Professor Rowena Johnson

Dual-energy X-ray absorptiometry (DXA) is an established method for osteoporosis screening and treatment monitoring, providing results that predict fracture risk. DXA is used not only to measure bone mineral density (BMD) in various anatomic sites, but also to perform vertebral fracture analysis, trabecular bone score (TBS) determination, and whole-body composition analysis. While DXA is central in osteoporosis screening, the test has limitations, and other factors beyond BMD measurements must be considered when planning treatments and follow-up strategies. For example, sex, race and ethnicity, prior fragility fractures, glucocorticoid use, and prior falls, all affect fracture risk. Despite a growing population of older individuals and growing evidence of variations in fracture risk, osteoporosis screening recommendations have not evolved significantly. Moreover, despite existence of screening recommendations, DXA remains underutilized, and osteoporosis underdiagnosed. This AJR Expert Panel Narrative Review discusses the current status of osteoporosis screening by DXA, addressing current practice recommendations, use of BMD results to guide risk predictions and management decisions, as well as challenges and limitations along with evolving solutions. Topics explored include DXA reporting and screening recommendations; fragility fracture risk assessment tools; role of TBS; race, ethnicity, and sex considerations; application in children; and CT-based BMD measurements and opportunistic screening.

PURPOSE: Chronic pain can affect up to 40% of patients after ankle inversion sprains. The current hypothesis to explain this high percentage of chronic pain is a partial/total rupture of anterior talofibular ligament (ATFL) superior fascicle, a structure that has recently been described as intra-articular and as having a different function than ATFL's inferior fascicle. This has created the need for diagnosing ATFL superior and inferior fascicles independently. Therefore, the objective of this study is to investigate if the ATFL's superior fascicle can be visualized on ultrasound, and to describe its ultrasonographic appearance. METHODS: Twenty fresh-frozen ankle specimens were used in this 4-phases study. First, the specimens were scanned on US to identify what was believed to be ATFL's superior fascicle. Second, ATFL's superior fascicle was sutured under direct arthroscopic vision. Next, the specimens were scanned on US to obtain an image of the sutured structure. Finally, the specimens were dissected to confirm that the suture was indeed placed on ATFL's superior fascicle. RESULTS: On the 20 specimens studied, full correlation was obtained between US, arthroscopic suture and specimen dissection. ATFL's superior fascicle US appearance is provided. CONCLUSION: ATFL's superior fascicle can be visualized on US, which will allow to undergo diagnosis of isolated injuries to that fascicle, a common finding in ankle microinstability. The results of this study will facilitate the diagnosis of partial or complete rupture of ATFL's superior fascicle, likely increasing the amount of ankle microinstability diagnosis, impacting clinical management of ankle sprain consequences.

Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention. In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report. We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment. © The Author(s) 2021.

This article covers the use of radiographs and MR imaging for diagnosing elbow disorders. It concentrates on these techniques, but other imaging techniques including computed tomography, ultrasound, and nuclear medicine are discussed when clinically important. The article covers the use of imaging for specific symptoms including lateral, medial, anterior, posterior and generalized elbow pain, focal swelling, restriction of movement, locking, and neurologic symptoms. Radiographs have been the mainstay of initial imaging of the elbow, while ultrasound examination is often used for soft tissue disease. MR imaging has the advantage over radiographs and ultrasound in accurately examining bone and soft tissue together. © 2019

Morton’s neuroma is a commonly encountered cause of forefoot pain, which may limit weight-bearing activities and footwear choices. Although the aetiology and pathomechanism of this condition is controversial, the histological endpoint is well established as benign perineural fibrosis of a common plantar digital nerve, typically within the third intermetatarsal space. The diagnosis of Morton’s neuroma is mainly based on characteristic symptoms and clinical findings, but may be confirmed by ultrasonography. Although ultrasound is a highly accurate diagnostic tool for Morton’s neuroma, it is subject to interoperator variability due to differences in technique and level of experience. In this paper, the authors review the anatomy of the common plantar digital nerves and surrounding structures in the forefoot, which are deemed relevant to the understanding of Morton’s neuroma, especially from a sonographic point of view. Several theories of the pathomechanism of Morton’s neuroma are briefly discussed. The main purpose of this article is to illustrate the ultrasound techniques for evaluating Morton’s neuroma and performing ultrasound-guided corticosteroid injections. © 2020 The Royal College of Radiologists

