Common Mistakes in Groin Pain Classification

Abstract

Groin pain is a common issue in athletes, and an accurate diagnosis is crucial for effective management. The complexity of the groin's anatomy, including the pubic symphysis and adductor muscles, makes diagnosing injuries in this area challenging. Additionally, the maturation of the pubic apophysis, particularly in adolescent athletes, can lead to conditions like apophysitis that are often misdiagnosed as other groin injuries. A major challenge is the inconsistent terminology, with terms like “athletic pubalgia” and “sports hernia” used interchangeably, causing confusion. The 2015 Doha Agreement helped standardize the classification of groin pain into adductor-, iliopsoas-, inguinal-, and pubic-related types. This review highlights common mistakes in imaging interpretation, particularly in diagnosing adductor- and pubic-related groin pain. Magnetic resonance imaging is a key tool, offering superior soft tissue detail that is crucial for accurate diagnosis, but misinterpretation remains common. This review will help clinicians and radiologists improve diagnostic accuracy and thus ultimately enhance patient outcomes.

Keywords

groin pain - magnetic resonance imaging - adductor-related groin pain - pubic-related groin pain - pubic apophysitis

Publikationsverlauf

Artikel online veröffentlicht:
07. Oktober 2025

• References

• 1 Lee SC, Endo Y, Potter HG. Imaging of groin pain: magnetic resonance and ultrasound imaging features. Sports Health 2017; 9 (05) 428-435
• 2 Hynes JP, O'Flaherty M, Glynn D, Eustace S, Kavanagh EC. Imaging of groin pain in athletes: patterns of injury at MRI and gender differences therein. Ir J Med Sci 2023; 192 (03) 1411-1418
• 3 Candela V, De Carli A, Longo UG. et al. Hip and groin pain in soccer players. Joints 2021; 7 (04) 182-187
• 4 Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health 2016; 8 (04) 313-323
• 5 Genovese EA, Tack S, Boi C. et al. Imaging assessment of groin pain. Musculoskelet Surg 2013; 97 (Suppl. 02) S109-S116
• 6 Zoga AC, Mullens FE, Meyers WC. The spectrum of MR imaging in athletic pubalgia. Radiol Clin North Am 2010; 48 (06) 1179-1197
• 7 Zoland MP, Iraci JC, Bharam S, Waldman LE, Koulotouros JP, Klein D. Sports hernia/athletic pubalgia among women. Orthop J Sports Med 2018; 6 (09) 2325967118796494
• 8 Zuckerbraun BS, Cyr AR, Mauro CS. Groin pain syndrome known as sports hernia: a review. JAMA Surg 2020; 155 (04) 340-348
• 9 Calatayud Moscoso Del Prado J, Fernández-Gil MÁ, Bueno Horcajadas Á, Kassarjian A. Groin pain in soccer players: anatomy, clinical presentation, biomechanics, pathology and imaging findings. Skeletal Radiol 2024; May 24 (Epub ahead of print)
• 10 Dempsey PJ, Power JW, MacMahon PJ, Eustace S, Kavanagh EC. Nomenclature for groin pain in athletes. Br J Radiol 2021; 94 (1126): 20201333
• 11 Weir A, Brukner P, Delahunt E. et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49 (12) 768-774
• 12 Schilders E, Mitchell AWM, Johnson R, Dimitrakopoulou A, Kartsonaki C, Lee JC. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surg Sports Traumatol Arthrosc 2021; 29 (08) 2424-2436
• 13 Pesquer L, Reboul G, Silvestre A, Poussange N, Meyer P, Dallaudière B. Imaging of adductor-related groin pain. Diagn Interv Imaging 2015; 96 (09) 861-869
• 14 Schilders E, Bharam S, Golan E. et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg Sports Traumatol Arthrosc 2017; 25 (12) 3969-3977
• 15 De Maeseneer M, Forsyth R, Provyn S. et al. MR imaging-anatomical-histological evaluation of the abdominal muscles, aponeurosis, and adductor tendon insertions on the pubic symphysis: a cadaver study. Eur J Radiol 2019; 118: 107-113
• 16 Tharnmanularp S, Muro S, Nimura A, Ibara T, Akita K. Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain. Anat Sci Int 2024; 99 (02) 190-201
