DOI: 10.1148/radiol.2473070049
(Radiology 2008;247:797-807.)
© RSNA, 2008
Athletic Pubalgia and the "Sports Hernia": MR Imaging Findings1
Adam C. Zoga, MD,
Eoin C. Kavanagh, MD,
Imran M. Omar, MD,
William B. Morrison, MD,
George Koulouris, MD,
Hector Lopez, MD,
Avneesh Chaabra, MD,
John Domesek, MD, and
William C. Meyers, MD
1 From the Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, 10th Floor, Philadelphia, PA 19107 (A.C.Z., E.C.K., W.B.M.); Department of Radiology, Northwestern University Hospital, Chicago, Ill (I.M.O.); Department of Radiology, The Alfred Hospital, Prahran, Victoria, Australia (G.K.); Department of Pathology, Anatomy and Cell Biology, JMC Department of Physical Therapy, Jefferson College of Health Professions, Philadelphia, Pa (H.L.); and Departments of Radiology (A.C., J.D.) and Surgery (W.C.M.), Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, Pa. Received January 8, 2007; revision requested March 1; final revision received September 6; accepted September 26; final version accepted November 7.
Address correspondence to A.C.Z. (e-mail: adam.zoga{at}jefferson.edu).
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ABSTRACT
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Purpose: To retrospectively determine the sensitivity and specificity of magnetic resonance (MR) imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard.
Materials and Methods: Institutional review board approval was granted for this HIPAA-compliant study, and informed consent was waived. MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17–71 years) who had been referred to a subspecialist because of groin pain were reviewed for findings including hernia, pubic bone marrow edema, secondary cleft sign, and rectus abdominis and adductor tendon injury. MR imaging findings were compared with surgical findings for 102 patients, physical examination findings for all 141 patients, and MR imaging findings in an asymptomatic control group of 25 men (mean age, 29.8 years; range, 18–39 years). Sensitivity and specificity of MR imaging for rectus abdominis and adductor tendon injury were determined by using a 
2 analysis, and significance of the findings was analyzed with an unpaired Student t test. Disease patterns seen at MR imaging were compared with those reported in the surgical and sports medicine literature.
Results: One hundred thirty-eight (98%) of 141 patients had findings at MR imaging that could cause groin pain. Compared with surgery, MR imaging had a sensitivity and specificity, respectively, of 68% and 100% for rectus abdominis tendon injury and 86% and 89% for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group (P < .001). Only two patients had hernias at surgery. At MR imaging, injury or disease could be fit into distinct groups, including osteitis pubis, adductor compartment injury, rectus abdominis tendon injury, and injury or disease remote from the pubic symphysis. Patients with injury involving the rectus abdominis insertion were most likely to go on to surgical pelvic floor repair.
Conclusion: MR imaging depicts patterns of findings in patients with athletic pubalgia, including rectus abdominis insertional injury, thigh adductor injury, and articular diseases at the pubic symphysis (osteitis pubis).
© RSNA, 2008
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INTRODUCTION
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For many years, lower abdominal pain and groin pain have been frequent causes of diagnostic and therapeutic confusion for orthopedic surgeons, sports medicine clinicians, abdominal surgeons, athletic training staff, and radiologists treating athletes (1,2). Terms including osteitis pubis, pubalgia, groin strain, abdominal muscle tear, and, more recently, sports hernia have become common diagnoses on team injury reports, in the sportscasting media, and on disabled lists throughout professional and collegiate athletics worldwide (3–7). However, many of these terms are poorly defined in the medical literature, leading to wide variability in diagnosis and in treatment algorithms.
It has been established that lower abdominal and groin injuries are exceedingly prevalent in amateur and professional athletes compared with the incidence of such injuries in the general population (8). Multiple injuries have been described in association with the clinical term athletic pubalgia, including injuries involving the rectus abdominis pubic attachment and its fascia, the hip adductor tendon origins, and the pubic symphysis itself (9,10).
Magnetic resonance (MR) imaging has been reported to be helpful in identifying an injury in patients with athletic pubalgia, while other investigators have reported that imaging studies, including MR imaging studies, are most often negative (11–13). To our knowledge, neither imaging findings for specific disorders in this disease spectrum nor the sensitivity and specificity of MR imaging for these injuries has been described (14). Thus, the purpose of our study was to retrospectively determine the sensitivity and specificity of MR imaging findings in patients with clinical athletic pubalgia, with either surgical or physical examination findings as the reference standard.
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MATERIALS AND METHODS
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Institutional review board approval was granted at both Thomas Jefferson University Hospital and the Drexel University College of Medicine as appropriate for study patients and control subjects. Informed consent was waived for all study patients and control subjects in this retrospective Health Insurance Portability and Accountability Act–compliant study.
Study Patients
MR imaging studies in 170 consecutive patients referred to a surgeon who specializes in athletic pubalgia for diagnoses including "athletic pubalgia" and "sports hernia" during a period from January 2005 through March 2006 were reviewed. Exclusion criteria included inadequate MR imaging coverage of the pubic symphysis in at least two planes; lack of a fluid-sensitive, fat-suppressed sequence; and MR imaging performed more than 120 days prior to the office visit. Ultimately, 141 patients were included in the study patient group. The mean age of the study patients was 30.1 years (range, 17–71 years), and there were 134 male patients and seven female patients. Because these were tertiary referrals, MR imaging studies had been performed at many imaging centers throughout the United States and Canada, with numerous imaging systems and variable imaging protocols.
