Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 5, pp 687–697 | Cite as

Novel pathomorphologic classification of capsulo-articular lesions of the pubic symphysis in athletes to predict treatment and outcome

  • Sascha Hopp
  • Ishaq Ojodu
  • Atul Jain
  • Tobias Fritz
  • Tim Pohlemann
  • Jens Kelm
Arthroscopy and Sports Medicine



Radiographic abnormalities of the symphysis as well as the formation of accessory clefts, indicating injury at the rectus-adductor aponeurosis, reportedly relate to longstanding groin pain in athletes. However, yet, no systematic classification for clinical and scientific purposes exists. We aimed to (1) create a radiographic classification based on symphysography; (2) test intra- and interobserver reliability; (3) characterise clinical significance of the morphologic patterns by evaluating success of injection therapy.

Patients and methods

We retrospectively reviewed symphysography, AP radiographs, and MRI of the pelvis from 70 consecutive competitive athletes, with chronic groin pain. Symphysographs were evaluated for intra- and interobserver variance using cohen’s kappa statistics. Morphologic studies of the different contrast distribution patterns and their clinical and radiological correlation with symptom relief were investigated. All patients were followed up to evaluate immediate and long-term response to the initial therapeutic injection with steroid.


Four reproducible symphysographic patterns were identified: type 0, no changes; type 1, symphyseal disk degeneration; types 2a with unilateral clefts, bilateral clefts (2b), suprapubic clefts (2c); and type 3, with expanded or multidirectional clefts. Analysis revealed excellent intra (0.94)—and interobserver (0.90) reliability. Our findings showed that 78.6% of our patients had significant short-term improvement enabling early resumption of physiotherapy, only in types 1 and 2 (p = 0.001), while type 0 and 3 did not respond. At follow-up, only 21.8% had permanent pain relief. Regarding the detection of pathologic clefts with symphysography, sensitivity (88%) and specifity (77%) were superior to that of MRI.


A reproducible symphysography-based classification of distinct morphologic patterns is proposed. It serves as a predictive tool for response to injection therapy in a select group of pathologic lesions. Complete recovery after injection can only be expected in a lesser percentage, as this might indicate surgical treatment for long-term non-responders.


Symphysography Classification Athletic pubalgia Groin pain Pubic symphysis 



The authors thank Tobias von Campe, medicine student, for his assistance in data collection for this study. We also thank Stefan Gräber, MD, University of Saarland, Institute for Medical Biometry, Epidemiology and Medical Statistics, Homburg/Saar, Germany, for his contribution in statistical analysis.

Author contributions

All authors contributed to the conception and design, interpretation of the data, critical revision, and final approval of the article. In addition, SH and TF were responsible for data acquisition; SH and SG were responsible for data analysis.



Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

Regional Medical Ethics Committee, Germany (IRB No. 24/16).


