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Nishimura H, Gao X, Niga S, Fukase N, Murata Y, Quinn PM, Saito M, Utsunomiya H, Uchida S, Huard J, Philippon MJ. Cleft Sign in MRI May Represent the Disruption of Cartilage Structure within Pubic Symphysis and Pubic Plate: A Cadaver Case Report. Diagnostics (Basel) 2024; 14:2098. [PMID: 39335777 PMCID: PMC11431435 DOI: 10.3390/diagnostics14182098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 09/13/2024] [Accepted: 09/19/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND/OBJECTIVES Long-standing groin pain is a severe issue for athletes, often associated with the cleft sign on magnetic resonance imaging (MRI) scans, yet its underlying causes are poorly understood. The purpose of this study is to histologically examine the pubic plate structure in cadavers with and without the cleft sign on MRI, shedding light on the pathology behind the cleft sign. METHODS Three fresh human pelvic cadavers underwent 3.0T MRI to detect the cleft sign before histological dissection of pubic plates. Pubic plate tissues were fixed in formalin, decalcified, and processed. Of the two cleft sign-negative specimens, one was cut into sagittal sections, and the other was cut into coronal sections for histology. For the cleft sign positive specimen, a sagittal section was cut. Moreover, 5 µm thick sections were cut at different axial levels for each orientation. Sections were subjected to Safranin O, Alcian blue, and Herovici's staining or hematoxylin and eosin staining. RESULTS MRI confirmed that one specimen had a cleft sign in the inferior region on both sides of the pubis and that two specimens had no cleft sign. Both sagittal and coronal sections showed the presence of a cartilage structure continuing from the pubic symphysis to 3 mm laterally within the pubic plate. In the specimen with a positive cleft sign, cartilage damage within the pubic symphysis and pubic plate was identified as revealed by Safranin O staining, Herovici's staining, and H&E staining. CONCLUSIONS This study elucidated the existence of a cartilage component extending from the pubic symphysis to the pubic plate. The cleft sign in MRI correlated with a disruption in the cartilage component in histology within this specific area.
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Affiliation(s)
- Haruki Nishimura
- The Linda & Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA; (H.N.); (X.G.); (P.M.Q.); (J.H.)
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu, Kitakyushu-city 808-1264, Fukuoka, Japan; (Y.M.); (S.U.)
| | - Xueqin Gao
- The Linda & Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA; (H.N.); (X.G.); (P.M.Q.); (J.H.)
| | - Sadao Niga
- JIN Orthopaedic & Sports Clinic, 3-10-7 Suzuya, Chuo-ku, Saitama-city 338-0013, Saitama, Japan
| | - Naomasa Fukase
- Department of Orthopaedic Surgery, Kobe University, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe-city 650-0017, Hyogo, Japan;
| | - Yoichi Murata
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu, Kitakyushu-city 808-1264, Fukuoka, Japan; (Y.M.); (S.U.)
| | - Patrick M. Quinn
- The Linda & Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA; (H.N.); (X.G.); (P.M.Q.); (J.H.)
| | - Masayoshi Saito
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashibaru, Mito-city 310-0035, Ibaraki, Japan;
| | - Hajime Utsunomiya
- Tokyo Sports & Orthopaedic Clinic, 4-29-9 Kamiikebukuro, Toyoshima-ku, Tokyo 170-0012, Japan;
| | - Soshi Uchida
- Department of Orthopaedic Surgery and Sports Medicine, Wakamatsu Hospital of University of Occupational and Environmental Health, 1-17-1 Hamamachi, Wakamatsu, Kitakyushu-city 808-1264, Fukuoka, Japan; (Y.M.); (S.U.)
| | - Johnny Huard
- The Linda & Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA; (H.N.); (X.G.); (P.M.Q.); (J.H.)
| | - Marc J. Philippon
- The Linda & Mitch Hart Center for Regenerative and Personalized Medicine, Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA; (H.N.); (X.G.); (P.M.Q.); (J.H.)
