Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain

Pubic bone injuries in primiparous women: magnetic resonance imaging in detection and differential diagnosis of structural injury

OBJECTIVE

To evaluate the utility of magnetic resonance imaging (MRI) in diagnosing structural injury in primiparous women at risk for pelvic floor injury.

METHODS

This was an observational study of 77 women who underwent 3T MRI after delivery. Women were operationally defined as high risk (n = 45) for levator ani muscle tears (risk factors: second-stage labor > 150 min or < 30 min, anal sphincter tear, forceps, maternal age > 35 years and birth weight > 4000 g) or low risk (n = 32): vaginally delivered without these risk factors (n = 12); delivered by Cesarean section after second-stage labor > 150 min (n = 14) or delivered by Cesarean section without labor (n = 6). All women were imaged using fluid-sensitive MRI sequences. Two musculoskeletal radiologists reviewed images for bone marrow edema, fracture, pubic symphysis measurements and levator ani tear.

RESULTS

MRI showed pubic bone fractures in 38% of women at high risk for pelvic floor injury and in 13% of women at low risk for pelvic floor injury (χ(2) (3) = 9.27, P = 0.03). Levator ani muscle tears were present in 44% of the high-risk women and in 9% of the low-risk women (χ(2) (3) = 11.57, P = 0.010). Bone marrow edema in the pubic bones was present in 61% of women studied across delivery categories. Complex patterns of injury included combinations of bone marrow edema, fractures, levator ani tears and pubic symphysis injuries. No MRI-documented injuries were present in 18% of women at high risk and 44% at low risk for pelvic floor injury (χ(2) (1) = 6.2, P = 0.013).

CONCLUSIONS

Criteria identifying primiparous women at risk for pelvic floor injury can predict increased risk of bone and soft tissue changes at the pubic symphysis. Fluid-sensitive MRI has utility for differential diagnosis of structural injury in postpartum women.

Review of MRI technique and imaging findings in athletic pubalgia and the "sports hernia"

The clinical syndrome of athletic pubalgia has prematurely ended many promising athletic careers, has made many active, fitness conscious adults more sedentary, and has served as a diagnostic and therapeutic conundrum for innumerable trainers and physicians worldwide for decades. This diagnosis actually arises from one or more lesions within a spectrum of musculoskeletal and visceral injuries. In recent years, MRI has helped define many of these syndromes, and has proven to be both sensitive and specific for numerous potential causes of athletic pubalgia. This text will provide a comprehensive, up to date review of expected and sometimes unexpected MRI findings in the setting of athletic pubalgia, and will delineate an imaging algorithm and MRI protocol to help guide radiologists and other clinicians dealing with refractory, activity related groin pain in an otherwise young, healthy patient. There is still more to be learned about prevention and treatment plans for athletic pubalgia lesions, but accurate diagnosis should be much less nebulous and difficult with the use of MRI as a primary imaging modality.

[Imaging features of pubalgia]

Pubalgia is a generic term used to describe groin pain due to a multitude of different etiologies such as skeletal (microtraumatic pubic symphysis arthropathy), muscular (adductor or rectus abdominis disorders), or abdominal wall (inguinal hernia) disorders. Diagnosis relies mainly on MRI for musculoskeletal disorders and ultrasound for abdominal wall disorders.

Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia)

BACKGROUND

Chronic groin pain in athletes presents often a diagnostic and therapeutic challenge. Sportsman's hernia (also called "athletic pubalgia") is a deficiency of the posterior wall of the inguinal canal, which is often repaired by laparoscopic mesh placement. Endoscopic mesh repair may offer a faster recovery for athletes with sportsman's hernia than nonoperative therapy.

METHODS

A randomized, prospective study was conducted on 60 patients with a diagnosis of chronic groin pain and suspected sportsman's hernia. Clinical data and MRI were collected on all patients. After 3 to 6 months of groin symptoms, the patients were randomized into an operative or a physiotherapy group (n = 30 patients in each group). Operation was performed using a totally extraperitoneal repair in which mesh was placed behind the symphysis and painful groin area. Conservative treatment included at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. The outcome measures were pre- and postoperative pain using a visual analogue scale and partial or full recovery to sports activity at 1, 3, 6, and 12 months after randomization.