• 17 Koh E, Boyle J. Pubic apophysitis in elite Australian Rules football players: MRI findings and the utility of VIBE sequences in evaluating athletes with groin pain. Clin Radiol 2020; 75 (04) 293-301
• 18 Sailly M, Whiteley R, Read JW, Giuffre B, Johnson A, Hölmich P. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br J Sports Med 2015; 49 (12) 828-834
• 19 Sato VN, Moriwaki TL, Ikawa MH. et al. Apophyseal injuries in soccer players. Skeletal Radiol 2024; January 15 (Epub ahead of print)
• 20 Serner A, van Eijck CH, Beumer BR, Hölmich P, Weir A, de Vos RJ. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med 2015; 49 (12) 813
• 21 Bou Antoun M, Reboul G, Ronot M, Crombe A, Poussange N, Pesquer L. Imaging of inguinal-related groin pain in athletes. Br J Radiol 2018; 91 (1092): 20170856
• 22 Zoga AC, Kavanagh EC, Omar IM. et al. Athletic pubalgia and the “sports hernia”: MR imaging findings. Radiology 2008; 247 (03) 797-807
• 23 Taylor R, Vuckovic Z, Mosler A. et al. Multidisciplinary assessment of 100 athletes with groin pain using the Doha Agreement: high prevalence of adductor-related groin pain in conjunction with multiple causes. Clin J Sport Med 2018; 28 (04) 364-369
• 24 Thorborg K. Current clinical concepts: exercise and load management of adductor strains, adductor ruptures, and long-standing adductor-related groin pain. J Athl Train 2023; 58 (7-8): 589-601
• 25 Sheen AJ, Stephenson BM, Lloyd DM. et al. ‘Treatment of the sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014; 48 (14) 1079-1087
• 26 Cunningham PM, Brennan D, O'Connell M, MacMahon P, O'Neill P, Eustace S. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol 2007; 188 (03) W291-W296
• 27 Brandon CJ, Jacobson JA, Fessell D. et al. Groin pain beyond the hip: how anatomy predisposes to injury as visualized by musculoskeletal ultrasound and MRI. AJR Am J Roentgenol 2011; 197 (05) 1190-1197
• 28 Branci S, Thorborg K, Bech BH, Boesen M, Nielsen MB, Hölmich P. MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med 2015; 49 (10) 681-691
• 29 Saito M, Niga S, Nihei T, Uomizu M, Ikezawa Y, Tsukada S. The cleft sign may be an independent factor of magnetic resonance imaging findings associated with a delayed return-to-play time in athletes with groin pain. Knee Surg Sports Traumatol Arthrosc 2021; 29 (05) 1474-1482
• 30 Albers SL, Spritzer CE, Garrett Jr WE, Meyers WC. MR findings in athletes with pubalgia. Skeletal Radiol 2001; 30 (05) 270-277
• 31 Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 2001; 35 (01) 28-33
• 32 Gaudino F, Spira D, Bangert Y. et al. Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome. Eur J Radiol 2017; 94: 46-52
• 33 Holl N, Gerhardt JS, Tischer T. et al. Comparison between dedicated MRI and symphyseal fluoroscopic guided contrast agent injection in the diagnosis of cleft sign in athletic groin pain and association with pelvic ring instability. Eur Radiol 2023; 33 (10) 7321-7329
• 34 MacMahon PJ, Hogan BA, Shelly MJ, Eustace SJ, Kavanagh EC. Imaging of groin pain. Magn Reson Imaging Clin N Am 2009; 17 (04) 655-666 , vi
• 35 Serner A, Weir A, Tol JL. et al. Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes. Scand J Med Sci Sports 2018; 28 (02) 667-676
• 36 Murphy G, Foran P, Murphy D, Tobin O, Moynagh M, Eustace S. “Superior cleft sign” as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman's hernia. Skeletal Radiol 2013; 42 (06) 819-825
• 37 Mathieu T, Van Glabbeek F, Van Nassauw L, Van Den Plas K, Denteneer L, Stassijns G. New insights into the musculotendinous and ligamentous attachments at the pubic symphysis: a systematic review. Ann Anat 2022; 244: 151959
• 38 Brennan D, O'Connell MJ, Ryan M. et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology 2005; 235 (01) 162-167