Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain

OBJECTIVES: To examine the relation between the clinical features of groin pain and groin magnetic resonance imaging (MRI) appearances in a group largely comprising elite Australian Rules football players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The relation between a past history of groin pain and these other MRI findings was also examined. METHOD: In a prospective study, 116 male subjects (89 footballers, 17 umpires, 10 sedentary men) were examined before history taking and groin MRI. The clinical history was not known to the examiner (GMV) and radiologists (JPS, GTF). Clinical evidence of groin pain and examination findings were correlated with the presence of increased signal intensity within the pubic bone marrow. A past history of groin pain was correlated with the presence of other MRI findings such as cyst formation, fluid signal within the pubic symphysis disc, and irregularity of the pubic symphysis. RESULTS: Fifty two athletes (47 footballers, five umpires) had clinical features of groin pain with pubic symphysis and/or superior pubic ramus tenderness. A high incidence of increased signal intensity (77%) within the pubic bone marrow was identified in this group. There was an association between this group of athletes and the MRI finding of increased signal intensity (p<0.01). There was also an association between a past history of groin pain and the presence of other MRI findings (p<0.01). CONCLUSIONS: Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow oedema. An association exists between the clinical features of osteitis pubis and the MRI finding of pubic bone marrow oedema. A high incidence of pubic bone marrow oedema was also noted. Degenerative features visualised by MRI, such as subchondral cyst formation, were associated with a past history of groin pain. A stress injury to the pubic bone is the most likely explanation for these MRI findings and may be the cause of the clinical entity osteitis pubis.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

Objective. To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. Design and patients. Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18–72 years, average 49 years; 11 women and 9 men). Results. All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. Conclusion. We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.     

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.     

Age estimation by multidetector CT images of the sagittal suture

Closure of cranial sutures progresses with age; therefore, macroscopic assessment of cranial sutures has been used as one method of age estimation. Postmortem computed tomography (PMCT), which many forensic medical departments and institutes have begun to adopt, has the potential to simplify the gathering of information from cranial sutures for both surface and cross-sectional evaluation. To examine the feasibility of age estimation by cross-sectional multidetector computed tomography images of the sagittal suture, PMCT findings of 125 subjects of known age and sex were retrospectively reviewed. The sagittal suture was divided into four segments, and 20 cross-sectional slices from each segment were analyzed. These slices were each categorized by visual evaluation into one of the seven stages defined by Harth et al. according to the degree of closure. The mean stage value of 20 slices was calculated for each segment. We were able to evaluate cross-sectional images of the sagittal suture by PMCT, and a positive correlation between age and closure degree was observed. Despite the prediction interval achieved with this method not being superior to traditional macroscopic or flat-panel CT assessment, multidetector CT is a potentially useful tool, in conjunction with other methods, for age estimation, particularly in adult females and in cases where only a skull is the sole remain.     

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.     

Radiation from "extra" images acquired with abdominal and/or pelvic CT: effect of automatic tube current modulation

PURPOSE: To retrospectively determine the number and usefulness of images acquired beyond the intended anatomic area of interest with abdominal and/or pelvic computed tomography (CT) and to assess the effect of automatic tube current modulation (ATCM) on associated radiation. MATERIALS AND METHODS: Superior and inferior levels at routine abdominal and/or pelvic CT were defined as the dome of the diaphragm and the inferior margin of the pubic symphysis, respectively. Records of 106 consecutive examinations (male-to-female ratio, 45:61; age range, 21-86 years) performed from June 1 to June 30, 2003, were reviewed to determine the number of "extra" images. Sixty-two abdominal and/or pelvic CT examinations performed concurrently with chest or thigh CT or for trauma were not included in the 106. Abdominal and/or pelvic CT was performed with either ATCM (n = 44) or manual selection of tube current (n = 62). CT parameters recorded for each extra image included tube current, peak kilovoltage, and gantry rotation time. Mean and median tube current-time products were calculated for extra images. Extra images were analyzed for pathologic findings. Statistical analysis was performed with the Student t test. RESULTS: Extra images were acquired above the dome of the diaphragm in 103 (97%) of 106 examinations and below the pubic symphysis in 100 (94%) of 106. A total of 1,280 extra images were acquired in 106 examinations (mean, 12 images per examination). Nineteen additional findings were observed on extra images. With ATCM, mean tube current-time product was 74.5 and 120.6 mAs for extra images acquired above the diaphragm and below the pubic symphysis, respectively; with manual selection, mean tube current-time products were 167.5 and 168.3 mAs (P <.05). CONCLUSION: Most extra images acquired at abdominal and/or pelvic CT contributed no additional information. With ATCM, the radiation dose was reduced by a mean of 56% (median, 72%) for extra images above the diaphragm and 29% (median, 36%) for images below the pubic symphysis, compared with dose levels with manual selection.     