Image Analysis
At MR imaging study review, note was made of the field strength and imaging protocol used. The majority (130 of 141) of MR imaging studies were furnished by the patients on either printed film or in Digital Imaging and Communications in Medicine compact disk format. Studies obtained in patients imaged at the authors' home imaging centers (11 of 141) were reviewed at a picture archiving and communication system workstation (Canon, Lake Success, NY). All studies were reviewed in consensus by three fellowship-trained musculoskeletal radiologists (A.C.Z., E.C.K., and I.M.O., with 5 years, 2 years, and 1 year of postresidency experience, respectively) who were blinded to all clinical information other than the fact that the patient had been referred for athletic pubalgia or sports hernia. MR imaging reports and any other imaging studies (computed tomography, scintigraphy, radiography) provided were not reviewed for this investigation.
MR images were reviewed for bone marrow edema around the pubic symphysis, fracture, osteitis pubis, and the presence of a secondary cleft sign. Osteitis pubis was defined as bone marrow edema spanning the symphysis and extending along the symphysis anteriorly to posteriorly with bony productive changes or subchondral resorption. A secondary cleft sign was defined as a curvilinear area with the signal intensity of fluid extending inferolaterally from the inferior aspect of the symphysis on coronal images (15). Any abdominal wall, inguinal, femoral, or internal hernia was recorded. Tendinous injury involving the rectus abdominis at its distal or caudal attachment and the adductor tendons (pectineus, adductor longus, adductor brevis, gracilis, and adductor magnus) at their proximal or rostral origins were noted. Tendon findings classified as pathologic included tendon enlargement, peritendinous fluid without intratendinous fluid signal intensity, partial tear, and complete disruption (16). Injury including strain and atrophy involving any of these muscles was recorded. Muscle strain was defined as intramuscular fluid signal intensity or fluid signal intensity around a myotendinous junction, and muscle atrophy was defined as intramuscular signal on T1-weighted images that was hyperintense to signal in surrounding muscles. Any other potential causes for groin pain were recorded, including internal derangement of the hip and abnormalities in the visceral pelvis. For the hip, findings compatible with acetabular labral tear, femoroacetabular impingement, or osteoarthritis according to published criteria (17,18) were recorded.
Reference Standard Physical Examination
Findings recorded at MR imaging review were compared with findings recorded at physical examination for all patients. The physical examination had been performed by a single subspecialist surgeon (W.C.M., with more than 10 years of experience in treating groin pain and athletic pubalgia). All physical examination findings were preoperative and were directed to patient symptoms. Findings suggesting injury involving the rectus abdominis tendon or muscle, adductor tendons, pubic symphysis, and other injuries remote from the groin had been recorded and were compared with the MR imaging findings. Imaging studies and outside reports were available to the surgeon at the time of physical examination. At the office visit, any athletic activity or endeavor related to the groin pain was recorded as well. MR imaging studies for all 141 patients were compared with physical examination findings. For analysis of this comparison, the findings at physical examination served as the reference standard.
Reference Standard Surgical Findings
Surgery was performed on the basis of the clinical assessment of the managing subspecialist surgeon (W.C.M.). Suspected rectus abdominis insertional injury was the most common indicator for surgery, and patients suspected of having only adductor injury were generally treated conservatively. For patients who went on to surgery (n = 102), surgical reports were reviewed and compared with findings at MR imaging, and surgical findings served as the reference standard. Injuries or disorders identified at surgery involving the rectus abdominis tendon or muscle, adductor tendons, and pelvic floor (including any hernias) were recorded. Other surgical findings that might be related to groin pain, including intrapelvic masses and inguinal or abdominal hernias, were recorded. Individual adductor tendons (eg, adductor longus, adductor brevis) were not consistently described on the surgical reports, so, for the purposes of MR imaging and surgical comparison, presence of tendinous injury in a common adductor compartment was used.
Control Subjects
To ensure that findings observed at MR imaging in our study patient group were not simply variations of normal findings, a group of control subjects was evaluated. This group was composed of 25 men younger than 40 years (the typical demographic for athletic pubalgia) with MR imaging studies covering the region of the pubic symphysis but with no groin pain reported at referral or on the standard pre–MR imaging patient questionnaire utilized in our department. Control group subjects were found through a search of the radiology information system database at Thomas Jefferson University Hospital, and indications for MR imaging included sacroiliac disease, coccydynia, piriformis syndrome, lumbar plexus disease, direct trauma, and various muscle strains remote from the groin, including strains of hip external rotator and hip flexor muscles. The mean age in this group of subjects was 29.8 years, and the age range was 18–39 years. All MR imaging studies for the control subjects were acquired at 1.5 T by using both fat-suppressed and non–fat-suppressed sequences. MR imaging studies in this group were reviewed by the same three reviewers in consensus and in the same manner as those in the study patient group. Findings were recorded by using the same data collection spreadsheet.
Statistical Analysis
Statistical analysis of the comparison between MR imaging and surgical findings for the rectus abdominis insertion and the adductor tendons was performed to assess whether MR imaging depicts injury and disease. Sensitivities and specificities of MR imaging for rectus abdominis and adductor tendon injury were established by using a 2 analysis for both physical examination and surgical findings as reference standards. Additionally, sensitivities and specificities of individual MR imaging findings, including bone marrow edema and a secondary cleft sign, as predictors for rectus abdominis insertion and adductor tendon injury were calculated. The frequency of abnormal MR imaging findings involving the pubic symphysis, rectus abdominis, and adductor tendons for this population of patients with groin pain was established, as was the frequency of other MR imaging findings that may relate to symptoms. Finally, the frequency of MR imaging findings involving the rectus abdominis insertion, the adductor tendons, and the pubic symphysis in the patient group was compared with the frequency of these individual findings in the control group by using an unpaired Student t test. A P value of less than .05 was considered to indicate a significant difference. Statistical analyses were performed by using commercially available statistical software (Instat, version 3.06 for Windows; GraphPad, San Diego, Calif).
