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

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1 MRI of Injuries at the Symphysis Pubis Musculoskeletal Imaging Original Research Patricia M. Cunningham 1 Darren Brennan Martin O Connell Peter MacMahon Pat O Neill Stephen Eustace Cunningham PM, Brennan D, O Connell M, MacMahon P, O Neill P, Eustace S Keywords: MRI, musculoskeletal imaging, pelvic imaging, sports medicine, trauma DOI: /AJR Received January 11, 2006; accepted after revision July 31, All authors: Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland. Address correspondence to P. M. Cunningham. WEB This is a Web exclusive article. AJR 2007; 188:W291 W X/07/1883 W291 American Roentgen Ray Society 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. roin pain is reported to account for G 2 5% of all sports injuries. In sports that involve excessive twisting and turning movements such as soccer, ice and field hockey, tennis, and Australian-rules football, groin injuries may rise to 5 7% of all injuries [1, 2]. In professional athletes, injuries account for chronic morbidity, and the associated persistent pain and stiffness frequently prevent competitive involvement. Such injuries lead to personal distress and have dramatic economic consequences for professional sporting organizations. Despite the prevalence and importance of groin injuries, the pattern and nature of injury to the symphysis pubis that account for groin pain in athletes remain unclear; hence, approaches to management are varied and poorly constructed, and the outcomes are unpredictable [3 6]. In clinical practice, the term athletic pubalgia is used to describe exertional pubic or groin pain [7], and although many causes of pubalgia are described ranging from a labral tear of the hip, sacroiliitis, and lower lumbar disk disease to pelvic soft-tissue derangement in females, most authors conclude that adductor dysfunction, osteitis pubis, and prehernia complex (also termed sportsman s hernia, conjoint tendon tear, external oblique tear, and rectus abdominis sheath tears ) are the most common causes [8 11]. Whether these entities are mechani- AJR:188, March 2007 W291

2 cally related is currently unclear. The purposes of this study were to determine the prevalence of adductor dysfunction and of osteitis pubis in soccer players presenting with pubalgia and, on the basis of these observations, to determine whether one of the ailments appears to precede or predispose the development of the other. Materials and Methods Study Subjects One hundred consecutive professional and amateur soccer players with debilitating groin pain and with symptoms and signs centered on the symphysis pubis were referred for MRI. In each player, sportsman s hernia had been excluded on the basis of clinical examination before referral [11]. There were 95 males and five females in the cohort, with a mean age of 27 years (range, years). In these patients, groin pain had been present for a mean of 3 months before referral for imaging. No difference in the pattern of presentation was noted in the amateur compared with the professional soccer players, and both groups participated in soccer at an advanced level. Control Subjects One hundred athletes (mean age, 23 years; range, years) without symptoms referable to the symphysis pubis who were referred for MRI of the pelvis were included in the study as control subjects. This group included 50 volunteers with no symptoms (rowers), 37 with unexplained hip pain (soccer players), and 13 with suspected sacroiliac dysfunction (soccer players). Methods The study and control group patients were imaged on a 1.5-T scanner (Intera, Philips Medical Systems) with a quadrature body coil. For each examination, the groin was imaged in the coronal plane using a turbo spin-echo T1-weighted sequence (TR/TE, 620/20; echo-train length, 6; low high mapping; 2 excitations; 15-cm field of view) and using a turbo STIR sequence (TR/effective TE, 2,000/20; inversion time, 160 milliseconds; echo-train length, 14; linear mapping; 2 excitations; 15-cm field of view) and in the axial plane using a turbo spin-echo T2-weighted sequence (2,000/80; echo-train length, 14; linear mapping; 2 excitations; 15-cm field of view). Image Interpretation For the study, the secondary cleft sign was used as an indicator of an adductor microtear at the symphyseal enthesis. This sign describes an abnormal inferior extension of the cleft in symphyseal fibrocartilage created by a microtear at the attachment of the conjoint gracilis that extends from adductor longus tendon to the inferior pubis [12]. For this study, osteitis pubis was recorded as present if paraarticular bone edema, either uni- or bilateral, was identified remote from the adductor attachment. Although supportive, additional features of osteitis pubis including paraarticular fatty marrow change, articular surface irregularity and stepoff, and inflammation in paraarticular soft tissues were not required for the diagnosis. This definition of osteitis pubis markedly increased the sensitivity of MRI to subtle osteitis pubis. Bone edema localized to the inferior pubis adjacent to the adductor attachment was attributed to the distraction traction effect from the adductor tendon attachment rather than to osteitis pubis, as described by other authors [13 15]. All images were reviewed independently by two fellowship-trained musculoskeletal radiologists who were blinded to the side of