin of lower anterior abdominal
wall
• Gluteal region
• Skin of scrotum or labia
• Distal superficial glands
• Skin of leg area drained by long
saphenous vein
• All drain to deep inguinal glands
along femoral vein
9. MOB TCD
Skin of Anterior Abdominal Wall
• Lower five intercostal nerves
• Subcostal nerve T12
• 10th intercostal nerve is at the level of
the umbilicus
• Iliohypogastric nerve L1
• Ilioinguinal nerve L1
10. MOB TCD
Cutaneous Nerves of Thigh
•
•
•
•
Subcostal nerve T 12
Iliohypogastric nerve L1
Ilioinguinal nerve L1
Femoral branch of the genitofemoral
nerve L1,2
• Lateral cutaneous nerve of the thigh
L2,3
• Femoral nerve L2,3,4
• Obturator nerve L2,3,4
11. MOB TCD
Anterior Abdominal Wall
•
•
•
•
Superficial fatty layer
Membranous layer of superficial fascia
Below umbilicus
Continuous with Colles’ fascia in the
perineum
12. MOB TCD
Blood Supply and Lymphatics
• Intercostal vessels
• Skin above umbilicus:
superficial veins and lymphatics drain
to axilla
• Skin below umbilicus:
superficial veins and lymphatics drain
to long saphenous vein
• Superficial inguinal glands
15. MOB TCD
Insertion – External Oblique
• Inserted into anterior half of
anterior two thirds outer lip of iliac
crest
• Aponeurosis in inguinal region
passes anterior to rectus muscle
• Forms the inguinal ligament
• Lacunar ligament
• Reflected portion of inguinal
ligament
16. MOB TCD
Inguinal and Lacunar Ligaments
• Inguinal ligament:
aponeurosis is folded back
from anterior superior iliac
spine to pubic tubercle to
form inguinal ligament
• Lacunar ligament:
triangular, attached to
pectineal line, lateral free
border medial margin of
femoral ring
17. MOB TCD
Insertion – External Oblique
•
•
•
•
•
Pubic crest
Gap for superficial ring
Pubic bone
Linea alba
Anterior wall of the
rectus sheath
• Zyphoid process
18. MOB TCD
Internal Oblique
• Muscular origin
• Lateral two thirds of
inguinal ligament
• Anterior two thirds
intermediate lip of iliac
crest
• Lumbar fascia
• Muscular fibres arch over
contents of inguinal canal
anterior to rectus muscle
19. MOB TCD
Insertion – Internal Oblique
• Into the costal margin, upper three as
fleshy fibres
• Next three as aponeurotic
• Inserted into linea alba
• Between zyphoid and half way between
umbilicus and pubic symphysis,
aponeurosis splits
• Anterior fuses with external oblique
• Posterior with transversus
20. MOB TCD
Internal Oblique – Conjoint Tendon
• Half way between umbilicus and
pubic symphysis
• Aponeurosis of the internal
oblique and transversus fuse to
form conjoint tendon
• Anterior portion of rectus sheath
• Inserted into pectineal line behind
superficial inguinal ring
21. MOB TCD
Transversus Abdominus
• Origin
• Lateral one third of inguinal ligament
• Anterior two thirds of inner lip of iliac
crest
• Lumbar fascia
• Lower border and inner surfaces lower
six ribs interdigitating with diaphragm
22. MOB TCD
Insertion – Transversus Abdominus
• Into zyphoid, linea alba
• Half way between umbilicus and
pubic symphysis
• Fuses with posterior lamella of
the internal oblique
• Below forms conjoint tendon
• Inserted into pectineal line
behind superficial inguinal ring
23. MOB TCD
Rectus Abdominus
•
•
•
•
•
Segmental muscle
Two heads
Anterior pubic symphysis
Pubic crest
Inserted anterior aspect
of 5,6,7th costal cartilages
• Adhesions anterior
• Segmental blood and
nerve supply from
intercostals
24. MOB TCD
Transversalis Fascia
• Lines deep aspect of
transversus abdominus
• Fuses with inguinal ligament
