CASE 57

By: Dr. Subramaniyan Ramanathan MD, Dr. Mahmoud Alheidous and Dr. Nizar Al-Nakshabandi. MD, FRCPC.

HISTORY: 25-year-old male with left groin pain.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

Pelvic radiograph shows mild articular erosions in the pubic symphysis more on the left side. Coronal T2W and post contrast T1W MRI shows diffuse marrow edema involving the left pubic body and to a lesser extent on the right side. Associated capsular thickening and enhancement noted in the symphyseal joint. Increased signal anterior noted subjacent to the common adductor-rectus abdominis aponeurosis insertion on the left side, suggesting chronic tenoperiosteal avulsion.

DIAGNOSIS:

Athletic pubalgia.

PEARLS AND DISCUSSION:

Athletic pubalgia is a clinical syndrome of chronic lower pelvic and groin pain, usually encountered in athletes. It is either a musculo-tendinous or osseous injury that involves the insertion of abdominal muscles on the pubis and the upper aponeurotic insertion of the adductor muscles. Although it can occur following an acute injury, it is most often the result of repeated microtrauma. It is popularly known as sports hernia or sportsman’s hernia and osteitis pubis.

Various abnormalities can be seen in MRI most common being abnormal marrow signal intensity isolated to the anterior-inferior aspect of the pubic body. Micro tears and partial tears can be seen involving the rectus abdominis–adductor aponeurotic attachment. The secondary cleft sign, which commonly appears on the side ipsilateral to the side of groin pain, represents a micro tear at the origin of the adductor longus and gracilis tendon. Associated osteitis pubis be diffuse subarticular marrow edema bordering the symphysis pubis. Periostitis, bony resorption, subchondral cysts and osteophytes are seen in more advanced conditions.

FURTHER READING:

1. Mullens FE, Zoga AC, Morrison WB et-al. Review of MRI Technique and imaging findings in athletic pubalgia and the "sports hernia" Eur J Radiol. 2011 

2. Litwin DE, Sneider EB, Mcenaney PM et-al. Athletic pubalgia (sports hernia). Clin Sports Med. 2011;30 (2): 417-34.

3. Omar IM, Zoga AC, Kavanagh EC, Koulouris G, Bergin D, Gopez AG, Morrison WB, Meyers WC. Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings. Radiographics. 2008 Sep-Oct; 28(5):1415-38.