- The Steadman Clinic, 181 West Meadow Dr., Suite 1000, Vail, CO 81657, USA
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Holl N, Gerhardt JS, Tischer T, Krüger J, Arevalo-Hernandez A, Lenz R, Weber MA. Comparison between dedicated MRI and symphyseal fluoroscopic guided contrast agent injection in the diagnosis of cleft sign in athletic groin pain and association with pelvic ring instability. Eur Radiol 2023; 33:7321-7329. [PMID: 37145146 PMCID: PMC10511360 DOI: 10.1007/s00330-023-09666-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/07/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE To compare dedicated MRI with targeted fluoroscopic guided symphyseal contrast agent injection regarding the assessment of symphyseal cleft signs in men with athletic groin pain and assessment of radiographic pelvic ring instability. METHODS Sixty-six athletic men were prospectively included after an initial clinical examination by an experienced surgeon using a standardized procedure. Diagnostic fluoroscopic symphyseal injection of a contrast agent was performed. Additionally, standing single-leg stance radiography and dedicated 3-Tesla MRI protocol were employed. The presence of cleft injuries (superior, secondary, combined, atypical) and osteitis pubis was recorded. RESULTS Symphyseal bone marrow edema (BME) was present in 50 patients, bilaterally in 41 patients and in 28 with an asymmetrical distribution. Comparison of MRI and symphysography was as followed: no clefts: 14 cases (MRI) vs. 24 cases (symphysography), isolated superior cleft sign: 13 vs. 10, isolated secondary cleft sign: 15 vs. 21 cases and combined injuries: 18 vs. 11 cases. In 7 cases a combined cleft sign was observed in MRI but only an isolated secondary cleft sign was visible in symphysography. Anterior pelvic ring instability was observed in 25 patients and was linked to a cleft sign in 23 cases (7 superior cleft sign, 8 secondary cleft signs, 6 combined clefts, 2 atypical cleft injuries). Additional BME could be diagnosed in 18 of those 23. CONCLUSION Dedicated 3-Tesla MRI outmatches symphysography for purely diagnostic purposes of cleft injuries. Microtearing at the prepubic aponeurotic complex and the presence of BME is a prerequisite for the development of anterior pelvic ring instability. CLINICAL RELEVANCE STATEMENT For diagnostic of symphyseal cleft injuries dedicated 3-T MRI protocols outmatch fluoroscopic symphysography. Prior specific clinical examination is highly beneficial and additional flamingo view x-rays are recommended for assessment of pelvic ring instability in these patients. KEY POINTS • Assessment of symphyseal cleft injuries is more accurate by use of dedicated MRI as compared to fluoroscopic symphysography. • Additional fluoroscopy may be important for therapeutic injections. • The presence of cleft injury might be a prerequisite for the development of pelvic ring instability.
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Affiliation(s)
- Norman Holl
- Institute of Diagnostic and Interventional Radiology, Paediatric and Neuroradiology, University Medicine Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
| | - Judith Sarah Gerhardt
- Institute of Diagnostic and Interventional Radiology, Paediatric and Neuroradiology, University Medicine Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Thomas Tischer
- Department of Orthopaedics, Rostock University Medical Center, Doberanerstr. 142, 18057, Rostock, Germany
| | - Jens Krüger
- Sportchirurgische Praxis Dr. Jens Krüger, Potsdamer Straße 132, 10783, Berlin, Germany
| | - Andres Arevalo-Hernandez
- Institute of Diagnostic and Interventional Radiology, Paediatric and Neuroradiology, University Medicine Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedics, Rostock University Medical Center, Doberanerstr. 142, 18057, Rostock, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Paediatric and Neuroradiology, University Medicine Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
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Dharmshaktu GS. Primary care level prevalence of osteitis pubis in non-athlete patients in hill region: A short communication and a proposal for simple radiological grading. J Family Med Prim Care 2023; 12:783-787. [PMID: 37312763 PMCID: PMC10259561 DOI: 10.4103/jfmpc.jfmpc_105_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/26/2021] [Accepted: 02/02/2023] [Indexed: 06/15/2023] Open
Abstract
Background Osteitis pubis (OP) is inflammation of pubic symphysis associated with varying degrees of supra-pubic, pelvic, or lower abdominal pain. The condition may be severe in many patients with significant disability and protracted course of recovery. The condition is frequently described in sportspersons or athletes but consensus on classification and treatment guidelines is non-existent due to rarity of the condition. Its presence in non-athletic population is limited to a series of few cases or anecdotal case reports. Our study describes salient features of pattern of this disorder diagnosed on clinico-radiological basis in cases referred from primary care centers to our tertiary care center. Materials and Method A total of 26 patients (mean age of 36.28 years, 25 females, and 1 male case) with radiological features suggestive of OP were included in the study and relevant demographic details were noted for each. A radiological grading (Grade A to E) for notification was developed and the cases were categorized accordingly. Results Most of the cases were hard-working women from villages. Pregnancy was the major condition for which they ever consulted a health-care facility. Chronic, but not disabling, supra-pubic pain was the chief complaint in most cases. In some cases, the primary presentation was for some other disorder like low back pain in two, hip pain in six cases, adjacent fracture in three, and old lumbar osteoporotic compression fracture in one case. Other notable associated disorders included polio, ankylosing spondylitis, femoroacetabular impingement, and hip dysplasia. Conservative management was done in all cases except one with associated fracture. Good clinical outcome was noted in all but one case. Grade A cases were maximum (7) followed by grade B (6), grade D (4), and grade C (3). Only one case of grade E was noted with almost ankylosed symphysis. Conclusion This article highlights acknowledgment and knowledge of OP in primary care settings and its anticipation even in normal population for a better understanding of prevalence and radiological presentation.