Objectives: An imaging classification for pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) injuries has been described. The study objective is to assess intra- & inter-observer agreement to diagnose and classify PLAC injuries with MRI, and assess the correlation with surgical findings. Methods: Retrospective study approved by our institution’s Research & Ethics Committee. The PLAC injury database was interrogated for the following inclusion criteria: - Acute post-traumatic PLAC injury - Dedicated MRI groin protocol - Surgical PLAC repair, between 2017-2020 2 experienced musculoskeletal radiologists (A&B) blinded for demographic & clinical data, scored the scans twice with a 6-week interval. The MRIs were scored for: type of PLAC injury (1-5), presence of pyramidalis, continuity or separation of pyramidalis -adductor longus connection, avulsion of the adductor longus (AL) fibrocartilage (FC), tear of the inguinal ligament (IL), injury to the pectineus. The surgical notes were scored by the same criteria. MRI classification of the different types of PLAC injuries Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Schilders E., Mitchell, A., Johnson, R., Dimitrakopoulou A., Kartsonaki C., Lee, J. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surg Sports Traumatol Arthrosc 29, 2424–2436 (2021). https://doi.org/10.1007/s00167-020-06180-5 Statistical method: Cohen’s weighted & unweighted Kappa were used to calculate intra- & inter-rater agreement for scoring the MRI & to calculate agreement between each radiologist with the surgical findings. A kappa score of 0.61-0.80 is substantial agreement, a score of 0.81-1.00 almost perfect agreement. Results: 80 athletes fulfilled the criteria Main sports were football 36(45.05%) & rugby 21(26.2%) 50 (64.95%) Professional athletes 26 (53.1%) competed in the premier league 45 (56.2%) Right sided injuries & 35 (43.8%) left sided with 50 (79.4%) of the athletes right foot dominant The surgical observations were: The pyramidalis muscle was present in 76 cases (95%), the AL was separated from the pyramidalis / anterior pubic ligament in 44 cases (55.0%) & in continuity in 35 cases (43.8%). All athletes had a full thickness AL FC avulsion. The FC was displaced in 55 (68.8%) & in situ in 25 (31.2%). An IL injury was found in 41 (51.2%) athletes & a partial pectineus avulsion in 39 (48.8%). Scoring the PLAC injury type: the intra-observer estimated weighted Kappa score for scorer A was 1, unweighted score 1, estimated weighted Kappa score for scorer B was 1.00 & unweighted Kappa score was 0.98. The interobserver estimated weighted Kappa score was 0.98, unweighted Kappa score 0.98 for first scoring of the type of PLAC injury on MRI. Interobserver agreement between scorer A & B for the criteria scored on MRI Interobserver Agreement Kappa Unweighted Kappa Weighted lower estimate upper lower estimate upper Type of PLAC 0.95 0.98 1 0.98 0.98 0.98 Pyramidalis 1 1 1 1 1 1 Pyramidalis oedema 0.74 0.85 0.96 0.73 0.73 0.73 Pyramidalis- Adductor Longus separation 1 1 1 1 1 1 Partial/ complete separation 0.9 0.96 1 0.9 0.9 0.9 Inguinal ligament injury 0.75 0.87 0.98 0.75 0.87 0.98 Partial pectineus avulsion 1 1 1 1 1 1 The comparison of the PLAC type on MRI with surgical findings were: Scorer A: estimated weighted Kappa score of 0.96 & unweighted score of 0.90 Scorer B: estimated weighted Kappa score of 0.98 & unweighted score of 0.92 Conclusions: This is the first study looking at the correlation between MRI and surgical findings in AL/ PLAC injuries. The study demonstrates almost perfect intra- & inter-observer agreement in classifying the type of PLAC injury, and excellent correlation between the MRI findings and surgical findings. A dedicated MRI groin is a reliable method to accurately diagnose and classify PLAC injuries, and aid surgical planning.

The worldwide rise in popularity of climbing and development of climbing as a competitive sport is reflected by its debut at the 2021 Summer Olympic Games in Tokyo. Digital primary periphyseal stress injuries in adolescent climbers may pose a significant risk to long-term skeletal health. The aim of this article is to critically review research on the diagnosis and management of primary periphyseal stress injuries of the fingers in adolescent climbers. We adopted a systematic approach to searching for relevant literature. Articles were identified after searches of the following electronic databases: Discover, Academic Search Complete, PubMed, Embase, SPORTDiscus, and ScienceDirect. Conclusive evidence suggests digital primary periphyseal stress injuries are a consequence of repetitive microtrauma. Pain reported by adolescent climbers on the dorsal aspect of the proximal interphalangeal joint should be investigated promptly to avoid serious negative consequences. Clinicians should be aware of the efficacy of imaging techniques to inform a clinical diagnosis. A conservative management approach is preferred but in rare cases surgical intervention may be necessary. A diagnostic and therapeutic algorithm for digital primary periphyseal stress injuries is presented.

