Pubic Related Groin Pain

Normal Anatomy Pubic symphysis is a nonsynovial amphiarthroidal joint Joint between the two pubic bones Lined medially with hyaline cartilage Separated by thick fibrocartilaginous disc Surrounded by 4 ligaments Anterior Posterior Superior Inferior Pubic symphysis provides attachment points for Rectus abdominis Adductor longus Inguinal ligament Pubic aponeurosis

Pathology Pain in and around the pubis Due to a variety of terms and lack of definitions with the literature the term “Pubic Related Groin Pain” is used following Doha agreement to refer to pain in and around the pubis Includes pathologies such as Osteomyelitis Osteitis pubis Pubis apophysitis Symphysis pubis stress injury

Mechanism of Injury Insidious Overuse kicking, sprinting, twisting or cutting

Subjective Examination Insidious onset of pain along the pubic symphysis May extend into the adductors or abdominals Worse with sprinting, twisting, kicking and cutting Unilateral or bilateral presentation

Objective Examination Local tenderness of the pubic symphysis and the immediately adjacent bone

Objective Examination Local tenderness of the pubic symphysis and the immediately adjacent bone

Further Investigation Bone scan MRI

Management Conservative management considered initially Rehabilitation focused on restoring normal lumbopelvic and hip mechanics to reduce the stress through the pubis See (McAleer, Gille et al. 2015) for a detailed rehabilitation programme

Conservative Reduce pain and inflammation NSAID’s Ice Massage Rest from aggravating activities for positions Restore Normal Range of Movement Lumbar spine, Hip (adductors) Joint mobilisation Joint manipulation Stretches N.B stretches should not replicate clients symptoms

Conservative Restore Normal Muscle Activation/ Strength Obliques Transversus abdominus Rectus abdominus Hip Flexors Hip Extensors and Abductors Deep Hip Rotators Hip adductor Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Conservative Restore Normal Muscle Activation Obliques Transversus abdominus Rectus abdominus (in positions in extension) Hip Flexors Hip Extensors and Abductors Deep Hip Rotators Restore Dynamic Stability Proprioceptive Training Sport Specific Training

Plan B Surgery Local injections Prolotherapy Surgical interventions

References Angoules, A. G. (2015). "Osteitis pubis in elite athletes: Diagnostic and therapeutic approach." World J Orthop 6(9): 672-679. Branci, S., K. Thorborg, M. B. Nielsen and P. Holmich (2013). "Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature." Br J Sports Med 47(10): 611-619. Hiti, C. J., K. J. Stevens, M. K. Jamati, D. Garza and G. O. Matheson (2011). "Athletic osteitis pubis." Sports Med 41(5): 361-376. McAleer, S. S., J. Gille, S. Bark and H. Riepenhof (2015). "Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy." Phys Ther Sport 16(3): 285-299. Sailly, M., R. Whiteley, J. W. Read, B. Giuffre, A. Johnson and P. Holmich (2015). "Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes." Br J Sports Med 49(12): 828-834. Weir, A., P. Brukner, E. Delahunt, J. Ekstrand, D. Griffin, K. M. Khan, G. Lovell, W. C. Meyers, U. Muschaweck, J. Orchard, H. Paajanen, M. Philippon, G. Reboul, P. Robinson, A. G. Schache, E. Schilders, A. Serner, H. Silvers, K. Thorborg, T. Tyler, G. Verrall, R. J. de Vos, Z. Vuckovic and P. Holmich (2015). "Doha agreement meeting on terminology and definitions in groin pain in athletes." Br J Sports Med 49(12): 768-774.