RESULTS

The athletes in both treatment groups had similar characteristics and pain scores. Operative repair was more effective than nonoperative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up (P < .001). Of the 30 athletes who underwent operation, 27 (90%) returned to sports activities after 3 months of convalescence compared to 8 (27%) of the 30 athletes in the nonoperative group (P < .0001). Of the 30 athletes in the conservatively treated group, 7 (23 %) underwent operation later because of persistent groin pain.

CONCLUSION

This randomized controlled study indicated that the endoscopic placement of retropubic mesh was more efficient than conservative therapy for the treatment of sportsman's hernia (athletic pubalgia).

Individualized multi-modal management of osteitis pubis in an Australian Rules footballer

OBJECTIVE

The purpose of this case report is to describe and discuss the successful management of osteitis pubis in a semi-elite Australian Rules football player through the utilization of an individualized multi-modal treatment approach provided by a chiropractor.

CLINICAL FEATURES

A 20-year-old male semi-elite Australian Rules football player presented to a chiropractic clinic with groin pain of eight months duration. A clinical diagnosis of osteitis pubis was made through synthesis of the patient history and physical examination.

INTERVENTION AND OUTCOME

Treatment consisted of high velocity low amplitude spinal manipulative therapy, mechanically assisted adjusting techniques utilizing a hand-held mechanical thrusting instrument and drop piece table, myofascial release and active release soft tissue techniques, proprioceptive neuromuscular facilitation stretching, and an individually designed rehabilitation program. Resolution of signs and symptoms occurred over four weeks. No recurrence of injury was reported over a six-month period.

CONCLUSIONS

This case suggests that the implementation of an individualized multi-modal management approach directed specifically toward an athlete's deficiencies and requirements, may lead to a more rapid recovery from osteitis pubis.

Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls

OBJECTIVE

Bone marrow edema (BME) at the pubic symphysis on magnetic resonance imaging (MRI) is usually associated with groin pain and stress injury of the pubic bone. Little is known of the pubic MR imaging findings of asymptomatic heavy training athletes in contact sports.

MATERIALS AND METHODS

Pelvic MRI of male asymptomatic soccer (n=10), ice hockey (n=10), bandy (n=10) and female floor-ball players (n=10) were compared with non-athlete controls (10 males, 10 females) without groin pain to analyse the presence of BME (on a four-point scale). To study the possible changes of BME directly following heavy physical activity, 10 bandy players underwent MRI before and immediately after a 2-h training session.

RESULTS

Magnetic resonance imaging showed minimal BME (grade 1) at the pubic symphysis in 19 of the 40 athletes (48%). Two soccer and 2 ice hockey players (20%) had moderate grade 2 pubic edema, but severe grade 3 BME findings were not found. Also 10 out of 20 (50%) of controls had grade 1 BME. The extent of increased signal was equally distributed in the asymptomatic athletes of different contact sports and controls. A heavy 2-h training session did not cause any enhanced signal at the pubic symphysis.

CONCLUSIONS

This study indicates that the presence of grade 1 pubic BME was a frequent finding in contact sports and comparable to that in non-athletes. Grade 2 BME was found only in asymptomatic athletes undergoing heavy training.

COMPARATIVE STUDY BETWEEN THE PUBIS OF ASYMPTOMATIC ATHLETES AND NON-ATHLETES WITH MRI

Objective: To compare the magnetic resonance imaging findings from the pubis of professional soccer players without any history or clinical findings of groin pain, and from sedentary individuals, also without symptoms, and to determine the prevalence of changes compatible with pubic overload. Methods: Nineteen professional soccer players without complaints of groin pain and seventeen sedentary individuals, also asymptomatic, underwent magnetic resonance imaging of the pubis. The results from the examinations were analyzed regarding the presence of degenerative changes, boned medullary edema and tendinopathy, and the two study groups were compared. Results: High prevalence of bone edema, tendinopathy and degenerative findings in the pubic symphysis was seen in the athletes, with statistically significant higher odds ratios and relative risk in the population studied. Conclusion: Professional soccer players are at a higher risk of developing changes in the pubic region, shown in magnetic resonance images, compared with sedentary individuals. These findings are not necessarily caused by groin pain, and are probably related to intense exertion.

Review: imaging of groin pain in the athlete

Chronic groin pain is a common entity in the sporting population and causes considerable morbidity. The differential diagnosis is wide, and this article presents a review of the common causes with particular reference to anatomy, ultrasound and magnetic resonance imaging (MRI) findings.

