Surface Mapping of the Musculotendinous Attachments at the Pubic Symphysis in Cadaveric Specimens: Implications for the Treatment of Core Muscle Injury

The Role of MRI in Groin Pain Syndrome in Athletes

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain

Groin pain is prevalent in orthopedic and sports medicine, causing reduced mobility and limiting sports activity. To effectively manage groin pain, understanding the detailed anatomy of supporting muscles is crucial. This study aimed to investigate the musculoaponeurotic attachments on the pubis and the relationship among intramuscular aponeuroses of abdominal and thigh adductor musculatures. Macroscopic analyses were performed in 10 pelvic halves. The bone morphology of the pubis was assessed in two pelvic halves using microcomputed tomography. Histological investigations were conducted in two pelvic halves. The external oblique aponeurosis extended to the adductor longus aponeurosis, forming conjoined aponeurosis, which attached to a small impression distal to the pubic crest. The gracilis aponeurosis merges with the adductor brevis aponeurosis and is attached to the proximal part of the inferior pubic ramus. The rectus abdominis and pyramidalis aponeuroses were attached to the pubic crest and intermingled with the gracilis-adductor brevis aponeurosis, forming bilateral conjoined aponeurosis, which attached to a broad area covering the anteroinferior surface of the pubis. Histologically, these two areas of conjoined aponeuroses were attached to the pubis via the fibrocartilage enthesis. Microcomputed tomography revealed two distinctive bone morphologies, a small impression and an elongated osseous prominence on pubis, corresponded to the two areas of conjoined aponeuroses. This study demonstrated close relationships between the aponeurotic attachment of the external oblique and adductor longus, and between the rectus abdominis, pyramidalis, gracilis, and adductor brevis. The findings of aponeurotic complexes would aid in diagnostic and surgical approaches for athletic groin pain.

Anatomy and terminology of groin pain: Current concepts

Groin pain is a common symptom in athletes. The complex anatomy of the area and the various terms used to describe the etiology behind groin pain have led to a confusing nomenclature. To solve this problem, three consensus statements have been already published in the literature: the Manchester Position Statement in 2014, the Doha agreement in 2015, and the Italian Consensus in 2016. However, when revisiting recent literature, it is evident that the use of non-anatomic terms remains common, and the diagnoses sports hernia, sportsman's hernia, sportsman's groin, Gilmore's groin, athletic pubalgia, and core muscle injury are still used by many authors. Why are they still in use although rejected? Are they considered synonyms, or they are used to describe different pathology? This current concepts review article aims to clarify the confusing terminology by examining to which anatomical structures authors refer when using each term, revisit the complex anatomy of the area, including the adductors, the flat and vertical abdominal muscles, the inguinal canal, and the adjacent nerve branches, and propose an anatomical approach, which will provide the basis for improved communication between healthcare professionals and evidence-based treatment decisions.

Cadaveric Analysis of Key Anatomic Structures of Athletic Pubalgia

PURPOSE

This study proposes to establish in-depth inspection of the anatomic structures involved with the pathology of athletic pubalgia in a cadaver model.

METHODS

Eight male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy.

RESULTS

The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilioinguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genitofemoral nerve were just lateral to the ilioinguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively.

CONCLUSION

Surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

New Insights into the Musculotendinous and Ligamentous attachments at the Pubic Symphysis: a systematic review

OBJECTIVE

Collection and meta-analysis of all relevant anatomical studies related to the pubic symphysis to provide a state of the art review of its musculotendinous and ligamentous attachments from 2010 to date.

METHODS

A systematic search of published literature databases (PubMed, Web of Science and Embase) was conducted according to the PRISMA guidelines from January 2010 up until now. All papers investigating the anatomy of the musculotendinous attachments of the pubis and the pubic ligaments were eligible. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS scale). A narrative analysis approach was adopted to synthesise the findings.

RESULTS

After screening and review of 1313 papers, a total of six studies investigating the anatomy of the pubic ligaments and tendons were included. Of the six articles included in this systematic review, five articles performed a macroscopic anatomical dissection, three articles performed a microscopic (histological) study, and one article combined microscopic examination with an MRI imaging examination. The anatomy of the pubic symphysis was examined in 76 anatomical cadavers (60 embalmed, 16 fresh frozen). In total 44 male cadavers (58%), 28 female cadavers (37%) and four cadavers whose gender was not stated were dissected.

CONCLUSION

The age-old accepted concept of the fusion of the rectus abdominis with the adductor longus via the aponeurotic plate is outdated. New anatomical concepts like the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC), recto-gracilis tendon, fusion of adductor brevis with gracilis, etc. are recently introduced. The awareness of anatomy and morphology of the pubic ligaments plays a significant role in understanding the diagnosis and treatment of groin pain.

A proposed algorithm for the treatment of core muscle injuries

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption

PURPOSE

To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.

RESULTS

Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.

CONCLUSIONS

A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.

LEVEL OF EVIDENCE

Level V, systematic review of Level I to V studies.

Hip Adductor Longus Tendon Origin Anatomy Is Consistent and May Inform Surgical Reattachment

Purpose

To define the topographic anatomy of the footprint of the adductor longus origin on the pubis and its underlying bony morphology to better inform surgical repair of adductor longus tendon injuries.

