Teaching Case

A 25-year-old male professional football player sought medical attention for the onset of severe groin pain the day after an important match, more intense on the right side. He denied having had any direct trauma or previous illness. Ultrasound (US) examination performed by the sports medicine doctor was reported negative. A Magnetic Resonance Imaging (MRI) of the pelvis was prescribed for the patient, referring to persistent pain.

On the coronal T2-weighted image, a linear hyperintensity is seen at the level of the pubic joint disc along the intra-articular space, representing the “physiologic cleft” (normal configuration) (Figures 1 and 2).

Linear hyperintensity on T2-weighted sequence can be appreciated along the right inferior (“secondary cleft sign”) margin of the right pubic ramus, representing tearing of the short adductor (gracilis, adductor brevis, pectineus) aponeurosis (Figures 1 and 2).

The exam also documents osteo-cartilaginous changes at the level of the pubic symphysis, mostly evident on the right side, due to repeated stress and microtraumas.

Groin injuries are among the most common and time-consuming injuries in football, accounting for 4–19% of all injuries, with an incidence of 0.2–2.1 injuries per 1000 hours of play in males [1].

While athletic pubalgia is the official medical term, the more commonly used name among patients is still “sports hernia”, also known as Gilmore’s hernia or Sportsman’s hernia. This term actually refers not to a hernia at all, since there is often no visible bulge, but rather a strain or tear in the soft tissue of the groin region, especially the aponeurosis or tendon insertions [2].

The Doha agreement meeting on terminology in groin pain in athletes aimed to clarify and categorise all possible causes of the pathology [3]. The consensus identified three major categories using a clinically-based taxonomy: A) defined clinical entities (adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain); B) hip-related groin pain; C) other musculoskeletal causes.

Groin injuries are historically considered challenging to diagnose and treat due to complex anatomy and subtle symptoms [4].

Ultrasound can be useful to rule out non-musculoskeletal causes (abdominal, gynaecological and urological conditions), and as a first screening. It can, in fact, be very useful in finding the site of the lesion, but good skill and experience are often required. Four areas should be investigated to check the four main sites of groin pain: the adductor point, iliopsoas, inguinal and pubic point.

If we cannot find the cause, but the patient still has pain, then an MRI is often required. A “secondary cleft sign” (involvement of the short adductor) or a “superior cleft sign” (involvement of the adductor longus or rectus-adductor aponeurosis) are very well demonstrated on T2-sequences and considered pathognomonic, unequivocally clarifying the cause of pain. Lesions most often involve only one aspect of the pubic ramus, but can exceptionally occur in both the two, as in the case of a combined cleft sign.

In some settings, a contrast injection symphysography is still performed. This shows a contrast leakage along the inferior or superior margin of the pubis ramus, or both, exactly as in MR imaging, but with a more invasive procedure and with potential side effects.

Therapeutic options may vary based on the level of sport practised. In the vast majority of cases, groin injuries are managed non-surgically with rest, lidocaine and physiotherapy. In some situations, surgical management may be required, especially in professional settings [5].

All patient data have been completely anonymised throughout the entire manuscript and related files.