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Weber MA. [Groin pain in athletes-sportsmen's groin]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:268-274. [PMID: 36715718 DOI: 10.1007/s00117-023-01117-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/31/2023]
Abstract
CLINICAL/METHODICAL ISSUE Groin pain in athletes can have various causes. Radiologically, osteitis pubis and clefts with affection of the interpubic disc as well as muscle and tendon tears near the pubic bone can be clearly identified. STANDARD RADIOLOGICAL METHODS Magnetic resonance imaging (MRI) is the imaging modality of choice, as well as single-leg stand imaging (flamingo view radiographs), and where appropriate symphysography. METHODICAL INNOVATIONS Optimized MRI sequence protocol with oblique (axial oblique) slices parallel to the linea arcuata of the iliac bone is recommended. High-resolution MRI sequences and symphysography can detect superior and secondary cleft formation. Instabilities of the pubic symphysis can be diagnosed using flamingo view radiographs. PERFORMANCE The MRI findings of osteitis pubis and clinical symptoms correlate. The presence of parasymphyseal bone marrow edema is the earliest morphological sign of acute osteitis pubis on MR imaging. Edema in the periosteal tissue and isolated muscle lesions next to the symphysis are generally associated with more severe clinical symptoms. ACHIEVEMENTS AND PRACTICAL RECOMMENDATIONS Close communication between radiologists and the referring physicians is indispensable when planning an adequate imaging protocol, and precise knowledge of the clinical symptoms in the case of clinical suspicion of osteitis pubis allows for a reliable diagnosis and provides important prognostic information.
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Affiliation(s)
- Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
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Ceballos-Laita L, Hernando-Garijo I, Medrano-de-la-Fuente R, Mingo-Gómez MT, Carrasco-Uribarren A, Jiménez-del-Barrio S. Hip Range of Motion and Strength in Male Athletes with Stage 1 Osteitis Pubis: A Cross-Sectional and Correlational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12824. [PMID: 36232123 PMCID: PMC9564700 DOI: 10.3390/ijerph191912824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/01/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The objectives of this study were: (1) to determine whether athletes with stage 1 osteitis pubis (OP) present differences in hip range of motion (ROM) and muscle strength, between both sides and compared with healthy athletes; (2) to investigate the relationship between the internal rotation (IR) ROM and pain intensity and physical function. METHODS a cross-sectional and correlational study was designed, in which 30 athletes (15 athletes with stage 1 OP and 15 healthy athletes) were included. Pain intensity, physical function, hip ROM and hip muscle strength were assessed. RESULTS The ROM assessment reported significant differences between both groups in the IR, external rotation (ER) and adduction (ADD) ROM of the painful side (PS) (p < 0.05). The OP group showed differences between both sides in IR ER and ADD ROM (p < 0.05). No statistically significant differences were found between or within groups in the maximum isometric strength of the hip (p > 0.05). A strong negative correlation between pain intensity and IR ROM (r = -0.640) and a strong positive correlation between physical function and IR ROM (r = 0.563) were found in the OP group. CONCLUSIONS Male athletes with stage 1 OP present a hip IR, ER and ADD ROM limitation in the PS compared to non-PS and to healthy athletes. IR ROM is correlated to pain intensity and physical function in athletes with stage 1 OP.
