Philadelphia University + Thomas Jefferson University

Core Concept

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“Athletic pubalgia used to have a bad reputation,” chuckles Adam Zoga, MD, Director of Jefferson Outpatient Imaging and the Musculoskeletal (MSK) Fellowship Program. “For a long time, the literature talked about ‘sports hernia’ as an occult spectrum of disease without imaging findings or reproducible results on physical examination. It seemed like every time you saw a pro athlete having a bad year, all of a sudden he’s out with a sports hernia—a lot of people thought it was a phantom injury.”

“But one day I was talking to the head doc for the Eagles and he had a player suffering from groin pain—a typical sign of sports hernia—and that he was going to see a general surgeon named Bill Meyers.” says Dr. Zoga, recalling how he first became involved in imaging the injury. Intrigued, he called Dr. Meyers—the first to describe athletic pubalgia (sports hernia)—and the two got together to read an MRI and talk about imaging in the diagnosis of pubalgia.

Over the next three months, Dr. Zoga and three MSK radiology fellows pored over a shopping cart filled with over 400 MRI exams from pubalgia patients Dr. Meyers had treated. The first thing that they realized was “that imaging was terrible. In 2006, we knew how to do an MRI of the knee, but nobody knew how to image the pubic symphysis.”

Analogous to the bound edge of a book, the pubic symphysis is the place where the pages (muscles and tendons) come together. The structure has to be flexible enough to allow the covers (the hips) to open, making movement and child birth possible. But when the binding stretches too far or bears too much force, tendons and muscles can detach, forming a pubalgia lesion.

Often, doctors would try to image the entire pelvis in order to get a look at core muscle injury, an approach made difficult by the simple fact that resolution is lost as the imaging area increases in size. As Zoga says, “the receiver coils really are the devil that is the details.” In MRI, these coils collect the signals given off by the magnetized protons in a process analogous to a camera gathering light. To account for the loss of resolution, Zoga and his team realized they could use two different coils to achieve the desired image quality. One would capture a wide-angle shot of the pelvis to get the lay of the land, while the other focused tightly on the pubic symphysis region to capture the finer details. 

Then, one day in 2007, Zoga got a chance to try out his team’s new protocol. While watching ESPN highlights he saw a Phillies player go down with what appeared to be a core muscle injury. The next day, Jefferson radiologists were performing an MRI on the frontal portion of the player’s pelvis, “when low and behold, we got these beautiful images of core muscle injury that’d never been seen before—they became the foundation of what is now the Jefferson Athletic Pubalgia MRI Protocol.”

“I showed the case to the Phillies docs and my radiology colleagues and they became believers. I presented it at the Society of Skeletal Radiology in 2007 and I was awarded best paper.” Since then, the Jefferson protocol—and the way doctors think—has evolved, with versions now available for imaging pre and post-operative lesions, including one specifically for women, among other bespoke options.

The future is prevention, says Dr. Zoga, “A left-handed baseball slugger doesn’t get a right-sided injury. He gets one on the backside where he’s opening up his hips most forcefully.” Often, pubalgia causes strain and other injuries on the side opposite the lesion, as the MSK system compensates for the original impairment. But with the option of prevention now on the table—popular with trainers for the Flyers—athletes can adapt their core to withstand the high-stress movements likely to cause injury.

Building on Dr. Meyers’ original insight, Jefferson’s MSK radiologists showed that, far from being a boogeyman haunting orthopedics journals, athletic pubalgia is a real injury with a definite appearance.