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Incidence of Pubic Bone Marrow Oedema in Australian Rules Football Players: Relation to Groin Pain

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Incidence of Pubic Bone Marrow Oedema in Australian Rules Football Players: Relation to Groin Pain 28 Br J Sports Med 2001;35:28–33 Br J Sports Med: first published as 10.1136/bjsm.35.1.28 on 1 February 2001. Downloaded from Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain G M Verrall, J P Slavotinek, G T Fon Abstract explanation for these MRI findings and Objectives—To examine the relation be- may be the cause of the clinical entity tween the clinical features of groin pain osteitis pubis. and groin magnetic resonance imaging (Br J Sports Med 2001;35:28–33) (MRI) appearances in a group largely comprising elite Australian Rules football Keywords: osteitis pubis; groin pain; magnetic reso- nance imaging; bone marrow oedema; stress injury players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The Diagnosing the cause of chronic groin pain in relation between a past history of groin sportsmen is diYcult. Athletes who participate pain and these other MRI findings was in sports with repetitive kicking, side to side also examined. movement, and twisting seem to be most at Method—In a prospective study, 116 male risk.1–3 Potential diagnoses include osteitis subjects (89 footballers, 17 umpires, 10 pubis, adductor muscle/tendon dysfunction, sedentary men) were examined before and posterior inguinal wall deficiency (sports history taking and groin MRI. The clini- hernia).4–9 In the evaluation of groin pain in cal history was not known to the examiner sportsmen, there is no consensus as to the clini- (GMV) and radiologists (JPS, GTF). cal and investigative approach to treatment. Clinical evidence of groin pain and Current investigations may include plain radio- examination findings were correlated graphy with or without stress views,10 11 triple with the presence of increased signal phase bone scan,12 ultrasound,13 14 herniogra- intensity within the pubic bone marrow. phy,615 and computed tomography scanning.16 A past history of groin pain was The magnetic resonance imaging (MRI) scan correlated with the presence of other has been shown to diVerentiate between some MRI findings such as cyst formation, causes of chronic groin pain,17 18 but to date this fluid signal within the pubic symphysis technique has not been used extensively in the disc, and irregularity of the pubic investigation of athletic groin pain. One retro- http://bjsm.bmj.com/ symphysis. spective study using MRI scan appearances in Results—Fifty two athletes (47 footballers, 11 soccer players with athletic chronic groin five umpires) had clinical features of groin pain speculated that a trabecular microfracture pain with pubic symphysis and/or supe- of the superior pubic ramus may result in rior pubic ramus tenderness. A high inci- altered weight bearing and increased stress on dence of increased signal intensity (77%) the pubic symphysis leading to symphysitis.19 within the pubic bone marrow was identi- One cause of chronic groin pain in athletes is fied in this group. There was an associ- osteitis pubis, a disorder characterised by pubic on September 28, 2021 by guest. Protected copyright. ation between this group of athletes and pain and chronicity. The cause is considered to the MRI finding of increased signal inten- be mechanical, with inappropriate stress and sity (p<0.01). There was also an associ- 1 SPORTSMEDvSA shear forces acting on the pubic symphysis. Sports Medicine ation between a past history of groin pain Mechanical factors implicated have included Clinic, Adelaide, and the presence of other MRI findings limited hip rotation,20 muscle action on the Australia (p<0.01). pelvis, in particular the adductor muscula- G M Verrall Conclusions—Athletes with groin pain ture,921 pelvic bone biomechanics,10 22 and 123 Department of and tenderness of the pubic symphysis overuse. Clinical features of osteitis pubis 1 Radiology, Flinders and/or superior pubic ramus have are described in a study of 59 athletes. The Medical Centre, clinical features consistent with the typical clinical history is pain that is unilateral Adelaide diagnosis of osteitis pubis. The increased and located in the adductor region. The most J P Slavotinek signal intensity seen on MRI is due to consistent signs seen were tenderness of the pubic symphysis (seen in 70%) and superior Perrett Medical pubic bone marrow oedema. An associ- Imaging, Adelaide ation exists between the clinical features pubic ramus (seen in 40%). These are the usual GTFon of osteitis pubis and the MRI finding of symptoms described for the clinical diagnosis pubic bone marrow oedema. A high of osteitis pubis in sports medicine textbooks Correspondence to: incidence of pubic bone marrow oedema and groin injury review articles.24–26 Standard Dr G M Verrall, was also noted. Degenerative features investigation of osteitis pubis includes plain SPORTSMEDvSA, 32 Payneham Rd, Stepney, visualised by MRI, such as subchondral radiography (asymmetrical bony