• Continuous with iliac fascia
• Except in region femoral
vessels
• Forms anterior wall of femoral
sheath
26. MOB TCD
Superficial Inguinal Ring
• Triangular opening in aponeurosis of
external oblique
• Base pubic crest
• Superior crus to pubic crest
• Inferior attached to pubic tubercle
• External spermatic fascia arises from
its margins
27. MOB TCD
Deep Inguinal Ring
• Oval opening 2.5 cm
• Above the middle of inguinal ligament
• Inferior epigastric artery medial to
ring
32. Passing through Deep Ring
Male
•
•
•
•
•
•
•
Vas deferens
Testicular artery
Pampiniform plexus of veins
Remains of processus vaginalis
Genital branch of genitofemoral nerve
Lymphatics from testes
Cremaster artery
MOB TCD
33. Passing through Superficial Ring
Male
•
•
•
•
•
Everything that went through deep ring
Plus:
Ilioinguinal nerve
Internal spermatic fascia
Cremaster muscle and fascia
MOB TCD
34. Passing through Deep Ring
Female
• Round ligament of uterus
• Remains of processus vaginalis
• Genital branch of genitofemoral
nerve
• Lymphatics from uterus, region of
cornu
MOB TCD
35. Passing through Superficial Ring
Female
• Everything that went through
deep ring:
• Plus ilioinguinal nerve
MOB TCD
36. MOB TCD
Inguinal Canal
• Contraction of the abdominal
muscles increases the
obliquity of the inguinal canal
• Protecting the two rings
Lytle, 1945
37. Increase in
Intra Abdominal Pressure
• Pain aggravated by an increase in
intraabdominal pressure
• Hernia
• Inguinal or femoral hernia
• Entrapment of the ilioinguinal nerve
MOB TCD
38. MOB TCD
Hernia
• Chronic pain in the groin in an
athlete
• May be due to a hernia or a
potential hernia
39. MOB TCD
Inguinal Hernia
• Sudden severe pain in lower
abdomen
• Associated with lifting a heavy
object
• Common history of a direct
inguinal hernia
40. MOB TCD
Indirect Inguinal Hernia
• Passes through
• Deep inguinal ring
• May extend to pass through
the superficial ring into the
scrotum
• Congenital or acquired
• Congenital inside the tunica
vaginalis (serous membrane,
covers part of testes)
• Acquired outside
41. MOB TCD
Direct Inguinal Hernia
• Direct inguinal hernia
• Enters through posterior wall of the
inguinal canal
• Leaves through superficial inguinal ring
• Above and medial to pubic tubercle
42. MOB TCD
Inguinal Versus Femoral Hernia
• Inguinal above and medial to pubic
tubercle
• Femoral below and lateral
46. MOB TCD
Saphenous Varix
• Swelling is soft
and diffuse
• Empties on
minimal pressure
• Refills on release
• Cough impulse is
present
47. MOB TCD
Gilmore’s Groin
• Common cause of chronic groin
pain in field sports
• Particularly soccer players
• Pain on any sudden change of
movement, sneezing, coughing
48. MOB TCD
Gilmore’s Groin
• Trying to sprint will increase the pain
• Pain is worse getting out of bed the
day after a match or a training
session
49. MOB TCD
Gilmore’s Groin
• Pain is increased by external
rotation
• Or hyperextension of hip
• Pain is localised to lower
anterior abdominal wall
• Adductor or perineal region
50. MOB TCD
Gilmore’s Groin
• Torn external oblique
aponeurosis
• Torn conjoint tendon
• A dehiscence between conjoint
tendon and the inguinal ligament
• The absence of a hernial sac
• Superficial inguinal ring on the
affected side is dilated and
tender
• Cough impulse
51. MOB TCD
Gilmore’s Groin Surgery
• Treatment is surgical
• 90% return to sport
• Strengthen lower abdominal
muscles
52. MOB TCD
Gilmore’s Groin Surgery
1. Plication of the transversalis
fascia in ‘shouldice hernia
repair’
