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

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.

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.

Incidental 18F-FDG Uptake of the Pubic Ramus and Abdominal Muscles due to Athletic Pubalgia During Acute Prostatitis

A 23-year-old African native male patient presented with fever, lumbalgia and dysuria after returning from a trip to Togo. His physical examination revealed pain over the pubic symphysis and rectal tenderness on digital exam. The C-reactive protein (CRP) level was elevated along with positive blood and urinary cultures for methicillin-resistant Staphylococcus aureus. An magnetic resonance imaging that has been performed to rule out arthritis/osteomyelitis in the pubis revealed edema of the symphysis. An ¹⁸F-FDG positron emission tomography/computed tomography supported the diagnosis of prostate infection and showed a focal uptake of the pubic symphysis, with diffuse hyper-metabolism of the insertions of the rectus abdominis and longus adductor muscles, corresponding to athletic pubalgia. Fever and CRP responded rapidly to antibiotherapy.

Novel pathomorphologic classification of capsulo-articular lesions of the pubic symphysis in athletes to predict treatment and outcome

INTRODUCTION

Radiographic abnormalities of the symphysis as well as the formation of accessory clefts, indicating injury at the rectus-adductor aponeurosis, reportedly relate to longstanding groin pain in athletes. However, yet, no systematic classification for clinical and scientific purposes exists. We aimed to (1) create a radiographic classification based on symphysography; (2) test intra- and interobserver reliability; (3) characterise clinical significance of the morphologic patterns by evaluating success of injection therapy.

PATIENTS AND METHODS

We retrospectively reviewed symphysography, AP radiographs, and MRI of the pelvis from 70 consecutive competitive athletes, with chronic groin pain. Symphysographs were evaluated for intra- and interobserver variance using cohen's kappa statistics. Morphologic studies of the different contrast distribution patterns and their clinical and radiological correlation with symptom relief were investigated. All patients were followed up to evaluate immediate and long-term response to the initial therapeutic injection with steroid.

RESULTS

Four reproducible symphysographic patterns were identified: type 0, no changes; type 1, symphyseal disk degeneration; types 2a with unilateral clefts, bilateral clefts (2b), suprapubic clefts (2c); and type 3, with expanded or multidirectional clefts. Analysis revealed excellent intra (0.94)-and interobserver (0.90) reliability. Our findings showed that 78.6% of our patients had significant short-term improvement enabling early resumption of physiotherapy, only in types 1 and 2 (p = 0.001), while type 0 and 3 did not respond. At follow-up, only 21.8% had permanent pain relief. Regarding the detection of pathologic clefts with symphysography, sensitivity (88%) and specifity (77%) were superior to that of MRI.

CONCLUSIONS

A reproducible symphysography-based classification of distinct morphologic patterns is proposed. It serves as a predictive tool for response to injection therapy in a select group of pathologic lesions. Complete recovery after injection can only be expected in a lesser percentage, as this might indicate surgical treatment for long-term non-responders.

Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients

With increasing participation and intensity of training in youth sports in the United States, the incidence of sports-related injuries is increasing, and the types of injuries are shifting. In this article, the authors review sports injuries of the lower extremity, including both acute and overuse injuries, that are common in or specific to the pediatric population. Common traumatic injuries that occur in individuals of all ages (eg, tears of the acetabular labrum and anterior cruciate ligament) are not addressed, although these occur routinely in pediatric sports. However, some injuries that occur almost exclusively in high-level athletes (eg, athletic pubalgia) are reviewed to increase awareness and understanding of these entities among pediatric radiologists who may not be familiar with them and thus may not look for them. Injuries are described according to their location (ie, hip, knee, or foot and ankle) and pathologic process (eg, apophysitis, osteochondritis dissecans). Examples of abnormalities and normal variants of the anatomy that are often misdiagnosed are provided. The injuries reviewed represent a common and growing subset of pathologic processes about which all pediatric and musculoskeletal radiologists should be knowledgeable. Understanding physeal injury is especially important because missed diagnoses can lead to premature physeal closure and osteoarthritis. ^©RSNA, 2016.

Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging

OBJECTIVE

The purpose of this study was to present a narrative review of the literature of musculoskeletal causes of adult hip pain, with special attention to history, physical examination, and diagnostic imaging.

METHODS

A narrative review of the English medical literature was performed by using the search terms "hip pain" AND "anterior," "lateral," and "posterior." Additionally, specific entities of hip pain or pain referral sources to the hip were searched for. We used the PubMed search engine through January 15, 2016.

RESULTS

Musculoskeletal sources of adult hip pain can be divided into posterior, lateral, and anterior categories. For posterior hip pain, select considerations include lumbar spine and femoroacetabular joint referral, sacroiliac joint pathology, piriformis syndrome, and proximal hamstring tendinopathy. Gluteal tendinopathy and iliotibial band thickening are the most common causes of lateral hip pain. Anterior hip pain is further divided into causes that are intra-articular (ie, labral tear, osteoarthritis, osteonecrosis) and extra-articular (ie, snapping hip and inguinal disruption [athletic pubalgia]). Entrapment neuropathies and myofascial pain should also be considered in each compartment. A limited number of historical features and physical examination tests for evaluation of adult hip pain are supported by the literature and are discussed in this article. Depending on the clinical differential, the gamut of diagnostic imaging modalities recommended for accurate diagnosis include plain film radiography, computed tomography, magnetic resonance imaging, skeletal scintigraphy, and ultrasonography.

CONCLUSIONS

The evaluation of adult hip pain is challenging. Clinicians should consider posterior, lateral, and anterior sources of pain while keeping in mind that these may overlap.