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Affiliation(s)
- Luis Ceballos-Laita
- Clinical Research in Health Sciences Group, Department of Surgery, Ophthalmology and Physiotherapy, University of Valladolid, 42004 Soria, Spain
| | - Ignacio Hernando-Garijo
- Clinical Research in Health Sciences Group, Department of Surgery, Ophthalmology and Physiotherapy, University of Valladolid, 42004 Soria, Spain
| | - Ricardo Medrano-de-la-Fuente
- Clinical Research in Health Sciences Group, Department of Surgery, Ophthalmology and Physiotherapy, University of Valladolid, 42004 Soria, Spain
| | - María Teresa Mingo-Gómez
- Clinical Research in Health Sciences Group, Department of Surgery, Ophthalmology and Physiotherapy, University of Valladolid, 42004 Soria, Spain
| | | | - Sandra Jiménez-del-Barrio
- Clinical Research in Health Sciences Group, Department of Surgery, Ophthalmology and Physiotherapy, University of Valladolid, 42004 Soria, Spain
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Amer ML, Omar K, Malde S, Nair R, Thurairaja R, Khan MS. The challenges in diagnosis and management of osteitis pubis: An algorithm based on current evidence. BJUI COMPASS 2022; 3:267-276. [PMID: 35783593 PMCID: PMC9231671 DOI: 10.1002/bco2.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 02/01/2023] Open
Abstract
Objective The objective of this study is to summarise the contemporary evidence regarding the prevalence, diagnosis, and management of osteitis pubis (OP) specially from urological point of view, while proposing an algorithm for the best management based on the current evidence. Methods We performed a literature search using the PubMed database for the term 'osteitis pubis' until December 2020. We assessed pre-clinical and clinical studies regarding the aetiology, pathophysiology, and management of OP. Case reports and case series were evaluated by study quality and patient outcomes to determine a potential clinical management algorithm. Results Osteitis pubis is a chronic painful condition of the symphysis pubis joint and its surrounding structures. Still, there is a paucity of data outlining the management plan and the possible triggers. The aetiology seems to be multifactorial with different proposals trying to explain the pathophysiology and correlate the findings to the outcome. The diagnosis is usually based on high suspicion index and clinical experience. The infective variant of the disease is aggressive and requires strict and active management. Universal consensus is still lacking regarding a formal algorithm of management of the condition, especially due to multiple specialities involved in the decision-making process. Conservative management remains the cornerstone; nevertheless, surgical interventions may be needed in special settings. Hence, a multi-disciplinary approach is of pivotal value in fashioning the plan for each case. The prognosis is usually satisfactory; however, a longstanding debilitating disease form is not uncommon. Conclusion OP remains a rare condition with real challenges in its diagnosis. The current management is focused on conservative management; however, surgical intervention is still needed in some difficult scenarios. Continued research into the triggers of OP, multidisciplinary approach, and standardised clinical pathways can improve the quality of care for patients suffering from this condition.
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Affiliation(s)
- Mohammed Lotfi Amer
- Faculty of MedicineTanta UniversityTantaEgypt
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Kawa Omar
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Sachin Malde
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Rajesh Nair
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Ramesh Thurairaja
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
| | - Muhammad Shamim Khan
- Department of UrologyGuy's and St. Thomas' NHS Foundation TrustLondonUK
- MRC Centre for Transplantation, Faculty for Life Sciences and Medicine, NIHR Biomedical Research CentreKing's College LondonLondonUK
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Athanasiou V, Ampariotou A, Lianou I, Sinos G, Kouzelis A, Gliatis J. Osteitis Pubis in Athletes: A Literature Review of Current Surgical Treatment. Cureus 2022; 14:e22976. [PMID: 35464551 PMCID: PMC9001088 DOI: 10.7759/cureus.22976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/05/2022] Open
Abstract
Osteitis pubis (OP) is a self-limiting, noninfectious inflammatory disease of the pubic symphysis and the surrounding soft tissues that usually improves with activity modification and targeted conservative treatment. Surgical treatment is required for a limited number of patients. This study aims to investigate the current literature on the surgical treatment of OP in athletes. A systematic review was conducted on two databases (MEDLINE/PubMed and Google Scholar) from 2000 to 2021. The inclusion criteria were adult patients with athletic OP who underwent surgical treatment and studies published in English. The exclusion criteria included pregnancy, infection OP, or postoperative complications related to other surgical interventions, such as urological or gynecological complications. Fifty-one surgically treated cases have been reported in eight studies, which included short-term, mid-term, and long-term studies ranging from one patient to 23 patients. The surgical treatment methods were as follows: (a) pubic symphysis arthrodesis, (b) open or endoscopic pubic symphysectomy, (c) wedge resection of the pubic symphysis, and (d) polypropylene mesh placed into the preperitoneal retropubic space endoscopically. The main indication for surgical intervention was failure of conservative measures and long-lasting pain, disability, and inability to participate in athletic activities. Wedge resection of the pubic symphysis has been the less preferred surgical treatment in the recently published literature. The most common surgical method of treatment of OP in athletes, which entailed the existence of posterior stability of the sacroiliac joint, in the current literature is open pubic symphysis curettage. Recently, there has been a tendency for pubic symphysis curettage to be performed endoscopically.