symptoms; discrepancies were resolved by consensus. The images were reviewed on printed film, with 20 images on each sheet. In each case, the reviewers assessed the images for the presence or absence of an adductor microtear, uni- or bilateral, and the presence or absence of osteitis pubis. The integrity of the symphyseal articular surfaces, the presence or absence of symphyseal fibrocartilage herniation, and the presence and distribution of bone edema were noted. Finally, the width of the pubic symphysis joint space, measured on the axial scans at the midpoint of the symphyseal joint space, was recorded. Statistical Analysis Statistical analysis was performed using the chisquare test. Ethics Committee Approval Approval for retrospective analysis of imaging data was obtained for this study from the hospital ethics committee. Gold Standard Symphyseal contrast injection was used to confirm the presence or absence of a secondary cleft due to an adductor microtear; its presence was correlated with the side of symptoms [16]. Symptom relief by subsequent injection of bupivacaine and steroids to the cleft confirmed that symptoms were referable to the presence of the cleft [16]. No contrast injections to the symphysis pubis were performed in the control subjects. Results Study Subjects Of the 100 patients, groin pain was considered secondary to inflammatory change at the symphysis pubis in 97 patients, unilateral sacroiliitis was identified in one patient, and a labral tear in the hip was identified in two patients. In both of those patients, a hip abnormality was suggested on the unenhanced images on the basis of a joint effusion. The labral tear was confirmed on subsequent MR arthrography in both cases, which were subsequently treated by intraarticular steroid injection without recourse to arthroscopy. Of 97 patients, isolated adductor microtears in the absence of osteitis pubis were identified in 47 patients (48.4%), isolated osteitis pubis was identified in nine patients (9.3%), and osteitis pubis and accompanied adductor microtear in 41 patients (42.3%) (Figs. 1 3). An accessory cleft was identified in 88 patients; in each case, the side of the cleft correlated with the side of the symptoms (Figs. 1 3). The cleft was identified at the posterior attachment of the adductor and gracilis tendons in 26 (29.5%) of the 88 patients, with the cleft extending all the way through the attachment in 50 patients (56.8%). An anterior cleft was identified in only 12 patients (13.6%). A unilateral cleft was seen in 59 patients (67%), with 35 (59.3%) on the left and 24 (40.7%) on the right. Bilateral clefts were present in 29 cases (33%). Bone edema was identified in 91 of the 100 patients who underwent imaging. Forty-nine (53.8%) of 91 patients had focal edema in the pubic tubercle at the site of the adductor microtear. Two patients had a focal abnormality in the bone, without evidence of an adductor microtear, that was thought to be the result of early abnormal traction effect before the development of an avulsion microtear. The remaining 40 patients had diffuse edema in the pubic bones, either uni- or bilaterally, that was considered to be secondary to osteitis pubis. An articular surface irregularity at the pubic symphysis was seen in 50 patients in conjunction with stepoff at the joint in seven patients (Fig. 4). In the study group, osteophyte formation either at the pubic symphysis or at the pubic tubercle was seen in 21 patients. In 82 of the 100 patients, posterior and superior protrusion of the symphyseal fibrocartilaginous disk was identified. The mean diameter of the symphysis pubis joint space was 5.8 mm, with a range of from 1 to 8 mm, as measured at the midpoint of the joint in the axial plane. Control Subjects The images and records of the control subjects who did not have clinical symptoms or signs of groin pain were also reviewed. None of these patients showed evi- W292 AJR:188, March 2007

3 MRI of Injuries at the Symphysis Pubis dence of bone edema at the symphysis pubis. This is a statistically significant difference when compared with the study group (χ 2 = , p < 0.001). None of the control subjects was found to have an accessory cleft secondary to adductor dysfunction, which is another statistically significant difference when compared with the study group (χ 2 = , p < 0.001). A A B Fig year-old male soccer player from study group with left groin pain. A, Coronal inversion-recovery turbo spin-echo image shows secondary cleft (arrow) to left due to microtear at adductor attachment. Note normal symphyseal articular surfaces and absence of paraarticular bone edema. B, Radiograph obtained after cleft injection. Symphyseal injection confirms left-sided adductor microtear with subsequent symptom resolution after steroid (40 mg of prednisolone) and bupivacaine (1 ml of 0.5%) injection to cleft. Fig year-old male soccer player from study group with long-standing bilateral groin pain that was worse on right side. A, Coronal inversion-recovery turbo spin-echo image shows secondary cleft (arrowhead) to right due to adductor enthetic microtear, accompanied by paraarticular bone edema and articular surface irregularity (arrow) due to osteitis pubis. B, Radiograph obtained after cleft injection. Symphyseal injection confirms presence of right adductor microtear (arrow) with symptom resolution after steroid (40 mg of prednisolone) and bupivacaine (1 ml of 0.5%) injection to cleft. A symphyseal articular surface irregularity with paraarticular fatty marrow change was identified in 27 of the control subjects without evidence of active inflammation, which was defined by the presence of either soft-tissue or bone edema. In 73 of the 100 control subjects, herniation of the fibrocartilaginous disk posteriorly and superiorly from the symphyseal articulation was noted. There was no statistically significant difference between the study group and control group with regard to fibrocartilaginous disk herniation (82% vs 73%, respectively; χ 2 = 2.32, p = 0.20). Discussion The symphysis pubis has uniquely evolved to dissipate and cushion the impaction forces imposed on the pelvis during gait. In healthy B AJR:188, March 2007 W293