2. Repair of torn conjoint tendon
3. Approximation of conjoint
tendon to the inguinal
ligament
4. Repair of the external oblique
5. Reconstitution of the
superficial inguinal ring
53. MOB TCD
Anatomy of Nerve Injuries
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•
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Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
54. MOB TCD
Anatomy of Nerve Injuries
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Must know the course of nerve
Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
56. MOB TCD
Extrinsic Factors
• External forces
• Fibro-osseous tunnels, tether the
nerve
• Oedema
• Callus formation as a result of a
fracture
• External compression due to specific
movements
• Mechanical compression
• Compartment syndromes
• The nerve is tender at the site of compression
63. MOB TCD
Ilio-Hypogastric Nerve L1
•
•
•
•
Branch of lumbar plexus
Lateral border of psoas
Anterior to quadratus lumborum
Neurovascular plane between internal
oblique and transversus
• Lateral cutaneous supplies upper part of
buttock
64. MOB TCD
Ilio-Hypogastric Nerve
• Pierces internal oblique
above anterior superior
iliac spine
• Pierces aponeurosis of
external oblique an inch
above superficial ring
• Supplies skin over lower
part of rectus sheath
• Can be trapped piercing
aponeurosis
66. MOB TCD
Ilio-Inguinal Nerve
• Pierces internal oblique
4 cm medial to
• Anterior superior iliac
spine
• Enters inguinal canal
• Leaves through superficial
ring
• Supplies the skin of the
medial part of the thigh
• Adjoining portion of the
scrotum and labia
67. MOB TCD
Ilio-Inguinal Nerve
• May be trapped post
surgery, due to adhesions
• Poor tone in abdominal
muscles
• Pain increased by
increased tension in the
anterior abdominal wall
• Hyperextension of hip
• Tenderness 4 cm from
anterior superior iliac spine
68. MOB TCD
Ilio-Inguinal Nerve Entrapment
• Pain increased
• Increased tension in the anterior
abdominal wall
• Hyperextension of hip
• Tenderness 4 cm medial to anterior
superior iliac spine
69. MOB TCD
CutaneousNerves
• Iliohypogastric in 5.6%
• Ilioinguinal 90.7%
• Union of branches of ilioinguinal
and genital branch of the
genitofemoral nerve 13%
• Genitofemoral passing through
superficial inguinal ring 35.2%
• Piercing inguinal ligament 5.6%
• Femoral branch 13%
Akita et al., 1999
70. MOB TCD
Genitofemoral Nerve
• Lumbar plexus L1,2
• Anterior aspect of the psoas
• Genital branch enters the deep
inguinal ring
• Femoral branch lies on the lateral
side of femoral artery in the
femoral sheath
71. MOB TCD
Femoral Branch Genitofemoral
• Enters thigh on lateral aspect of
femoral artery in femoral sheath
• Pierces anterior wall of the
sheath
• Supplies skin a hands breath
below the inguinal ligament
72. MOB TCD
Genitofemoral Nerve
• Union with ilioinguinal nerve on
anterior aspect of spermatic cord
• Supplies ventral aspect of scrotum
and adductor region
• Cutaneous branch on the dorsalcaudal aspect
• May also supply dorsal scrotum
Akita et al., 1999
74. MOB TCD
Lateral Cutaneous Nerve
• The lateral cutaneous nerves of the
thigh L2,3
• Lumbar plexus in psoas
• Lateral aspect of psoas
• Pierces inguinal ligament
• Lies in fibrous tunnel
• Divides into two
• Pierces deep fascia
75. MOB TCD
Lateral Cutaneous Nerve of Thigh
• A centimeter medial to anterior
superior iliac spine
• Crosses the lateral angle of
femoral triangle
• Divides into two
• Pierces deep fascia
• Anterolateral aspect of the thigh
