Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad.

OBJECTIVES: To assess bone marrow edema at the pubic symphysis with magnetic resonance imaging (MRI), and its relation to training and osteitis pubis in an elite group of junior soccer players. SETTING: Soccer players on scholarship at the Australian Institute of Sport (AIS). PATIENTS: Nineteen players from an elite junior men's soccer squad. INTERVENTION/ASSESSMENT: Serial MRI examinations of the pubic symphysis over a 4-month training and playing period, training session questionnaire, and review of clinical diagnosis, investigations, and records on presentation of athletes with groin pain at the Department of Sports Medicine. MAIN OUTCOME MEASURES: Assessment of bone marrow edema (4-point scale) on MRI scans, review of athlete questionnaires, and review of clinical records. RESULTS: Initial MRI scans showed moderate to severe bone marrow edema at the pubic symphysis in 11 of the 18 asymptomatic players. There was a greatly decreased risk of developing groin pain (osteitis pubis) with more training prior to entry of the AIS soccer program (odds ratio per 4 sessions of training, 0.003). The correlation between initial bone marrow edema grading and pre-AIS training was small. The increase in bone marrow edema grading from baseline over the scans was 0.5 (90% CL, 0.4). CONCLUSIONS: Substantial amounts of bone marrow edema at the pubic symphysis can occur in asymptomatic elite junior soccer players, but it is only weakly related to the development of osteitis pubis. Progressing training loads more slowly in athletes presenting with low current training loads may be a useful strategy for the prevention of osteitis pubis in junior soccer players.     

Magnetic resonance findings of osteitis pubis

PURPOSE: To determine the correlation of MR findings with clinical features of osteitis pubis and to look for associating injuries complicating chronic cases. MATERIALS AND METHODS: Pelvic MR images of the 22 elite athletes with groin pain were taken. Correlation analysis between the MR findings and clinical properties was carried out. RESULTS: Six of the MR findings had strong correlation with duration of symptoms. Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema had significant correlation with acuity of the case. On the contrary, subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes correlated with the chronicity of the case. Associated tendon injuries correlated with the duration of symptoms; i.e., all tendon injuries were in chronic cases. CONCLUSION: Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema are the most reliable MRI findings of osteitis pubis that has a history of less than six months. Subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes (or pubic beaking) are the most reliable MRI findings of the chronic disease that has been present for more than six months. Associated pathologies, especially adductor or other tendon injuries, underlie more than half of the chronic cases of osteitis pubis.     

Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury

Traumatic osteitis pubis is a non-specific entity that relates to chronic groin injury and has recently been described as being akin to a pubic bone stress injury. It is uncertain whether or not reduction of hip joint range of motion occurs in traumatic osteitis pubis. The purpose of this study was to establish whether there is a reduction of hip range of motion in athletes who have chronic groin injury diagnosed as pubic bone stress injury. A case-control study was performed whereby 89 Australian Rules footballers underwent, with clinical history unknown, clinical and MRI examination of the groin region. Clinical criteria (pain with tenderness) and MR-criteria (pubic bone marrow oedema) were used for diagnosis of pubic bone stress injury. End-range internal and external rotation hip motion was measured using a goniometer. Athletes with and without symptoms were compared, as were athletes with current symptoms with athletes who had recovered from their groin pain episode. Chronic groin injury was diagnosed in 47 athletes with 37 having pubic bone stress injury. Thirteen athletes had previous groin injury. A reduction of internal and external hip range of motion was demonstrated in athletes with pubic bone stress injury (p < 0.05) and in athletes who had current symptoms compared to those who had recovered from their groin pain episode (p < 0.05). A reduction in hip range of motion was evident in athletes with chronic groin injury diagnosed as pubic bone stress injury. There may be a role for increasing hip range of motion in rehabilitation.     

Sports-related groin pain: evaluation with MR imaging

Our purpose was to assess the role of MRI in evaluating themusculoskeletal system in athletes with chronic pain laterally in the groin of unknown etiology. Magnetic resonance imaging (MRI) of the pubic ring was performed in 11 young athletes (soc cer players) with long-standing groin n pain. MR findings were: compared with plain films and isotope examination (bone scan Tc 99M). Abnormal MRI findings included a broadend andirregular symphysis witha characteristics pattern of low signal intensity on T1W and high signal intensity on T2W images localized in the superior pubic ramus at a distance from the symphasis. Positive findings wer also observed on plain films and on nuclear medicine studies. However, the imaging findings in the superior pubic ramus of the symphysis was located considerably more laterally on MRI. MRI is :a valuable method for evaluating discrete and ambiguous pelvic pain in athletes. particularly for identifying concomitant changes in the superior ramus, which may give rise to long-standing localized laterally in the groin.     

