Image-Guided Symphyseal Steroid Injection for Sports-Related Groin Pain

A recent study demonstrated the effectiveness of fluoroscopy-guided corticosteroid symphyseal injection in the treatment of sports-related groin pain.¹

Sports-related groin pain comprises up to 5% of sports injuries, with a higher prevalence in kicking sports and ice hockey.² Three forms of symphyseal derangement associated with various forms of groin pain have been identified using magnetic resonance imaging (MRI): rectus abdominis and adductor longus attachment microtearing, short adductor attachment microtearing, and osteitis pubis.^3-5

“Despite recognizing the value of MRI in identifying these subgroups and despite accepting the value of steroid injections in patient recovery and management,” no prior research has investigated correlations between pre-treatment imaging and image-guided interventions, wrote the study investigators. They investigated these links using clinical and MRI findings from 45 athletes (44 male; mean age, 29) in field-based kicking sports who suffered groin pain due to symphyseal derangement.

In addition, the researchers examined participants’ response to treatment with a fluoroscopy-guided steroid and local anesthetic injection in the symphysis pubis. The mean follow-up period following the procedure was 23 months.

The following results were observed:

• 42% of patients had an isolated superior cleft sign, and 89% of these patients showed symptom improvement post-injection (complete improvement in 63% of patients and partial improvement in 26%)
• 7% of patients had an isolated secondary cleft, all of whom demonstrated improvement: 33% had complete resolution, and 67% had partial resolution
• 11% of patients had isolated osteitis pubis, with complete improvement in 40% of the group, partial improvement in 20%, and no improvement in 40%
• 31% of patients had a complex injury, and all of these patients experienced symptom improvement: complete recovery in 36%, and partial recovery in 64%
• 9% of patients showed no abnormal findings at the symphysis pubis; one of these patients had complete resolution after injection, 2 had a partial improvement, and 1 had no improvement
• Overall, 58% of patients demonstrated a sustained response after at least 6 months

Taken together, these results are in line with previous findings that support the effectiveness of local steroid injection in treating sports-related groin pain. They further suggest that it is “particularly effective in managing pain relating to inflammation and microtearing at the combined rectus abdominis-adductor longus attachment, the superior cleft sign,” as indicated by the higher rates of complete recovery in this group, the investigators concluded.

Summary and Clinical Applicability

Fluoroscopy-guided corticosteroid symphyseal injection is effective in managing sports-related groin pain, particularly in patients showing an isolated superior cleft sign on MRI.

Limitations

Study limitations include the lack of a control group and the small sample size.

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References

1. 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-guided injection of steroid and local anesthetic. AJR Am J Roentgenol. 2017;13:1-9. doi:10.2214/AJR.16.17578
2. Morelli V, Smith V. Groin injuries in athletes. Am Fam Physician. 2001;64(8):1405-1415.
3. Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med. 2001; 35(1):28-33. doi:10.1136/bjsm.35.1.28
4. Brennan D, O’Connell MJ, Ryan M, et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology. 2005;235(1):162-167. doi:10.1148/radiol.2351040045
5. Murphy G, Foran P, Murphy D, Tobin O, Moynagh M, Eustace S. “Superior cleft sign” as a marker of rectus abdominis/adductor longus tear in patients with suspected sportsman’s hernia. Skeletal Radiol. 2013;42(6):819-825. doi:10.1007/s00256-013-1573-z