Athletic Pubalgia

Osteitis Pubis represents painful inflammation and/or degenerative changes at the area of the pubic symphysis. Radiographs may show widening of the pubic symphysis, sclerosis, cystic changes, or marginal erosions. MRI findings include bilateral subchondral bone marrow edema which is relatively symmetric in osteitis pubis in athletes. Ultrasound is limited in its assessment of bony structures but pubic symphyseal effusion, spurring and diastasis can be seen. Rectus abdominis and Adductor longus pathology are common causes of athletic pubalgia and MRI findings include abnormal T2 signal representing tendonitis. An aponeurotic plate disruption is represented by bilateral caudal rectus detachment that spans midline. These injuries on ultrasound have a focal anechoic defect at the origin of the adductor longus aponeurosis or rectus abdominis muscle Tendon hypoechogenicity, thickening, or loss of normal fibrillar echotexture represent tendinitis. Dynamic sonogram is a useful assessment of the transversus muscle and rectus abdominis muscle during increased intra-abdominal pressure which can elicit the laxity of the posterior inguinal wall. Ultrasound is also useful to exclude the diagnosis of an inguinal hernia. Sonography also provides an ideal modality for image-guided interventions given real-time imaging and lack of radiation for intra-articular or tendon injections. Treatment There are a wide variety of treatment options available including conservative management and operative approaches. A trial of conservative management including exercises and muscle strengthening is usually attempted first and surgery is reserved for those that have failed to improve. Surgical management includes both open and minimally invasive approaches with laparoscopic repair resulting in faster return back to sports. Recommendation from the British Hernia Society based on currently available data is for surgeon experience to guide surgical technique for the treatment of sports hernias.