New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: A systematic review

Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain

“…The inconsistency regarding the connection between the adductor longus and rectus abdominis has been debated for centuries, with several studies proposing diverse theories, including the idea that adductor longus was connected to the rectus abdominis via the aponeurotic plate (Becker et al 2010 ; Davis et al 2012 ; Pesquer et al 2015 ; Robertson et al 2009 ; Robinson et al 2007 ; Zoga et al 2010 ). However, diverse conflicting evidence exists in the literature, including the anastomosis between the adductor longus and the contralateral adductor longus and rectus abdominis (Norton-old et al 2013 ; Pesquer et al 2015 ); the connection between the internal tendon of the gracilis and rectus abdominis (Mathieu et al 2022 ; Schilders et al 2017 ); and the direct connection between the pyramidalis, anterior pubic ligament, and adductor longus (Schilders et al 2017 ). Regarding the attachment of adductor longus and the connection with rectus abdominis, the current study macroscopically and histologically demonstrated the different layers between the external oblique–adductor longus aponeurosis and rectus abdominis–pyramidalis–gracilis–adductor brevis aponeurosis, which corroborated the results of previous studies that refuted the existence of an aponeurotic plate between the adductor longus and rectus abdominis (De Maeseneer et al 2019 ; Pieroh et al 2021 ).…”

“…In contrast, our study observed that only the intermuscular aponeurotic component of the adductor brevis and gracilis formed the conjoined aponeurosis and attached to the proximal part of the inferior pubic ramus. Furthermore, some studies indicated that the lateral tendon of the rectus abdominis was attached to the superior border of the pubis, whereas the internal tendon was attached to the pubic symphysis, connecting to the fascia lata and gracilis (Mathieu et al 2022 ; Schilders et al 2017 ). However, our findings showed that the rectus abdominis–pyramidalis aponeurosis was attached to the pubic crest and connected to the gracilis–adductor brevis aponeurosis.…”

“…Groin pain is a common problem in orthopedic and sports medicine, as evidenced by epidemiological findings indicating that groin-related injuries account for 2–10% of athletic injuries, with a higher prevalence observed among males (de Sa et al 2016 ; Ekstrand et al 2011 ; Via et al 2019 ; Mathieu et al 2022 ). Sports requiring sudden changes in direction, including football, rugby, ice hockey, and tennis, can cause repeated stress on the pubic symphysis and supporting muscles, thereby leading to reduced mobility and loss of sports activity (Minnich et al 2011 ; Mosler et al 2018 ; Orchard 2015 ; Riff et al 2019 ; Saito et al 2021 ).…”

“…Preceding anatomical studies have proposed that the rectus abdominis connects to the adductor longus via the aponeurotic plate (Becker et al 2010 ; Mathieu et al 2022 ; Robertson et al 2009 ). However, the more recent anatomical concepts have revealed complex and diverse connections among the musculotendinous structures attaching to the pubis, including the gracilis, adductor brevis, adductor longus, rectus abdominis, and pyramidalis (Davis et al 2012 ; Norton-old et al 2013 ; Schilders et al 2017 ).…”

“…Based on anatomy textbook descriptions, the attachment of these tendons is typically described as every single structure attaching to the area on the anterior surface of the pubic body and pubic symphysis (Snell 2012 ; Standring 2016 ), regardless of individual tendon connections and characteristics of their conjoined attachments. Thus, the precise anatomical relationship between these tendons as well as the attachment site on the pubis remain inconclusive (Davis et al 2012 ; De Maeseneer et al 2019 ; Mathieu et al 2022 ; Pesquer et al 2015 ; Riff et al 2019 ; Schilders et al 2017 ), and the bone morphology of the attachment site is not yet understood.…”