US in pubalgia

Abstract

There is considerable confusion over the word "pubalgia" with regard to the definition and the etiological causes of this condition. The term pubalgia should be used to indicate disabling pain affecting the pubic region in people who practise sports. Pubalgia affects 10% of those who practise sports and it is particularly prevalent in football players. According to the literature, about 40% of cases of pubalgia are caused by overuse of the symphysis pubis with progressive lesions affecting the rectus abdominal muscles, adductors (rectal-adductor syndrome) and the symphysis itself (osteitis pubis and joint injury). An initial study of the tendons is carried out by ultrasound (US) whereas magnetic resonance imaging (MRI) should be performed to study the bones and joints.Another 40% of cases of pubalgia are caused by "sports hernia" defined as anteroinferior abdominal wall insufficiency. These alterations can only be identified at dynamic US examination.About 20% of cases of pubalgia are caused by diseases of the neighboring structures or joints such as diseases of the hip, iliopsoas, hamstring, sacred iliac or nerves, or by urogenital diseases.

Keywords: Pubalgia; Sports hernia; Ultrasound.

Fig. 1

Anatomical diagram of the symphysis pubis and the tendon insertions. The rectus adductor syndrome particularly involves the insertion of the rectus abdominis (1) and the adductor longus (2). Pectineus (3), vessels (4), transverse (5).

Fig 2

Rectus adductor syndrome. Adductor tendon injury: edema, calcification, rupture. This image of the proximal portion of the adductor longus (+ … +) shows diffuse hypoechoic enlargement and calcification of the tendon (arrow), periosteal detachment (arrowhead) in areas of hypoechoic focal tearing of fibers (∗).

Fig. 3

Rectus adductor syndrome. Tendon injuries of the rectus muscles. Sagittal scan of the distal insertion of the left rectus abdominis on the pubis (1) in a tennis player. Within the tendon of the rectus (+) there are irregular calcifications (arrows).

Fig. 4

Alterations of the bone margins in rectus adductor symphysis syndrome. (a): the superior-anterior margin of the pubic bone on the right near the symphysis presents irregularities (arrows). (b): corresponding CT findings.

Fig. 5

Enlargement of the symphysis pubis. (a): a postero-anterior projection for the study of the symphysis pubis showing retraction and deformation of the bone margins. (b): incidental finding during the study of a urethral pathology (right side) showing enlargement of the symphysis caused by pubalgia due to rectus adductor symphysis syndrome.

Fig. 6

Complication of the rectus adductor syndrome. Partial detachment (∗) of the tendon of the rectus abdominis (a), partial tear (∗) of the adductor longus (b). Second degree distraction (∗) of adductor magnus (c) and corresponding MRI (d).

Fig. 7

Pubic abscess in a female swimmer. (a): US image shows soft tissue swelling around the symphysis (1) and liquefactive necrosis between the symphysis and the bladder. (b): MRI confirming US diagnosis. (c): this image shows the needle tip (arrows) collecting a sample for bacterial cultivation.

Fig. 8

Clearly increased signal from a cancelous area of the left pubic bone due to osteitis.

Fig. 9

Osteitis pubis, radiography. Progressive trophic alterations caused by osteitis leading to the deformation of the symphysis pubis and progressive hardening of the bone structure. (a): early stage; (b): advanced stage.

Fig.  10

Diagram depicting the relationship between the transverse muscle bundles (1) and the muscle belly of the rectus (2). Above the transverse umbilical plane (a) the bundle arising from the transverse muscular epimysium joins the linea alba running behind the rectus, and below the umbilical line (b) it runs in front of the rectus.

Fig. 11

Diagram of the internal abdominal wall with the points of greatest parietal weakness.

Fig. 12

Diagram of the conjoint tendon. The conjoint tendon (a) arises from the union of the distal transverse bundles (1) and the internal oblique muscle (2) which are joined on the pubic tubercle (3) and the inguinal ligament (4).

Fig. 13

Normal and dynamic US findings showing sports hernia. Transverse scan in the right iliac fossa at rest (a) and during contraction of the abdominal muscles and partial flexion (b). (b) shows the increased diameter of the rectus abdominis (1) and of the lateral abdominal muscles (2); the bowel loop (3) is "pinched" between the two muscles.

Fig. 14

Professional footballer: sports hernia before surgery (a) and after surgery (b). Axial scans in the right (a) and left (b) iliac fossa. Strangulation of the intestinal loop (1) is visible between the transverse (2) and rectus (3) muscles while (b) shows the surgical “net” (arrows) protecting the space between the transverse and the rectus muscles.

Fig. 15

Iliopsoas impingement at US follow up. (a): diagram of the relationships between the ileum and the psoas muscles. (b) and (c): axial sections. (d) and (e): sagittal sections of the inguinal region. (b) and (d): with flexed thigh; (c) and (e): with extended leg. When the thigh is flexed the psoas tendon is visible (+ … +); it is inserted between the ileum and the underlying bone margin, and it moves medially (c) when the thigh is extended.

Fig. 16

Ileopectineal bursitis. Sagittal scan of the right hip joint showing enlargement with irregular margins of the ileopectineal bursa (1).

Fig. 17

Enthesitis of the iliotibial tract and the transverse bundle which causes ilioinguinal nerve irritation. US shows enlargement, and the insertion (∗) on the tubercle of the iliac crest (1) of the iliotibial band (arrows) appears hypoechoic in the portion where it merges with the gluteal fascia. US also shows the initial tear of the tendon structures (+ .. +). The symptoms in the ilioinguinal nerve region are caused by irritation of the nerve passing near the enthesopathy.

Fig. 18

Lipoma in the adductor muscle. (a): parasagittal scan of the anteromedial root of the right thigh showing a well defined solid mass (1) displacing the vessels. This finding is suggestive of lipoma as confirmed by MRI (b).