Sportsmen hernia: what do we know?

Athletes and other physically active people often suffer prolonged inguinal pain, which can become a serious debilitating condition and may place an athlete's career at risk. A sportsmen hernia is a controversial cause of this chronic groin pain, as it is difficult to be defined. From an anatomical point of view, the definition and the name of this entity should be reviewed. In the majority of athletic manoeuvres, a tremendous amount of torque or twisting occurs in the mid-portion of the body and the front, or anterior portion, of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that the forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles, and just this last possibility could be defined as "sportsmen hernia." In conclusion, this global entity could be considered to be an imbalance of the muscles (abductor and abdominal) at the pubis, that leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis, once a true origin is not detected, that may lead to a degenerative arthropathy of the pubic symphysis in the advanced stages. Based on this, this entity could be re-named as "syndrome of muscle imbalance of the groin" and the sportsmen hernia could be considered as an entity included in this syndrome. It is recommended that a multidisciplinary approach is given to this entity, since the present literature does not supply the proper diagnostic studies and the correct treatment which should be performed in these patients.

Adductor longus mechanics during the maximal effort soccer kick

Groin pain is a common cause of athletic disability and often involves the adductor longus. A common complaint of patients with groin problems is pain while preparing to kick the ball. The purpose of this study was to examine muscle length and activation of the adductor longus while kicking a soccer ball. Three-dimensional joint positions and muscle activation were obtained from 15 National Collegiate Athletic Association (NCAA) Division 1 male soccer players during maximal effort kicks. Musculoskeletal modeling techniques incorporating joint position and muscle attachments were used to estimate adductor longus length from the beginning of the kicking leg's swing phase until ball strike. The maximum rate of stretch of the adductor longus (22.3 +/- 5.3 cm/s) and maximum hip extension (23.3 +/- 8.80) occurred near 40% of swing phase. Activation of the adductor longus occurred between 10% and 50% of the swing phase. Adductor longus maximum length occurred at 65% of the swing phase. Maximum hip abduction (25.3 +/- 5.40) occurred at 80% of swing phase. The adductor longus appears to be at risk of strain injury during its transition from hip extension to hip flexion. This knowledge could be applied to muscle injury prevention and rehabilitation programs to aid with treatment of adductor longus related groin pain.

Subpubic cartilaginous cystic lesion presenting as a vulvar mass: a case report

Introduction

A subpubic cartilaginous cyst is a rare and innocent defect originating from the symphysis pubis and may present as a vulvar mass and/or chronic abdominal pain. The symphysis pubis is a non-synovial amphiarthrodial joint that forms a fibrocartilaginous union between the two pubic bones and in general lies without mainstream interest, despite its clinical relevance. This case report focuses attention on this joint.

Case presentation

A 55-year-old Caucasian woman presented with a painful and rapidly increasing vulvar mass. Imaging techniques revealed a cyst-like structure originating from a degenerated symphysis pubis. The cyst was excised, however, recovery was complicated by a symphysiolysis.

Conclusion

A subpubic cartilaginous cyst is a rare cystic lesion originating from the symphysis of the pubic bone which presents as a vulvar mass which might be complicated by symphysiolysis. Several diseases affect the symphysis pubis and result in significant discomfort and disability in patients. The symphysis pubis is therefore clinically important and should not be omitted in the differential diagnosis of a vulvar mass and/or chronic abdominal pain.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Bone biopsy of the parasymphyseal pubic bone region in athletes with chronic groin injury demonstrates new woven bone formation consistent with a diagnosis of pubic bone stress injury

BACKGROUND

There is little scientific evidence available regarding the pathologic basis for chronic groin injury in athletes, a known difficult clinical problem.

HYPOTHESIS

Histological analysis of the superior pubic ramus in athletes with diagnosed chronic groin injury may reveal the nature of the pathologic process.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Ten athletes with a diagnosis of chronic groin injury by clinical criteria (at least 6 weeks of pain) and magnetic resonance imaging criteria (unequivocal increase in T2 signal intensity) underwent bone biopsy of the superior pubic ramus. The biopsy site was located in the parasymphyseal region in the area of increased magnetic resonance image signal intensity. Histologic analysis of the specimens was then undertaken.