• Anterior portion of gluteal region
76. MOB TCD
Lateral Cutaneous Nerve of Thigh
• Entrapment in the fascial tunnel
• Injured in the thigh by asymmetric bars
in gymnastics
• Causes meralgia paraesthetica
• Post laparoscopic surgery
77. MOB TCD
Femoral Nerve L2,3,4
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•
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•
The largest branch of the lumbar plexus
Lateral aspect of psoas
Passes under the inguinal ligament
Outside femoral sheath
2 cm below
Divides into terminal branches
Muscular
Articular
Cutaneous
78. MOB TCD
Femoral Nerve
Muscular branches
• Rectus femoris
• Vastus medialis
• Vastus lateralis
• Vastus intermedius
• Sartorius, pectineus
Cutaneous
• Medial cutaneous nerves of thigh
• Intermediate cutaneous nerves of thigh
• Saphenous
Articular branches to hip and knee joints
79. MOB TCD
Femoral Nerve
• Dancers may stretch the nerve
by prolonged hyperextension of
the hip
• Compress the nerve under the
inguinal ligament
• The nerve may also be
compressed due to a
haematoma following a partial
tear of the iliacus
O’Brien, 1997
81. MOB TCD
Obturator Nerve
•
•
•
•
•
•
The obturator nerve L2-3-4
Lumbar plexus in psoas
Medial aspect of psoas
Side wall of pelvis under peritoneum
Leaves through obturator foramen
Divides into anterior and posterior
divisions
82. MOB TCD
Obturator Nerve
• Supplies the parietal peritoneum
on side wall of the pelvis
• It is related to the ovary
• Pathology in the ovary or
endometriosis may result in
referred pain to the hip, knee or
medial side of the high
83. MOB TCD
Anterior Divison Obturator
• The anterior division of the
obturator leaves pelvis
• Anterior to obturator
externus
• Descends in front of
adductor brevis
• Behind pectineus and
adductor longus
obturator nerve
84. MOB TCD
Anterior Divison Obturator
•
•
•
•
Adductor longus
Adductor brevis
Gracilis
It gives an articular twig to the
hip joint
• Skin on the medial side of the
thigh
86. MOB TCD
Posterior Divison Obturator
• It may be entrapped as it leaves the pelvis
• Pierces and supplies the obturator externus
• Causing spasm of the adductor muscles
87. MOB TCD
Posterior Divison Obturator
• Supplies adductor portion of adductor magnus,
above hiatus
• Articular twig to knee joint and cruciate
ligaments
• Causing spasm of the adductor muscles
• It may be entrapped as it leaves the pelvis or
between fascial planes
89. MOB TCD
Howship Rhomberg Sign
• Pressure on obturator nerve
• Pain on inner aspect of thigh
relieved by flexion of hip
• Increased by extension,
adduction and medial rotation
97. MOB TCD
Rectus Femoris Muscle
•
•
•
•
•
•
Upper half of anterior inferior iliac spine
Area above actetabulum
Inserted into quadriceps tendon
Flexes hip
Extends knee
Femoral nerve
98. MOB TCD
Hip Joint
•
•
•
•
•
Synovial ball and socket joint
Multiaxial
Three degrees of freedom
Movement in three planes
Close pack extension and
medial rotation
• Least pack semiflexion
99. MOB TCD
Hip Joint
• One of most stable joints in the
body
• Articular surface of hip joint are
reciprocally curved
• Superior surface of femur and
acetabulum sustain greatest
pressure
100. MOB TCD
Acetabulum
•
•
•
•
•
Y shaped epiphyseal cartilage
Start to ossify at 12
Fuse 16-17
Acetabular notch is inferior
Nonarticular fossa, thin related
medially to obturator internus
• Pad of fat, proprioceptive nerves
101. MOB TCD
Articular Surface of Hip Joint
• Semilunar articular surface
covered with hyaline cartilage
• Deepened by labrum
