Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail

Comparison of two surgical interventions for advanced stages pubis and pubic symphysis tuberculosis in adults: A retrospective study of 33 cases

PURPOSE

To compare the clinical efficacy of two surgical interventions in treating advanced stages TB of the pubis and pubic symphysis.

METHODS

Between June 2010 and January 2020, 33 cases of the advanced pubis and pubic symphysis TB were treated with a one-stage debridement procedure (debridement only group, n = 15) or a one-stage debridement with bone grafting and plate fixation procedure (debridement + plating group, n = 18). The visual analog scale (VAS) score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), operation time, intraoperative blood loss, complications, time of bone graft fusion, and improvement in the mental component summary (MCS) and physical component summary (PCS) of Short Form-36 (SF-36) were compared and analyzed.

RESULTS

All patients were followed for 24.9 (SD 1.6) months. All patients were completely cured of the pubis and pubic symphysis TB with no recurrence. There were no significant differences (P >0.05) between the two groups in terms of age, follow-up period and intraoperative blood loss. The post-operative VAS scores, ESR and CRP levels, PCS and MCS scores of two groups significantly improved compared to pre-therapy. The mean operation time in debridement + plating group was 140.9 (43.2) min, which was significantly longer than in debridement only group [94.9(21.8) min, P < 0.01]. The final follow-up (FFU) indices of the VAS score in debridement only group were higher than those in debridement + plating group [1.9 (0.8) vs 1.3 (0.5), P=0.012]. A satisfactory average bony fusion time of 12.2 (3.3) months was achieved in debridement + plating group .

CONCLUSIONS

A one-stage debridement, bone grafting, and reconstruction plate fixation procedure achieved reconstruction of the integrity and stability of the pelvic ring, pain relief, and rapid cure of bone TB. This procedure is a safe and effective treatment option for advanced pubis and pubic symphysis TB.

Midterm Functional Outcomes of Arthroscopically Treated Recalcitrant Osteitis Pubis in Competitive Soccer Players

Background

Outcomes after arthroscopic debridement for isolated osteitis pubis in athletes are unknown, and midterm results following this method have not been established.

Purpose/Hypothesis

To evaluate the safety and efficiency of arthroscopic treatment for recalcitrant osteitis pubis in competitive soccer players. It was hypothesized that this treatment modality would yield clinical improvement in functional and patient satisfaction scores compared with preoperative values.

Study Design

Case series; Level of evidence 4.

Methods

At a single center, 10 consecutive male soccer players (mean age, 23.6 ± 4.4 years; range, 19-32 years) with a mean follow-up period of 72.2 ± 13.4 months (range, 60-97 months) were evaluated. All patients presented with symptomatic osteitis pubis and failed to respond to nonoperative treatment. Arthroscopic pubic symphysiectomy was performed in the supine position, and penile manipulation was performed in all cases to mitigate risks associated with neurovascular structures and the root of the penis. Outcome measurements were time to return to sports, visual analog scale (VAS) for pain, Nirschl Phase Rating Scale (NPRS), Nonarthritic Hip Score (NAHS), modified Harris Hip Score (mHHS), and patient satisfaction. Preoperative and postoperative radiographs were also assessed.

Results

The mean time to return to sports was 4.6 ± 1.7 months (range, 3-8 months). The mean VAS pain score decreased from 9.3 ± 0.8 (range, 8-10) to 0.2 ± 0.4 (range, 0-1) (P = .005). The mean NPRS decreased from 6.6 ± 0.5 (range, 6-7) to 0.3 ± 0.5 (range, 0-1) (P = .004). The mean NAHS increased from 35.8 ± 16.7 (range, 14-72) to 98.2 ± 2.7 (range, 93-100) (P = .005). The mean mHHS increased from 47.4 ± 10.6 (range, 27-60) to 98.2 ± 4.5 (range, 86-100) (p = .005). The mean patient satisfaction was 9.7 ± 0.7 (range, 8-10). Scrotal swelling was observed in 4 patients, which was resolved 36 to 48 hours postoperatively.

Conclusion

Arthroscopic treatment of osteitis pubis may be an option for recalcitrant cases when nonoperative treatment fails. However, further studies are needed to determine whether this technique and the outcomes of this study can be reproduced.

Hip Range of Motion and Strength in Male Athletes with Stage 1 Osteitis Pubis: A Cross-Sectional and Correlational Study

BACKGROUND

The objectives of this study were: (1) to determine whether athletes with stage 1 osteitis pubis (OP) present differences in hip range of motion (ROM) and muscle strength, between both sides and compared with healthy athletes; (2) to investigate the relationship between the internal rotation (IR) ROM and pain intensity and physical function.