Objectives: Proximal adductor longus avulsions and pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) injuries are reported uniquely in male athletes and appear underreported in female athletes. The aim of the study is to investigate potential variations in the symphyseal anatomy between males and females which could account for the difference in occurrence of PLAC injuries, and aid MRI image interpretation. Methods: Approval was obtained from our institution’s Local Research and Ethics Committee. A layered dissection of the soft tissues of the anterior symphyseal area was performed on six female and eight male fresh-frozen cadavers to systematically investigate anatomical structures of the anterior pubic area, namely the pyramidalis muscles and the rectus abdominis, and their anatomical relationship with the adductor longus. The ratio between the internal tendon (IT) and total width (TW) of the rectus abdominis was calculated independently by 2 observers. The level of agreement between the observers was measured using the Bland and Altman method. Results: A PLAC was found in all specimens. The rectus abdominis was found to have both an external and internal tendon in 100% of the male and 66.6 % of the female cadavers. The mean IT/TW ratio was 40.1% (25.8%-59.2%) in males and 38.0% (31.6%-48.9%) in females. The small bias of -0.17%, as shown by the mean of differences between the two scorers’ percentages was not significant (paired t test, P>0.05). In males the internal tendon of rectus abdominis decussates with the contralateral tendon and runs deep to the anterior pubic ligament, to insert caudally. In females the internal tendon of the rectus abdominis tendon, when present, by contrast inserts cranial to the deep portion of the anterior pubic ligament, caudally to the pelvic ridge. It does not interlace with the internal tendon from the contralateral side. Female anterior symphyseal anatomy (Pyramidalis removed) Male anterior symphyseal anatomy (Pyramidalis removed) Conclusions: The PLAC is present in both males and females and therefore does not account for the difference in occurrence of proximal adductor avulsions. When present, the relative width of the internal tendon of the rectus abdominis is similar for both genders. However, in males the internal tendon runs deep to the anterior pubic ligament forming a pulley system. With abduction and extension of the leg, the internal tendon can cause a disruption of the anterior pubic ligament and adductor longus fibrocartilage which can account for the higher incidence of adductor avulsions/ PLAC injuries in male athletes. The absence of this pulley system in women and the parallel orientation of the internal tendons of the rectus abdominis is protective against PLAC injuries, and also allows widening of the pubic symphysis during pregnancy and childbirth.

Purpose The purpose of the study is to review the MRI findings in a cohort of athletes who sustained acute traumatic avulsions of the adductor longus fibrocartilaginous entheses, and to investigate related injuries namely the pyramidalis- anterior pubic ligament - adductor longus complex (PLAC). Associated muscle and soft tissue injuries were also assessed. Methods The MRIs were reviewed for a partial or complete avulsion of the adductor longus fibrocartilage, as well as continuity or separation of the adductor longus from the pyramidalis. The presence of a concurrent partial pectineus tear was noted. Demographic data was analysed. Linear and logistic regression was used to examine associations between injuries. Results The mean age was 32.5 (SD 10.9). The pyramidalis was absent in 3 of 145 patients. 85 of 145 athletes were professional and 52 competed in the football Premier League. 132 had complete avulsions and 13 partial. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. Six types of PLAC injuries patterns were identified. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%). Conclusion The proximal adductor longus forms part of the PLAC and is rarely an isolated injury. The term PLAC injury is more appropriate term. MRI imaging should assess all the anatomical components of the PLAC post-injury, allowing recognition of the differentpatterns of injury.

