No stress-related signs, such as widening, subchondral cysts, or asymmetries were noticed at the apophyseal plate of the comparison group, whereas the clinical series depicted these changes. Management principles were essentially antalgic. All injured players underwent conservative treatment with complete rest from aggravating activities.
No analgesic medication was given, nor were there local injections of any infiltrates. All the injured football players performed daily rehabilitation under the supervision of a sports physiotherapist.
The rehabilitation plan was divided into three stages: stage 1, obtain complete analgesia with local physical modality treatment and then start progressive adductor stretching. Stage 2 worked to correct postural control impairment from initial static positions working towards complex dynamic exercise focusing on pelvic and trunk control.
Finally, in stage 3, progressive football-specific exercises were conducted in a graduated manner until the player could perform all duties required in a normal training or playing session.
Patients were moved forward or back through these stages according to their reports of pain during and subsequent to the sessions. This case series documents a previously under-recognised clinical entity: apophyseal injury of the pubic symphysis.
Meindl et al 6 showed that the maturation of the pubic symphysis is a complex process which depends on: age, gender, race and environmental factors. In the clinical group presented here, these athletes were submitted to heavy training loads in an early football specialisation strategy, and we speculate that the loading likely influences the maturation of the pubic apophysis.
This reinforces our hypothesis that the maturation of the pubic apophysis bridges adolescence and adulthood, and may represent the start of the endochondral ossification of the secondary ossification centre. As with other apophysitis, pubic apophysitis remains a clinical diagnosis supported by radiological investigations.
Symptom onset is typically gradual. Clinically, pain is reproduced through palpation of the adductor longus insertion on the pubis. Some hip testing appeared to be positive despite the absence of demonstrable joint pathology. The FADDIR test is reported to display poor specificity, 18 and the pain reproduced by this testing might be explained by the compression force applied on this region during the adduction and internal rotation of the hip.
In this study, X-rays, ultrasound and MRI were used to rule out differential or additional diagnosis. In the opinion of the authors, CT scan allowed the best depiction of the pubic apophysis both on axial and coronal view, while T1 fat-saturation MRI 1. Unfortunately, due to radiation on the gonadal region of these adolescent boys, the use of CT scan was restricted, and only performed in cases where other investigations were inconclusive.
Previous studies on apophysitis questioned the role of tensile forces in their causality. We suggest that pathogenesis may be related to the combination of traction and compressive forces. The proximity of the symphysis joint and its capsule may add some shearing forces that may impact the apophyseal maturation.
Practically, adolescent football players who are under heavy training load following an early specialisation model may be at risk of developing this apophysitis. Football academies should pay attention to prodromal adductor-related symptoms in this population in order to allow physiological maturation of the pubic apophysis and avoid chronic symptoms. Training load and strict monitoring of adductor symptoms should be conducted in order to minimise this risk. The full maturation of the pubic symphysis may become an indirect sign of readiness to cope with adult training load.
Skeletally immature athletes should remain in an at-risk group until complete maturation of the pubic apophysis. In this case series, all patients were managed conservatively without any early recurrence. We suggest that mechanical loads need to be greatly decreased on the proximal adductor tendon to allow a correct maturation of the ossification centre. This clinical entity responds well to initial rest, then progressive and careful rehabilitation guided by pain response.
This may decrease the risk of future complications such as fusion delay or later non-union. This contrasts with the more commonly encountered skeletally mature entity of adductor-related groin pain 20 which is shown to respond to an immediate loading programme.
We suggest that in cases of presumed adductor-related groin pain, where athletes report increased symptoms after starting a loading programme, the exclusion of pubic apophysitis as a differential diagnosis is an important step lest the athlete be inappropriately subjected to injections eg, corticosteroids or surgical release of the adductors.
Sequelae of apophysitis are often described in Osgood-Schlatter and Sinding Larsen diseases, as resulting in chronic symptoms with insertional tendinopathy. The same long-term evolution may be proposed in pubic apophysitis. Incomplete apophyseal fusion may be seen in participants who keep playing despite apophyseal stress, and develop chronic symptoms.
This clinical series was intended to highlight a new observation as regards groin pathoanatomy. As a result, it has a number of limitations. The physical examination was standardised but the imaging performed was according to the clinical reasoning, bias and local imaging resources of the individual sports medicine physician. This did result in some variance in the imaging used in each case.
In future analyses, imaging of each modality will be performed in a larger cohort to document the differences in imaging appearance in symptomatic and asymptomatic subjects. Similarly, follow-up imaging examination could be performed to ascertain the natural course of identified abnormalities and their association with symptoms. We suggest that in early adulthood, repeated stress on the proximal adductor insertion may lead to impairment of the pubic apophysis associated with chronic symptoms.