METHODS

a cross-sectional and correlational study was designed, in which 30 athletes (15 athletes with stage 1 OP and 15 healthy athletes) were included. Pain intensity, physical function, hip ROM and hip muscle strength were assessed.

RESULTS

The ROM assessment reported significant differences between both groups in the IR, external rotation (ER) and adduction (ADD) ROM of the painful side (PS) (p < 0.05). The OP group showed differences between both sides in IR ER and ADD ROM (p < 0.05). No statistically significant differences were found between or within groups in the maximum isometric strength of the hip (p > 0.05). A strong negative correlation between pain intensity and IR ROM (r = -0.640) and a strong positive correlation between physical function and IR ROM (r = 0.563) were found in the OP group.

CONCLUSIONS

Male athletes with stage 1 OP present a hip IR, ER and ADD ROM limitation in the PS compared to non-PS and to healthy athletes. IR ROM is correlated to pain intensity and physical function in athletes with stage 1 OP.

The challenges in diagnosis and management of osteitis pubis: An algorithm based on current evidence

Objective

The objective of this study is to summarise the contemporary evidence regarding the prevalence, diagnosis, and management of osteitis pubis (OP) specially from urological point of view, while proposing an algorithm for the best management based on the current evidence.

Methods

We performed a literature search using the PubMed database for the term ‘osteitis pubis’ until December 2020. We assessed pre‐clinical and clinical studies regarding the aetiology, pathophysiology, and management of OP. Case reports and case series were evaluated by study quality and patient outcomes to determine a potential clinical management algorithm.

Results

Osteitis pubis is a chronic painful condition of the symphysis pubis joint and its surrounding structures. Still, there is a paucity of data outlining the management plan and the possible triggers. The aetiology seems to be multifactorial with different proposals trying to explain the pathophysiology and correlate the findings to the outcome. The diagnosis is usually based on high suspicion index and clinical experience. The infective variant of the disease is aggressive and requires strict and active management. Universal consensus is still lacking regarding a formal algorithm of management of the condition, especially due to multiple specialities involved in the decision‐making process. Conservative management remains the cornerstone; nevertheless, surgical interventions may be needed in special settings. Hence, a multi‐disciplinary approach is of pivotal value in fashioning the plan for each case. The prognosis is usually satisfactory; however, a longstanding debilitating disease form is not uncommon.

Conclusion

OP remains a rare condition with real challenges in its diagnosis. The current management is focused on conservative management; however, surgical intervention is still needed in some difficult scenarios. Continued research into the triggers of OP, multidisciplinary approach, and standardised clinical pathways can improve the quality of care for patients suffering from this condition.

Osteitis Pubis in Athletes: A Literature Review of Current Surgical Treatment

Osteitis pubis (OP) is a self-limiting, noninfectious inflammatory disease of the pubic symphysis and the surrounding soft tissues that usually improves with activity modification and targeted conservative treatment. Surgical treatment is required for a limited number of patients. This study aims to investigate the current literature on the surgical treatment of OP in athletes.

A systematic review was conducted on two databases (MEDLINE/PubMed and Google Scholar) from 2000 to 2021. The inclusion criteria were adult patients with athletic OP who underwent surgical treatment and studies published in English. The exclusion criteria included pregnancy, infection OP, or postoperative complications related to other surgical interventions, such as urological or gynecological complications.

Fifty-one surgically treated cases have been reported in eight studies, which included short-term, mid-term, and long-term studies ranging from one patient to 23 patients. The surgical treatment methods were as follows: (a) pubic symphysis arthrodesis, (b) open or endoscopic pubic symphysectomy, (c) wedge resection of the pubic symphysis, and (d) polypropylene mesh placed into the preperitoneal retropubic space endoscopically.

The main indication for surgical intervention was failure of conservative measures and long-lasting pain, disability, and inability to participate in athletic activities. Wedge resection of the pubic symphysis has been the less preferred surgical treatment in the recently published literature. The most common surgical method of treatment of OP in athletes, which entailed the existence of posterior stability of the sacroiliac joint, in the current literature is open pubic symphysis curettage. Recently, there has been a tendency for pubic symphysis curettage to be performed endoscopically.

Imaging Review of Hockey-related Lower Extremity Injuries

Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.

[Arthroscopically assisted minimally invasive symphysioplasty for the treatment of pubic related groin pain]

OBJECTIVE

Therapy of pubic related groin pain via minimally invasive symphysioplasty.

