Secondary and superior cleft sign

Injuries that occur immediately near the pubic bone

The cleft signs are injuries that occur immediately near the pubic bone, the symptoms of which are often mistaken for those of osteitis pubis but which have little to do with this inflammatory process.

As the symptoms associated with the cleft signs resemble those associated with osteitis pubis, adductor tendonitis as well as ‘sports hernia’, these conditions should be ruled out before starting therapy.

With an injury associated with a cleft sign, a small gap forms between the pubis bone and the attached adductor musculature. Loading the adductor musculature or the rectus abdominis triggers the pain.

The superior cleft and secondary cleft signs differ only in terms of the region where the cleft between the bone and the musculature occurs.

The causes of these cleft signs, which manifest with load-dependent adductor and groin pain, have not yet been fully clarified. Possible causes include instability (macro- or micro-instability) of the pubic symphysis, chronic overloading of the adductor musculature with elevated tensile stress on the bony attachment but also acute injuries after a fall onto the pelvis.


Secondary cleft sign
Image of a secondary cleft sign
Symphysography secondary cleft sign
CT-supported symphysography with evidence of a secondary cleft sign

Along with a thorough examination of the patient and the typical pain triggers in the adductor musculature near the pubic bone, which occasionally radiates to the opposite side, cleft signs are confirmed using MRI.

A symphysography often provides additional useful information. This radiographic or CT-supported examination enables the extent of the cleft sign and its precise localisation to be imaged.


Therapy for cleft signs has not yet been fully verified and only promises limited success.

Along with targeted injections into the pubic bone cleft with solutions containing cortisone, hyaluronic acid or ACP, there is also the option of surgical treatment. If there has been no improvement with non-surgical treatment (rest, injection and physiotherapy), an option for performance-oriented athletes is surgery, which I have been performing for many years. The aim of the operation is to close the defect between the bone and the musculature.