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<v ->This is a 24-year-old professional athlete.

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Who's actually functionally impaired

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and that he cannot generate any abdominal force

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with a leg drive and has groin pain and pain with abduction.

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Now, when I think about adduction syndromes,

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I go right to the symphysis pubis and to the adductors,

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the adductor longus, especially.

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But bear in mind,

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there are a number of adductor and groin syndromes,

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but especially adductor syndromes.

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You could have tendinopathy

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of the adductor longus or brevis.

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You could have muscular atrophy,

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the generation, calcific tendonitis.

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You could even have involvement of the surrounding

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adjacent adductor muscles,

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including the pectineus, which is less common.

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I've seen periosteal ossification from prior injuries,

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impaired adduction,

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and then you can get this entity known as

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baseball pitcher-hockey goalie groin

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in which the abductor is housed in a sheath.

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So here's the sheath.

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The inductor is inside it,

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and it's almost like a muscular hernia.

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In fact, it is a form of muscular hernia

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where the abductor may prolapse through that sheath.

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So you've gotta be on the lookout

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for some of these really weird subtle entities.

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Now, I'm gonna to start you out this time

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with a series of sagittals.

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I've got a sagittal T1 on the left.

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In the middle,

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I've got a sagittal T2 with a bit of fat suppression.

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On the right, I have a very heavily water-weighted image.

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And what I'm looking for on the sagittal is

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how the rectus comes down.

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And I will look at both sides.

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So, what I mean by that is I'm looking at the belly

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of the rectus for its size and its volume

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because frequently people that have sports hernia syndrome

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have a symmetry.

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They have an imbalance.

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And that imbalance, as we said in the cell analogy,

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can even extend over to the oblique.

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So I'm gonna inspect those in the coronal.

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But then I work my way down very carefully,

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and I look at the rectus distally,

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and it's prepubic component.

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And I'm looking for erosions and irregularity.

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Now, I don't necessarily see an erosion on T1,

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but I see a little bit of a irregularity

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in the anterior pubic bone.

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Is that enough?

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Well, I don't know yet.

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I'm gonna look for signs of inflammation, or separation,

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or a small clefs, and low and behold, not cartilage,

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eccentrically positioned along the inferior aspect

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and interior aspect of the pubis along the deep fibers

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of the prepubic plate is this area

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of high signal on T2, and oh yeah,

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it's there on the proton density, fat suppression image two.

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Now we wanna get a bit of corroboration here.

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So let's pull down our axial and our coronal.

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I'm gonna go up a little bit.

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Just looking at the pubic bone,

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you can see it's a little bit obliqued.

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So 24-year-old gentlemen, no, he wasn't born this way,

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he created it.

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He created this remodeling from stress, and from squatting,

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and from doing inverted leg presses.

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Let's ave a look at his Inguinal Canal

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while we're at it cause he has groin pain.

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You can see the medial and lateral walls on the right side,

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which is where his symptoms are, are okay.

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The roof is okay.

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But we'll keep an eye on that

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in the coronal projection and come back to it in a minute.

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Let's look at the prepubic plate.

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There's some subtle higher signal in the prepubic plate.

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But then let's go to something even more water-weighted.

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In the symphysis pubis, there's high signal intensity.

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In fact, too much high signal.

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That's typical of Athletic Pubalgia

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or so-called osteitis pubis,

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or premature arthrosis from overusing the pelvis.

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But those patients have pain, but not diminished function.

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The ones that have diminished function are

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the ones that have clefts at the origin of the adductors.

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And he's got it.

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Normal side, abnormal side.

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Let's make it bigger.

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There it is.

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That's the cleft side,

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right at the origin, along the under surface,

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which is tricky in the sagittal projection

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along the undersurface.

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And you also saw along the anterior surface,

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delamination of the lower prepubic plate

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and the right adductor longus.

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So a beautiful but subtle cleft sign.

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You've gotta keep searching and hunting and hunting.

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Now, are we done yet?

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No, because remember we've got a

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checklist of things we're looking for.

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We're looking for other other injuries

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that have occurred due to compensation by the patient.

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We're checking the contralateral side.

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we're checking the labor of the ligamentum Terry's,

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the hip, everything that's available to us

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that we think can present with groin pain.

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And as we keep scrolling on this patient,

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in the back, I'm looking at the sacrum,

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the sacriliac joints, the ilium, all the skeleton.

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And as I get a little bit forward,

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something else strikes me.

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Look at the asymmetry in the Inguinal Canal,

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inflamed on the right, compared with the left.

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This can produce irritation of the ilioinguinal nerve,

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which travels with it.

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And generalized inflammation could contribute,

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in this case, to the patient's groin pain.

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But the main finding, that micro cleft sign on the right,

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typical of classic adductor sports hernia syndrome.