4 Fig year-old male soccer player from study group with right groin pain. A and B, Coronal inversion-recovery turbo spin-echo image (A) and axial T1-weighted turbo spin-echo image (B) show right-sided secondary cleft at site of adductor microtear without osteitis pubis. Axial image (B) shows posterior herniation of symphyseal fibrocartilage (arrow). Fig. 4 Coronal T1- weighted image of 27-year-old soccer player in study group shows articular surface irregularity at symphysis pubis with superior articular surface stepoff, reflecting symphyseal laxity. A individuals, gait results in the rapid weight transfer from one side of the pelvis to the other with the associated forces centered on and applied to the symphysis. For sports in which players twist, turn, and kick, the applied forces are magnified, thus resulting in severe biomechanical strain on the symphysis and its associated support structures. As a result, groin injury presenting as groin pain is one of the most common musculoskeletal injuries encountered in athletes participating in these sports [17 22]. The articular surfaces of the symphysis pubis are covered by hyaline articular cartilage on either side and are the margins of a central fibrocartilaginous disk that primarily functions to dissipate impaction forces. In adults, a physiologic fluid-filled cleft develops in the fibrocartilage. Anteriorly, the fibrocartilaginous disk and symphyseal joint are supported by an aponeurosis created by the tendons of the anterior abdominal wall, particularly rectus abdominis muscles, and, to a lesser extent, by the aponeurosis created by the gracilis and adductor longus tendons. The gracilis and adductor longus tendons merge from both the right and left legs to provide support anteriorly and, to a greater extent, inferiorly where they merge with the arcuate ligament [12] (Fig. 5). Superiorly, the fibrocartilage and symphyseal joint are supported by the superior pubic ligament [12], but in the absence of supporting musculature superiorly and posteriorly, repeated impaction forces lead to gradual herniation of the fibrocartilaginous disk superiorly and posteriorly, as was identified in 82 of the 100 symptomatic patients in the study group. The same finding was identified in 73 of the control subjects without groin pain, which suggests that herniation of the fibrocartilaginous disk is an asymptomatic mechanical phenomenon. In this study, fibrocartilage herniation was associated with narrowing of the joint space in most cases and with parasymphysial osteophytes in a minority of cases. Whether fibrocartilage herniation precedes or predisposes an individual to developing osteitis pubis is unclear. Similarly, reflecting the complex aponeurosis that merges anteriorly and inferiorly to the symphysis and combines with muscles of the anterior abdominal wall and of both thighs, injury to the symphysis often results in pain that radiates to the groin, inside aspect of the thigh, and lower abdomen [23]. Although groin pain may be secondary to many entities remote from the symphysis, including hip and sacroiliac derangement, in most cases, exertional groin pain or pubalgia results from injury to the symphysis pubis and its supporting structures. Although this study focused on adductor dysfunction and osteitis pubis, in many cases, pubalgia is attributed to sportsman s hernia. This entity is one in which inguinal ligament laxity leads to widening and tearing of support structures of the internal ring. Although this single abnormality has been popularized as sportsman s hernia, confusion has given rise to a number of descriptive terms for the same entity including prehernia complex, conjoint tendon tear, external oblique tear, and rectus abdominis sheath tear [24 27]. In this study, sportsman s hernia was excluded in each of the study subjects on the basis of clinical examination before referral for MRI. Although herniography has been used and can show internal ring lax- B W294 AJR:188, March 2007

