1. Pubic Related Groin Pain

2. 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

3. 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

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

5. 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

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

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

8. Further Investigation
Bone scan
MRI

9. 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

10. 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

11. 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

12. 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

13. Plan B
Surgery
Local injections
Prolotherapy
Surgical interventions

14. References
Angoules, A. G. (2015). "Osteitis pubis in elite athletes: Diagnostic and therapeutic approach." World J Orthop 6(9):
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):
Hiti, C. J., K. J. Stevens, M. K. Jamati, D. Garza and G. O. Matheson (2011). "Athletic osteitis pubis." Sports Med 41(5):
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):
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):
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):