INDICATIONS

Therapy of refractory pubic related groin pain based on osteitis pubis.

CONTRAINDICATIONS

Groin pain from causes other than pubic related groin pain.

SURGICAL TECHNIQUE

After a minimally invasive approach, an incision in the anterior capsule is made while protecting the dorsal capsule parts and the arcuate pubic ligament. The symphysis end plates are remodeled arthroscopically assisted using a surgical burr. The newly created pubic symphysis joint is filled with autogenous fibrin to support the formation of a new discus interpubicus.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing for 4 weeks with 20 kg using crutches is recommended. During the first 4 weeks the range of motion should be restricted.

RESULTS

Since 2010, 10 athletes (7 men, 3 women; average age 34.1 ± 7.8 (23-47) years) have undergone arthroscopically assisted minimally invasive symphysioplasty and treatment of femoroacetabular impingement syndrome. The average follow-up time was 5.1 (2-9) years. All patients returned to their sport level. The mean preoperative Nonarthritic Hip Score (NAHS) of 64.4 ± 15.1 (32.1-86.5) points improved to a mean postoperative NAHS of 91.4 ± 9.8 (62.4-98.75) points (p < 0.0001). The average patient satisfaction (scale 0 to 10; 10 highest satisfaction) was 9.8 ± 0.4 (9-10).

Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique

Background:

Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes.

Purpose:

To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed.

Results:

Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin.

Conclusion:

Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Pubic and adductor related groin pain in an athlete: A case report linking pathology to conservative care

STUDY DESIGN

Case Report.

BACKGROUND

Groin pain in athletes is considered a common condition among males participating in sports that require sprinting, twisting, pivoting and kicking activities. While the condition is considered self-limiting, it often keeps athletes away from sport for a prolonged period of time. Much controversy exists regarding the pathogenesis of groin pain. This conflict translates to disagreement regarding diagnostic criteria, reporting and management strategies.

CASE PRESENTATION

a 28-year old recreational soccer player presented with a five-month history of groin pain that was resistant to passive care. With reference to the current conservative management literature, the athlete was progressed through an individualized multimodal program of care.

OUTCOMES

Following 10-weeks of care, the athlete was able to return to sport participation pain-free.

CONCLUSION

It is suggested that groin pain in athletes is likely multifactorial and therefore the management should reflect its multifactorial nature. Conservative therapy can evidently reduce the time to return to play however the benefits of incorporating plyometrics into the rehabilitation program should be investigated.

Adult female patient with osteitis pubis and pelvic instability requiring surgery: A case report

Background

Osteitis pubis (OP) is an inflammatory condition of the symphysis pubis (SP) characterized by focal pain and local tenderness. Pelvic instability (PI) is commonly associated with this condition. It is still not clear if OP leads to PI or it is PI that leads to OP. The exact cause of osteitis pubis is not yet known, although several predisposing factors have been suggested to contribute to this condition. In most cases, it is self-remitting and rarely needs surgical intervention.

Case presentation

A 63-year old woman presented with a 12-month history of persistent pain at the symphysis pubis and non-responsive to analgesics. The pain was aggravated by physical activity such as standing and walking. Physical examination showed focal tenderness at the symphysis pubis with no tenderness over the sacroiliac joints or lumbar region. The diagnosis was confirmed by characteristic findings on radiographs, CT and MRI. Surgery was considered after all conservative measures failed. The patient underwent a wedge-shaped resection of the symphysis pubis; the bone defect was filled autologous tri-cortical bone and fixed with dual plating. The outcome was satisfactory with radiologic union and symptom resolution postoperatively.

Conclusions

Osteitis pubis due to pelvic instability can cause chronic and persistent pain. In cases where conservative treatment fails, surgery should be considered. We recommend wide surgical resection of all non-viable bone at the symphysis pubis with the addition of tri-cortical iliac bone graft. Double plating should be considered in order to maximize the rate of fusion and further stabilize the fixation.

A novel press-fit minimally-invasive symphysiodesis technique

Objective

Instability of the pubic symphysis often results in a poor outcome and reduced mobility of the patient. In some cases, an arthrodesis of the pubic symphysis is required. Until today, there is no data published how many of these procedures are performed annually and there is also no data about the outcome after this extensive surgery.

Methods

We developed a novel surgical technique to address the arthrodesis of the pubic symphysis in a minimally invasive approach. Therefore, we used for this purpose modified instruments and performed the transplantation of a cylindrical bone substitute into the pubic symphysis, without an extensive approach or dissecting the anterior or posterior symphyseal ligaments.

