Available online 24 February 2024, 152238

Author links open overlay panel, , , , , , ABSTRACTObjective

Pubis-related groin pain remains a difficult topic in orthopedic and sports medicine. A better understanding of the anatomy of the adductors and the pubic ligaments is necessary. The aim of this study is to map all the musculotendinous attachments to the pubic ligaments and to investigate in detail all the possible inter-adductor fusions.

Methods

The pubic symphyses were dissected in eight male and fourteen female embalmed cadavers (mean age 85 years), focusing on the fusion between the adductors, pubic ligaments, and musculotendinous attachments at the pubic ligaments. The 95% confidence intervals for the prevalence of the different conjoint tendons and tendon attachment to ligament were calculated.

Results

The presence of three types of conjoint tendons was found: adductor brevis and gracilis (AB/G) 90.9 [72.2 – 97.5]%; adductor brevis and adductor longus (AB/AL) 50.0 [30.7 – 69.3]%; adductor longus and gracilis (AL/G) 50.0 [30.7 – 69.3]%. The AL, AB and G were in every cadaver attached to the anterior pubic ligament (APL). 64% of the AB and 100% of the G were attached to the inferior pubic ligament (IPL).

Conclusion

The proximal anatomy of the adductors is more complex than initially described. This study identified three possible conjoint tendons between the proximal adductors. The AB/G conjoint tendon was significantly more present than the AB/AL or AL/G conjoint tendon. The IPL has attachments only from the AB and G. Rectus Abdominis (RA) and AL were not attached to IPL. Mapping the musculotendinous attachments on the pubic ligaments creates more clarity on the pathophysiology of lesions in this area.

Section snippetsINTRODUCTION

The pubic symphysis and the peri-symphyseal area have become of increasing interest for sports physicians, orthopedic surgeons and radiologists dealing with complex pain syndromes in the groin area. Between 2% and 10% of all athletic injuries involve the groin, and up to 13% of soccer injuries are groin related (Ekstrand et al., 2011). Evaluation and treatment of groin pain in athletes is challenging. The anatomy is complex, multiple pathologies often coexist, different pathologies may cause

Methods

For this study, human embalmed cadavers, donated to the Laboratory of Human Anatomy and Embryology (Department ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp) by means of a written testament to use their bodies after death for scientific and educational purposes, were used. This study conforms to the Declaration of Helsinki (World Medical Association. 2013) and to the guidelines of study ethics in anatomical research within the framework of the Anatomical Quality

Conjoint tendons

Adductor Brevis (AB) and gracilis (G) fusion – 90,9% (20/22) of the specimens had a conjoint tendon of the AB and gracilis and 81.8% (18/22) of the specimens had a bilateral fusion of the AB and G (Table 1; Fig. 3). The prevalence of the AB/G conjoint tendon is 90.9 [72.2 – 97.5] % (with 95% Wilson confidence intervals). Both the AB and the G arise from the ridge of the bone of the ventral arc of the pubic symphysis, AB from the middle/inferior border and G from the inferior border. The

DISCUSSION

This study reveals new insights into the proximal attachments and fusions of the AL, AB and G, which may be relevant to the pathogenesis, diagnosis and treatment of pubic related groin pathology. Over the years, some research has been done on the anatomy surrounding the symphysis pubis. The subject of these studies mostly concerned the distal attachment of the abdominal muscles and the proximal attachment of the adductors. For centuries, the concept that the AL is connected with the RA via an

CONCLUSION

This anatomical study described novel observations of the proximal attachments of the AL, AB and G at the pubic symphysis. The presence of three types of conjoint tendons was found: AB/G fusion, AB/AL fusion, and AL/G fusion. The prevalence of each conjoint tendon was calculated. There were significantly more AB/G conjoint tendons. All the musculotendinous attachments at the pubic ligaments were mapped. The APL had a large surface area were multiple tendons (RA, AL, AB and G) will attach. Only

Ethical statement

This submitted manuscript has been prepared in full accordance with the ethical statement letter of Elsevier.

To the best of our knowledge, the authors have no conflict of interest, financial or otherwise.

CRediT authorship contribution statement

Emile Schacht: Data curation, Project administration. Benjamin De Vlam: Data curation, Project administration. Levi Van Winckel: Data curation, Project administration. Lenie Denteneer: Conceptualization, Supervision, Validation. Luc Van Nassauw: Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing. Francis Van Glabbeek: Conceptualization, Data curation, Methodology, Supervision, Validation, Writing – review & editing. Thomas Mathieu:

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors wish to sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research will potentially improve patient care and increase mankind's overall knowledge. Therefore, these donors and their families deserve our highest gratitude. The authors also wish to thank David Malan of the department ASTARC for his skillful assistance during cadaveric dissections.

REFERENCES (27)T. Mathieu et al.New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: A systematic review

Ann Anat

(2022)

P. Pieroh et al.The topography and morphometrics of the pubic ligaments

Ann Anat. Jul

(2021)

I. Becker et al.The adult human pubic symphysis: a systematic review

J. Anat.

(2010)

L. Budinoff et al.

Anatomical and developmental bases for the ventral arc of the human pubis. Am. J. Biol. Anthropol

(1990)

L.D. Brown et al.Interval estimation for a binomial proportion

Statistical Science

(2001)

C.A. Byrne et al.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)

A. CuttsShrinkage of muscle fibres during the fixation of cadaveric tissue

J Anat

(1988)

J.A. Davis et al.New insights into the proximal tendons of adductor longus, adductor brevis and gracilis

Br. J. Sports Med.

(2012)

R.M. DegenProximal Hamstring Injuries: Management of Tendinopathy and Avulsion Injuries

Curr Rev Musculoskelet Med

(2019)

J. Ekstrand et al.Epidemiology of muscle injuries in professional football (soccer)

Am. J. Sports Med.

(2011)

O. Elattar et al.Groin Injuries (Athletic Pubalgia) and Return to Play

Sports Health

(2016)

J.G. Gamble et al.The symphysis pubis

Anatomic and pathologic considerations. Clin. Orthop. Relat. Res.,

(1986)

M.N. Hébert-Blouin et al.Hilton's law revisited

Clin Anat

(2014)

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