Athletic osteitis pubis

Athletic osteitis pubis is a painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis. The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction. The differential diagnosis for osteitis pubis is extensive and includes many other syndromes resulting in groin pain. Imaging, particularly in the form of MRI, may be helpful in making the diagnosis. Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. Prolotherapy injections of dextrose, anti-inflammatory corticosteroids and a variety of surgical procedures have been reported in the literature with varying efficacies. Future studies of athletic osteitis pubis should attempt to define specific and reliable criteria to make the diagnosis of athletic osteitis pubis, empirically define standards of care and reduce the variability of proposed treatment regimens.     

Successful treatment of osteitis pubis by using totally extraperitoneal endoscopic technique

Osteitis pubis is characterized by pain, inflammation, and sclerosis in the pubic symphysis. It is often a self-limiting disease in athletes, but persistent pain may occasionally need surgery. Video-assisted placement of extraperitoneal retropubic synthetic mesh to support the damaged area may hasten the healing of this injury. During 1997 - 2002 five elite level male athletes with chronic groin pain associated with osteitis pubis were operated. The diagnosis was based on clinical findings, x-ray, magnetic resonance imaging (MRI), and isotope bone scanning. A 10 x 15 cm polypropylene mesh was placed into preperitoneal retropubic space using video-assisted technique. The pain and return to sport were asked at 1, 6, and 12 months after surgery. Preoperative technetium bone scan revealed an enhanced isotope uptake of pubic bone in each patient. T2-weighted MRI (n = 3) indicated bone marrow edema, which was decreased postoperatively on repeated MRI scans. Periosteal edema and irritation were also seen at operation. No complications were associated with the insertion of mesh. All 5 athletes returned to their sport activities between one to two months after surgery. After one year, no tenderness or pain was observed in the pubic bone. When conservative treatment fails, the placement of retropubic mesh is safe and a mini-invasive method to hasten the rehabilitation of osteitis pubis in selected cases. The postoperative recovery was uneventful, and the patients returned rapidly to their sporting activities.     

Diagnostics in athletes with long-standing groin pain

Chronic adductor dysfunction, osteitis pubis and abdominal wall deficiency are mentioned as pathologies explaining long-standing groin pain (LGP) in athletes. The main objective of this study was to evaluate the validity of diagnostic tests used to identify these pathologies in athletic OKE. Additionally, starting points for intervention were searched for. A systematic literature search was performed to retrieve all relevant diagnostic studies and studies describing risk factors. The methodological quality of the identified studies was evaluated. Seventeen studies provided an insight into pathologies; eight provided relevant information for intervention. Adduction provocation tests are moderately valid for osteitis pubis. A pelvic belt might provide some insight into the role of the pubic symphysis during adduction provocation. Palpation can be used for provocation of adductors and symphysis. Roentgen, bone scan and herniography show poor validity. Bilateral abdominal abnormalities on ultrasound appear to be a valid marker for LGP. Magnetic resonance imaging (MRI) can visualize edema and other abnormalities, although the relation to groin pain is not unambiguous. The methodological quality of the studies ranged from poor to good. MRI and ultrasound should be the primary diagnostic tools after clinical examination.     

Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome

Background and purposeOsteitis pubis (OP), a common pathology in elite athletes, is an aseptic inflammatory process of the pubic symphysis bone, and may involve surrounding soft tissues, tendons and muscles. OP is typically characterized by (often recurring) groin pain and is an important cause of time-off from sports activity in athletes. Aim of this retrospective study was to analyze magnetic resonance imaging (MRI) findings in professional football players with clinical diagnosis of OP and to correlate MRI findings with clinical outcome.Material and methodsAll professional football players (23 males, 1 female; mean age: 21 ± 3.7 years; range: 16–30 years) with groin pain and clinical diagnosis of OP, who underwent pelvic MRI in our institution were retrospectively analyzed. The MR images were analyzed regarding the presence of bone marrow edema and its extension, whether fluid in the symphysis pubis or periarticular soft tissue edema with a rim-like periosteal distribution or edema in the muscles located around the symphyseal joint were present, whether degenerative changes of the symphysis pubis and of signs of symphyseal instability were encountered. A quantitative measurement of the signal intensity in bone marrow edema on 3 T STIR sequences was performed, normalizing these values to the mean signal intensity values in the ipsilateral iliopsoas muscle. All patients were classified according to a 3-point grading scale.For each patient, both the symptoms 18 months after the initial MRI examination, the duration of time off from playing football and the kind of treatment applied were evaluated.ResultsAmong all professional athletes, in 20/24 (83.3%) MRI showed signs of OP with bone marrow edema at the pubic bone. 12 of these patients showed complete clinical recovery without any symptoms after 18 months, while in 8 patients partial recovery with persistence of groin pain during higher sports activity was observed. Patients with edema in periarticular soft tissues or in the muscles around the symphyseal joint on MRI at the beginning of symptoms presented significantly more often with a partial recovery after returning to high sports activity (p = 0.042 and p = 0.036, respectively). A partial recovery was also significantly associated with higher normalized mean signal intensity values in bone marrow edema on STIR sequences at the beginning of symptoms (mean = 4.77 ± 1.63 in the group with partial recovery vs. mean = 2.86 ± 0.45 in the group with complete recovery; p = 0.0019). No significant association was noticed between MRI findings and time of abstinence from high sports activity, as well as between the 3-point grading scale and the time off from high sport activity and recovery at 18 months.ConclusionsEdema in periarticular soft tissues, edema with extension to the muscles located around the symphyseal joint, as well as higher normalized signal intensity values in bone marrow edema on STIR sequences in the pubic bones at the beginning of groin pain are the most reliable MRI findings of a poor clinical long-term outcome of OP in professional football players and should be regarded as negative prognostic factors.     

Osteitis Pubis in the Active Patient

For more than 3 months, a young male soccer player had groin pain diagnosed as stemming from a “tight groin.” His discomfort, however, was characteristic of the overuse injury osteitis pubis: gradually worsening pain with significant tenderness on palpation of the symphysis pubis. X-ray and bone scan verified the diagnosis. Conservative treatment for osteitis pubis is often successful; our patient responded to a typical regimen of rest; flexibility and strength exercises for the low back, hip, and thigh; and a gradual return to running and full soccer activity.     

Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail

Seven rugby players with osteitis pubis and vertical instability at the pubic symphysis were treated operatively after nonoperative treatment had failed to improve their symptoms. The vertical instability was diagnosed based on flamingo view radiographs showing greater than 2 mm of vertical displacement. The players had undergone at least 13 months of nonoperative therapy before surgery was considered. Operative treatment consisted of arthrodesis of the pubic symphysis by bone grafting supplemented by a compression plate. At a mean follow-up of 52.4 months, all patients were free of symptoms and flamingo views confirmed successful arthrodesis with no residual instability of the pubic symphysis. Based on our results with this procedure, we believe that arthrodesis of the pubic symphysis has a role in the treatment of osteitis pubis that is recalcitrant to nonoperative treatment. The combination of osteitis pubis and vertical pubis symphyseal instability may be the cause of failure of nonoperative treatment.     

Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls

Objective  

Bone marrow edema (BME) at the pubic symphysis on magnetic resonance imaging (MRI) is usually associated with groin pain and stress injury of the pubic bone. Little is known of the pubic MR imaging findings of asymptomatic heavy training athletes in contact sports.     

A Complete Approach to Groin Pain

IN BRIEF: Focused history questions and physical exam maneuvers are especially important with groin pain because symptoms can arise from any of numerous causes, sports related or not Questions for the patient should attempt to rule out systemic symptoms and clarify the pain pattern. Some of the most possible causes of groin pain include stress fracture of the femoral neck or pubic ramus, Legg-Calvé Perthes disease, slipped capital femoral epiphysis, acetabular labral tears, iliopectineal bursitis, avulsion fracture, osteitis pubis, strain of the thigh muscles or rectus abdominis, inguinal hernia, ilioinguinal neuralgia, and the ‘sports hernia.’ Depending on the diagnosis, conservative treatment is often effective.     

Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia

Athletic pubalgia (sportsman's hernia) is often repaired by surgery. The presence of pubic bone marrow edema (BME) in magnetic resonance imaging (MRI) may effect on the outcome of surgery. Surgical treatment of 30 patients with athletic pubalgia was performed by placement of totally extraperitoneal endoscopic mesh behind the painful groin area. The presence of pre‐operative BME was graded from 0 to 3 using MRI and correlated to post‐operative pain scores and recovery to sports activity 2 years after operation. The operated athletes participated in our previous prospective randomized study. The athletes with (n = 21) or without (n = 9) pubic BME had similar patients' characteristics and pain scores before surgery. Periostic and intraosseous edema at symphysis pubis was related to increase of post‐operative pain scores only at 3 months after surgery (P = 0.03) but not to long‐term recovery. Two years after surgery, three athletes in the BME group and three in the normal MRI group needed occasionally pain medication for chronic groin pain, and 87% were playing at the same level as before surgery. This study indicates that the presence of pubic BME had no remarkable long‐term effect on recovery from endoscopic surgical treatment of athletic pubalgia.     

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.     

MRI of the pelvic ring joints postpartum: normal and pathological findings

PURPOSE: To assess the joints of the pelvic ring postpartum and to discern normal postpartum findings and pathologic lesions using MRI. MATERIALS AND METHODS: MR images were obtained in six women with severe pelvic ring pain after delivery, in 13 women after uncomplicated vaginal delivery, and in 11 healthy, nulliparous non-pregnant volunteers. Distances of the pubic gap, signal intensities of the pubic cartilage, and signal changes of the pelvic ring bones were determined and evaluated. RESULTS: Both postpartum groups had significantly larger distances of the interpubic gap compared to the nulliparous group (P = 0.0002). The mean signal intensity of cartilage of the symphysis pubis was significantly different on the T1-weighted and T2-weighted MR images in postpartum women compared to nulliparous women (P = 0.001), indicating a higher water content of the pubic cartilage. 13 of all 19 postpartum women had bruises of parasymphyseal pubic bones. One pubic symphysis rupture and one sacral stress fracture were detected in two symptomatic women. CONCLUSION: MR imaging is a useful adjunct to clinical examination to identify patients with lesions of the pelvic ring postpartum. MRI of the pelvic ring of asymptomatic postpartum women can demonstrate signal changes of the pubic cartilage and small bruises of the pubic bones.     

Groin pain in athletes: role of magnetic resonance

INTRODUCTION: Aim of our work was to evaluate the diagnostic role and potentials of Magnetic Resonance Imaging (MRI) in the study of groin pain in athletes and in the differential diagnosis among the pathological conditions that cause this syndrome. MATERIAL AND METHODS: MRI examinations were performed with a 1.5 T superconductive magnet, and a 0.2 T permanent magnet. Spin-Echo (SE) T1-w, PD, SE T2-w, Gradient-Echo (GE) T2-w and fat saturation sequences were used, on axial, sagittal and coronal scan planes. We performed MRI on twenty-five athletes (22 men and 3 women; age range 17 to 32 years) with chronic groin pain of questionable origin who had been complaining of it for at least 6 months. In 22 cases, radiographs were available; Computed Tomography (CT) had been performed in 3 cases and Ultrasound (US) in 7 cases. Nine patients were submitted to MRI after the symptoms had disappeared. RESULTS: In all patients, MRI provided an accurate depiction of pubic bone alterations and of adjacent myotendinous structures. In 14 cases, osteitis pubis was diagnosed, which was bilateral in 2 cases only (muscular asymmetry of the rectus abdominis was found in 4 of these patients); 4 patients had myotendinous posttraumatic changes (1 hematoma of the psoas muscle and 3 injuries of the abductor muscles of the thigh); 4 patients presented isolated dysmetria of rectus abdominis muscles, with unilateral involvement of the sacroiliac joint in 1 patient; 3 patients had inguinal hernia, surgically confirmed in all cases. DISCUSSION: Osteitis pubis, intended as reactive intraspongiuos edema of the pubic bones, is the most frequent cause of groin pain in athletes. In the early diagnostic phases, both plain films and CT may be negative or not specific. On the other hand, MRI has always proved to be a valuable diagnostic technique in detecting the osteitic change as an area of low signal intensity on T1-w images and of high and homogeneous signal intensity on T2-w scans without fat suppression. Dysmetria of the straight muscles of the abdomen, which may be associated, is always well depicted by MRI on axial planes. Both posttraumatic and dysmetric changes of the muscular structures adjacent to the pubis are well documented by US and MRI. The latter, however, thanks to its multiplanar capabilities, allows better spatial assessment of the alteration, especially if located at peri-insertional level. Possible associated diseases such as the involvement of the sacroiliac joints are also well shown by MRI. Inguinal hernias are easily demonstrated by MRI, which allows the direct visualization of the hernial sac within the inguinal canal. CONCLUSIONS: In our experience, only MRI can permit an accurate and early diagnosis of the different sport-related pubic conditions. MRI is also a valuable tool in monitoring the alterations with reference to their response to treatment, which may also help bring the athletes back to their activities.     

