1
Imaging of the Pubic Symphysis: Anatomy and
Pathologic Conditions
Connie C. So, MD • Lillian S. Niakan, MD • Ricardo D. Garza-Gongora, MD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.
See the slide presentation here.
Knowledge of the anatomy of the pubic symphysis is import-
ant for understanding pathologic conditions of the joint. Un-
recognized pathologic conditions of the pubic symphysis can
lead to anterior pelvic instability and cause inguinal pain. The
anatomy includes the pubic bone landmarks, pubic symphy-
seal joint, pubic ligaments, and surrounding myotendinous at-
tachments. The pubic crest, pubic tubercle, and pectineal line
are bone landmarks, which are identifiable on radiographs and
can help predict locations of soft-tissue attachments. The pubic
symphyseal joint is structurally classified as a secondary carti-
laginous joint (composed of fibrocartilage and found at the skel-
etal midline) and is functionally classified as an amphiarthrosis
(permitting a small amount of movement). The joint consists of
a wedge-shaped fibrocartilaginous disk lying between the hya-
line cartilage–lined surfaces of the pubic bones (Fig 1).
The shape of the bones differs with age owing to apoph-
yses at the symphyseal margins. Awareness of apophyses
averts misdiagnosis as avulsion fractures in younger patients.
In adulthood, the bones at the symphyseal margins are usu-
ally parallel, but apophyseal injury may cause the adolescent
configuration to persist.
MUSCULOSKELETAL IMAGING
©
RSNA, 2023
RADIOGRAPHICS FUNDAMENTALS
The ligaments surrounding the pubic symphysis are the
anterior, posterior, superior, and inferior pubic ligaments, of
which the anterior and inferior pubic ligaments blend with the
fibrocartilaginous disk and provide stability. Myotendinous at-
tachments also contribute to anterior pelvic stability, of which
the rectus abdominis, adductor longus, and rectus abdominis–
adductor longus (RA-AL) aponeurosis are the most important
(Fig 2). The rectus abdominis and adductor longus act as antag-
onists. Injury to one alters the dynamic balance across the pu-
bis and commonly extends to involve the RA-AL aponeurosis,
such as in athletic pubalgia.
Various pathologic conditions of the pubic symphysis ex-
ist. In acute trauma or postpartum symphyseal injury, pubic
diastasis can occur and is diagnosed as separation of the pu-
bic symphysis by more than 10 mm without accompanying
pubic fracture. In patients with osteoporosis, parasymphyseal
insufficiency fractures tend to orient parallel to the symphy-
sis. Misdiagnosis can occur owing to an irregular appearance,
but an ipsilateral sacral or contralateral pubic ramus stress
fracture helps establish the correct diagnosis. Athletic pubal-
gia is a general term for myotendinous or osseous injury of
Figure 1. Anterior view illustration of the
pubic symphyseal joint shows the fibrocartilag-
inous disk (white) situated between the hyaline
cartilage (light blue) lining the pubic bones.
During growth, apophyseal cartilage under-
goes enchondral ossification with irregular
islands resulting in small subchondral ridges
along the pubic bones. Alternating ridges
and grooves may help protect against vertical
shearing forces. A small fluid-filled cleft, the
primary cleft, is seen in the posterosuperior
portion of the disk in approximately 10% of
adults and is believed to occur during develop-
ment due to weight-bearing forces.
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February 2023 So et al 2

RadioGraphics 2023; 43(2):e220058

https://doi.org/10.1148/rg.220058
Slide Presentation Content Codes: CT, MK
Abbreviation: RA-AL = rectus abdominis–adductor
longus
TEACHING POINTS
„ The pubic symphysis is a secondary cartilaginous joint, with a fibrocartilag-
inous disk lying between hyaline cartilage–lined pubic bones. The anterior
and inferior pubic ligaments blend with the disk and provide stability.
„ The rectus abdominis and adductor longus are the most important muscles
for maintaining anterior pelvic stability and counterbalance each other via
their aponeurosis.
„ Various pathologic conditions of the pubic symphysis can lead to anterior
pelvic instability and cause inguinal pain.
understanding of the pubic symphysis is fundamental for ac-
curate image reporting and enhanced patient care. The pubic
symphysis is integral to anterior pelvic stability, and a high-
yield review of the anatomy and pathologic conditions of the
pubic symphysis can better equip the radiologist when evalu-
ating inguinal pain.
Author affiliations.—From the Musculoskeletal Section, Department of Ra-
diology, Baylor Scott & White Medical Center, 2401 S 31st St, Temple, TX
76508. Presented as an education exhibit at the 2021 RSNA Annual Meet-
ing. Received March 20, 2022; revision requested April 14 and received
April 27; accepted May 3. Address correspondence to C.C.S. (email:
Connie.So@bswhealth.org).
Acknowledgment.—The authors acknowledge the artwork collaboration by
Bryan D. Moss, AAS, and Connie C. So, MD.

Disclosures of conflicts of interest.—All authors have disclosed no relevant

the pubic symphysis occurring during athletic activities, es-
pecially soccer, ice hockey, and American football. Osteitis
pubis is noninfectious inflammation of the pubic symphysis
and should be distinguished from osteomyelitis, with the lat-
ter typically having more profound bone marrow edema and
soft-tissue fluid. The pubic symphysis may also be affected by
degenerative disease, metabolic bone disease, chondrocalci-
nosis, seronegative spondyloarthropathy, and rheumatoid
arthritis. Parasymphyseal tumors include metastatic disease,
multiple myeloma, and primary malignancies such as chon-
drosarcoma, osteosarcoma, and fibrosarcoma.
In this slide presentation, we review the anatomy and patho-
logic conditions of the pubic symphysis. Having a thorough
relationships.
Suggested Readings
Gibbon WW, Hession PR. Diseases of the pubis and pubic symphysis: MR
imaging appearances. AJR Am J Roentgenol 1997;169(3):849–853.
Koulouris G. Imaging review of groin pain in elite athletes: an anatomic ap-
proach to imaging findings. AJR Am J Roentgenol 2008;191(4):962–972.
O’Connell MJ, Powell T, McCaffrey NM, O’Connell D, Eustace SJ. Symph-
yseal cleft injection in the diagnosis and treatment of osteitis pubis in
athletes. AJR Am J Roentgenol 2002;179(4):955–959.
Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and “sports
hernia”: optimal MR imaging technique and findings. RadioGraphics
2008;28(5):1415–1438.
Vix VA, Ryu CY. The adult symphysis pubis: normal and abnormal. Am J
Roentgenol Radium Ther Nucl Med 1971;112(3):517–525.

Figure 2. Anterior view illustration shows the myotendinous attachments surrounding the pubic symphysis, with the muscles shown
on the left and their attachments shown on the right. Emphasized with asterisks, the rectus abdominis (red) and adductor longus (dark
blue) are the most important muscles for maintaining anterior pelvic stability via their aponeurosis (black zigzag). Paired adductor longus
tendons merge across the midline, which has been described as a “moustache” configuration. In the sagittal plane (rotated rectangular
cutout on the right), the counterbalance of the rectus abdominis and adductor longus is depicted. A = anterior, L = lateral head of rectus
abdominis, M = medial head of rectus abdominis, P = posterior.

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