Currently there is no consensus on the most appropriate management of Adductor Longus Avulsions and selection of athletes for operative or non-operative treatment. An MRI study identified 6 types of injury to the Pyramidalis-Anterior Pubic Ligament- Adductor Longus Complex (PLAC) following Adductor Longus Avulsions, often associated with partial Pectineus Avulsions. Alternate hypothesis: the distribution of PLAC injuries associated with Adductor Avulsions is different in athletes with failed conservative treatment compared to athletes with successful conservative or surgical treatment. Methods The PLAC injury database was examined at our institution for the following inclusion criteria: High level or Professional Athletes, PLAC injury score type 1-6 (Table 1), with further division into: Group A: Failure of non-operative treatment (> 44 days after index injury), completion of structured rehabilitation program Group B: Successful non-operative or surgical treatment (<20 days of the index injury). Hypotheses were tested using Chi-square, effect size Cramer’s V and post hoc cell differences using Bonferroni adjustment (p< 0.004). Results: Group A (n=120), Group B (n=109) Most common PLAC types found in group A were type 3 and 6 (Table1), n=39 (33%) and n=40 (33%) respectively. Most common types found in group B were type 1 and 3, n=37 (34%) and n=21 (19%) respectively. Overall, PLAC type distribution and groups were dependent (X2 (5, 229) = 26, p = 0.00009; moderate effect size (Cramer’s V = 0.304)). The variation between frequency of type 1 and 6 injuries between the groups reflected the significant cell differences between observed and expected values (p=0.0002 and p=0.0001 respectively). Conclusion Variability exists in PLAC injury patterns between athletes who had successful conservative or surgical management compared to athletes who had failed conservative treatment. This original study can help to select the appropriate treatment for PLAC injuries associated with Adductor Avulsions. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1: Types of PLAC injuries Type 1 2 3 4 5 6 Group A 120 16 (13%) 16 (13%) 39 (33%) 6 (5%) 3 (3%) 40 (33%) Group B 82+27 30 +7 (34%) 18 +1 (18%) 15+6 (19%) 8+1 (8%) 5+2 (6%) 6+10 (15%) Table 2: Distribution of PLAC injury types between Group A (failed non-operative treatment) and Group B (successful surgical or non-operative treatment)

The Anterior Pubic ligament spans the Symphyseal joint and forms part of the Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC). A recent MRI study demonstrated that anterior Pubic ligament (APL) tears of the bridging part are often associated with PLAC injuries and Pectineus injuries. No cases have previously been reported of isolated APL tears in professional football. The aim of this study is to desccribe this new entity, detail the clinical symptoms and MRI findings. Material and Methods Our PLAC database was interrogated for APL tears. Adductor Longus avulsions, partial or complete, were excluded. Demographics, type of sport and level were recorded. The mechanism of injury, clinical presentation and MRI findings were evaluated. All athletes in our clinic presenting with acute groin pain are imaged using a specific MRI protocol. Results Four professional Football players fulfilled the inclusion criteria (average age 24 years (21-28)). Injury occurred when two players did the splits and two were taking a penalty. All players felt a pop and developed severe immediate pubic related groin pain. None of the players could continue playing. Clinically there was exquisite pain on palpation of the Symphyseal joint. One player had a feeling of unstable pubic bones. All had reduced adductor strength bilaterally (Table 1). The MRI showed a typical APL ligament tear where it bridges the Symphyseal joint (Figure 1). Three of the four players had previous MRI imaging which did not demonstrate the APL tear. Time between injury and diagnosis was 28-388 days. Conclusion Isolated APL tears are a newly reported cause of Pubic-related groin pain. Players who feel a pop and develop severe post traumatic Pubic pain should routinely have a dedicated MRI groin protocol. Axial oblique images through the Symphyseal area, thinly sliced, are essential to diagnose this condition which is easily missed with incorrect MRI protocols. Age injury mechanism Pain location ADD R ABD R ADD L ABD L ADD/ABD R ADD/ABD L 28 split Pubis/Perineal 13 36 11 30 0.36 0.36 25 split Pubis/Adductor 19 33 21 27 0.57 0.77 25 Penalty kick Pubis/Adductor 12 18 15 23 0.66 0.65 21 Penalty kick Pubis/Adductor 26 34 27 33 0.76 0.82 Table 1: Clinical presentation of anterior pubic ligament tear. Strength measurements of Adductors and Abductors in pounds (Microfet) and as a ratio (ADD = adduction; ABD = abduction). Figure 1: T2 axial oblique: yellow arrow demonstrates anterior pubic ligament tear.

