MRI of Athletic Pubalgia
Christopher Beaulieu, M.D., Ph.D. Stanford University Medical Center Groin Pain
Hip joint Arthritis Femoracetabular impingement (FAI) Osseous stress injuries AVN Tendinopathy or tear $0<4>09/49:?=49I,88,>4:9:<-?<=4>4= SCFE
Inguinal or femoral hernia (traditional) “Sports or sportsman’s hernia” “Sports Hernia”
Originally, described as a weakness in the abdominal wall without true herniation of bowel. “incipient hernia” Later, a variety of predominantly musculotendinous disorders about the pubis recognized and lumped under this term, having nothing to do with hernia whatsoever A somewhat better term the syndrome of groin pain in athletes is athletic pubalgia Athletic Pubalgia
Groin pain in an individual that cannot be attributed to hip joint or hip tendon pathology, often in competitive athletes May be acute, but is more often chronic Encompasses osseous, myotendinous, as well as abdominal wall disorders Current terminology in fashion is “core (muscle) injury” Etiology
Sports with rapid change in direction and twisting or kicking American football Soccer Rugby Australian rules football Hockey Trail running (?) Anatomic Structures Involved
Bones - pubic symphysis Tendons and muscles Rectus abdominis Adductors, long and short Inguinal ligament and abdominal wall muscles
Modified from Falvey et al. Br J Sports Med 2016;50:423-430 Injury Patterns
Osteitis pubis - bone marrow edema Rectus-adductor “pubic plate” injury Adductor longus tendinopathy/tear Short adductor tendinopathy/tear Muscle tear Pubic bone marrow edema, Osteitis Pubis Radiographic Signs
Primary (symphyseal) cleft Normal physiologic cleft between pubic bones, closed superiorly and inferiorly by cartilage and ligaments Secondary cleft Fluid extending from the primary cleft and tracking parallel to the inferior margin of inferior pubic rams. Related to tears of the short adductors (adductor brevis, gracilis, pectineus) Superior cleft Fluid tracking parallel to the inferior margin of the superior pubic ramus. A marker of tear of the adductor longus or rectus-adductor aponeurosis. Symphyseal Cleft Injection Radiographic Signs
Becker et al, J Anat. 2010 Nov; 217(5): 475–487. Byrne, C.A., et al, AJR 209:380-388, 2017 Large FOV Cor T1 and T2FS Central Pubic Plate Disruption 22 y.o. Running Back
29 y.o. Quarterback with 2 weeks of Groin Pain
56 y.o. Runner with RT Groin Pain Incipient Hernia = Gilmore’s Groin
Minnich, JM et al, Am J Sports Med 39, 1341-1349. 78 y.o. Man with Prostate Ca and XRT Take Home Points
Athletic pubalgia is an important clinical syndrome with complex anatomy Primarily involves myotendinous structures about the pubic symphysis Some interaction with inguinal canal injury and traditional hernia exists At least 4 injury areas need to be assessed:
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