Results

Using this novel technique, a minimally invasive symphysiodesis was achieved in radiological findings, after the procedure.

Conclusion

Thus, this actually minimally invasive surgical technique seems to be a promising advancement for the arthrodesis of the pubic symphysis.

Relationship Between Pubic Symphysis Separation and Postpartum Pelvic Girdle Pain: A Retrospective Study of 32 Cases

BACKGROUND

Pain severity of postpartum pelvic girdle pain (PGP) does not seem closely related to the symphysis gap.

OBJECTIVE

To determine the relationship between the pubic symphysis gap and postpartum PGP in women treated with the squeeze-and-clap maneuver.

DESIGN

Retrospective study.

SETTING

Hospital Clinic PATIENTS: 32 patients with postpartum PGP.

METHODS

The patients were grouped by the pubic symphysis gap as: group A (6-11 mm), group B (12-20 mm), and group C (21-30 mm).

MAIN OUTCOME MEASUREMENTS

GP severity was measured by visual analogue scale (VAS). The symphysis gap was measured on radiographs. All patients were treated with the squeeze-and-clap maneuver. The VAS scores and the symphysis gaps at the first clinic visit and the second clinic visit 4-8 weeks later were analyzed.

RESULTS

There was no significant difference in VAS scores between the three groups at the first clinic visit and the second clinic visit. VAS scores of the three groups were all significantly decreased at the second clinic visit compared with the first clinic visit (all P < .001). The symphysis gap was significantly decreased in group C at the second clinic visit (P = 0.004), but not in group A and group B.

CONCLUSION

Pubic symphysis separation was not associated with pain severity of postpartum PGP.

Hip Arthroscopic Management Can Improve Osteitis Pubis and Bone Marrow Edema in Competitive Soccer Players With Femoroacetabular Impingement

BACKGROUND

There is a dearth of knowledge regarding the correlation between femoroacetabular impingement (FAI) and osteitis pubis (OP) among symptomatic soccer players.

PURPOSE

To elucidate whether arthroscopic FAI correction is effective for young competitive soccer players with FAI combined with OP or perisymphyseal pubic bone marrow edema (BME).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 577 consecutive patients who underwent arthroscopic FAI correction were retrospectively reviewed with a minimum 2-year follow-up. Competitive soccer players who were professional, college, and high school athletes were included. The authors assessed the modified Harris Hip Score and Nonarthritic Hip Score preoperatively and at 6 months, 1 year, and 2 years after surgery. In addition, players were divided into groups according to radiographic evidence of OP and BME (2 groups each). Clinical outcomes, return to play, and radiographic assessments were compared between groups.

RESULTS

Twenty-eight hips met the inclusion criteria. The median modified Harris Hip Score significantly improved after hip arthroscopy (81.4, preoperatively; 95.7 at 6 months, P = .0065; 100 at 1 year, P = .0098; 100 at 2 years, P = .013). The median Nonarthritic Hip Score also significantly improved (75.0, preoperatively; 96.3 at 6 months, P = .015; 98.8 at 1 year, P = .0029; 100 at 2 years, P = .015). Furthermore, 92.0% of players returned to play soccer at the same or higher level of competition at a median 5.5 months (range, 4-15 months); 67.8% had radiological confirmation of OP; and 35.7% had pubic BME. The alpha angle was significantly higher in pubic BME group than the no-pubic BME group (64.8° vs 59.2°, P = .027), although there was no significant difference between the OP and no-OP groups. The prevalence of tenderness of the pubic symphysis significantly decreased preoperatively (32.1%) to postoperatively (3.6%). Magnetic resonance imaging findings confirmed that pubic BME disappeared in all players at a median 11 months (range, 6-36) after initial surgery.

CONCLUSIONS

Arthroscopic management for FAI provides favorable clinical outcomes, a high rate of return to sports, and, when present, resolution of pubic BME among competitive soccer players.

Management of osteitis pubis in athletes: rehabilitation and return to training - a review of the most recent literature

Osteitis pubis is a common cause of chronic groin pain, especially in athletes. Although a precise etiology is not defined, it seems to be related to muscular imbalance and pelvic instability. Diagnosis is based on detailed history, clinical evaluation, and imaging, which are crucial for a correct diagnosis and proper management. Many different therapeutic approaches have been proposed for osteitis pubis; conservative treatment represents the first-line approach and provides good results in most patients, especially if based on an individualized multimodal rehabilitative management. Different surgical options have been also described, but they should be reserved to recalcitrant cases. In this review, a critical analysis of the literature about athletic osteitis pubis is performed, especially focusing on its diagnostic and therapeutic management.

