title: Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI.
abstract: OBJECTIVE
  The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other.
  
  
  METHODS
  One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test.
  
  
  RESULTS
  Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001).
  
  
  CONCLUSIONS
  In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.
authors.affiliation: Department of Radiology, Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland.
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Cunningham
authors.forename: Darren
authors.initials: D
authors.lastname: Brennan
authors.forename: Martin
authors.initials: M
authors.lastname: O'Connell
authors.forename: Peter
authors.initials: P
authors.lastname: MacMahon
authors.forename: Pat
authors.initials: P
authors.lastname: O'Neill
authors.forename: Stephen
authors.initials: S
authors.lastname: Eustace
mesh_terms: D000293:Adolescent; D000328:Adult; D018771:Arthralgia / Q000175:diagnosis / Q000209:etiology; D004487:Edema / Q000473:pathology; D005260:Female; D006119:Groin / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D010000:Osteitis / Q000175:diagnosis* / Q000209:etiology; D010388:Pelvis / Q000293:injuries* / Q000473:pathology; D011631:Pubic Symphysis / Q000293:injuries* / Q000473:pathology*; D016037:Single-Blind Method; D012916:Soccer / Q000293:injuries*; D018461:Soft Tissue Infections / Q000175:diagnosis* / Q000209:etiology; D017695:Soft Tissue Injuries / Q000175:diagnosis* / Q000209:etiology