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RESULTS
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Study Patients
Among the 141 study patients, 38 (27%) were professional athletes and another 48 (34%) were collegiate athletes. Only 14 (10%) study patients reported no specific athletic endeavor. The most common activities reported were American football (n = 41 [29%]); soccer (n = 23 [16%]); competitive running and baseball (n = 15 [11%]); hockey (n = 14 [10%]); rodeo activities, weightlifting, and lacrosse (n = 5 for each [4%]); and golf (n = 4 [3%]). Ten other athletic activities were reported by one patient each. Of the 14 patients who reported no specific athletic endeavor, 12 described exercise or working out as a general activity, and 10 reported having undergone previous lower abdominal surgery.
MR Imaging Techniques
One hundred seventeen (83%) of 141 MR imaging examinations were performed at 1.5 T, two (1%) were performed with a 3-T system, 16 (11%) were performed with either 0.2-T or 0.3-T open systems, and six (4%) were performed with 0.6-T or 0.7-T units. Protocols were variable, with 106 (75%) of 141 studies dedicated to the pelvis, 19 (13%) dedicated to the hip but covering the pubic symphysis, and 16 (11%) dedicated to the pubic symphysis itself. In general, MR imaging fields of view were large. The mean minimum field of view for coronal sequences was 32.8 cm, but this increased to 37.2 cm if the studies dedicated to the pubic symphysis were excluded. One hundred four (74%) of the 141 MR imaging examinations covered the pubic symphysis in three planes, with the other 37 (26%) examinations involving the use of only two planes in that location. The sagittal plane was the plane most frequently omitted at the pubic symphysis.
Comparison of MR Imaging with Physical Examination Findings
Physical examination findings were compared with those at MR imaging in all study patients (Fig 1, Table 1). Ninety-three (66%) of 141 patients had physical examination findings that suggested rectus abdominis tendon injury (Fig 2). Of these 93 patients, 60 (65%) had injury involving the rectus abdominis tendon that was noted at MR imaging. Among the 93 patients with physical examination findings that suggested rectus abdominis tendon injury, 53 (57%) had bone marrow edema around the pubic symphysis (regardless of extent or symmetry) and 52 (56%) had a secondary cleft sign at MR imaging. Fifteen (11%) of 141 patients had physical examination findings that suggested injury isolated to the adductor compartment. Of these 15 patients, nine (60%) had adductor tendon injury at MR imaging, but three of these nine patients also had MR imaging findings involving the rectus abdominis tendon. Of the 15 patients with isolated adductor tendon injury at physical examination, only three (20%) had pubic symphysis bone marrow edema, while four (27%) had a secondary cleft sign (Fig 3). At physical examination, 71 (50%) of 141 patients had findings suggestive of injury involving both the rectus abdominis tendon and the adductor compartment. MR imaging revealed both rectus abdominis tendon and adductor tendon injury in only 38 (54%) of these 71 patients, but 46 (65%) had bone marrow edema around the pubic symphysis and 43 (61%) had a secondary cleft sign (Fig 4).
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Figure 1: Flowchart of MR imaging findings, with physical examination results as the reference standard. * = No T2-weighted fat-saturated or short inversion time inversion-recovery MR imaging performed (n = 11), imaging coverage was inadequate (n = 15), MR imaging was performed more than 3 months after office visit (n = 3).
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Figure 2a: Acute-on-chronic unilateral rectus abdominis injury in professional hockey player. (a) Sagittal and (b) axial T2-weighted fast spin-echo fat-saturated MR images (repetition time msec/echo time msec, 4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 24 cm) show disruption (arrowheads) of rectus abdominis muscle attachment at the anteroinferior pubis with its accompanying periosteum. Note the normal-appearing rectus abdominis tendon attachment on the right (arrow). An isolated tear of the rectus abdominis muscle was found at surgery.
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Figure 2b: Acute-on-chronic unilateral rectus abdominis injury in professional hockey player. (a) Sagittal and (b) axial T2-weighted fast spin-echo fat-saturated MR images (repetition time msec/echo time msec, 4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 24 cm) show disruption (arrowheads) of rectus abdominis muscle attachment at the anteroinferior pubis with its accompanying periosteum. Note the normal-appearing rectus abdominis tendon attachment on the right (arrow). An isolated tear of the rectus abdominis muscle was found at surgery.
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Figure 3: Coronal short inversion time inversion-recovery MR image (3400/40; inversion time, 150 msec; number of signals acquired, two; echo train length, eight; field of view, 28 cm) shows acute grade 2 injury (straight arrow) of right adductor longus muscle, with intramuscular edema extending more distally into the muscle belly (curved arrow). Note that the adductor longus tendon origin (arrowhead) on the right is enlarged compared with that on the left; this appearance is compatible with chronic injury. No rectus abdominus muscle injury, secondary cleft sign, or pubic symphysis bone marrow edema was noted, and the patient was treated conservatively for an adductor tendon strain.