RESULTS

Evidence of new woven bone was seen in all biopsy specimens. Signs of old bony injury were seen in 8 of the 10 specimens. There was no evidence of inflammation or osteonecrosis.

CONCLUSION

Histologic analysis of bone biopsy specimens taken from the parasymphyseal pubic bone region with magnetic resonance imaging T2-weighted increased signal intensity of athletes diagnosed by clinical and magnetic resonance imaging criteria as having chronic groin injury demonstrates new woven bone formation. This is consistent with the athlete having a bone stress injury that may contribute significantly to athletic groin pain.

A suspicious vulvar mass diagnosed as a subpubic cartilaginous cyst

BACKGROUND

Subpubic cartilaginous cysts were initially described in 1996 with few reports to date.

CASE

We describe a 62-year-old woman with a history of breast cancer who presented with a painful, fixed, vulvar mass. MRI revealed an 18 x 10 x 12 mm3 mass extending from the anterior portion of the symphysis pubis without bony involvement. Excision was performed. Histologically, the mass consisted of fibrocartilage with extensive degenerative changes, compatible with a subpubic cartilaginous cyst. Over 24 months later, there has been no recurrence.

CONCLUSION

Subpubic cartilaginous cyst is a rare, benign lesion occurring on the vulva and should be considered in the differential diagnosis of a painful, superior vulvar mass.

Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings

OBJECTIVE

Groin pain in elite athletes is a common yet challenging diagnostic and management dilemma for the sports clinician, accounting for a significant proportion of athletic injuries. It is often debilitating and, if severe enough, may compromise an athlete's career. Traditionally, groin pain has been poorly understood by radiologists.

CONCLUSION

A major reason groin pain has been misunderstood is the complexity of the anatomy of this region, which this article discusses in detail in an effort to inform the reader.

Prevention and management of osteitis pubis in the Australian Football League: a qualitative analysis

OBJECTIVES

To examine current practices and develop a set of recommendations for the management of osteitis pubis in the Australian Football League (AFL).

DESIGN

A qualitative study using in-depth interviews to gather data and thematic coding to analyze findings.

SETTING

Participants were interviewed in their workplace or at a convenient meeting point.

PARTICIPANTS

Thirty-six medical and fitness staff from the 16 AFL clubs.

RESULTS

Respondents from all clubs viewed osteitis pubis as an overuse injury and recognized that the key to prevention is balancing pelvic integrity and load. Osteitis pubis was described as the end result of a continuum of groin pathology, and recognition of predisposing factors and early detection were identified as the key elements of optimal management. Management strategies included rest, training modification, cross-training, correction of predisposing factors, physical therapy and a progression back to competition. Most clubs also conduct generic prevention and education programs.

CONCLUSIONS

Overall, respondents perceived that awareness and management of osteitis pubis is currently at a high level in the AFL. Management of osteitis pubis requires the balancing of pelvic integrity and mechanical load through the pelvis and the early identification of warning signs.

Bone marrow edema-like signal in the athlete

Sports medicine is one of the most rapidly growing subspecialties in orthopaedics and therefore radiologists will be confronted with it more and more often. With the increased use of MR imaging in evaluating joint and muscle pathology in athletes new challenges emerge. One of these challenges is the role of BME, high-signal intensity on T2-weighted MR images. Some studies find a positive association between BME and clinical complaints, whereas other studies do not. Even more interesting is the finding that BME seems to appear quite often in asymptomatic athletes, although little has been reported in the literature about the MR imaging findings in the asymptomatic knee of the dedicated athlete. As the field of sports medicine expands, radiologists will increasingly deal with the presence of BME in athletes.

Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes

BACKGROUND

In athletes, osteitis pubis is regarded as a problem of overuse, with instability and movement of the anterior pelvis. There is no evidence to conclusively support any treatment modality. Recovery with nonoperative management can take an extended period of time, often unsatisfactory for professional athletes.

HYPOTHESIS

Curettage of the pubic symphysis is a viable option for nonoperative treatment of resistant osteitis pubis in athletes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study presents the results of curettage of the pubic symphysis in 23 athletes with osteitis pubis that was refractory to initial nonoperative therapies. Patients met the criteria for the study if they had symptoms suggestive of osteitis pubis and underwent isolated pubic symphysis curettage. The discomfort had been present for a mean of 13.22 months before presentation. Patients were reviewed at 24.31 months (range, 12.5-59.6 months) postoperatively. Twelve of the patients also underwent a postoperative magnetic resonance imaging scan at 19.10 months; any findings of residual osteitis pubis were noted.