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Lenz R, Holl N, Lutter C, Krüger J, Weber MA, Tischer T. Leistenschmerz beim Sportler. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00516-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Holmes RD, Yan YY, Mallinson PI, Andrews GT, Munk PL, Ouellette HA. Imaging Review of Hockey-related Lower Extremity Injuries. Semin Musculoskelet Radiol 2022; 26:13-27. [PMID: 35139556 DOI: 10.1055/s-0041-1731795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.
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Affiliation(s)
- R Davis Holmes
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Yet Yen Yan
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Radiology, Changi General Hospital, Singapore
| | - Paul I Mallinson
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Gordon T Andrews
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter L Munk
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Hugue A Ouellette
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
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Eberbach H, Fürst-Meroth D, Kloos F, Leible M, Bohsung V, Bode L, Wenning M, Hagen S, Bode G. Long-standing pubic-related groin pain in professional academy soccer players: a prospective cohort study on possible risk factors, rehabilitation and return to play. BMC Musculoskelet Disord 2021; 22:958. [PMID: 34789227 PMCID: PMC8600924 DOI: 10.1186/s12891-021-04837-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Despite being a common overuse entity in youth soccer, scientific data on risk factors, rehabilitation and return to play for long-standing pubic-related groin pain is still rare. The current prospective cohort study aims to evaluate potential risk-factors, propose a criteria-based conservative rehabilitation protocol and assess return-to-play outcomes among professional youth soccer players suffering from long-standing pubic-related groin pain. Methods Male soccer players with long-standing (> 6 weeks) pubic-related groin pain from a professional soccer club’s youth academy were analyzed for possible risk factors such as age, team (U12 - U23), younger/older age group within the team, position and preinjury Functional movement score. All injured players received a conservative, standardized, supervised, criteria-based, 6-level rehabilitation program. Outcome measures included time to return to play, recurrent groin pain in the follow-up period and clinical results at final follow-up two years after their return to play. Results A total of 14 out of 189 players developed long-standing pubic-related groin pain in the 2017/2018 season (incidence 7.4%). The average age of the players at the time of the injury was 16.1 ± 1.9 years. Risk factor analysis revealed a significant influence of the age group within the team (p = .007). Only players in the younger age group were affected by long-standing pubic-related groin pain, mainly in the first part of the season. Injured players successfully returned to play after an average period of 135.3 ± 83.9 days. Only one player experienced a recurrence of nonspecific symptoms (7.1%) within the follow-up period. The outcome at the 24-month follow-up was excellent for all 14 players. Conclusions Long-standing pubic-related groin pain is an overuse entity with a markedly high prevalence in youth soccer players, resulting in a relevant loss of time in training and match play. In particular, the youngest players in each team are at an elevated risk. Applying a criteria-based rehabilitation protocol resulted in an excellent return-to-play rate, with a very low probability of recurrence. Trial registration The trial was retrospectively registered under DRKS00016510 in the German Clinical Trials Register on 19.04.2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04837-x.