acetabulare
• Wedge shaped fibrocartilage
102. MOB TCD
Articular Surface
•
•
•
•
•
Head of femur 2/3rd of sphere
Pit for ligamentum teres
Covered with articular cartilage
Cartilage thicker posterior superior
Epiphyseal line for head
intracapsular
103. MOB TCD
Femur
• Trabeculae develop along lines of
stress
• Calcar femorale is the cortical
bone on inferior aspect of neck
• Neck is cancellous bone
104. MOB TCD
Capsule of Hip
•
•
•
•
Proximally attached
Margins of the acetabular fossa
Base of labrum
Distally, anterior to the
intertrochanteric line
• Inferiorly, femoral neck close to
lesser trochanter
105. MOB TCD
Capsule of Hip
• Posterior
• Free border, finger’s breadth
from trochanteric crest due to
insertion of obturator externus
• Into trochanteric fossa and
• Root greater trochanter
106. MOB TCD
Capsule of Hip
• Strongest superiorly
• Anteromedially, deep fibres
reflected head of rectus femoris
• Iliopsoas is anterior
• Lateral deep fibres of gluteus
minimus
107. MOB TCD
Retinacular Fibres
• Fibres of capsule reflected
along neck to articular margin
called retinacular fibres
• Blood supply to head run under
retinacular fibres
108. MOB TCD
Ligaments of Hip
•
•
•
•
•
•
•
Labrum acetabulare
Transverse ligament
Ligament of head
Iliofemoral ligament
Pubofemoral ligament
Ischiofemoral ligament
Zona orbicularis
109. MOB TCD
Ligaments of Hip
• Transverse ligament is part of the
labrum
• Ligamentum teres is triangular
• Its base is attached to transverse
ligament and the apex to the pit
on the head of femur
• Blood supply to epiphysis from
obturator artery
• Only supplies a flake of bone in
elderly
110. MOB TCD
Iliofemoral Ligaments
• Thickening of capsule
• Lower half of anterior inferior
iliac spine and adjoining
acetabulum
• Distally
• Upper and lower parts of
inter trochanteric line
111. MOB TCD
Iliofemoral Ligaments
• One of strongest ligaments in
body
• Tightens in extension
• Helps maintain erect posture
• Facet on anterior aspect of
neck
• Prevents hyperextension
• Fulcrum reducing hip
112. MOB TCD
Pubofemoral Ligament
• Superior pubic ramus
• Inferior part of inter trochanteric
line and upturned part
• Relatively weak
• Prevents abduction
• Bursa between it and iliofemoral
113. MOB TCD
Ischiofemoral Ligament
• Ischium to posterior part of
joint (weak)
• Circular fibres called zona
orbicularis
• Centre of gravity in front of
head
• Synovial under obturator
externus
114. MOB TCD
Synovial Membrane
• Lines inner portion of capsule
and nonarticular structures
• Ligament of head
• Fat in acetabular fossa
• May communicate with psoas
bursa
• Bursa under obturator externus
115. MOB TCD
Bursa Under Glueus Maximus
• Trochanteric bursa
• Posterolateral aspect of
greater trochanter
gluteofemoral
• Vastus lateralis ischial bursa
• Ischial tuberosity
116. MOB TCD
Blood Supply to Head of Femur
• Child: obturator artery via
ligamentum teres supplies
epiphysis
• Elderly: main supply via
retinacular vessels from
trochanteric and cruciate
anastamoses
• Medial and lateral circumflex
femoral vessels
117. MOB TCD
Blood Supply
• Superior gluteal supplies the upper
part of the acetabulum
• Inferior gluteal supplies the inferior
and posterior and the capsule
• Transverse and ascending
branches of lateral circumflex
femoral artery
• Transverse and ascending branch
of medial circumflex femoral
• Cruciate and trochanteric
anastomosis
118. MOB TCD
Blood Supply
• Fractures of neck may cause
avascular necrosis, extra
capsular arteries enter the