RESULTS

Mean visual analog scale for pain improved from 6.9 preoperatively to 2.8 postoperatively (P = .36). Twenty-one patients returned to pain-free running by 3.14 months (range, 1.5-6 months), 17 to training by 4.44 months (range, 2.5-7 months), and 16 to full activity by 5.63 months (range, 2.5-12 months). Overall, 61% of patients reported an activity grade of 4 at postoperative review, defined as no pain with full activity. There were no significant postoperative complications in the study group. Marrow edema improved in most cases for which magnetic resonance imaging was available preoperatively and postoperatively. Patient satisfaction with the procedure was high, with 78% of participants feeling their symptoms were better or much better than preoperatively.

CONCLUSION

The authors suggest that this relatively simple procedure can be of significant benefit to those athletes wishing to return to their previous levels of physical activity when more nonoperative measures have proven unsuccessful.

Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training

BACKGROUND

Osteitis pubis is characterized by diffuse pain, inflammation, and bony changes in the pubic symphysis. Bone marrow edema in magnetic resonance imaging is associated with stress injury and osteitis of the pubic bone.

HYPOTHESIS

Laparoscopic mesh repair decreases inflammation and pain in the pubic periosteum. The presence of extensive bone marrow edema may correlate with the severity of symptoms and may guide the surgical treatment of osteitis pubis.

STUDY DESIGN

Case control study; Level of evidence, 4.

METHODS

Surgery (n = 8) was performed by placement of totally extraperitoneal endoscopic mesh behind the symphysis. Nonoperative treatment (n = 8) included physical therapy and corticosteroids. Preoperative and postoperative pain was measured by the visual analog scale. Athletes were followed up from 1 to 6 years (mean, 2.7 years). All magnetic resonance imaging scans were analyzed blindly by 2 radiologists. Twenty asymptomatic ice hockey or soccer players served as controls in magnetic resonance imaging.

RESULTS

The patients treated surgically had higher preoperative pain scores than did the patients treated conservatively. Seven of 8 athletes (88%) treated surgically returned to sport activities after 2 months of convalescence. No complications were associated with surgery. In the nonoperative group, 4 patients (50%) still had disabling symptoms after 1 year of follow-up, and they stopped their elite sports during 3 years of follow-up. The presence of bone marrow edema was distributed in the surgical (100%), nonoperative (88%), and asymptomatic athletes (65%) with no statistical difference between the groups.

CONCLUSION

This study indicated that the placement of retropubic mesh was an efficient method for the treatment of severe pubic enthesopathy in athletes. Abnormal magnetic resonance imaging findings were also common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making.

Gas-filled parasymphyseal pubic cyst associated with degenerative joint disease

Parasymphyseal cysts are a rare and poorly understood entity. This case report describes a gas-containing parasymphyseal cystic lesion associated with degenerative change and vacuum phenomenon in the pubic symphysis. The mass was discovered incidentally in a 72-year-old asymptomatic male who underwent a transrectal ultrasound-guided biopsy of the prostate and the nature of the lesion was confirmed on magnetic resonance imaging (MRI) and computed tomography (CT). We hypothesize that the gas within the parasymphyseal cystic mass arose from a vacuum phenomenon in the pubic symphysis, with subsequent extrusion of gas from the joint into the cyst itself. It is important for radiologists to be aware of the existence of this entity to avoid unnecessary surgery for patients.

Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis

OBJECTIVE

The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis.

SUBJECTS AND METHODS

Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details.

RESULTS

In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues.

CONCLUSION

Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury

BACKGROUND

Little data exist on the results of treatment for sports-related chronic groin injury.

HYPOTHESIS

Sports-related chronic groin injury treated with a conservative (rest) program results in a satisfactory outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Professional Australian male football players, at the end of the playing season, had their groin injury diagnosed using specific clinical and magnetic resonance imaging (MRI) criteria. Those assessed as having a non-hip-related cause for their chronic groin injury were treated principally by 12 weeks of complete rest from active weightbearing activities. Response to treatment was assessed at different stages of rehabilitation by recording the number of athletes who had returned to playing football and the number of athletes without symptoms.

