Adam C. Zoga MD, Presenter: Speakers Bureau, Bayer AG

Conor Patrick Shortt MBBCh, Abstract Co-Author: Nothing to Disclose

William B. Morrison MD, Abstract Co-Author: Medical Advisory Board, ONI Medical Systems, Inc

Octavia N Devon MD, Abstract Co-Author: Nothing to Disclose

William C. Meyers MD, Abstract Co-Author: Nothing to Disclose

We have observed a subset of patients with athletic pubalgia and physical examination suggesting internal derangement of the ipsilateral hip (resistance, pain with active flexion and external rotation). We sought to establish the incidence of concomitant hip pathology in patients with pubic symphysis injury and describe an imaging protocol utilizing MRI, direct MR arthrography (MRA), and diagnostic intraarticular anesthetic injection.

137 subjects (M:F=108:39, mean age=32.5) referred for athletic pubalgia also had physical examination suggesting internal derangement of the ipsilateral hip. All had MRI utilizing a pubalgia protocol and direct MRA of the hip. At arthrography, 3cc of 0.5% bupivicaine and 1cc of 1% lidocaine were infused intraarticular. Subjects were interviewed regarding change in groin pain immediately post-procedure, 2 hours later, and the following day. MRI and MRA were reviewed for injury at the symphysis (osteitis pubis, rectus abdominis, adductor tendon, hernia) as well as pathology at the hip (labral tear, cartilage loss, FAI). The incidence of concomitant pathology was established and the sensitivity, specificity and positive predictive value of the anesthetic arthrogram for labral tear were calculated using MRA as the reference standard.   

At MRI, 99/137(72%) had lesions at the pubic symphysis and 97/137(71%) had ipsilateral acetabular labral tears. 67/137(49%) had concomitant symphysis and labrum lesions. Using intraarticular anesthetic as a diagnostic test, 25/31(81%) with symphysis lesions but no labral tear by MRI had no relief, 18/30(60%) with labral tears and no symphysis lesion had relief and 36/67(54%) with concomitant lesions had relief. For all subjects with labral tears, 55/97(57%) had relief yielding a specificity of 83% and a positive predictive value of 89%.

Concomitant pathology at the pubic symphysis and the ipsilateral hip is common in the setting of athletic pubalgia. While physical examination plays a primary role, intraarticular anesthetic injection is a useful tool for guiding treatment. If there is clinical suspicion for concomitant hip and groin pathology, both an MRI with a pubalgia protocol and direct MRA of the hip are indicated. 

With clinical athletic pubalgia and ipsilateral hip pathology, optimal imaging includes a dedicated pubalgia MRI, direct MR arthrogram of the hip and a diagnostic intraarticular anesthetic injection.

Zoga, A, Shortt, C, Morrison, W, Devon, O, Meyers, W, MRI of Athletic Pubalgia:  Incidence and Imaging of Concomitant Pubic Symphysis and Ipsilateral Hip Pathology.  Radiological Society of North America 2008 Scientific Assembly and Annual Meeting, February 18 - February 20, 2008 ,Chicago IL. http://archive.rsna.org/2008/6012123.html