Purpose or Learning Objective: To compare dedicated magnetic resonance imaging (MRI) with targeted fluoroscopy-guided symphyseal contrast agent injection for the assessment of the symphyseal cleft sign and pelvic ring instability in men with athletic groin pain.
Methods or Background: In this ongoing study, 68 athletic men (mean age: 32 years; 58 soccer players) were included. All patients were referred to our clinic by an experienced surgeon in private practice after initial clinical examination using a standardized procedure. Symphyseal cleft injection of a contrast agent was performed with fluoroscopic guidance. Standing single-leg stance radiography and a dedicated 3-T MRI protocol was also performed. The presence of the superior cleft sign, secondary cleft sign, and osteitis pubis, as defined by Byrne et al,1 was recorded.
Results or Findings: Mean symptom duration was 11 months. Symphyseal bone marrow edema was present in 53 of 68 patients (bilaterally in 43 patients). MRI examinations showed the isolated superior cleft sign in 14 and the isolated secondary cleft sign in 18 patients. In 15 patients, both cleft signs were present simultaneously. For fluoroscopic examinations, the isolated superior cleft sign was seen in 9, isolated secondary cleft sign in 24 patients, and in 10 patients both cleft signs were present simultaneously. In six cases, a combined superior and secondary cleft sign was observed on MRI, but only an isolated secondary cleft sign was shown in symphysography. Anterior pelvic ring instability was observed in 25 patients and linked to a superior cleft sign in 6 and to a secondary cleft sign in 9 patients.
Conclusion: Dedicated 3-T MRI outmatches symphysography for purely diagnostic purposes of superior and secondary clefts. Additional symphysography may be important for therapeutic injection of corticosteroids and local anesthetics. Microtearing at the prepubic aponeurotic complex is a prerequisite for the development of anterior pelvic ring instability.
Reference
Byrne CA, Bowden DJ, Alkhayat A, Kavanagh EC, Eustace SJ. Sports-related groin pain secondary to symphysis pubis disorders: correlation between MRI findings and outcome after fluoroscopy injection of steroid and local anesthetic. AJR Am J Roentgenol 2017;209(2):380–388