RESULTS

Twenty-seven athletes were considered to have chronic groin injury. Clinical and MRI (pubic bone marrow edema N = 26 [96%]), hyperintense line N = 25 [93%]) criteria suggested a pubic bone stress injury as diagnosis for the chronic groin injury. Eighty-nine percent of athletes returned to sport in the subsequent playing season, with 100% having returned by the second playing season after diagnosis. Forty-one percent of the athletes were without symptoms at the commencement of the following playing season, rising to 67% by the end of that playing season.

CONCLUSIONS

Conservative management of athletic chronic groin injury resulted in an excellent outcome when assessed by the return to sport criterion. However, the results were only satisfactory if the criterion of ongoing symptoms after treatment was used. More research is needed to compare the efficacy of all treatments that are used in this troublesome condition.

Patterns of Bone and Soft-Tissue Injury at the Symphysis Pubis in Soccer Players: Observations at MRI

OBJECTIVE

The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other.

MATERIALS AND METHODS

One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test.

RESULTS

Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001).

CONCLUSION

In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

The athletic hernia: a systematic review

The athletic hernia is an obscure condition of uncertain etiology commonly seen in soccer and rugby players. The pain is often debilitating and may place an athletic career at risk. Treatment failures are frustrating to the athlete and the physician. The anatomy involved, diagnostic criteria, and treatment modalities are inconsistently described in the medical, surgical and orthopaedic literature. There is no evidence-based consensus available to guide decision-making. We performed an overview of the anatomy and pathoanatomy and a systematic review of the literature to gain insight into the disease and its treatment. Most studies are Level IV. The most common operative finding is a deficient posterior wall of the inguinal canal, although other abdominal wall abnormalities are frequently found. Open and laparoscopic repairs produce excellent results, but the latter allows earlier return to play. Magnetic resonance imaging appears to have excellent diagnostic potential for athletic hernia. A multidisciplinary approach to groin pain in the athlete is recommended.

Magnetic resonance findings of osteitis pubis

PURPOSE

To determine the correlation of MR findings with clinical features of osteitis pubis and to look for associating injuries complicating chronic cases.

MATERIALS AND METHODS

Pelvic MR images of the 22 elite athletes with groin pain were taken. Correlation analysis between the MR findings and clinical properties was carried out.

RESULTS

Six of the MR findings had strong correlation with duration of symptoms. Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema had significant correlation with acuity of the case. On the contrary, subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes correlated with the chronicity of the case. Associated tendon injuries correlated with the duration of symptoms; i.e., all tendon injuries were in chronic cases.

CONCLUSION

Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema are the most reliable MRI findings of osteitis pubis that has a history of less than six months. Subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes (or pubic beaking) are the most reliable MRI findings of the chronic disease that has been present for more than six months. Associated pathologies, especially adductor or other tendon injuries, underlie more than half of the chronic cases of osteitis pubis.

When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.

Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad

OBJECTIVES

To assess bone marrow edema at the pubic symphysis with magnetic resonance imaging (MRI), and its relation to training and osteitis pubis in an elite group of junior soccer players.

SETTING

Soccer players on scholarship at the Australian Institute of Sport (AIS).

PATIENTS

Nineteen players from an elite junior men's soccer squad. INTERVENTION/ASSESSMENT: Serial MRI examinations of the pubic symphysis over a 4-month training and playing period, training session questionnaire, and review of clinical diagnosis, investigations, and records on presentation of athletes with groin pain at the Department of Sports Medicine.

MAIN OUTCOME MEASURES

Assessment of bone marrow edema (4-point scale) on MRI scans, review of athlete questionnaires, and review of clinical records.

RESULTS

Initial MRI scans showed moderate to severe bone marrow edema at the pubic symphysis in 11 of the 18 asymptomatic players. There was a greatly decreased risk of developing groin pain (osteitis pubis) with more training prior to entry of the AIS soccer program (odds ratio per 4 sessions of training, 0.003). The correlation between initial bone marrow edema grading and pre-AIS training was small. The increase in bone marrow edema grading from baseline over the scans was 0.5 (90% CL, 0.4).