5 MRI of Injuries at the Symphysis Pubis ity [28] and although, more recently, Albers et al. [9] have shown the utility of MRI in revealing both muscular signal changes and myofascial bulging in affected patients, clinical examination is still considered to be the gold standard for this diagnosis [15]. The results of this study suggest that isolated adductor dysfunction with a microtear at its attachment is a more frequent cause of pubalgia in soccer players than isolated osteitis pubis. Indeed, our findings show that when osteitis pubis does occur, it is usually in association with a microtear at the pubic attachment of the adductor longus. Although somewhat speculative, the described patterns of disease at the symphysis suggest that an adductor microtear is frequently a primary event, followed by the development of osteitis presumably secondary to the induced muscular instability, laxity, and secondary impaction of surfaces at the symphysis. Similarly, sportsman s hernia or laxity and inflammation at the internal ring orifice, the third recognized cause of groin pain, may develop as a result of attempts to compensate for imbalance at the symphysis incurred by an adductor microtear. The fact that groin pain is frequently due to soft-tissue derangement, an adductor microtear, or a sportsman s hernia accounts for normal findings on radiographs and bone scans that are traditionally seen in these patients and further increases the requirement for MRI in this population. It is worth noting that, similar to the findings of an MRI study of Australian-rules football players, bone edema and inflammation at the symphysis were present in only the symptomatic study group; thus, when those findings are absent, an imager should have a high level of confidence in excluding disease. Similarly, we found that the cleft created by a microtear at the adductor enthesis was also present in only the symptomatic group, as was shown in another study [29]. Why a microtear at the adductor attachment occurs so frequently in soccer players is unclear. Although it is possible that overuse of the adductor longus muscle with associated increased contractility and power in the muscle belly cannot be accommodated by the small enthetic adductor attachment, it is likely that a microtear is the consequence of tendon stretching and applied traction to the enthesis due to twisting and turning [12, 14] or, more likely, is secondary to both. The initial tear appears to occur at the tendon attachment to the inferior border of the symphyseal fibrocartilage and to extend gradually to the true bone enthesis. The extension of the physiologic cleft within the fibrocartilage created by such a tear allows interposition of fluid between the tendon and pubic bone and appears to restrict healing. Repeated activity leads to progression of the tear, inflammation, pain, and imbalance at the symphysis and subsequently to osteitis pubis. This cycle can be dramatically halted by autotenotomy where superimposed macrotrauma leads to complete detachment of the adductor longus tendon from bone with resolution of symptoms within weeks. In most, the detached tendon ultimately lengthens but heals with extensive scar formation preserving some function but limiting the imposed traction effect. Management of groin injuries requires rest regardless of the cause. Sportsman s hernia diagnosed on the basis of clinical discomfort elicited by scrotal digital invagination [11, 25] was excluded in all the patients in this study. When confirmed by clinical findings, laxity of the internal ring is treated surgically by suture repair termed Gilmore groin repair. Whether such a procedure facilitates recovery of osteitis pubis is unclear; the symptoms improve in many either due to renewed groin stability or as a result of enforced rest after surgery [30 33]. Gilmore s groin repair that is, tightening the internal ring has no impact on the adductor attachment. When an adductor microtear is identified, symptom resolution may follow guided steroid injection to the symphyseal cleft, which communicates to the site of the tear [16]. Physiotherapy, focusing on the development of core stability, has been shown to reduce symptom recurrence [34]. In refractory cases, mimicking the effects of autotenotomy, surgical tenotomy is undertaken, with division of the adductor tendon from the pubic attachment. After undergoing postprocedural physiotherapy, individuals gen- A B C Fig. 5 Diagrams show secondary cleft. A, Diagram of symphysis pubis shows inferior attachment of adductor longus and gracilis conjoined tendon to inferior pubis (long arrow), passing over anterior pubis to merge with contralateral conjoined tendon and into inferior margin of symphyseal fibrocartilage. Rectus abdominis muscle (short arrow) attaches superiorly to superior margin of pubis, merges with contralateral rectus abdominis tendon, and merges inferiorly with conjoined tendon of adductor longus and gracilis muscles. B, Diagram of symphysis pubis. Within fibrocartilage is physiologic cleft limited inferiorly by intact cartilage (arrow). C, Diagram shows development of secondary cleft (arrow) due to tear at conjoined tendon attachment to inferior margin of fibrocartilage and at conjoined tendon enthesis. AJR:188, March 2007 W295

6 erally return to participating in sports within 3 months of the procedure [35]. There are a number of limitations to this study. First, the control population in this study included a mixed group of athletes, rowers and soccer players, in contrast to the study population who were all soccer players. Although this difference is a potential limitation, no difference in the imaging appearances at the symphysis were recorded between the two sporting groups. Second, although previous authors have advocated and shown the utility of gadolinium enhancement in characterizing groin ailments [13], gadolinium administration was considered unnecessary in this study because the secondary cleft sign was used as a marker of adductor dysfunction [12]. Finally, we acknowledge that one cannot make a true prediction about the pathogenesis of groin pain, as was attempted in this study, without conducting a longitudinal study. 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