Novel pathomorphologic classification of capsulo-articular lesions of the pubic symphysis in athletes to predict treatment and outcome

INTRODUCTION

Radiographic abnormalities of the symphysis as well as the formation of accessory clefts, indicating injury at the rectus-adductor aponeurosis, reportedly relate to longstanding groin pain in athletes. However, yet, no systematic classification for clinical and scientific purposes exists. We aimed to (1) create a radiographic classification based on symphysography; (2) test intra- and interobserver reliability; (3) characterise clinical significance of the morphologic patterns by evaluating success of injection therapy.

PATIENTS AND METHODS

We retrospectively reviewed symphysography, AP radiographs, and MRI of the pelvis from 70 consecutive competitive athletes, with chronic groin pain. Symphysographs were evaluated for intra- and interobserver variance using cohen's kappa statistics. Morphologic studies of the different contrast distribution patterns and their clinical and radiological correlation with symptom relief were investigated. All patients were followed up to evaluate immediate and long-term response to the initial therapeutic injection with steroid.

RESULTS

Four reproducible symphysographic patterns were identified: type 0, no changes; type 1, symphyseal disk degeneration; types 2a with unilateral clefts, bilateral clefts (2b), suprapubic clefts (2c); and type 3, with expanded or multidirectional clefts. Analysis revealed excellent intra (0.94)-and interobserver (0.90) reliability. Our findings showed that 78.6% of our patients had significant short-term improvement enabling early resumption of physiotherapy, only in types 1 and 2 (p = 0.001), while type 0 and 3 did not respond. At follow-up, only 21.8% had permanent pain relief. Regarding the detection of pathologic clefts with symphysography, sensitivity (88%) and specifity (77%) were superior to that of MRI.

CONCLUSIONS

A reproducible symphysography-based classification of distinct morphologic patterns is proposed. It serves as a predictive tool for response to injection therapy in a select group of pathologic lesions. Complete recovery after injection can only be expected in a lesser percentage, as this might indicate surgical treatment for long-term non-responders.

Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients

Background

Clinical assessments and rehabilitation in athletic groin pain (AGP) have focused on specific anatomical structures and uniplanar impairments rather than whole body movement.

Objective

To examine the effectiveness of rehabilitation that targeted intersegmental control in patients with AGP and to investigate post rehabilitation changes in cutting biomechanics.

Methods

Two hundred and five patients with AGP were rehabilitated focusing on clinical assessment of intersegmental control, linear running and change of direction mechanics in this prospective case series. Hip and Groin Outcome Score (HAGOS) was the primary outcome measure. Secondary measures included pain-free return to play rates and times, pain provocation on squeeze tests and three-dimensional (3D) biomechanical analysis during a 110° cutting manoeuvre.

Results

Following rehabilitation, patients demonstrated clinically relevant improvements in HAGOS scores (effect size (ES): 0.6–1.7). 73% of patients returned to play pain-free at a mean of 9.9 weeks (±3.5). Squeeze test values also improved (ES: 0.49–0.68). Repeat 3D analysis of the cutting movement demonstrated reductions in ipsilateral trunk side flexion (ES: 0.79) and increased pelvic rotation in the direction of travel (ES: 0.76). Changes to variables associated with improved cutting performance: greater centre of mass translation in the direction of travel relative to centre of pressure (ES: 0.4), reduced knee flexion angle (ES: 0.3) and increased ankle plantar flexor moment (ES: 0.48) were also noted.

Conclusions

Rehabilitation focused on intersegmental control was associated with improved HAGOS scores, high rates of pain-free return to sporting participation and biomechanical changes associated with improved cutting performance across a range of anatomical diagnoses seen in AGP.

Laparoscopic Treatment of Pubic Symphysis Instability With Anchors and Tape Suture

Patients with pubic symphysis instability who had failed nonoperative treatments may benefit from surgical repair. This disease process is rare, most commonly seen in postpartum women and athletes, and its surgical treatment is invasive and nonphysiological. Currently described surgical interventions, although limited, include plating, which provides an overly rigid construct with the risk of failure and possibly poor long-term outcomes particularly in athletes, and treatments such as curettage, more commonly used in the treatment of osteitis pubis. An emerging option is minimally invasive laparoscopic fixation using knotless anchors with a tape suture in a crisscross configuration. This possibly allows more physiological movement of the pubic symphysis in a less invasive manner. A detailed technical description and discussion of the technique are provided.

