Athletic Pubalgia and the “Sports Hernia”: MR Imaging Findings

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 χ2 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

References

  • 1 Renstrom P, Peterson L. Groin injuries in athletes. Br J Sports Med 1980; 14(1): 30–36. Crossref, MedlineGoogle Scholar
  • 2 Kavanagh EC, Koulouris G, Ford S, McMahon P, Johnson C, Eustace SJ. MR imaging of groin pain in the athlete. Semin Musculoskelet Radiol 2006;10(3):197–207. Crossref, MedlineGoogle Scholar
  • 3 Moeller JL. Sportsman's hernia. Curr Sports Med Rep 2007;6(2):111–114. MedlineGoogle Scholar
  • 4 Morelli V, Smith V. Groin injuries in athletes. Am Fam Physician 2001;64(8):1405–1414. MedlineGoogle Scholar
  • 5 Overdeck KH, Palmer WE. Imaging of hip and groin injuries in athletes. Semin Musculoskelet Radiol 2004;8(1):41–55. Crossref, MedlineGoogle Scholar
  • 6 LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia 2003;7(2):68–71. Crossref, MedlineGoogle Scholar
  • 7 Fon LJ, Spence RA. Sportsman's hernia. Br J Surg 2000;87(5):545–552. Crossref, MedlineGoogle Scholar
  • 8 Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28(1):2–8. Crossref, MedlineGoogle Scholar
  • 9 Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: definition and surgical treatment. Ann Plast Surg 2005;55(4):393–396. Crossref, MedlineGoogle Scholar
  • 10 Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001;29(4):521–533. Crossref, MedlineGoogle Scholar
  • 11 Albers SL, Spritzer CE, Garrett WE, Meyers WC. MR findings in athletes with pubalgia. Skeletal Radiol 2001;30(5):270–277. Crossref, MedlineGoogle Scholar
  • 12 Barile A, Erriquez D, Cacchio A, De Paulis F, Di Cesare E, Masiocchi C. Groin pain in athletes: role of magnetic resonance [in Italian]. Radiol Med (Torino) 2000;100(4):216–222. MedlineGoogle Scholar
  • 13 Lynch SA, Renstrom PA. Groin injuries in sport: treatment strategies. Sports Med 1999;28(2):137–144. Crossref, MedlineGoogle Scholar
  • 14 Nelson EN, Kassarjian A, Palmer E. MR imaging of sports-related groin pain. Magn Reson Clin N Am 2005;13(4):727–742. Crossref, MedlineGoogle Scholar
  • 15 Brennan D, O'Connell MJ, Ryan M, et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology 2005;235(1):162–167. LinkGoogle Scholar
  • 16 El-Khoury GY, Brandser EA, Kathol MH, Tearse DS, Callaghan JJ. Imaging of muscle injuries. Skeletal Radiol 1996;25(1):3–11. Crossref, MedlineGoogle Scholar
  • 17 Boutin RD, Newman JS. MR imaging of sports-related hip disorders. Magn Reson Imaging Clin N Am 2003;11(2):255–281. Crossref, MedlineGoogle Scholar
  • 18 Kassarjian A, Yoon LS, Belzile E, Connolly SA, Millis MB, Palmer WE. Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement. Radiology 2005;236(2):588–592. LinkGoogle Scholar
  • 19 Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med 1988;32(2):134–139. Google Scholar
  • 20 Dorland's illustrated medical dictionary. 30th ed. Philadelphia, Pa: Saunders, 2006. Google Scholar
  • 21 Meyers WC, Lanfranco A, Castellanos A. Surgical management of chronic lower abdominal and groin pain in high performance athletes. Curr Sports Med Rep 2002;1(5):301–305. Crossref, MedlineGoogle Scholar
  • 22 Gibbon WW, Hession PR. Diseases of the pubis and pubic symphysis: MR imaging appearances. AJR Am J Roentgenol 1997;169(3):849–853. Crossref, MedlineGoogle Scholar
  • 23 Verral GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 2001;35(1):28–33. Crossref, MedlineGoogle Scholar
  • 24 O'Connell MJ, Powell T, McCaffrey NM, O'Connell D, Eustace SJ. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. AJR Am J Roentgenol 2002;179(4):955–959. Google Scholar
  • 25 Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353(9151):439–443. Crossref, MedlineGoogle Scholar
  • 26 Cunningham PM, Brennan D, O'Connell M, MacMahon P, O'Neill P, Eustace S. Patterns of bone and soft tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol 2007;188(3):W291–W296. Crossref, MedlineGoogle Scholar
  • 27 Edelman DS, Selesnick H. “Sports” hernia: treatment with biologic mesh (Surgisis)–a preliminary study. Surg Endosc 2006;20(6):971–973. Crossref, MedlineGoogle Scholar
  • 28 Morelli V, Weaver V. Groin injuries and groin pain in athletes: part 1. Prim Care 2005;32(1):163–183. Crossref, MedlineGoogle Scholar
  • 29 Zand KR, Reinhold C, Haider MA, Nakai A, Rohoman L, Maheshwari S. Artifacts and pitfalls in MR imaging of the pelvis. J Magn Reson Imaging 2007;26(3):480–497. Crossref, MedlineGoogle Scholar

Article History

Published in print: 2008