What are the new findings? The diagnosis of pubic apophysitis needs to be considered in adolescent athletes reporting adductor-related groin pain.
An athlete in his early 20s should be considered as skeletally immature. Signs of apophyseal plate stress may be assessed with CT scan, however, the risk of exposure to ionising radiation in this age group makes this ill-advised. More modern MRI examinations appear a promising alternative.
Conservative treatment should be the first line of management to allow physeal maturation. Contributors MS was involved in the original study design, data collection, data analysis and manuscript preparation. RW and PH were involved in study design and manuscript preparation. BG and JWR were involved in the radiological data collection and analysis of the asymptomatic comparison group. AJ was involved in the data analysis.
All authors have reviewed and approved the final submission. Provenance and peer review Not commissioned; externally peer reviewed. You will be able to get a quick price and instant permission to reuse the content in many different ways. Skip to main content. Log in via OpenAthens. Log in using your username and password For personal accounts OR managers of institutional accounts.
Forgot your log in details? Register a new account? Forgot your user name or password? Search for this keyword. Advanced search. Log in via Institution. You are here Home Archive Volume 49, Issue 12 Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Email alerts. Article Text. Article menu. Original article. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes.
Abstract Background Sport-related pubalgia is often a diagnostic challenge in elite athletes. Statistics from Altmetric. Adolescent Tendon Growth Pelvic Soccer Introduction Sport-related pubalgia in adult athletes remains a diagnostic and management challenge for the sports physician.
Comparison group We also characterised an asymptomatic comparison group. Figure 1 Axial CT scan depicting the clinical staging of maturation stages 1, 2, 3a and 3b from the comparison group. Comparison group Participants referred for imaging for pain in the groin region were excluded from analysis. Clinical examination The physical examination followed the protocol described by Holmich et al. Radiology During the clinical evaluation and workup, investigations were ordered and performed when clinically indicated.
Results History In this clinical series, players were aged between View this table: View inline View popup. Table 1 Investigations performed and ages for each athlete in the clinical painful group. Physical examination Adduction against resistance was reported as painful with associated antalgic weakness in 20 of 26 participants, and was painful in all 26 participants when tested in end-range hip abduction. Radiology All 26 participants underwent X-ray investigation. Figure 2 Anteroposterior pelvic X-ray showing pubic symphysis stress-related signs.
Figure 3 Ultrasound appearance of a stage 2 subject longitudinal section, superior is left in the image, anterior is upper. Figure 4 T1 fat-saturation MRI showing depiction of the pubic symphysis and adjacent apophysis. Figure 5 Axial CT scan depicting pubic apophysis. Figure 6 CT scans from three of the participants within the symptomatic group demonstrating stress-related changes at the pubis. Comparison group Maturation status of the pubis was classified according to the demonstration of a physis and the ossicle as described above.
Figure 7 Distribution of the maturation status stages 1—4 of the 31 asymptomatic comparison subjects as determined by CT examination according to chronological age years. Clinical management Management principles were essentially antalgic. Discussion This case series documents a previously under-recognised clinical entity: apophyseal injury of the pubic symphysis.
Symphyseal maturational anatomy Meindl et al 6 showed that the maturation of the pubic symphysis is a complex process which depends on: age, gender, race and environmental factors.
Diagnostic strategy As with other apophysitis, pubic apophysitis remains a clinical diagnosis supported by radiological investigations. Pathomechanics Previous studies on apophysitis questioned the role of tensile forces in their causality. Clinical implications Practically, adolescent football players who are under heavy training load following an early specialisation model may be at risk of developing this apophysitis.
Limitations This clinical series was intended to highlight a new observation as regards groin pathoanatomy. Pubic apophysitis may explain some adductor-related groin pain in adolescent athletes.
How might it impact on clinical practice in the near future? Musculoskeletal injuries in young athletes. Clin Fam Pract ; 5 : — OpenUrl CrossRef. Overuse injuries in pediatric athletes. Orthop Clin North Am ; 34 : — Apophyseal avulsion fractures of the hip and pelvis. Orthopedics ; 32 : Morelli V , Weaver V. Advanced search. Log in via Institution. You are here Home Archive Volume , Issue Traction apophysitis of the fifth metatarsal base in a child: Iselin's disease.
Email alerts. Article Text. Article menu. Traction apophysitis of the fifth metatarsal base in a child: Iselin's disease. Summary Although Iselin's disease, apophysitis of the fifth metatarsal base, is not infrequent in clinical practice, it is accepted as a rare cause of lateral foot pain in young adolescents.
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