Pubic-Related Radiographic Findings in Male Football Players With Long-Standing Groin Pain, and Asymptomatic Controls - Are They Clinically Relevant?

Abstract

The Aspetar pubic symphysis radiographic scoring protocol is reliable in male football players, but its clinical significance is unclear. We investigated the prevalence of pubic-related radiographic findings and their association with groin pain and disability in male football players and asymptomatic controls. We included 39 symptomatic male football players with long-standing groin pain, 18 asymptomatic male football players, and 20 asymptomatic male non-football athletes. Standing anteroposterior pelvic radiographs were analyzed by two radiologists for pubic-related bone lucency, proliferation, sclerosis, fragmentation, and joint space width (JSW, millimeters). Findings were combined into a Pubic Symphysis Radiographic Severity Score (PSRS Score, 0-8). Groin pain and disability were measured using the Five-Second Squeeze Test (5SST, 0-10) and the Hip and Groin Outcome Score (HAGOS, 100-0). For symptomatic football players, asymptomatic football players, and asymptomatic non-football athletes, the pubic-related radiographic findings prevalence's were, respectively: bone lucency: 87%, 83%, and 40%; proliferation: 67%, 61%, and 25%; sclerosis: 64%, 50%, and 15%; and fragmentations: 15%, 6%, and 0%, while the mean JSW was 3 mm in all three groups. There were no differences between symptomatic and asymptomatic football players in any findings (p ≥ 0.39). Bone lucency, proliferation, and sclerosis were more frequent in football players than non-football athletes (p < 0.002). PSRS Score showed poor correlation with 5SST and HAGOS. In conclusion, pubic-related radiographic findings are not associated with groin pain or disability. Pubic-related radiographic findings are more common in male football players than male non-football athletes.

Keywords: athletes; football; groin pain; long‐standing pain; pubic symphysis; radiographs.

FIGURE 1

Participant flow.

FIGURE 2

Pubic‐related radiographic findings as described by Serner et al. [22].^. (A) Bone lucency. Definition: “A clear area of decreased attenuation compared to the surrounding bone, which corresponds to an erosion‐like configuration and/or cyst.” [22], Subclassifications: Erosion‐Like Configuration (ELC), Superior/Central ELC, Inferior ELC and Cysts. Definitions: ELC: “Irregularities of the cortical bone surface, potentially accompanied by loss of the adjacent trabecular bone.” [22], Superior/Central ELC: ELC at the superior two thirds of the joint surface [22], Inferior ELC: ELC at the lower third of the joint surface ‐ “If the entire lower half was considered to have an erosion‐like configuration, both of the above were scored as positive” [22], Cysts: “Areas of bone lucency with a sclerotic rim inside the trabecular bone compartment, without accompanying cortical bone surface irregularity.” (B) Proliferation. Definition: “Clear osteophyte outgrowths at the joint margins or within the articular space.” [22], Subclassifications: Superior, Central and Inferior Proliferation. Definitions: Superior proliferation: “This can be considered “bone spurs” or classified as “pubic beaking” when bilateral. Well rounded (smooth) bumps at the superior aspect, even if asymmetrical in size, were not considered proliferation. For superior proliferation, the “sharpness” of the superior bone corner angle was used for assistance with angles higher than 90 deg. (obtuse angle) considered “rounded” and scored negative/absent, whereas angles lower than 90 deg. (acute angle) were considered “sharp” and scored as positive/present.” [22], Central proliferation: “Proliferation at the central portion of the articular space.” [22], Inferior proliferation: “Similar considerations as superior proliferation.” [22]. (C) Fragmentation. Definition: “Clear loose fragment(s) within the symphyseal joint space, or at the inferior medial margin of the pubic bone.” [22], Subclassifications: Central and inferior fragmentation. Definitions: Central fragmentation: “Clear loose fragment(s) within the symphyseal joint space” [22], Inferior fragmentation: “Clear loose fragment(s) at the inferior medial margin of the pubic bone.” [22]. (D) Sclerosis. Definition: “A clear area of increased attenuation of the subchondral bone compared to the surrounding bone, corresponding to an area of increased bone density.” [22]. (E) Pubic Symphysis Joint Space Width. Definition: “Symphyseal joint space measured in millimeters at the narrowest point of the joint surfaces.” [22], Subclassification: Narrow Joint Space Width. Definition: Narrow Joint Space Width. “if measured to less than 3mm” [22].

FIGURE 3

Prevalence of pubic‐related radiographic findings. p values are from χ ²‐tests across all three groups. ELC = Erosion‐Like Configuration.

FIGURE 4

Examples of anteroposterior radiographs of athletes with and without groin pain. (A) Symptomatic football player: 26 years, 178 cm, 72 kg, dominant leg: Right, bilateral groin pain, pain duration: 2 months, worst pain last week 8, 5SST: 8, HAGOS Pain 100, Symptoms 66.7, ADL 81.3, Sport 37.5, PA 25, QoL 75; Clinical Entities: Bilateral adductor‐related, bilateral iliopsoas‐related, bilateral inguinal‐related, and pubic‐related groin pain. Pubic‐related radiographic findings total = 0 and JSW: 3 mm. (B) Symptomatic football player: 25 years, 182 cm, 75 kg, dominant leg: Right, right‐sided groin pain, pain duration: 6 weeks, worst pain last week: 7, 5SST: 8, HAGOS Pain 78.1, Symptoms 54.2, ADL 68.8, Sport 42.7, PA 0.0, QoL 43.8; Clinical Entities: Right‐sided adductor‐related groin pain, right‐sided inguinal‐related groin pain. Pubic‐related radiographic findings total = 0 and JSW: 4 mm. (C) Asymptomatic football player: 23 years, 180 cm, 79 kg, dominant leg: Right, HAGOS Pain 100, Symptoms 100, ADL 100, Sport 100, PA 100, QoL 100, Pubic‐related radiographic findings total = 14: Bilateral bone lucency, ELC, central/superior ELC; right‐sided cysts, bilateral proliferation, superior proliferation, central proliferation, inferior proliferation; bilateral sclerosis; JSW = 2 mm. (D) Symptomatic football player: 24 years, 188 cm, 80 kg, dominant leg: Right, bilateral groin pain, pain duration: 48 months, worst pain last week: 9, 5SST: 6, HAGOS Pain 37.5, Symptoms 29.2, ADL 31.3, Sport 29.2, PA 12.5, QoL 18.8; Clinical Entities: Bilateral adductor‐related, bilateral iliopsoas‐related, left inguinal‐related, and pubic‐related groin pain; Pubic‐Related Radiographic Finding total = 13: Bilateral findings of Bone lucency, ELC, central/superior ELC, proliferation, superior proliferation, central proliferation, and sclerosis. Left sided inferior proliferation, fragmentation, inferior fragmentation. JSW 1 mm. (E) Asymptomatic non‐football athlete: 19 years, 184 cm, 72 kg, dominant leg: Left, HAGOS Pain 100, Symptoms 100, ADL 100, Sport 100, PA 100, QoL 100, Pubic‐related radiographic findings: Bilateral bone lucency, ELC, central/superior ELC; left‐sided cysts, bilateral proliferation, superior proliferation; right‐sided central proliferation, and JSW = 2 mm.