Abstract
PurposeAdductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.MethodsA layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.ResultsThe pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.ConclusionThe study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.
Highlights
The symphyseal and perisymphyseal area has become of increasing interest for hip surgeons, sports physicians and radiologists dealing with hip impingement and complex pain syndromes of the inguinal/adductor and lower abdominal area
The aponeurosis anterior to the pyramidalis muscle and rectus abdominis is comprised of two layers (Fig. 3a, b)
A point of disagreement is the insertion of the internal tendon: some authors [15, 25] report it connects with the ligaments covering the symphysis pubis; our observations were that the internal tendon in males attaches to the fascia lata and gracilis and this is similar to findings of Schilders [27] and Schache [26]
Summary
The symphyseal and perisymphyseal area has become of increasing interest for hip surgeons, sports physicians and radiologists dealing with hip impingement and complex pain syndromes of the inguinal/adductor and lower abdominal area. Some studies suggest that a direct anatomical connection exists between the caudal rectus abdominis muscle and the proximal origin of the adductor longus [6, 14, 19, 20, 34]. It has been the first author’s clinical observation that athletes with traumatic adductor longus avulsions often present with associated unilateral abdominal pain and lower abdominal haematomas. When examined on MRI scans or intraoperatively, it is the first author’s experience that in such patients, it is the pyramidalis muscle, and not the rectus abdominis, that remains attached to the adductor longus preventing caudal and lateral retraction
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