Non-anatomic fixation for longstanding traumatic pubic diastasis using a bone graft: A report of two cases

The incidence of internal fixation failure of symphysis diastasis varies from 6% to 75%. Hardware breakage or migration and symphysis disruption recurrence are often asymptomatic and only in a few cases reoperation is required. This report describes the managements of two cases after failed internal fixation and neglected traumatic symphysis diastasis when it was technically impossible to achieve anatomical reduction of the anterior pelvic ring. Internal fixation and a bone graft for the symphysis without anatomical reposition were performed. Both of the patients achieved good results and had no complaints of pain during daily activities. Restoration of the anatomy should not be the aim in treating recurrence of the symphysis diastasis after failed fixation. The aim of the surgery was static fixation of the anterior pelvic ring with bone grafting.

Nonoperative Management, Rehabilitation, and Functional and Clinical Progression of Osteitis Pubis/Pubic Bone Stress in Professional Soccer Players: A Case Series

Study Design Case series. Background Pubic bone stress (PBS) is a common acute or chronic response of the pelvis in sports where sprinting, kicking, twisting, and cutting are the dominant movements. There are few nonoperative rehabilitation strategies for the condition reported in the literature, and the outcome of conservative treatment has not been documented. Case Description Five professional and academy soccer players complaining of pubic symphysis pain, confirmed as PBS on magnetic resonance imaging and objective assessment, were treated with a nonoperative rehabilitation program that featured functional and clinical objective markers as progression criteria. Interventions in the acute phase included pharmacological and physical therapeutic modalities to reduce pain initially. Rehabilitation management focused on improving range of motion at the hips and thorax, adductor strengthening, trunk and lumbopelvic stability, gym-based strength training, and field-based rehabilitation and conditioning. Clinical follow-up was performed at least 8 months following return to play. Outcomes All players demonstrated reduced or resolved pain, increased adductor squeeze strength, and return to pain-free training and match play. Return-to-training time averaged 40.6 days (range, 30-60 days) and return to play averaged 49.4 days (range, 38-72 days) within the 5 players. At final follow-up (mean, 29.6 months; range, 16-33 months), there had been no recurrences. Discussion This report of 5 cases suggests that a nonoperative protocol, using clinical and functional progression criteria, may be successful in rehabilitating athletes with PBS for return to sport within 11 weeks. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(9):683-690. Epub 3 Aug 2017. doi:10.2519/jospt.2017.7314.

Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome

BACKGROUND AND PURPOSE

Osteitis pubis (OP), a common pathology in elite athletes, is an aseptic inflammatory process of the pubic symphysis bone, and may involve surrounding soft tissues, tendons and muscles. OP is typically characterized by (often recurring) groin pain and is an important cause of time-off from sports activity in athletes. Aim of this retrospective study was to analyze magnetic resonance imaging (MRI) findings in professional football players with clinical diagnosis of OP and to correlate MRI findings with clinical outcome.

MATERIAL AND METHODS

All professional football players (23 males, 1 female; mean age: 21±3.7years; range: 16-30 years) with groin pain and clinical diagnosis of OP, who underwent pelvic MRI in our institution were retrospectively analyzed. The MR images were analyzed regarding the presence of bone marrow edema and its extension, whether fluid in the symphysis pubis or periarticular soft tissue edema with a rim-like periosteal distribution or edema in the muscles located around the symphyseal joint were present, whether degenerative changes of the symphysis pubis and of signs of symphyseal instability were encountered. A quantitative measurement of the signal intensity in bone marrow edema on 3T STIR sequences was performed, normalizing these values to the mean signal intensity values in the ipsilateral iliopsoas muscle. All patients were classified according to a 3-point grading scale. For each patient, both the symptoms 18 months after the initial MRI examination, the duration of time off from playing football and the kind of treatment applied were evaluated.

RESULTS

Among all professional athletes, in 20/24 (83.3%) MRI showed signs of OP with bone marrow edema at the pubic bone. 12 of these patients showed complete clinical recovery without any symptoms after 18 months, while in 8 patients partial recovery with persistence of groin pain during higher sports activity was observed. Patients with edema in periarticular soft tissues or in the muscles around the symphyseal joint on MRI at the beginning of symptoms presented significantly more often with a partial recovery after returning to high sports activity (p=0.042 and p=0.036, respectively). A partial recovery was also significantly associated with higher normalized mean signal intensity values in bone marrow edema on STIR sequences at the beginning of symptoms (mean=4.77±1.63 in the group with partial recovery vs. mean=2.86±0.45 in the group with complete recovery; p=0.0019). No significant association was noticed between MRI findings and time of abstinence from high sports activity, as well as between the 3-point grading scale and the time off from high sport activity and recovery at 18 months.