Introduction and Purpose A recent MRI study defined the different types of PLAC injuries (Table 1) and noted that Adductor Longus Avulsions are seldom isolated, being most commonly associated with injuries to the Pyramidalis and Pectineus. Mechanisms of injury of the Adductor Longus and PLAC differ between different sports. The aim of the study was to examine the hypothesis that the prevalence of the type of PLAC injury is dependent on the type of sport. Materials and Methods Retrospective study. The PLAC injury database in our institution was interrogated using the following inclusion criteria: acute post traumatic PLAC injury; PLAC injury score (type 1-6); type of sport, n>3 per sport. The distribution of PLAC injury types across sports was examined alongside the incidence of associated partial Pectineus tears. Hypotheses were tested using Chi-square test, effect size using Cramer’s V. Results 257 athletes fulfilled the inclusion criteria. The experimental hypothesis, that the type of PLAC injury is dependent on the type of sport is accepted and is significant across all sports. (X2 (30, 257) = 63.7 (LR), p = 0.0003; small effect size (Cramer’s V = 0.232)). Football (n=188, 73%) with (n=128, 50%) professional, Rugby (n=43, 17%), Racket sports (n=11, 4%), professional Ice Hockey (n=5, 2%), Martial Arts (n=6, 2%), Water Skiing (n=4, 2%). The occurrence of a partial Pectineus Avulsion is also significant across all sports (X2 (3, 192) = 10.2, p = 0.017;small effect size (Cramer’s V = 0.230)). Associated Pectineus Avulsions were: Football (24%), Rugby (44%), Martial Arts and Water Skiing (100%). Conclusion The study confirms different PLAC injury patterns across different sports, including a considerable variation in the prevalence of associated Pectineus injuries. This is clinically relevant and important knowledge to facilitate accurate MRI assessment of these injuries, and appropriate planning of surgical treatment. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1: Types of PLAC injuries PLAC TYPE Total Football Professional Football Rugby Racket Sports Ice Hockey Martial Arts Water Skiing Type 1 67(25) 8(14) 40(31) 12(28) 7(64) 0 0 0 Type 2 45(18) 12(20) 19(15) 7(16) 0 0 4(66) 3(75) Type 3 63 (24) 15(25) 36(28) 8(19) 2(18) 2(40) 0 0 Type 4 21 (8) 2(3) 9(7) 7(16) 0 1(20) 1(17) 1(25) Type 5 9(4) 1(2) 2(2) 5(12) 0 0 1(17) 0 Type 6 52 (21) 22(36) 22(17) 4(9) 2(18) 2(40) 0 0 Total 257 60 128 43 11 5 6 4 Table 2: Frequency of PLAC type by sport (integers in brackets are percentages)

Introduction and Purpose An imaging classification for Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC) injuries has recently been described. The objective of this study was to assess intra-and inter-observer agreement on MRI PLAC injury classification and make comparisons with surgical findings. Methods: Retrospective study The PLAC injury database in our institution was interrogated using the following inclusion criteria: Acute post-traumatic PLAC injury, dedicated MRI protocol, complete Adductor Longus (AL) Avulsion, surgical PLAC repair 2017-2020. Two expert musculoskeletal radiologists, blinded for demographic and clinical data, scored the MRI scans twice in a 6-week interval. Both MRI and surgical findings were scored for type of PLAC injury (1-5), injury to Pectineus and Lacunar Ligament (LL). Cohen’s weighted and unweighted Kappa were used to calculate intra- and inter-rater agreement for scoring the MRI scan and to calculate agreement between each radiologist with the surgical findings. Results: 80 athletes fulfilled the inclusion criteria. Main sports were Football (n=36, 45%), Rugby (n=21, 26%), Other (n=23, 29%). Surgical findings: The Pyramidalis was present in (n=76, 95%). AL was separated from Pyramidalis (n=44, 55.0%), in continuity (n=35, 43.8%). The AL was displaced in (n=55, 68.8%) and in situ in (n=25, 31.2%). LL injury (n=41, 51.2%). Partial Pectineus Avulsion (n=39, 48.8%). Scoring PLAC injury type, the intraobserver weighted Kappa score was 1 for both radiologists, the interobserver weighted Kappa score 0.98. The weighted Kappa score for MRI/Surgical correlation for PLAC injury type was 0.96 for first scorer and 0.98 for the second. Conclusion This original study established excellent correlations between MRI and surgical findings in AL/PLAC injuries. There was an almost perfect intra- and inter-observer agreement on the PLAC injury type diagnosis. A dedicated MRI groin study protocol is a reliable method to accurately diagnose PLAC injury, assess the different anatomical structures and facilitate effective planning for surgical treatment. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1 Types of PLAC injuries Interobserver agreement Kappa unweighted Kappa weighted lower estimate upper lower estimate upper Type of PLAC 0.95 0.98 1.00 0.98 0.98 0.98 Pyramidalis 1 1 1 1 1 1 Pyramidalis oedema 0.74 0.85 0.96 0.73 0.73 0.73 Pyramidalis-AL separation 1 1 1 1 1 1 Partially/complete 0.9 0.96 1.0 0.9 0.9 0.9 Lacunar ligament injury 0.75 0.87 0.98 0.75 0.87 0.98 Partial pectineus avulsion 1 1 1 1 1 1 Table 2: interobserver agreement between radiologist for the first score