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Figure 4a: Acute rectus abdominis and adductor tendon injuries in professional baseball pitcher. (a) Axial T2-weighted fast spin-echo fat-saturated MR image (4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 36 cm) shows traumatic disruption (arrow) of lateral fibers of the left rectus abdominis at its insertion. The normal medial and lateral bundles of the right rectus abdominis muscle and the medial bundle of the left rectus abdominis tendon (arrowheads) are seen as intact. (b) Coronal short inversion time inversion-recovery MR image (3400/40; inversion time, 150 msec; number of signals acquired, two; echo train length, eight; field of view, 28 cm) shows a secondary cleft sign (straight arrow) on the left, with a large avulsion (curved arrow) of the left adductor longus and brevis tendons.
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Figure 4b: Acute rectus abdominis and adductor tendon injuries in professional baseball pitcher. (a) Axial T2-weighted fast spin-echo fat-saturated MR image (4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 36 cm) shows traumatic disruption (arrow) of lateral fibers of the left rectus abdominis at its insertion. The normal medial and lateral bundles of the right rectus abdominis muscle and the medial bundle of the left rectus abdominis tendon (arrowheads) are seen as intact. (b) Coronal short inversion time inversion-recovery MR image (3400/40; inversion time, 150 msec; number of signals acquired, two; echo train length, eight; field of view, 28 cm) shows a secondary cleft sign (straight arrow) on the left, with a large avulsion (curved arrow) of the left adductor longus and brevis tendons.
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At physical examination, 16 patients had findings most compatible with osteitis pubis, without concomitant rectus abdominis insertion or adductor tendon injury. Of these patients, all 16 (100%) had bone marrow edema that spanned the pubic symphysis and extended from anterior to posterior at the subchondral region of the symphysis, and none had rectus abdominis insertional injury at MR imaging (Fig 5). At physical examination and MR imaging, osteitis pubis manifests as an arthritis involving the fibrous pubic symphysis joint. However, MR imaging findings of osteitis pubis were not always observed in isolation in this group, as six (38%) of these 16 patients also had adductor compartment injury at MR imaging and seven (44%) had intrinsic hip disease at MR imaging.
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Figure 5: MR imaging findings of osteitis pubis in collegiate football player. Axial T2-weighted fast spin-echo fat-saturated MR image (4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 36 cm) shows intense, symmetric bone marrow edema (arrows) spanning the subchondral bone on both sides of the pubic symphysis, with fluid signal intensity in the joint space. No secondary cleft sign was seen, and no adductor or rectus injury was identified. This patient was treated conservatively for osteitis pubis.
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Comparison of MR Imaging with Surgical Findings
One hundred two patients (97 male patients, five female patients; mean age, 28.3 years, range, 17–48 years) in our study patient group went to surgery for groin pain (Fig 6, Table 2). At surgery, 91 (89%) of 102 patients were found to have injury involving the rectus abdominis at or near its insertion. In this subset of 91 patients with surgically proved rectus abdominis injury, 62 had ipsilateral rectus abdominis tendon injury at MR imaging (sensitivity, 68%) (Fig 7). Of the 29 false-negative interpretations, all 29 were described as grade 1 injury, or tendon degeneration, on the surgical report (Fig 8). There were no false-positive MR imaging findings at the rectus abdominis tendon, yielding an MR imaging specificity and positive predictive value of 100% for rectus abdominis insertional injury. Of the 91 patients with rectus abdominis tendon injury at surgery, 16 also had injury that involved the contralateral rectus abdominis tendon, and 15 of these 16 patients had bilateral rectus abdominis insertional injury at MR imaging. Ten patients in the study patient group had rectus abdominis muscle atrophy at MR imaging, and all 10 had surgical findings of rectus abdominis insertional injury. A small subgroup of 10 patients with true-positive findings of rectus abdominis injury at surgery were also in the group of 14 patients who reported no specific athletic endeavor. When examined as a distinct group, these 10 patients tended to be older than the general population of study patients (mean age, 41.1 years), and nine had undergone prior hernia repair (Fig 9).
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Figure 6: Flowchart of MR imaging findings, with surgical results as the reference standard. * = No T2-weighted fat-saturated or short inversion time inversion-recovery MR imaging performed (n = 11), imaging coverage was inadequate (n = 15), MR imaging was performed more than 3 months after office visit (n = 3).
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Figure 7a: (a) Axial schematic depicts normal (right) and torn (left) rectus abdominis tendon insertions. Note the medial and lateral bundles of the rectus abdominis (RA) muscles on the right and their close proximity to the most anterior thigh adductor, the pectineus (P). On the left, there is a defect involving the lateral head of the left rectus abdominis (arrow). Symph = symphysis. (b) Sagittal schematic shows the most common pattern of rectus abdominis (RA) tendon injury in our series. Extent of rectus abdominis avulsion (arrows) that we noted frequently in patients with rectus abdominis insertional injury proved at surgery is shown in red. (c) Axial T2-weighted fast spin-echo fat-saturated (2400/60; number of signals acquired, one; echo train length, eight; field of view, 32 cm) and (d) sagittal T2-weighted fast spin-echo (2400/60; number of signals acquired, one; echo train length, eight; field of view, 24 cm) MR images in collegiate lacrosse player show avulsion of the rectus abdominis at its pubic insertion (arrow in c, arrowheads) as well as retraction of the adductor longus tendon origin (arrow in d). At surgery, this patient had tears at both the rectus abdominis insertion and the adductor tendon origin.