CONCLUSIONS

Substantial amounts of bone marrow edema at the pubic symphysis can occur in asymptomatic elite junior soccer players, but it is only weakly related to the development of osteitis pubis. Progressing training loads more slowly in athletes presenting with low current training loads may be a useful strategy for the prevention of osteitis pubis in junior soccer players.

Abnormalities in and Around the Hip: MR Imaging Versus Sonography

Sonography and MR imaging should be considered complementary rather than competing modalities. They demonstrate similar abnormalities of the soft tissues, but MR imaging is able to demonstrate intraosseous and articular abnormalities and offers a better anatomic overview because of its larger field of view, whereas sonography offers dynamic evaluation and can provide real-time guidance for percutaneous procedures. Both of these modalities have roles in the imaging evaluation of injuries in and around the hip.

MR Imaging of Sports-Related Groin Pain

With increasing participation in professional and recreational athletics, activity-limiting pelvic and groin pain presents a growing challenge for patients and health care providers. The causes of musculoskeletal-related groin pain among athletes are diverse, with considerable overlap in history and physical examination findings. Pubalgia is a clinical diagnosis invoked when no more specific cause ofa patient's symptoms can be determined on history and physical examination. In many cases, dedicated MR imaging of the hip and pelvis can provide a prompt and specific diagnosis, which allows for early treatment and return to participation.

Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury

Traumatic osteitis pubis is a non-specific entity that relates to chronic groin injury and has recently been described as being akin to a pubic bone stress injury. It is uncertain whether or not reduction of hip joint range of motion occurs in traumatic osteitis pubis. The purpose of this study was to establish whether there is a reduction of hip range of motion in athletes who have chronic groin injury diagnosed as pubic bone stress injury. A case-control study was performed whereby 89 Australian Rules footballers underwent, with clinical history unknown, clinical and MRI examination of the groin region. Clinical criteria (pain with tenderness) and MR-criteria (pubic bone marrow oedema) were used for diagnosis of pubic bone stress injury. End-range internal and external rotation hip motion was measured using a goniometer. Athletes with and without symptoms were compared, as were athletes with current symptoms with athletes who had recovered from their groin pain episode. Chronic groin injury was diagnosed in 47 athletes with 37 having pubic bone stress injury. Thirteen athletes had previous groin injury. A reduction of internal and external hip range of motion was demonstrated in athletes with pubic bone stress injury (p < 0.05) and in athletes who had current symptoms compared to those who had recovered from their groin pain episode (p < 0.05). A reduction in hip range of motion was evident in athletes with chronic groin injury diagnosed as pubic bone stress injury. There may be a role for increasing hip range of motion in rehabilitation.

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome

BACKGROUND

Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation.

HYPOTHESIS

Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season.

RESULTS

Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not.

CONCLUSION

Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.

Surgery for posterior inguinal wall deficiency in athletes

This study retrospectively evaluated the outcome for patients undergoing herniorraphy for chronic groin pain due to posterior inguinal wall deficiency, and correlated the outcome with preoperative investigation findings. There were 47 patients (with a total of 52 herniorraphies) who were contacted by phone between six and 50 months post surgery. Subjects had a diagnosis of posterior inguinal wall deficiency made on history and clinical examination. Thirty seven patients had an ultrasound scan prior to the surgery (three bilateral) with a total of 40 symptomatic groins scanned. There were 26 abnormal scans (22 posterior inguinal wall deficiency and four hernias) and 14 normal scans. Twenty nine patients had a technetium-99m bone scan with 22 having increased uptake at the symptomatic pubic tubercle, while 13 had increased uptake at other sites in the groin. Seventy seven percent of patients had a full return to sport after surgery and the average time to return to sport was four months. There was no significant difference in outcome between subjects who had an abnormal ultrasound scan on the symptomatic side and those who had a normal scan. There was a significant difference in outcome between patients who had a bone scan with increased uptake at the symptomatic pubic tubercle and those who did not (p < 0.04). Our study supports previous research that good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Ultrasound scan does not appear to aid in predicting surgical outcome, while the role of isotope bone scanning requires further study.

Delayed onset of transversus abdominus in long-standing groin pain

Long-standing groin pain is a persistent problem that is commonly difficult to rehabilitate. Theoretical rationale indicates a relationship between the motor control of the pelvis and long-standing groin pain; however, this link has not been investigated.

PURPOSE

The current experiment aimed to evaluate motor control of the abdominal muscles in a group of Australian football players with and without long-standing groin pain.