Introduction and purpose: To date, Proximal Adductor Longus Avulsions and Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC) injuries are reported uniquely in male athletes. This study compared the Symphyseal anatomy of males and females to establish whether anatomical variations could account for the observed sex difference in occurrence of PLAC injuries, and aid MRI image interpretation. Methods: The anterior Symphyseal area was systematically dissected in six female and eight male fresh-frozen cadavers to examine PLAC and Rectus Abdominis (RA), and their anatomical relationship. The level of agreement for the observers was measured using the Bland and Altman method. Results: A PLAC was found in all specimens. The RA was found to have both an external and internal tendon (IT) in 100% of male and 66.6 % of female cadavers. The small bias of -0.17% + 3.58% in the mean of differences in the percentage width of the total RA insertion between the two scorers was not significant (paired t test, P>0.05). In males the IT of RA decussates with the contralateral tendon and runs deep to the Anterior Pubic ligament (APL), to insert caudally. In females the IT of the RA tendon, when present, by contrast inserts cranial to the deep portion of the APL, and does not interlace with the IT from the contralateral side (Figure 1 and 2). Conclusions: The PLAC is present in both sexes and therefore does not account for the difference in occurrence of proximal adductor avulsions. However, in males the IT runs deep to the APL forming a pulley system which can be disrupted with forced abduction of the leg. The absence of this pulley system in women and the parallel orientation of the internal tendons of the RA is protective against PLAC injuries, and allows widening of the pubic symphysis during pregnancy and childbirth.

Background: Adductor avulsions are complex injuries often involving multiple structures, as indicated by several magnetic resonance imaging (MRI) studies. However, no studies have compared MRI assessments using a dedicated groin protocol with surgical findings. Hypothesis: It was hypothesized that MRI assessments using a dedicated groin protocol would correlate closely with surgical findings, applicable to both experienced and novice users of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC) classification. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study analyzed 161 athletes who underwent MRI using a dedicated groin protocol, followed by surgical repair of the PLAC. Two musculoskeletal radiologists—1 experienced (rater A) and 1 inexperienced (rater B) in the use of the PLAC classification—independently assessed the MRI scans twice, 6 weeks apart, using a structured 3-step protocol to evaluate (1) adductor longus fibrocartilage (intact, partially avulsed, or completely avulsed), (2) pyramidalis separation from adductor longus (intact, partially separated, or completely separated), and (3) pectineus status (intact or partially avulsed). Agreement between MRI and surgical findings was evaluated using a PLAC injury classification (types 1-5), with intra- and interobserver reliability measured by Cohen kappa. Results: Among the 161 athletes, 93 played soccer, of whom 69 were professional. All athletes exhibited complete fibrocartilage avulsion, with 83 athletes (52%) showing adductor longus separation from the pyramidalis. Isolated adductor longus avulsions (PLAC type 1) were observed in only 36 athletes (22%). The interobserver kappa score between MRI assessments and surgical findings was 0.942 for rater A and 0.858 for rater B. Intraobserver ratings were 0.967 for rater A and 0.875 for rater B. Both inter- and intraobserver scores indicated almost perfect agreement. In combination, these statistical findings support the validity, reliability, and applicability of the MRI protocol using the PLAC classification system for 2 users with varying levels of experience. Conclusion: Adductor avulsions were rarely isolated, typically involving multiple muscles. The PLAC classification effectively captured the complexity of these injuries. When used in conjunction with a dedicated MRI protocol, the PLAC classification demonstrated almost perfect agreement and concordance with surgical findings. Together, the PLAC classification and MRI protocol offered a more comprehensive and accurate representation of patients’ clinical and radiological features and provided valuable guidance for surgical planning.