MR findings in athletes with pubalgia

Objective. To describe the MR findings in athletes with pubalgia. Design and patients. Pelvic MR images of 32 athletes (30 men, 2 women) with pubalgia were studied. T1-weighted and T2-weighted (SE and FSE) and STIR images in the axial and coronal planes were obtained on a 1.5-T system. Images were reviewed for general pelvic pathology. Special attention was given to the pubic symphysis, groin and pelvic musculature, and to the abdominal wall musculature. Results. Thirty surgically confirmed cases comprise the study group. Abnormalities in the following were found: pubic symphysis (21/30), abdominal wall (27/30), groin musculature, including rectus abdominis (21/30), pectineus (6/30), and adductor muscle group (18/30). Conclusions. Pubalgia is a complex process which is frequently multifactorial. The MRI findings can alter the surgical approach. Received: 19 May 2000 Revision requested: 27 July 2000 Revision received: 6 October 2000 Accepted: 27 November 2000     

凸阵探头经体表与腹腔镜线阵探头经直肠联合检查在超声诊断子宫脱垂中的应用

目的探讨凸阵探头经体表与腹腔镜线阵探头经直肠联合检查在超声观察子宫脱垂患者中的优越性。方法分别对52例子宫脱垂患者行单一的凸阵探头经体表及腹腔镜线阵探头经直肠检查,两者检查后,分析相关资料,并将联合检查与单一检查结果进行比较。结果(1)超声诊断子宫脱垂应以耻骨联合中央处骨回声切面作为参考平面,可将宫颈内口低于骨回声上缘和宫颈外口低于骨回声下缘分别作为单一凸阵探头经体表和腹腔镜线阵探头经直肠检查的参照标准。(2)凸阵探头经体表与腹腔镜线阵探头经直肠联合检查能避开耻骨联合骨回声的声影干扰全程显示子宫脱垂及其周围组织结构的变化,较单一检查具有优越性。结论凸阵探头经体表与腹腔镜线阵探头经直肠联合检查是一种较单一检查优越,能从耻骨联合上下两方兼顾提高子宫脱垂诊断准确率的、简单易学的方法。     

Three dimensional surface analyses of pubic symphyseal faces of contemporary Japanese reconstructed with 3D digitized scanner

Three dimensional pubic bone images were analyzed to quantify some age-dependent morphological changes of the symphyseal faces of contemporary Japanese residents. The images were synthesized from 145 bone specimens with 3D measuring device. Phases of Suchey–Brooks system were determined on the 3D pubic symphyseal images without discrepancy from those carried out on the real bones because of the high fidelity. Subsequently, mean curvatures of the pubic symphyseal faces to examine concavo-convex condition of the surfaces were analyzed on the 3D images. Average values of absolute mean curvatures of phase 1 and 2 groups were higher than those of phase 3–6 ones, whereas the values were approximately constant over phase 3 presumably reflecting the inactivation of pubic faces over phase 3. Ratio of the concave areas increased gradually with progressing phase or age classes, although convex areas were predominant in every phase.     

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.     

超声腹腔镜线阵探头经直肠诊断子宫脱垂的初步探讨

目的探讨超声对子宫脱垂的诊断方法和价值。方法回顾性分析运用超声腹腔镜线阵探头经直肠诊断临床证实的32例子宫脱垂患者的声像图资料,并与子宫位置正常者30例作对比。结果 (1)腹腔镜探头经直肠检查可清晰显示直肠段前方子宫或阴道、膀胱或尿道等组织结构声像图,子宫脱垂程度不同具有不同的声像图表现,部分可显示脱垂过程的动态变化。(2)耻骨联合中央处骨回声下缘回声位置固定,容易辨认;以耻骨联合中央处骨回声下缘作为参照物,根据宫颈外口是否低于耻骨联合中央处骨回声下缘可诊断子宫脱垂。结论超声腹腔镜线阵探头经直肠诊断子宫脱垂可以以耻骨联合中央处骨回声下缘为参照物,能为临床明确病情提供帮助。     

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.     

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.     

非增强螺旋CT曲面重组诊断输尿管结石的价值

目的:探讨非增强螺旋CT曲面重组图像在输尿管结石诊断中的应用价值。方法:对52例输尿管结石行非增强螺旋CT扫描并行曲面重组(CPR)。结果:52例CPR图像均能显示输尿管全程,并能清楚显示输尿管内结石大小、部位、形态以及结石上方输尿管梗阻扩张程度。结论:CPR图像能在一个平面上显示输尿管全貌,对输尿管结石的诊断具有重要价值。     

Pelvic instability after bone graft harvesting from posterior iliac crest: report of nine patients