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Figure 7b: (a) Axial schematic depicts normal (right) and torn (left) rectus abdominis tendon insertions. Note the medial and lateral bundles of the rectus abdominis (RA) muscles on the right and their close proximity to the most anterior thigh adductor, the pectineus (P). On the left, there is a defect involving the lateral head of the left rectus abdominis (arrow). Symph = symphysis. (b) Sagittal schematic shows the most common pattern of rectus abdominis (RA) tendon injury in our series. Extent of rectus abdominis avulsion (arrows) that we noted frequently in patients with rectus abdominis insertional injury proved at surgery is shown in red. (c) Axial T2-weighted fast spin-echo fat-saturated (2400/60; number of signals acquired, one; echo train length, eight; field of view, 32 cm) and (d) sagittal T2-weighted fast spin-echo (2400/60; number of signals acquired, one; echo train length, eight; field of view, 24 cm) MR images in collegiate lacrosse player show avulsion of the rectus abdominis at its pubic insertion (arrow in c, arrowheads) as well as retraction of the adductor longus tendon origin (arrow in d). At surgery, this patient had tears at both the rectus abdominis insertion and the adductor tendon origin.
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Figure 7c: (a) Axial schematic depicts normal (right) and torn (left) rectus abdominis tendon insertions. Note the medial and lateral bundles of the rectus abdominis (RA) muscles on the right and their close proximity to the most anterior thigh adductor, the pectineus (P). On the left, there is a defect involving the lateral head of the left rectus abdominis (arrow). Symph = symphysis. (b) Sagittal schematic shows the most common pattern of rectus abdominis (RA) tendon injury in our series. Extent of rectus abdominis avulsion (arrows) that we noted frequently in patients with rectus abdominis insertional injury proved at surgery is shown in red. (c) Axial T2-weighted fast spin-echo fat-saturated (2400/60; number of signals acquired, one; echo train length, eight; field of view, 32 cm) and (d) sagittal T2-weighted fast spin-echo (2400/60; number of signals acquired, one; echo train length, eight; field of view, 24 cm) MR images in collegiate lacrosse player show avulsion of the rectus abdominis at its pubic insertion (arrow in c, arrowheads) as well as retraction of the adductor longus tendon origin (arrow in d). At surgery, this patient had tears at both the rectus abdominis insertion and the adductor tendon origin.
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Figure 7d: (a) Axial schematic depicts normal (right) and torn (left) rectus abdominis tendon insertions. Note the medial and lateral bundles of the rectus abdominis (RA) muscles on the right and their close proximity to the most anterior thigh adductor, the pectineus (P). On the left, there is a defect involving the lateral head of the left rectus abdominis (arrow). Symph = symphysis. (b) Sagittal schematic shows the most common pattern of rectus abdominis (RA) tendon injury in our series. Extent of rectus abdominis avulsion (arrows) that we noted frequently in patients with rectus abdominis insertional injury proved at surgery is shown in red. (c) Axial T2-weighted fast spin-echo fat-saturated (2400/60; number of signals acquired, one; echo train length, eight; field of view, 32 cm) and (d) sagittal T2-weighted fast spin-echo (2400/60; number of signals acquired, one; echo train length, eight; field of view, 24 cm) MR images in collegiate lacrosse player show avulsion of the rectus abdominis at its pubic insertion (arrow in c, arrowheads) as well as retraction of the adductor longus tendon origin (arrow in d). At surgery, this patient had tears at both the rectus abdominis insertion and the adductor tendon origin.
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Figure 8a: (a) Coronal short inversion time inversion-recovery MR image (4400/44; inversion time, 150 msec; number of signals acquired, 1.5; echo train length, eight; field of view, 44 cm) acquired at 1.5 T in professional football player 12 hours after he experienced severe, sharp right groin pain while hyperextending at the trunk shows hyperintense signal (arrow) within the rectus abdominis muscle near its pubic insertion. There was no pubic symphysis bone marrow edema and no adductor injury at MR imaging at this time. (b) Coronal short inversion time inversion-recovery MR image acquired 9 weeks later with the same imaging system and similar parameters because of a recurrent injury shows a large secondary cleft sign (arrowheads) and complete avulsion of the common adductor longus tendon at its origin. (c) T2-weighed fast spin-echo axial image from the second study shows a tear of the right rectus abdominis tendon insertion (arrow); this was subsequently repaired surgically. This case emphasizes the importance of identifying rectus abdominis injury early.
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Figure 8b: (a) Coronal short inversion time inversion-recovery MR image (4400/44; inversion time, 150 msec; number of signals acquired, 1.5; echo train length, eight; field of view, 44 cm) acquired at 1.5 T in professional football player 12 hours after he experienced severe, sharp right groin pain while hyperextending at the trunk shows hyperintense signal (arrow) within the rectus abdominis muscle near its pubic insertion. There was no pubic symphysis bone marrow edema and no adductor injury at MR imaging at this time. (b) Coronal short inversion time inversion-recovery MR image acquired 9 weeks later with the same imaging system and similar parameters because of a recurrent injury shows a large secondary cleft sign (arrowheads) and complete avulsion of the common adductor longus tendon at its origin. (c) T2-weighed fast spin-echo axial image from the second study shows a tear of the right rectus abdominis tendon insertion (arrow); this was subsequently repaired surgically. This case emphasizes the importance of identifying rectus abdominis injury early.
