Stephen Bird

Hi Linh,

The pubic aponeurosis certainly can tear and we see this with traction injuries mainly generated by adductor longus or rectus abdominus.

With the adductor longus tears or the pubic aponeurosis when you scan the adductor longus in ling axis you can see it separating from the undersurface of the pubic tubercle with a cleft developing. On MRI this is seen as a secondary cleft sign.

When rectus abdominus causes the tear we see this more anteriorly about half way between the central axis of the symphysis pubis and the lateral edge of the pubic tubercle. You see again a cleft forming and also bony change from the avulsion. It is usually asymmetrical which makes it easy to notice.

Apophyseal injuries in young athletes are quite different as this is a bony injury rather than an aponeurosis failure.

I don’t see conjoint tendon problems with mesh repairs particularly. Others may have a different opinion, however after a mesh repair I am more interested in neural entrapment from the fastening clips rather than conjoint tendon problems. The conjoint tendon is really just the pubic aponeurosis end of the posterior wall and after a mesh repair the posterior wall has been replaced / reinforced by mesh.

I use 2 techniques for increasing abdominal pressure.

The first technique I have the bed tilted at 45 degrees so it is comfortable for me to scan and also I have some gravitational pressure. I ask the patient to put their thumb on their lips and blow on it like they are blowing up a balloon. I can ask them to blow harder or softer so I can control the pressure.

The second technique is to do the same trick with the patient standing erect.
In the erect position it is technically difficult to scan and navigate, however you do have maximum pressure.

The combination of these 2 techniques covers all bases.


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