Osteitis pubis in athletes. Infection, inflammation or injury?

Medical records of 59 patients (9 females and 50 males), who presented to sports medicine clinics at the Australian Institute of Sport and the University of British Columbia between 1985 and 1990 and who were diagnosed as suffering osteitis pubis, were reviewed and comparison of data obtained was made with the literature. Women average 35.5 years of age (30 to 59 years) and men 30.3 years (13 to 61 years). Sports most frequently involved were running, soccer, ice hockey and tennis. Clinical presentations of osteitis pubis fell into 4 main groups. 'Mechanical' (sport-related) was the largest group (n = 48), followed by 'obstetric' (n = 5), 'inflammatory' (n = 4) and 'other' (n = 2). Period of follow-up averaged 10.3 months (1 to 20 months) in women and 17.5 months (2 to 96 months) in men. Full recovery, when documented, averaged 9.5 months in men and 7.0 months in women. Osteitis pubis recurred in 25% of these men and none of these women at follow-up. The most frequent symptoms were pubic pain and adductor pain. Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin. Men also revealed tenderness of one or both the superior pubic rami and evidence of decreased hip rotation (unilateral or bilateral). Evidence of pelvic malalignment and/or sacroiliac dysfunction was frequently seen in both men and women. There was poor correlation between radiographic and isotope bone scan findings and the site and duration of symptoms and signs. Femoral head ratios were estimated on 30 hips in the series and 2 were judged to be at the upper limit of normal, perhaps indicating a form of epiphysiolysis producing tilt deformity of the head of the femur. It is clear that osteitis pubis in athletes is not uncommon and that factors such as loss of rotation of hips and previous obstetric history are important in the aetiology and management of this condition. Pelvic infection, which was believed to be the primary factor of osteitis pubis in the literature up until the 1970s, plays a very small role in this condition in athletes.     

Correlation of MRI and histomorphological findings in bone marrow oedema syndrome of the hip

Bone marrow oedema syndrome (BMOS) of the hip includes severe hip joint pain, focal loss of radiodensity in radiographs, increased uptake in bone scintigrams and the pattern of bone marrow oedema in the femoral heads in MRI scans. In 15 patients (16 hip joints) we found the clinical and radiological signs of BMOS. On T1-weighted MRI images areas of low signal intensity could be observed in the head, neck and the intertrochanteric region of the femur in various extensions. These areas showed a significant increase in signal intensity on the T2-weighted images. Because pain was resistant to conservative therapy all these patients were treated by core decompression of the femoral head in a prospective study. Bone cores were evaluated histologically using undecalcified sections and quantitative microradiography. The existence of intramedullary oedema in exactly the regions exhibiting the MRI pattern of bone marrow oedema was verified histologically; however, bone and marrow changes similar to those of early avascular necrosis (AVN) were also visible. These findings support our assumption that BMOS might be a transitory initial phase of AVN. Therefore core decompression treatment for patients suffering pain from BMOS is recommended after excluding other diseases.     

Herniographic findings in athletes with unclear groin pain

BACKGROUND: Groin pain in athletes is a common symptom and may, among many other entities, be caused by skeletal changes in the symphysis and the pubic bone or hernia. MATERIAL AND METHODS: Herniographies in 51 athletes -- mainly soccer players -- with unclear groin pain were reviewed. The prevalence of various hernias and skeletal changes at the symphysis and os pubis was registered. A questionnaire was also sent to the patients 3-20 years after the herniography. RESULTS: A hernia was found in 13 patients. Four patients had an indirect inguinal hernia. Eight patients had a direct inguinal hernia and 1 had an obturator hernia. The prevalence of direct inguinal hernia was higher than expected in young men. This may be explained by strain at physical exercise. Bone changes at the pubic symphysis were found in 32 patients, 21 of whom had advanced changes. CONCLUSION: A hernia can be found with herniography in one-fourth of athletes with long-standing unclear groin pain. Therefore herniography should be included in the diagnostic procedure. Lesions of the symphysis may be the result of strain of tendons, ligaments and fascias. This may predispose for an inguinal hernia as well.     

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome

BACKGROUND: Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation. HYPOTHESIS: Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season. RESULTS: Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not. CONCLUSION: Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.