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Figure 8c: (a) Coronal short inversion time inversion-recovery MR image (4400/44; inversion time, 150 msec; number of signals acquired, 1.5; echo train length, eight; field of view, 44 cm) acquired at 1.5 T in professional football player 12 hours after he experienced severe, sharp right groin pain while hyperextending at the trunk shows hyperintense signal (arrow) within the rectus abdominis muscle near its pubic insertion. There was no pubic symphysis bone marrow edema and no adductor injury at MR imaging at this time. (b) Coronal short inversion time inversion-recovery MR image acquired 9 weeks later with the same imaging system and similar parameters because of a recurrent injury shows a large secondary cleft sign (arrowheads) and complete avulsion of the common adductor longus tendon at its origin. (c) T2-weighed fast spin-echo axial image from the second study shows a tear of the right rectus abdominis tendon insertion (arrow); this was subsequently repaired surgically. This case emphasizes the importance of identifying rectus abdominis injury early.
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Figure 9a: MR imaging findings in recreational soccer player with chronic groin pain and remote history of prior right inguinal hernia repair. (a) Axial T2-weighted fast spin-echo fat-saturated MR image (4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 24 cm) shows intact left rectus abdominis tendon (arrowheads). There is atrophy of the medial and lateral bundles of the rectus abdominis on the right (arrow). (b) Coronal T1-weighted MR image (400/25; number of signals acquired, two; field of view, 24 cm) shows diffuse fatty infiltration of the distal right rectus abdominis muscle (arrow).
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Figure 9b: MR imaging findings in recreational soccer player with chronic groin pain and remote history of prior right inguinal hernia repair. (a) Axial T2-weighted fast spin-echo fat-saturated MR image (4000/85; number of signals acquired, 1.5; echo train length, eight; field of view, 24 cm) shows intact left rectus abdominis tendon (arrowheads). There is atrophy of the medial and lateral bundles of the rectus abdominis on the right (arrow). (b) Coronal T1-weighted MR image (400/25; number of signals acquired, two; field of view, 24 cm) shows diffuse fatty infiltration of the distal right rectus abdominis muscle (arrow).
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Eleven (11%) of the 102 patients who underwent surgery had no rectus abdominis insertional findings at surgery or MR imaging. Eight (73%) of these 11 patients had MR imaging findings of osteitis pubis. Additionally, one patient had MR imaging findings typical of endometriosis. Two patients with no rectus abdominis injury had inguinal hernias repaired at surgery, and the inguinal hernias were observed in both at MR imaging (one direct, one indirect). Seventy-four (73%) of 102 patients had adductor tendon injury at surgery. Of these 74 patients, 64 (86%) had abnormal findings at MR imaging involving the ipsilateral adductor compartment (sensitivity, 86%). Three patients were considered to have adductor tendon injury at MR imaging that was not seen at surgery. There were 10 false-negative assessments of the adductor tendons with MR imaging, and 25 patients had normal adductor tendons at MR imaging and normal adductor tendons at surgery, yielding a positive predictive value for MR imaging assessment of adductor tendon injury of 96%, with a specificity of 89%.
Bone marrow edema around the pubic symphysis was present in 56 (55%) of the 102 patients who went to surgery. This finding correlated with rectus abdominis insertional injury in 52 (57%) of 91 patients with surgically proved rectus abdominis injury at the pubic attachment with only four false-positives, but 30 patients with rectus abdominis injury at surgery had no pubic bone marrow edema detected at MR imaging. Pubic symphysis bone marrow edema as an indicator of rectus abdominis insertional injury had a sensitivity of 57% and a specificity of only 60%. The secondary cleft sign was another frequent MR imaging observation in the 102 patients who underwent surgery, in that it was present in 60 (59%) of these patients but was noted in only six (15%) patients who did not undergo surgery and in none of the control group patients. The sensitivity of a secondary cleft sign as an indicator of rectus abdominis injury was 57%, with a specificity of 60%. Overall, pubic symphysis bone marrow edema and a secondary cleft sign were much more prevalent in the surgical group (54% and 59%, respectively) than the nonsurgical group (18% and 15%, respectively).
For the complete study patient group of 141 patients, regardless of therapeutic course, 138 (98%) had findings at MR imaging that were deemed likely to be related to groin pain. Along with rectus abdominis and adductor tendon injuries, common MR imaging findings included a secondary cleft sign (in 66 patients [47%]) and bone marrow edema around the pubic symphysis (in 63 patients [45%]). Twenty-three (16%) of 141 patients had findings at MR imaging remote from the symphysis, including 15 (11%) who had intrinsic ipsilateral hip disease. Patients with hip disease at MR imaging were older than the general population of study patients (mean age, 50 years). Additional but less frequent MR imaging findings included adnexal mass (n = 2), pubic ramus fracture (n = 1), endometriosis (n = 1), pubic osteomyelitis (n = 1), uterine fibroids (n = 1), pudendal nerve entrapment (postoperative fibrosis in the pudendal canal) (n = 1), and sartorius tendinopathy typical of an externally snapping hip (n = 1).
Control Subjects
In the 25 subjects assigned to the control group, there were very few MR imaging findings in the region of the pubic symphysis. No subjects had a secondary cleft sign or bone marrow edema around the pubic symphysis. No rectus abdominis injuries, including strain, insertional tear, or tendon asymmetry, were seen. Two subjects had MR imaging findings of adductor muscle strain, but adductor tendons were recorded as normal in all 25 subjects at MR imaging. No other bone or soft-tissue abnormality around the pubic symphysis was seen in this group of subjects. When compared with findings in the control group, MR imaging findings of rectus abdominis insertional injury, adductor tendon injury, pubic symphysis bone marrow edema, and a secondary cleft sign were significantly more common in the study patient group (P < .001 for each).