Methods

Five cadaveric pelvis specimens were dissected, making 10 adductor footprints available for analysis. The adductor longus tendon origin was isolated and the surrounding tissue debrided. The circumference of the tendinous attachment to the pubic crest was marked before excising the tendon and fibrocartilage enthesis from the pubis. Radiopaque paint was prepared by mixing 30 mL of all-purpose acrylic paint (Anita’s no. 11150 Island Blue; Rust-Oleum Corp, Vernon Hills, IL) with 15g of E-Z-HD 98% w/w barium sulfate (Bracco Diagnostics Inc., Anjou Quebec, Canada) and applied to the marked footprint. The specimens underwent a 1.0-mm slice computed tomographic scan with 3-dimensional reconstructions. Synapse PACS (FujiFilm, Valhalla, NY) software for measurements of the tendon footprint and underlying bone.

Results

Average age and weight of the specimens at the time of death was 37 years and 204.6 ± 48.7 lbs, respectively. The width and length of the tendon origin was 12.0 ± 1.1 mm and 10.9 ± 1.1 mm, respectively. The distance of the center of the footprint from the center of the pubic tubercle was 8.5 ± 1.4 mm lateral and 12.2 ± 0.4 mm caudal. The osseous thickness underlying the footprint was 18.7 ± 3.7 mm at an angle of 34.5 ± 1.5° in relation to the sagittal plane. The correlation between specimen body weight and the thickness of the bone underlying the footprint was strongly positive (r = 0.92).

Conclusions

We found that there is a consistent angle from the center of the adductor longus tendon footprint to the point of maximal underlying bony thickness, as well as a positive correlation between body mass index and osseous thickness, which may inform anatomic reattachment of this tendon.

Clinical Relevance

Our findings will assist surgeons in identifying the footprint of the adductor longus tendon and safely perform anatomic repair of adductor longus tendon avulsions.

Core Muscle and Adductor Injury

Core muscle injury is a common but difficult problem to treat. Although it can affect all individuals, it is most commonly seen in male athletes in cutting, twisting, pivoting, and explosive sports. Owing to the high association of femoroacetabular impingement, we believe these individuals are best treated with a multidisciplinary approach involving both orthopedic and general surgeons. Conservative treatment should be the first step in management. When conservative means are unsuccessful, operative intervention to correct all the pathologic issues around the pubis can have extremely high success rates.

Athletic Pubalgia (Sports Hernia): Presentation and Treatment

Often referred to as a "sports hernia" or "core muscle injury," athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. Symptoms can appear acutely or insidiously, primarily as groin and lower abdominal pain that can radiate toward the perineum and proximal adductors. Pain is exacerbated by athletic activity such as kicking, cutting, and sprinting. The pubis acts as a pivot point between the abdominal musculature and lower-extremity adductors, and therefore, pain with palpation over the symphysis or its surrounding structures is typical in athletic pubalgia. Symptoms can be reproduced during a resisted sit-up or with a forced cough or sneeze. Clinical examination should include an evaluation of articular hip pathology to identify underlying femoroacetabular impingement syndrome. Magnetic resonance imaging can aid in ruling out other pathologies and identify specific findings including tears or strains of the ipsilateral rectus abdominis or adductor tendons. Lidocaine injections can be used to localize the source of the pain. First-line treatment consists of a period of rest and anti-inflammatories, followed by a course of focused physical therapy. If conservative therapy fails to allow an athlete to return to activity, a variety of open or laparoscopic surgical techniques can be used. The surgical principles include reattachment of the rectus abdominis and repair or reinforcement of the abdominal musculature in layers to re-create the inguinal ligament anatomy. At times, variations of pelvic floor repair are performed or the addition of an adductor tenotomy or repair is used concomitantly. Numerous studies report a high rate of return to play after surgical management. Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity.

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy: a 10-year experience in the treatment of athletic pubalgia

BACKGROUND

Athletic pubalgia, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. Hence, a few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology (Brody in Hernia 21:139-147, 2016, https://doi.org/10.1007/s10029-016-1520-8 ; Rossidis et al. in Surg Endosc 29:381-386, 2015, https://doi.org/10.1007/s00464-0143679-3 ). However, these studies are small and few in quantity but have demonstrated promising results. Thus, we sought to further study this combined surgical approach as a treatment for this multifactorial disease to improve our understanding and outcomes.

METHODS

With IRB approval, we retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of athletic pubalgia at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intraoperative and postoperative complications, and time to return to athletic activities.

RESULTS

A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all performed by a single surgeon at two academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n = 18), triathlon (n  = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4 min. Most patients were found to return to athletic activity in 28 days following a standardized physical therapy regimen (92.5%). Postoperative complications included recurrence of pain/symptoms (7.5%, n = 7), urinary retention (2.2%, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1%,  n = 1), and adductor brevis hematoma 3 months following surgery and rehabilitation (1.1%, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain.

CONCLUSIONS

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy appears to be a relatively quick and safe procedure with few postoperative complications. The majority of treated athletes are able to return to full athletic activities within 28 days of operation. While a return of symptoms has been seen in some patients, it is frequently observed on the contralateral side.

Editorial Commentary: Core Muscle Injury: The Anatomy Is Enlightening

Core muscle injuries are being diagnosed with increasing frequency in athletes. Knowledge of the anatomy is key to understanding the pathology. Notably, the origin on the pubis of the majority of adductor long muscles is via direct insertion of the muscle to the bone and not via a tendon, thus making direct repair difficult.