CONCLUSIONS

Edema in periarticular soft tissues, edema with extension to the muscles located around the symphyseal joint, as well as higher normalized signal intensity values in bone marrow edema on STIR sequences in the pubic bones at the beginning of groin pain are the most reliable MRI findings of a poor clinical long-term outcome of OP in professional football players and should be regarded as negative prognostic factors.

Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study

PURPOSE

The incidence of groin pain in athletes is steadily increasing. Symptomatic pubic overload with groin pain and aseptic osteitis pubis represent well-known and frequently misdiagnosed overuse injuries in athletes. This study investigated the benefits of standardised non-surgical treatment for swift return-to-football.

METHODS

In a prospective double-blinded controlled study, 143 amateur football players with groin pain as well as radiological signs and clinical symptoms of pubic overload were analysed for 1 year. Two randomised study groups participated in an intensive physical rehabilitation programme, either with or without shock wave therapy. The control group did not participate in any standardised rehabilitation programme but only stopped participating in sports activity. Follow-up examinations took place 1, 3 months and 1 year after the beginning of therapy. Endpoints were visual analogue scale (VAS), functional tests, the time of return-to-football, recurrent complaints and changes in the MR image.

RESULTS

Forty-four football players with groin pain and aseptic osteitis pubis were randomised into two study groups; 26 received shock wave therapy, 18 did not. Clinical examination showed pubic overload as a multi-located disease. Players receiving shock wave therapy showed earlier pain relief in the VAS (p < 0.001) and returned to football significantly earlier (p = 0.048) than players without this therapy. Forty-two of 44 players of both study groups returned to football within 4 months after the beginning of therapy and had no recurrent groin pain within 1 year after trauma. Fifty-one players of the control group returned to football after 240 days (p < 0.001), of whom 26 (51%) experienced recurrent groin pain. Follow-up MRI scans did not show any effect of shock wave therapy.

CONCLUSION

Non-surgical therapy is successful in treating pubic overload and osteitis pubis in athletes. Shock wave therapy as a local treatment significantly reduced pain, thus enabling return-to-football within 3 months after trauma. Early and correct diagnosis is essential for successful intensive physiotherapy.

LEVEL OF EVIDENCE

I.

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Groin Injuries (Athletic Pubalgia) and Return to Play

Context:

Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high-level competition.

Evidence Acquisition:

PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results and Conclusion:

Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.

Correlation Between Cam-Type Femoroacetabular Impingement and Radiographic Osteitis Pubis

A mechanistic link has been suggested between cam-type femoroacetabular impingement and increased stress on the symphysis pubis. This retrospective study was conducted to determine whether there is an increased prevalence of osteitis pubis, as evidenced by imaging, in patients with femoroacetabular impingement compared with age-matched control subjects. Search of a radiologic database of a large academic health institution for all patients with cam-type femoroacetabular impingement diagnosed by magnetic resonance imaging or magnetic resonance arthrogram between January 2000 and October 2013 identified 46 cases. Two radiologists reviewed these cases independently and confirmed the presence of femoroacetabular impingement based on alpha angle and other characteristics of cam morphology. The imaging studies were further evaluated for characteristics of osteitis pubis, with severity graded from minimal to severe on a 4-point Likert scale. A control group composed of age-matched subjects without diagnosed femoroacetabular impingement was also evaluated for osteitis pubis. A statistically significant increase in the prevalence of osteitis pubis was found in patients with femoroacetabular impingement compared with age-matched control subjects, with a prevalence of 43.48% in the femoroacetabular impingement group compared with 12.77% in the control group (P=.0012). On the 4-point Likert scale, the average severity of osteitis pubis in the group with femoroacetabular impingement was 1.5 (minimal to mild) compared with 0.53 (no osteitis pubis to minimal findings) in the control population. This significant increase in osteitis pubis in patients with femoroacetabular impingement supports the clinical link between these 2 processes. [Orthopedics. 2016; 39(3):e417-e422.].

Arthroscopic debridement of the pubic symphysis: an experimental study

PURPOSE

Open curettage of the symphysis has shown promising results in patients with recalcitrant osteitis pubis. However, this has been bedevilled with an extended intraoperative morbidity. Aim of this study was to come up with a novel arthroscopic debridement of the pubic symphysis and to bring to the fore the potential risks of soft tissue damage.