  1. 1.
    Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, Long JN,, Garth WP, Vasconez LO (2005) Torre de la JI. Athletic pubalgia: definitions and surgical treatment. Ann Plast Surg 55:393–396CrossRefPubMedGoogle Scholar
  2. 2.
    Gilmore J (1998) Groin pain in the soccer athlete: fact, fiction and treatment. Clin Sports Med 17:787–793CrossRefPubMedGoogle Scholar
  3. 3.
    Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Bjerg AM, Krogsgaard K (1999) Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 353:439–445CrossRefPubMedGoogle Scholar
  4. 4.
    Gamble JR, Simmons SC, Freedman M (1986) The symphysis pubis. Anatomic and pathological considerations. Clin Orthop Relat Res 203:261–272Google Scholar
  5. 5.
    Becker I, Woodley SJ, Stringer MD (2010) The adult human pubic symphysis: a systematic review. J Anat 217:475–487CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Davis JA, Stringer MD, Woodley SJ (2012) New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. Br J Sports Med 46(12):871–76CrossRefPubMedGoogle Scholar
  7. 7.
    Norton-Old KJ, Schache AG, Barker PJ, Clark RA, Harrison SM, Briggs CA (2013) Anatomical and mechanical relationship between the proximal attachment of adductor longus and the distal rectus sheath. Clin Anat 26(4):522–530CrossRefPubMedGoogle Scholar
  8. 8.
    Robinson P, Salehi F, Grainger A, Clemence M, Schilders E, O’Connor P, Agur A (2007) Cadaveric and MRI study of the muculotendinous contributions to the capsule of the symphysis pubis. Am J Rad 188:440–445Google Scholar
  9. 9.
    Cunningham PM, Brennan D, O’Connell M, MacMahon P, O’Neill P, Eustace S (2007) Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: Observations at MRI. AJR 188:291–296CrossRefGoogle Scholar
  10. 10.
    Garvey JF, Read JW, Turner A (2010) Sportsman hernia: what can we do? Hernia 14(1):17–25CrossRefPubMedGoogle Scholar
  11. 11.
    Batt ME, McShane JM, Dillingham MF (1995) Osteitis pubis in collegiate football players. Med Sci Sports Exerc 27:629–33CrossRefPubMedGoogle Scholar
  12. 12.
    Fricker PA, Taunton JE, Ammann W (1991) Osteitis pubis in athletes. Infection, inflammation or injury? Sports Med 12:266–79CrossRefPubMedGoogle Scholar
  13. 13.
    Verral GM, Slavotinek JP, Fon GT (2001) Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 35:28–33CrossRefGoogle Scholar
  14. 14.
    Williams PR, Thomas DP, Downes EM (2000) Osteitis pubis and instability of the pubic symphysis: when nonoperative measures fail. Am J Sports Med 28:350–355CrossRefPubMedGoogle Scholar
  15. 15.
    Garras DN, Carothers JT, Olson SA (2008) Single-leg-stance (flamingo) radiographs to assess pelvic instability: how much motion is normal? J Bone Joint Surg Am 290(10):2114–2118CrossRefGoogle Scholar
  16. 16.
    O’Connell MJ, Powell T, McCaffrey NM, O’Connell D, Eustace S (2002) Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. AJR 179: 955–959Google Scholar
  17. 17.
    Brennan D, O’Connell MJ, Ryan M, Cunningham P, Taylor D, Cronin C, O’Neill P, EIstace S (2005) Secondary cleft sign as a marker on injury in athletes with groin pain: MR image appearance and interpretation. Radiology 235:162–167CrossRefGoogle Scholar
  18. 18.
    Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A, Gibbon WW, Bismil Q (2009) Adductor-related groin pain in recreational athletes. Role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 91:2455–2460CrossRefPubMedGoogle Scholar
  19. 19.
    Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G, Lopez H, Chaabra A, Domesek J, Meyers WC (2008) Athletic pubalgia and the “sports hernia”: MR imaging findings. Radiology 247:797–807CrossRefPubMedGoogle Scholar
  20. 20.
    Murphy G, Foran P, Murphy D, Tobin O, Moynagh M, Eustace S (2013) “Superior cleft sign” as a marker of rectus abdominis/adductor longus tear in patients with suspected sportsman’s hernia. Skeletal Radiol 42(6):819–825CrossRefPubMedGoogle Scholar
  21. 21.
    Besjakov J, Von Scheele C, Ekberg O, Gentz CF, Westlin NE (2003) Grading Scale of radiographic findings in the pubic bone and symphysis in athletes. Acta Radiol 44:79–83PubMedGoogle Scholar
  22. 22.
    Ashby EC (1994) Chronic obscure groin pain is commonly caused by enthesopathy: ‘tennis elbow’ of the groin. Br J Surg 81:1632–1634CrossRefPubMedGoogle Scholar
  23. 23.
    Hopp SJ, Culemann U, Kelm J, Pohlemann T, Pizanis A (2013) Osteitis pubis and adductor tendinopathy in athletes: a novel arthroscopic pubic symphysis curettage and adductor reattachment. Arch Orthop Trauma Surg 133(7):1003–1009CrossRefPubMedGoogle Scholar
  24. 24.
    McArthur TA, Narducci CA, Lopez-Ben RR (2014) The role of pubic symphyseal CT arthrography in the imaging of athletic pubalgia. AJR 203(5):1063–1068CrossRefPubMedGoogle Scholar
  25. 25.
    Lovell G, Galloway H, Hopkins W, Harvey A (2006) Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med 16(2):117–122CrossRefPubMedGoogle Scholar
  26. 26.
    Paajanen H, Hermunen H, Karonen J (2011) Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls. Skeletal Radiol 40(1):89–94CrossRefPubMedGoogle Scholar
  27. 27.
    Choi H, McCartney M, Best TM (2011) Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med 45(1):57–64CrossRefPubMedGoogle Scholar
  28. 28.
    Holt MA, Keene JS, Graf BK, Helwig DC (1995) Treatment of osteitis pubis in athletes: results of corticosteroid injections. Am J Sports Med 23:601–606CrossRefPubMedGoogle Scholar
  29. 29.
    Schilders E, Bismil Q, Robinson P, O’Connor PJ, Gibbon WW, Talbot JC (2007) Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 89:2173–2178PubMedGoogle Scholar
  30. 30.
    Radic R, Annear P (2008) Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med 36:122–28CrossRefPubMedGoogle Scholar
  31. 31.
    Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM et al (2015) Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 49(12):768–74CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Sascha Hopp
    • 1
    • 2
  • Ishaq Ojodu
    • 2
    • 3
  • Atul Jain
    • 2
    • 4
  • Tobias Fritz
    • 2
  • Tim Pohlemann
    • 2
  • Jens Kelm
    • 5
  1. 1.Lutrina Clinic KaiserslauternCentre for Knee Surgery, Orthopaedics and Sports Traumatology, Groin Pain and Core Muscle Injury CentreKaiserslauternGermany
  2. 2.Department of Trauma, Hand and Reconstructive SurgeryUniversity of SaarlandHomburgGermany
  3. 3.Ondo State Trauma CentreOndoNigeria
  4. 4.Department of OrthopaedicsMaulana Azad Medical College and associated Lok Nayak HospitalNew DelhiIndia
  5. 5.Chirurgisch-Orthopädisches ZentrumIllingenGermany

Personalised recommendations