Objective. To report the imaging findings in nine patients who developed pelvic instability after bone graft harvest from the posterior aspect of the iliac crest. Design and patients. A retrospective study was performed of the imaging studies of nine patients who developed pelvic pain after autologous bone graft was harvested from the posterior aspect of the ilium for spinal arthrodesis. Plain films, bone scans, and CT and MR examinations of the pelvis were reviewed. Pertinent aspects of the clinical history of these patients were noted, including age, gender and clinical symptoms. Results. The age of the patients ranged from 52 to 77 years (average 69 years) and all were women. The bone graft had been derived from the posterior aspect of the iliac crest about the sacroiliac joint. All patients subsequently developed subluxation of the pubic symphysis. Eight patients had additional insufficiency fractures of the iliac crest adjacent to the bone graft donor site, and five patients also revealed subluxation of the sacroiliac joint. Two had insufficiency fractures of the sacrum and one had an additional fracture of the pubic ramus. Conclusions. Pelvic instability is a potential complication of bone graft harvesting from the posterior aspect of the iliac crest. The pelvic instability is manifested by insufficiency fractures of the ilium and subluxation of the sacroiliac joints and pubic symphysis. Received: 25 January 2000 Revision requested: 22 May 2000 Revision received: 15 September 2000 Accepted: 4 January 2001     

Postmortem computed tomography age assessment of juvenile dentition: comparison against traditional OPT assessment

Age estimation is one of the primary demographic features used in the identification of juvenile remains. Determining the accuracy and repeatability of age estimations based on postmortem computed tomography (PMCT) data compared with those using conventional orthopantomography (OPT) images is important to validate the use of PMCT as a single imaging technique in forensic and disaster victim identification (DVI). In this study, 19 juvenile mandibles and maxilla of known age underwent both OPT and PMCT. Three raters then estimated dental age using the resulting images and 3D reconstructions. This assessment showed excellent agreement between the age estimations using the two techniques for all three observers. PMCT also offers a greater range of measurements for both the dentition and the whole human skeleton using a single image acquisition and therefore has the potential to improve both the speed and accuracy of age estimation.     

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.     

MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts.

PURPOSETo investigate the MR findings in patients who have had osteoplastic frontal sinus flaps placed for inflammatory sinonasal disease.METHODSThe MR images of 13 patients who had improvement of symptoms after osteoplastic frontal sinus flap placement with fat autograft were prospectively evaluated for the presence of high intensity on T2-weighted scans, contrast enhancement, and replacement of frontal sinus fat by lower-signal soft tissue. All studies were performed on a 1.5-T unit using a 5-in round surface coil placed over the nasion. Sagittal T1-weighted, axial and coronal fast spin-echo T2-weighted, and precontrast and postcontrast axial and coronal T1-weighted images were obtained through the operative bed. The T2-weighted and postgadolinium sequences were done with a fat-suppression technique.RESULTSHyperintensity within the frontal sinuses on T2-weighted images and enhancement (peripherally and/or centrally where fat was replaced with soft tissue) were found to some degree in all patients. The degree of replacement of frontal sinus fat with soft tissue ranged from 4% to 85% (mean, 43%). Five patients with persistent symptoms had no distinguishing MR features when compared with asymptomatic patients.CONCLUSIONSAlthough increased T2-weighted intensity, fat replacement, and enhancement are findings compatible with inflammation, these changes may be seen in patients who are asymptomatic after placement of osteoplastic frontal sinus flaps; they may represent the normal granulation process. MR findings after flap placement are nonspecific and have limited utility in distinguishing symptomatic patients with recurrent inflammatory disease from asymptomatic patients whose imaging findings are related to postoperative scar tissue.     

MRI diagnosis of brown tumor based on magnetic susceptibility

A 56-year-old male with chronic renal failure was incidentally found to have lytic bone lesions in the pubic symphysis, left femoral head, left acetabulum, left iliac bone, and L1 vertebra on computed tomography (CT). Subsequent magnetic resonance imaging (MRI) of the abdomen was performed (for evaluation of a renal lesion) which demonstrated marked loss of signal intensity in the L1 bone lesion on increasing TE gradient echo images, consistent with magnetic susceptibility effect due to hemosiderin. Brown tumor was confirmed at biopsy. The susceptibility imaging probes one particular histological characteristic of tissues and allows a restricted differential of lytic tumors that contain significant hemosiderin, including brown tumor.     

Grading scale of radiographic findings in the pubic bone and symphysis in athletes

PURPOSE: Radiographic abnormalities in the pubic bone and symphysis are often seen in athletes with groin pain. The aim was to create a grading scale of such radiologic changes. MATERIAL AND METHODS: Plain radiography of the pelvic ring including the pubic bone and the symphysis was performed in 20 male athletes, age 19-35, with long-standing uni- or bilateral groin pain. We used two control groups: Control group 1: 20 healthy age-matched men who had undergone radiologic examination of the pelvis due to trauma. Control group 2: 120 adults (66 men and 54 women) in 9 age groups between 15 and 90 years of age. These examinations were also evaluated for interobserver variance. RESULTS AND CONCLUSION: The grading scale was based on the type and the amount of the different changes, which were classified as follows: No bone changes (grade 0), slight bone changes (grade 1), intermediate changes (grade 2), and advanced changes (grade 3). The grading scale is easy to interpret and an otherwise troublesome communication between the radiologist and the physician was avoided. There was a high interobserver agreement with a high kappa value (0.8707). Male athletes with long-standing groin pain had abnormal bone changes in the symphysis significantly more frequently and more severely (p>0.001) than their age-matched references. In asymptomatic individuals such abnormalities increased in frequency with age both in men and women.