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DISCUSSION
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Our results allow us to draw several conclusions. First, true hernias are exceedingly rare in this population, not only at MR imaging but also at physical examination and surgery. The term sports hernia is therefore misleading when considering the spectrum of injury and disease we did encounter, although a defect in the rectus abdominis insertion at the pelvic floor or the posterior inguinal wall may loosely be interpreted as a hernia (19). We suggest that the term hernia, on imaging studies, be reserved for lesions that meet a more strict definition of hernia: "a protrusion of a loop or knuckle of an organ or tissue through an abnormal opening in the boundary which contains it" (20). We found lesions that met this definition to be very uncommon in our study patients (occurring in two [2%] of the 102 patients who underwent surgery). Instead, we propose that on imaging reports terms more descriptive of the true disorders, such as rectus abdominis tendinosis or tear, be used.
We did observe distinct patterns of MR imaging findings around the pubic symphysis in our study patients, in agreement with previously published surgical findings (21). One group had bone marrow edema that spanned the pubic symphysis, a high frequency of bony productive changes, and no imaging findings of rectus abdominis insertional defect or adductor tendon tear. These patients also had no rectus abdominis or pelvic floor defect at physical examination. The term that best fits this pattern of MR imaging findings is osteitis pubis, as relatively symmetric bone marrow edema around the symphysis from anterior to posterior was the most consistent MR imaging finding (22). These MR imaging findings seem to correlate with those in a group of patients described in the surgical literature (23) who had a true articular instability at the pubic symphysis, which was exacerbated by athletic activities. Generally, these patients did not go to surgery, and a conservative treatment plan, including symphyseal injection of methylprednisolone and bupivicaine, was employed (24).
A second pattern of disease at MR imaging primarily involved the thigh adductor tendons, with or without bone marrow edema around the pubic symphysis, but with no MR imaging findings of rectus abdominis insertional disorder. This group, most commonly, also had no findings of rectus abdominis injury at physical examination. Several injury patterns clinically isolated to the adductor compartment have been reported, including chronic, degenerative tendinopathies; acute muscle and tendon strains; and even herniations of adductor muscle through its epimysium. We propose that this pattern of MR imaging findings isolated to the adductor compartment without findings of rectus abdominis injury reflects one or more of these adductor variants and should be reported as such. In general, isolated adductor injuries are reported to be responsive to conservative treatment plans, including rest, physical therapy, and, sometimes, compartmental methylprednisolone and bupivicaine injections (25).
The most frequent pattern of MR imaging findings in our study patients was rectus abdominis insertional injury or both rectus abdominis and thigh adductor tendon injury. These patients also frequently had pubic bone marrow edema and a secondary cleft sign. Most commonly, the tendinous injury involved a reproducible location, at the insertional fibers of the rectus abdominis tendon on the anteroinferior aspect of the pubic bone, approximately 1 cm lateral to the symphysis. When the rectus abdominis and adductor tendons were both involved, the injury was often confluent on MR imaging, extending from the insertional rectus abdominis fibers into the immediately adjacent or even contiguous proximal or rostral fibers of the adductor longus and brevis tendons at the anterior undersurface of the pubis lateral to the symphysis. With this injury pattern, bone marrow edema in the subjacent pubis was often asymmetric and predominantly anterior, in contrast to the more diffuse marrow edema pattern observed in the osteitis pubis group. There was typically a perceptible rectus abdominis injury or defect at physical examination, and nearly all went to surgery for pelvic floor reconstruction. At surgery, this group unanimously had findings of rectus abdominis insertional injury, yielding a specificity and positive predictive value of MR imaging for rectus abdominis injury at the pubic attachment of 100%. As for the significance of the secondary cleft, our observations, as well as those in a recent report of pubalgia in soccer players (26), lead the authors to believe that the secondary cleft itself may actually represent a breach in the rectus abdominis tendon insertion extending into the adductor tendon origin.
Given the differences in treatment algorithms and the published differences in success rates for conservative therapies, we conclude that differentiating this rectus abdominis insertional injury group from other injury groups should be a primary goal of the imager (21). Within the rectus abdominis insertional injury group, a subgroup of 10 patients had MR imaging evidence of rectus abdominis injury but reported no specific athletic endeavor. These patients tended to be older (mean age, 41.1 years) than the general population of study patients, and only one had evidence of concomitant adductor tendon injury. Of these 10 patients, nine reported prior inguinal hernia repair ipsilateral to the pain and the rectus abdominis insertional abnormality on MR imaging. Additionally, six of 10 patients in this subgroup had atrophy of the ipsilateral rectus abdominis muscle at MR imaging.
A final group of study patients had either no findings or only minimal findings around the pubic symphysis but had evidence for remote disease that could reasonably cause referred pain to the groin. Most commonly, the MR imaging findings indicated an internal derangement of the hip joint in the form of labral tear, arthropathy, or femoroacetabular impingement. Older patients in our study group were less likely to have imaging findings that placed them in the rectus abdominis injury, adductor tendon injury, or osteitis pubis groups and were more likely to have disease involving the ipsilateral hip at MR imaging.