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Affiliation(s)
- Helge Eberbach
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - David Fürst-Meroth
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Ferdinand Kloos
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Magnus Leible
- Freiburg Youth Academy, Sports-Club Freiburg e.V., Schwarzwaldstr. 193, 79117, Freiburg, Germany
| | - Valentin Bohsung
- Freiburg Youth Academy, Sports-Club Freiburg e.V., Schwarzwaldstr. 193, 79117, Freiburg, Germany
| | - Lisa Bode
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Markus Wenning
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Schmal Hagen
- Department of Orthopedic and Trauma Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.,Department of Orthopedic Surgery, University Hospital Odense, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - Gerrit Bode
- Sporthopaedicum Straubing, Bahnhofplatz 27, 94315, Straubing, Germany
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Dempsey PJ, Power JW, MacMahon PJ, Eustace S, Kavanagh EC. Nomenclature for groin pain in athletes. Br J Radiol 2021; 94:20201333. [PMID: 34328792 DOI: 10.1259/bjr.20201333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Currently, there is much variation in the terminology used to describe groin pain in athletes. Several groups have attempted to reach consensus on nomenclature in this area. This article outlines the current status of groin pain nomenclature for the radiologist, highlighting inherent heterogeneity, recent attempts to reach a consensus, the need for a radiological consensus and why imprecise terminology should be avoided when reporting.
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Affiliation(s)
- Philip J Dempsey
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jack W Power
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Peter J MacMahon
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Steven Eustace
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eoin C Kavanagh
- Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland
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Saito M, Niga S, Nihei T, Uomizu M, Ikezawa Y, Tsukada S. The cleft sign may be an independent factor of magnetic resonance imaging findings associated with a delayed return-to-play time in athletes with groin pain. Knee Surg Sports Traumatol Arthrosc 2021; 29:1474-1482. [PMID: 33452578 DOI: 10.1007/s00167-020-06410-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/07/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate the prevalence of magnetic resonance imaging (MRI) findings and define prognostic factors of the return-to-play time in young athletes with groin pain. METHODS A total of 1091 consecutive athletes were retrospectively screened; 651 athletes, aged 16-40 years, with pain in the groin regions were assessed using MRI. Of these athletes, 356 were included for analysing the time to return-to-play. Univariate and multiple linear regression analyses were used to determine the associations between the time to return-to-play (primary outcome variable) and the following variables: age, sex, body mass index, type of sports, Hip Sports Activity Scale, clear trauma history, and 12 MRI findings. RESULTS Four MRI findings, including cleft sign, pubic bone marrow oedema of both the superior and inferior ramus, and central disc protrusion of the pubic symphysis, appeared together in more than 44% of the cases. The median time to return-to-play was 24.7 weeks for athletes with a cleft sign on MRI, which was significantly longer than the 11.9 weeks for athletes without the sign. The median time to return-to-play was 20.8 weeks for athletes with BMI > 24, which was significantly longer than the 13.6 weeks for athletes with BMI ≦ 24. In multiple linear regression analysis of 356 athletes, in whom hip-related groin pain was excluded, and who were followed-up until the return-to-play, the body mass index and cleft sign were the independent factors associated with a delayed return-to-play. In contrast, iliopsoas muscle strain and other muscle injuries were associated with a shorter return-to-play. CONCLUSIONS Multiple MRI findings were present in almost half of all cases. Body mass index and the cleft sign were independently associated with a delayed return-to-play time in young athletes suffering from groin pain. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Masayoshi Saito
- Department of Orthopaedic Surgery, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Sadao Niga
- JIN Orthopaedic & Sports Clinic, 3-10-7 Suzuya, Chuo-ku, Saitama, Saitama, 338-0013, Japan.