trochanter at the base of neck
• Medial and lateral circumflex
femoral vessels and superior
gluteal
119. MOB TCD
Nerve Supply
•
•
•
•
•
Femoral nerve
Obturator nerve
Superior gluteal nerve
Nerve to quadratus femoris
Posterior dislocation may
damage sciatic
• Pain in hip referred to knee
120. MOB TCD
Stability of Hip
• One of the most stable joints
• Congenital dislocations is
common
• 1.5 per 1000 live births
• Female : Male = 8:1
• Ultrasound best method of
detecting
122. MOB TCD
Inferior and Posterior Relations
• Obturator externus
• Passes inferior and then posterior to
joint
• Superior gluteal nerve
• Inferior gluteal nerve
• Sciatic nerve
• Posterior cutaneous nerve thigh
• Nerves to obturator internus and
quadratus femoris
• Pudendal nerve
123. MOB TCD
Lateral Relations
• Gluteus minimus
• Gluteus medius
• Superior gluteal vessels and nerves
between
• Iliotibial tract
• Superficial three quarters of gluteus
maximus
126. MOB TCD
Movements: Extension
•
Hamstrings first 10°
1. Long head of biceps
2. Semitendinosus
3. Semimembranosus
•
•
•
123, extended knee ++
Adductor magnus
Gluteus maximus most efficient when hip is
flexed 45 °
133. MOB TCD
Hip Problems in Children
•
•
•
•
Apophysitis
Avulsion fractures
After 13 years
11-40% of all hip and
pelvic fractures
Boyd et al., 1997
• Anterior superior iliac
spine
• Anterior inferior iliac
spine
• Ischial tuberosity
commonest
135. MOB TCD
Pain in a Child
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•
•
•
•
•
5-10 year old child
Aching pain in hip
Limp
Limitation of movement
Perthe’s
Osteochondritis of head of femur
136. MOB TCD
Stability of Hip
• One of the most stable joints
• Congenital dislocations is
common
• 1.5 per 1000 live births
• Female : Male = 8:1
• Ultrasound best method of
detecting
137. MOB TCD
Femoral Anteversion
• Femoral version is the
angular difference
between axis of femoral
neck and transcondylar
axis of the knee
• Femoral anteversion
ranges from 30º - 40º at
birth
• Decreases progressively
15º at skeletal
maturation
• Adults
• Anteversion
• Average of 8º in men and
14º in women
• Most common cause of
in-toeing
• If associated with internal
tibial torsion may lead to
patellofemoral
subluxation due to an
increase in the Q-angle
138. MOB TCD
Tumors and Neoplasms
• Young, healthy athletes
do get cancer!
• Fortunately most tumors
are benign!
• Bone pain at night
• Tumor till proved
otherwise
Renstrom, 2008
139. MOB TCD
Hip Joint Labral Tear
• Chronic
• Secondary to acetabular dysplasia
• Part of ‘rim lesion’ complex
Renstrom, 2008
•
140. MOB TCD
Labrum Tears and Cartilage Loss
• Labrum tears and cartilage loss are
common in patients with mechanical
symptoms in the hip
• In young, active patients with a
complaint of groin pain
• The diagnosis of a labrum tear should
be suspected and investigated as
radiographs and the history may be
nonspecific for this diagnosis
Burnett et al., 2006
141. MOB TCD
MR – Arthrography (MRA)
• MR arthrogram has an accuracy
of 91% for labral tears
Chan et al., 2005
• Sensitivity labral tear
• MR 25%,
• MRA 92%
Toomayan et al., 2006
142. MOB TCD
Pincer Impingement
• The acetabulum covers too much of the
•
•
•
•
femoral head
Secondary to ‘retroversion’ of the socket
Or a ‘profunda’ socket that is too deep
Most of the time, the cam and pincer forms
exist together
Female, 30-40 years
Renstrom, 2008
143. MOB TCD
Cam Impingement
•
•
Loss of roundness contributes to
abnormal contact between the head and
socket
Male, 20-30 years
Renström, 2008