Athletic pubalgia is a clinical term used frequently in the orthopedics and sports medicine clinic to describe groin pain elicited by specific, often athletic, activities. Each of the injury patterns described above can be a source of athletic pubalgia. As treatment plans have diverged in recent years on the basis of the specific structures involved, it is necessary for the treating clinician to accurately localize the injury and determine its severity and extent (27,28). Without question, MR imaging is an imaging modality with all of the necessary strengths, including fluid sensitivity, high spatial resolution, and multiplanar capabilities, to accomplish this task. But artifacts related to respiratory and peristaltic motion, as well as morphologic and pathologic idiosyncrasies, can make adequate image acquisition and accurate diagnosis difficult (29). For the purposes of this article, we have used the more frequently published term of rectus abdominis insertion for the caudal attachment of this tendon at the pubic symphysis, but its central, stationary, and large load-bearing properties must be acknowledged here. At MR imaging, it is apparent that an intimate relationship exists between the lateral fibers of the rectus abdominis tendon at its insertion, the anterior fibers of the adductor longus and brevis tendons at their origin, and the joint capsule of the pubic symphysis, as well as the anterior pubic periosteum. After having compared MR imaging findings with physical examination and surgical results, it seems clear that a pattern of injury in this location primarily involving the rectus abdominis insertion and related structures was frequently observed in association with clinical athletic pubalgia. In our study patient group, an injury in this location corresponded strongly with a treatment plan that included surgical pelvic floor reconstruction, while other injury patterns were more likely to be treated conservatively.
In reviewing our discordance between MR imaging and surgical findings, the most frequent error was a false-negative MR imaging finding of rectus abdominis insertional injury. This is clearly a particularly difficult region to image. However, our findings in the study patients can help us develop a better understanding of MR imaging patterns that should alert us to injuries and disease in this location. Some patients had a high-grade injury at the rectus abdominis insertion that was visible in a transverse plane. But other patients with rectus abdominis injury at surgery had no abnormal MR imaging signal intensity at the rectus abdominis tendon itself but did have periosteal and bone marrow edema at the anteroinferior pubic bone on the side of the injury, suggesting a bony reactive process related to tendon avulsion. It has been suggested that a weakness of the rectus abdominis at its insertion may serve as a destabilizing trigger for subsequent, more debilitating injury. Indeed, one of the patients enrolled in our study patient group had undergone multiple MR imaging examinations that clearly showed progression of injury, which initially involved the rectus abdominis muscle, and later involved both the rectus abdominis tendon and the adductor tendons.
Our study had limitations. First, we reviewed MR imaging studies from many different imaging centers that were obtained by using variable MR imaging systems from different vendors that had different structural designs and different field strengths. Furthermore, protocols varied widely with regard to plane selection, sequence selection, field of view, and imaging point of center. The variance in protocol, imaging system, and imaging technique rendered some observed findings subtle and surely left some injury and disease occult. However, our study's use of three fellowship-trained reviewers in consensus may have helped to limit these instances. Another limitation centered on the reference standards used throughout this investigation. True- and false-positivity of MR imaging findings were based on either surgical findings or findings at physical examination performed by a single general surgeon, albeit a recognized and experienced surgeon, and surgical assessment of tendinous injury and disease can be difficult. In this same regard, surgical exploration was generally focused on a much smaller anatomic region than the area covered with MR imaging. Finally, our control subjects were matched to the study patients for age and sex but not for athletic activity. Additionally, the control subject group was smaller than the study population because of a limited availability of MR imaging studies performed in asymptomatic, age-matched patients. Finally, our study patient group was biased toward those with injury or disease that required surgery. This was a consequence of our recruitment methods.
In conclusion, we have found MR imaging to be a specific imaging modality for both rectus abdominis and adductor tendon injuries and to have extremely low false-positivity in patients with athletic pubalgia. Injury and disease involving the rectus abdominis pubic insertion should be recognized, reported, and distinguished from isolated adductor compartment syndromes and primary articular disorders such as osteitis pubis. True hernias are very uncommon in this patient population. Although sensitivity was good, our false-negative rate for rectus abdominis tendon injury in this series was unacceptably high, and we encourage the investigation and development of new protocols and techniques for optimization of imaging this region and its injuries and diseases. The frequency of hip disorder in our study patients suggests that any assessment of groin pain with MR imaging should include at least cursory imaging of the ipsilateral hip. Future efforts should center on improved MR imaging techniques for athletic pubalgia, thorough description of the disease spectrum associated with this clinical scenario, and a study design that includes an activity- and age-matched control population to increase statistical power.
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ADVANCE IN KNOWLEDGE
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- MR imaging is helpful in the work-up of patients with athletic pubalgia.
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IMPLICATION FOR PATIENT CARE
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- MR imaging is both sensitive (98%) and specific (89%–100%) in patients with athletic pubalgia for injuries involving the rectus abdominis, the adductor tendon origin, and the symphysis itself.
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FOOTNOTES
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Author contributions: Guarantor of integrity of entire study, A.C.Z.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; manuscript final version approval, all authors; literature research, A.C.Z., E.C.K., I.M.O., G.K., H.L., A.C., J.D., W.C.M.; clinical studies, A.C.Z., E.C.K., I.M.O., W.B.M., H.L., W.C.M.; statistical analysis, A.C.Z., E.C.K., G.K.; and manuscript editing, A.C.Z., E.C.K., I.M.O., W.B.M., W.C.M.
Authors stated no financial relationship to disclose.
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TOP
ABSTRACT
INTRODUCTION