| | - Tadahiro Nihei
- JIN Orthopaedic & Sports Clinic, 3-10-7 Suzuya, Chuo-ku, Saitama, Saitama, 338-0013, Japan
| | - Mari Uomizu
- Department of Orthopaedic Surgery, Nerima General Hospital, 1-24-1 Asahigaoka, Nerima-ku, Tokyo, 176-8530, Japan
| | - Yuji Ikezawa
- JIN Orthopaedic & Sports Clinic, 3-10-7 Suzuya, Chuo-ku, Saitama, Saitama, 338-0013, Japan
| | - Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, 3-2-1 Higashihara, Mito, Ibaraki, 310-0035, Japan
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The pre-signing medical examination: The radiologists' role. Eur J Radiol 2019; 118:239-244. [PMID: 31439248 DOI: 10.1016/j.ejrad.2019.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE to review the role of the radiologist in reporting pre-signing medical imaging prior to athlete transfer between clubs. METHOD When a professional athlete transfers from one club to another they may undergo a transfer or "pre-signing" medical examination, of which imaging forms a major component. The purpose of imaging is to enable the overseeing sports physician to make a risk assessment on the athlete that may influence decisions such as the duration of contract offered. Imaging studies have to be performed and reported often within limited time constraints, usually by MSK radiologists specialised in sports imaging. This article describes the role of the sports radiologist in reporting pre-signing medical imaging studies, and discusses some of the common pathology identified, as well as some of the ethical and medicolegal issues encountered. RESULTS Not applicable. This is a review article. CONCLUSION the sports radiologists report of the pre-signing medical is an important component of the decision making process to sign an athlete, and is closely linked to the physical examination.
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Abstract
CLINICAL/METHODICAL ISSUE Osteitis pubis is one of the most common causes of chronic groin pain in many professional athletes. Symphysitis pubis with instability of the joint due to softening of the joint capsule and muscular imbalance of the corresponding muscles increases the instability of the sympyseal region, thus, resulting in a vicious cycle. STANDARD RADIOLOGICAL METHODS Magnetic resonance imaging (MRI). METHODICAL INNOVATIONS Optimized MRI sequence protocol with oblique (axial oblique) layers parallel to the linea arcuata of iliac bone together with large image field for depiction of the entire pelvis and high-resolution sequences focused on the symphysis pubis. PERFORMANCE Recently, the correlation between MRI signs of osteitis pubis and long-term clinical outcome in a group of professional soccer players was examined. In particular, edema in the peri-osseous tissue and isolated muscle lesions around the symphysis at the onset of symptoms were associated with partial recovery of the athletes. Furthermore, a significant association of increased normalized signal intensity in the pubic bone on STIR (short-tau inversion recovery) sequences (corresponding presence and signal intensity of bone marrow edema) and a poor complete clinical improvement was observed. ACHIEVEMENTS An optimized MRI protocol allows the diagnosis of osteitis pubis and provides important prognostic information. PRACTICAL RECOMMENDATIONS In case of clinical suspicion on osteitis pubis, MR imaging with an optimized sequence protocol should be performed.
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Krishnamoorthy VP, Kunze KN, Beck EC, Cancienne JM, O'Keefe LS, Ayeni OR, Nho SJ. Radiographic Prevalence of Symphysis Pubis Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome. Am J Sports Med 2019; 47:1467-1472. [PMID: 30995415 DOI: 10.1177/0363546519837203] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis. PURPOSE To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. RESULTS 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013). CONCLUSION A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.
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Affiliation(s)
- Vignesh P Krishnamoorthy
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle N Kunze
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Edward C Beck
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Jourdan M Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Lauren S O'Keefe
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Paajanen H, Hermunen H, Ristolainen L, Branci S. Long-standing groin pain in contact sports: a prospective case-control and MRI study. BMJ Open Sport Exerc Med 2019; 5:e000507. [PMID: 31191965 PMCID: PMC6539155 DOI: 10.1136/bmjsem-2018-000507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives We aimed to prospectively evaluate the prevalence of long-standing groin pain and related MRI findings in contact sports. Methods This case–control study followed three male elite-level soccer, ice-hockey and bandy teams (102 players) for 2 years. All athletes with long-standing groin pain lasting >30 days and age-matched controls (1:3) from the same teams were examined clinically, using pelvic MRI and Hip and Groin Outcome Scores (HAGOS). Primary outcome measures were annual prevalence of groin pain and underlying MRI findings. Results The annual prevalence of chronic groin pain was 7.5%. Training characteristics and pain scores of athletes were similar in all teams. On MRI, there was no significant difference in the percentage of pubic bone marrow oedema (p = 0.80) between symptomatic players (8/15; 53%) versus controls (20/43; 47%), but adductor tendinopathy and degenerative changes at the pubic symphysis were twice more common among players with pain. Rectus muscle or iliopsoas pathology were seldom observed. Lower HAGOS subscales (p < 0.01) were recorded in players who experienced groin pain compared with the controls. Conclusion Long-standing groin pain was observed annually in 1 of 14 athletes in contact sports. Abnormalities in the pubic symphysis were common MRI findings in both symptomatic and asymptomatic players. Trial registration number NCT02560480
