Presentation
Left thigh and groin pain for more than six months. Possible sports injury.
Patient Data
There is significant marrow edema in the pubic bodies, more marked on the left side. The articular margins of the pubic symphysis appear irregular. There is associated mild capsular hypertrophy.
There is a subtle crescentric hyperintensity on T2 weighted images along the anteroinferior margin of the left pubic body adjoining the adductor longus tendon. This appears contiguous with the high signal intensity interpubic disc. The appearance suggests a "secondary cleft sign", which probably represents a micro-tear at the attachment of the adductor longus tendon.
The rectus abdominis appear unremarkable.
The adductor muscles and the obturator externus and internus muscles reveal normal signal intensity with no suggestion of muscle strain.
The annotated images demonstrate a tear at the origin of the left adductor longus tendon.
Case Discussion
The symphysis pubis provides attachment to a number of muscles of the anterior and anterolateral abdominal wall as well as adductor muscles of the thigh. The most important of these are the rectus abdominis and adductor longus muscles, which form a common adductor-rectus aponeurosis. This blends with the ligamentous tissues of the pubic symphysis and its fibrocartilaginous disc and is of prime importance in anterior pelvic stability. Any tear or injury of these tendons or muscles often involves the common aponeurosis. The altered biomechanics can result in further tearing of other adductor muscles or the contralateral common aponeurosis, thus resulting in instability of the pubic symphysis.
"Athletic pubalgia" is a term which includes pubic symphysis tendinous and aponeurotic injuries resulting in chronic exretional pubic and groin pain.
Osteitis pubis refers to the osseous changes in the pubic bones secondary to chronic shearing and distracting forces on the unstable pubic symphysis.
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