erosions with South Australia, 5069 cyst formation, were associated with a sclerotic bony margins at the symphysis) and [email protected] past history of groin pain. A stress injury the triple phase bone scan (increased uptake on Accepted 3 August 2000 to the pubic bone is the most likely the delayed phase of the scan).1101227 These www.bjsportmed.com Groin pain in Australian rules footballers 29 Br J Sports Med: first published as 10.1136/bjsm.35.1.28 on 1 February 2001. Downloaded from investigations are useful for the diagnosis of taken at least six weeks of intensive training. this condition but are not of prognostic value.16 The groin region, hip, and back of the subjects Australian rules football is a collision contact were examined and then a history was obtained sport with speed, strength, and agility demands by direct interview. Questions sought to ascer- similar to rugby or American football. It diVers tain the presence or absence of current groin from these football codes, with more kicking pain symptoms, location and side of pain, and evasion and higher aerobic demands duration of symptoms, and past history of pain. because of the continuous nature of play and Tenderness was graded (0 = none; 1 = mild; thus is similar to world football. A high level of 2 = moderate; 3 = considerable) for the athletic training is required to play at the elite anterior-superior pubic symphysis. The pres- level in Australian rules football, and a large ence or absence of tenderness was recorded on number of overuse injuries are reported at jun- the right and left sides in relation to the ior and senior levels.28 As overuse is considered superior pubic ramus, adductor muscle origin, to be associated with the development of sports and the region superior to the pubic tubercle. related chronic groin pain, including the Subjects were considered symptomatic when diagnostic entity osteitis pubis, this is a possible they had groin pain located in the pubic explanation for the high incidence of this con- symphysis and adjacent pubic bone region, dition in elite Australian rules football players. adductor area, and/or lower abdominal area Clinical evaluation and MRI were used to during and/or after exercise occurring in the assess a group of athletes, predominantly elite recent six week preseason period and they also Australian rules football players, with a high had tenderness of the pubic symphysis and/or incidence of sports related chronic groin pain. adjacent superior pubic ramus. The principal aim of the study was to correlate Pain in the groin region without associated clinical features of groin injury such as pain tenderness, and pain with tenderness in loca- and tenderness with the MRI finding of pubic tions other than the pubic symphysis and/or bone marrow oedema (BMO). The incidence superior pubic ramus was noted, but these of groin MRI abnormalities, such as BMO, cyst athletes were not considered symptomatic. formation, and irregularity of the pubic sym- physis, was recorded, with the relation between a past history of groin pain and these other MRI SCAN groin MRI abnormalities also being studied. After examination and history taking, MRI scans (1.5T GE Signa, 1.0T Siemens Impact) Methods were performed on all 116 subjects using T1 SUBJECTS and fat suppressed T2 sequences. The images After ethical approval from the committee on were obtained in planes coronal and axial with clinical investigations, signed informed consent respect to the pubic body (3–4 mm slices). The was obtained from each participant. Eighty time between MRI and examination ranged nine footballers, all male, were recruited from from 0 to 12 days (median 3 days). Images were independently reviewed without clinical infor- two national competition teams (Australian http://bjsm.bmj.com/ Football League (AFL); n = 60) and one state mation by two musculoskeletal radiologists competition team (South Australian National (JPS, GTF). Discordant cases were reviewed by Football League (SANFL); n = 29). At the end the radiologists, and consensus was reached. of the preseason, after at least six weeks of T2 fat suppression images were subjectively intensive training, subjects from each team graded on the right and left side for (a) inten- were recruited with the following priorities: (a) sity of bone marrow signal (0 = normal; I = athletes with current groin pain; (b) athletes subtle/equivocal; II = moderate; III = severe), with previous groin pain; (c) athletes who had (b) size (extent) of signal change (long axis on September 28, 2021 by guest. Protected copyright. never had any previous episode of groin pain. dimension <2 cm, >2 cm), and (c) hyperinten- Seventeen running athletes were recruited sity of the adductor muscle origins. BMO was from the umpires used for the Australian rules considered present when either grade II or III football competitions (AFL and SANFL) as signal intensity was present, indicating an active subjects who, unlike the footballers, do unequivocal change in bone marrow appear- not undertake significant twisting and cutting ances.
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