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Affiliation(s)
- Hannu Paajanen
- Department of Surgery, University of Eastern Finland, Kuopio, Finland
| | - Heikki Hermunen
- Department of Radiology, Mikkeli Central Hospital, Mikkeli, Finland
| | - Leena Ristolainen
- Department of Orthopaedics, Orton Orthopaedic Hospital, Helsinki, Finland
| | - Sonia Branci
- Department of Radiology, Rigshospitalet, Copenhagen, Denmark.,Arthroscopic Center Amager, Hvidovre Hospital, Copenhagen, Denmark
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Maas KJ, Avanesov M, Laqmani A, Weinrich J, Sauer M, Kaul MG, Adam G, Regier M, Behzadi C. Inter- and Intraobserver reproducibility of T2 relaxation times of the discus interpubicus: A feasibility study at 3 Tesla. PLoS One 2018; 13:e0202698. [PMID: 30133521 PMCID: PMC6105013 DOI: 10.1371/journal.pone.0202698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To quantify standard values of the discus interpubicus in healthy subjects and to determine reliability and repeatability using T2 relaxation time measurements at 3T. Methods 20 asymptomatic participants (10 male, 10 female; mean age: 27.3 years ±4.1, BMI: 22.2 ±1.8) underwent a 3T Magnetic Resonance Imaging (MRI) of the pelvic region in a supine position. We included sagittal and para-axial T2w sequences centred over the pubic symphysis in order to identify the complete discus interpubicus. For quantitative analysis, a multi-echo Turbo Spin Echo (TSE) sequence (including 12 echo times between 6.4 and 76.8 ms) was acquired and analysed by using an in-house developed quantification plugin tool (qMapIt) extending ImageJ. Two readers in consensus defined three central slices of the pubic symphysis with the greatest length. For each slice, both readers separately placed three regions-of-interest (ROI) covering the whole discus interpubicus. Both readers repeated the ROI placements in identical fashion after a four-week interval on the original MRI images. Statistical analysis included intraclass correlation coefficient (ICC), nonparametric Wilcoxon test, Fisher exact test and mean relaxation time in ms and 95% confidence intervals. Results T2 relaxation time analysis was performed for all 20 participants. In total, a mean relaxation time of all analysed segments for both observers was 48.6 (±6.3 ms), with a mean relaxation time for observer 1 of 48.7 (±6.0 ms) and for observer 2 of 48.5 ms (±6.6ms). The calculated ICC comparing inter- and intrarater reproducibility was excellent in all segments (≥0.75). Conclusion T2 mapping of the discus interpubicus demonstrates good inter- and intrarater repeatability as well as reliability. Mean relaxation times were calculated with 48.6ms in healthy volunteers.
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Affiliation(s)
- Kai-Jonathan Maas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Avanesov
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Azien Laqmani
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julius Weinrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Sauer
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael G. Kaul
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Regier
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cyrus Behzadi
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
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Abstract
PURPOSE OF REVIEW To discuss the clinical significance of the most common hip and groin injuries in baseball players, as well as an algorithmic approach to diagnosis and treatment of these injuries. RECENT FINDINGS (a) Limitations in throwing velocity, pitch control, and bat swing speed may be secondary to decreased mobility and strength within the proximal kinetic chain, which must harness power from the lower extremities and core. (b) Approximately 5.5% of all baseball injuries per year involve the hip/groin and may lead to a significant amount of time spent on the disabled list. Injuries involving the hip and groin are relatively common in baseball players. Our knowledge of the mechanics of overhead throwing continues to evolve, as does our understanding of the contribution of power from the lower extremities and core. It is paramount that the team physician be able to accurately diagnose and treat injuries involving the hip/groin, as they may lead to significant disability and inability to return to elite levels of play. This review focuses on hip- and groin-related injuries in the baseball player, including femoroacetabular impingement, core muscle injury, and osteitis pubis.
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Affiliation(s)
- Ryan A Mlynarek
- Sports Medicine and Hip Preservation, Hospital for Special Surgery, New York, NY, USA. .,Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA.
| | - Struan H Coleman
- Sports Medicine and Hip Preservation, Hospital for Special Surgery, New York, NY, USA
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