METHODS

Ten participants with long-standing groin pain and 12 asymptomatic controls were recruited for the study. Participants were elite or subelite Australian football players. Fine-wire and surface electromyography electrodes were used to record the activity of the selected abdominal and leg muscles during a visual choice reaction-time task (active straight leg raising).

RESULTS

When the asymptomatic controls completed the active straight leg raise (ASLR) task, the transversus abdominus contracted in a feed-forward manner. However, when individuals with long-standing groin pain completed the ASLR task, the onset of transversus abdominus was delayed (P < 0.05) compared with the control group. There were no differences between groups for the onset of activity of internal oblique, external oblique, and rectus abdominus (all P > 0.05).

CONCLUSIONS

The finding that the onset of transversus abdominus is delayed in individuals with long-standing groin pain is important, as it demonstrates an association between long-standing groin pain and transversus abdominus activation.

Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation

PURPOSE

To determine whether the secondary cleft sign demonstrated in the symphysis pubis at magnetic resonance (MR) imaging is a marker of injury in athletes presenting with groin pain.

MATERIALS AND METHODS

Ethics review board approval was not required for studies involving retrospective image or case record review; informed consent for review was not required. Eighteen male athletes (mean age, 24 years; age range, 19-32 years) were included for study. All patients underwent radiography and MR imaging (coronal fast spin-echo T1-weighted, transverse fast spin-echo T2-weighted, and coronal turbo short inversion time inversion-recovery [STIR] imaging) of the pelvis. Subsequent image-guided nonionic contrast material injection was followed by a 0.5% bupivacaine hydrochloride (1 mL) and methyprednisolone acetate (20 mg) injection into the central cleft of the symphysis pubis. Comparison was made between imaging findings at symphyseal cleft injection and appearances at preprocedure MR imaging, with specific reference to the presence of a secondary cleft. The sensitivity and specificity of MR imaging in demonstrating the secondary cleft sign were compared with those of the reference standard, imaging at symphyseal cleft injection. MR images from a reference group of 70 asymptomatic athletes who underwent STIR imaging of the pelvis were analyzed for evidence of a secondary cleft.

RESULTS

Osteitis pubis was diagnosed in six patients on the basis of radiography and/or MR imaging. A secondary cleft was identified in 12 of 18 patients at MR imaging, was best visualized at coronal STIR imaging, and was confirmed in each patient during contrast material injection into the central physiologic symphyseal cleft. In no patient was a secondary cleft identified at symphyseal cleft injection and not identified at MR imaging (sensitivity and specificity, 100%). In each patient, the side of the secondary cleft corresponded to the side of symptoms that responded to local anesthetic and steroid injection. Four of the six patients with osteitis pubis had evidence of a secondary cleft. In one patient, a secondary cleft was not identified at MR imaging or symphyseal cleft injection, but adductor avulsion was identified at MR imaging. No evidence of a secondary cleft sign at MR imaging was identified in the reference group.

CONCLUSION

The secondary cleft sign demonstrated at MR imaging is a marker of groin injury in athletes presenting with groin pain.

Totally extraperitoneal endoscopic (TEP) treatment of sportsman's hernia

Sportsman's hernia is a term used to describe a weakness or disruption of is a term used to describe the musculotendinous part of the posterior inguinal wall, which causes persistent groin pain in athletes. A video-assisted placement of extraperitoneal synthetic mesh to support the damaged area may heal this injury. Forty-one male athletes at an elite level (mean age 27 +/- 7.1 years) with chronic groin pain, which was resistant to conservative therapy, were referred to surgery by sports clinics or club doctors. The majority of the patients were soccer (58%) or ice hockey players (27%) at a professional level. A 10 x 15 cm polypropylene mesh was placed into the preperitoneal space using a totally extraperitoneal video-assisted technique. The severity of pain, and the time to return to sports, were determined after 1 month and after the mean follow-up of 4 years. On operation, no macroscopic abnormality was found in 24 patients (58%), obvious musculotendinous tear was present in 10 patients, and muscle asymmetry was present in 7 patients. All except 2 patients (95%) returned to their sport activities after 1 month of convalescence. No immediate or long-term complications were associated with the operation. The placement of a retropubic mesh was safe and a mini-invasive method to repair sportsman's hernia and chronic groin pain of athletes.