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<v ->I'd like to show you a clinical case now

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of a 30 year old soccer player with thigh and groin pain.

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But right before I do I wanna show you this sagittal image.

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And sagittal imaging not really part of mainstream MRI

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when you're evaluating people for hernias or sports hernias.

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For classic hernias, yes.

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But it is absolutely a critical sequence to have

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because this may be the only pulsing sequence

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and projection that you see the abnormality on.

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And it should be, as we'll see in a minute,

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a proton density fat suppression sequence,

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the most heavy water weighted sequence you can get

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or it should be an axial or axial oblique through this area

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with a small field of view

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again using heavy water weighting.

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So what are we actually looking for?

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In a healthy young individual,

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the rectus abdominis central bundle comes down

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and forms the prepubic plate.

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When you have pubic instability

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you start to delaminate the plate.

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So what you'll see is a very small

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thin area of hyper-intensity,

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oh, so subtle in the beginning

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a so-called cleft

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between the prepubic plate and the pubic bone.

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This cleft may have a longitudinal medial

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to lateral appearance in the axial projection.

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Let's have a look at our case.

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So here's our 30 year old soccer player

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and remember he's 30, look at his pubic synthesis.

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He's got an erosion,

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that hypo intensity on either side.

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No that's not red marrow that's edema

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or swelling in the bone from micro instability.

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There is your superior pubic ligament.

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There's your arcuate ligament.

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They're both still present and attached fortunately so,

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let's pull down his water weighted image

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and there's the edema that I promised you he had.

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We talked about in a prior vignette

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we don't like to see the capsule more than 10 millimeters

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of hyper intensity,

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top to bottom or front to back.

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The whole capsule is hyper intense

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and at the bottom

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it looks very irregular adjacent to these erosions.

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So he's torn his pubic capsule thus the micro instability.

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Now when you have micro instability or micro movement

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eventually the structures that are attached to it

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are burdened and they eventually

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will start to separate or delaminate

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in much the same way that say the subscapularis

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made the laminate from the lesser tuberosity.

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And let's see if that has happened.

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We go to the axial, heavily water weighted image,

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long TR, short T not a T2 weighted image

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which is not one of my favorites

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to look at chronic ligamentous and fibrous tissue disease.

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And on this appropriate high resolution sequence

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we should see the prepubic plate

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this black structure flush on the cortex of the pubic bone.

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And it is not, it is separated by these two clefts.

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You can see why sometimes patients

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will have bilateral groin pain

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and sometimes the groin pain starts on one side

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flips over to the other side because they separate

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maybe on the dominant side or non-dominant side

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and then on the other side.

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So this is a delamination of the prepubic plate

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from the underlying bone producing sports hernia syndrome.

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This gentlemen was unable to generate top speed

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at a leg drive while running on turf.

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Now I really value the sagittal image

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especially when these clefts are more subtle.

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Unfortunately, this specific sagittal image was obtained

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with a true T2 spin echo with narrowly any fat suppression.

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So that makes it rather difficult

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but you still see in this young

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otherwise healthy individual

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this small little area

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of hyper intensity in the right pubic bone

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as a form of delamination

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which usually by the way

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does occur from superior to inferior.

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So you wanna look at the top.

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If we go to the other side

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got the same thing happening on the contralateral side.

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This is the typical central form mid form,

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in other words, mid from top to bottom

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or from cranial to caudal

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form of sports hernia syndrome

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with prepubic plate delamination

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from osteitis pubis, Athletic Pubalgia

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as a result of overuse.

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Let's move on Dr. PL.