METHODS

This study was conducted on six human cadavers (mean age 83 years). CT scans were obtained for measurement of the symphyseal morphology. Consequent upon these measurements, four different potential arthroscopic portals were defined with the intention to gain adequate insight and to reach the whole joint space with instruments: one suprapubic portal and three anterior portals (antero-superior, antero-central and antero-inferior). Soft tissue, except for musculotendinous attachments and neurovascular structures, was dissected. A two-portal arthroscopic debridement under image intensifier control with resection of the symphyseal disc and abrasion of the subchondral bone were performed.

RESULTS

Considering the narrow joint space, small instruments/scope (4.5/2.7 mm) is recommended. Correct portal placement and debridement procedure can only be reliably performed under fluoroscopic imaging in two radiographic projections (outlet and inlet view) with a mean total fluoroscopic time of 15-20 s and a dose area product between 100 and 120 cGy cm(2). Two portals have proved beneficial: the suprapubic portal for instruments and the antero-central portal for the scope. Other portals had several limitations, e.g. potential instrumental conflict (anterior-superior) or damaging of neurovascular and other soft tissue structures (anterior-inferior).

CONCLUSION

With well-defined arthroscopic portals and adherence to basic principles of arthroscopic surgery, debridement of the pubic symphysis can be performed reproducibly without compromising important anatomical structures. This less invasive arthroscopic debridement is a safely applicable procedure and therefore might be a reasonable alternative to open curettage. One may assume that this technique will lead to a shorter rehabilitation time and will provide a successful therapy especially in the treatment of professional athletes in the future.

Multicenter Outcomes of Endoscopic Pubic Symphysectomy for Osteitis Pubis Associated With Femoroacetabular Impingement

PURPOSE

To investigate outcomes of athletic patients treated with concurrent femoroacetabular impingement (FAI) and osteitis pubis (OP) surgery including endoscopic pubic symphysectomy.

METHODS

We performed a multicenter retrospective case series of 7 consecutive adult patients (4 men) with a mean age of 33 years with symptomatic FAI and OP who underwent arthroscopic surgery for the former and endoscopic pubic symphysectomy for the latter with a mean follow-up period of 2.9 years (range, 2.0 to 5.0 years). The visual analog scale (VAS) score, the Non-Arthritic Hip Score (NAHS), and patient satisfaction were measured. Complications and revision surgical procedures were reported, and preoperative and postoperative radiographs were assessed.

RESULTS

The mean preoperative VAS score of 6.7 (range, 4 to 8) improved to a mean postoperative VAS score of 1.5 (range, 0 to 7) (P = .03). The mean preoperative NAHS of 50.2 points (range, 21 to 78 points) improved to a mean postoperative NAHS of 84.7 points (range, 41 to 99 points) (P = .03). The mean patient satisfaction rating was 8.3 (range, 3 to 10). Two male patients had postoperative scrotal swelling that resolved spontaneously. There were no other complications. Preoperative and postoperative radiographs showed no anterior or posterior pelvic ring instability. One patient underwent pubic symphyseal arthrodesis because of continued pain.

CONCLUSIONS

Endoscopic pubic symphysectomy is a minimally invasive treatment for athletic OP with encouraging early outcomes that may be performed concurrently with surgery for FAI in co-afflicted patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Endoscopic Pubic Symphysectomy for Athletic Osteitis Pubis

Osteitis pubis is a common form of athletic pubalgia associated with femoroacetabular impingement. Endoscopic pubic symphysectomy was developed as a less invasive option than open surgical curettage for recalcitrant osteitis pubis. This technical note demonstrates the use of the anterior and suprapubic portals in the supine lithotomy position for endoscopic burr resection of pubic symphyseal fibrocartilage and hyaline endplates. Key steps include use of the suprapubic portal for burr resection of the posteroinferior symphysis and preservation of the posterior and arcuate ligaments. Endoscopic pubic symphysectomy is a minimally invasive bone-conserving surgery that retains stability and may be useful in the treatment of recalcitrant osteitis pubis or osteoarthritis. It nicely complements arthroscopic surgery for femoroacetabular impingement and may find broader application in this group of co-affected athletes.

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

BACKGROUND/AIM

The aim of this paper was to use a clinical example to describe a treatment strategy for the management of recurrent chronic groin pain and evaluate the evidence of the interventions.

METHODS

A professional footballer presented with chronic recurrent OP/PBS. The injury was managed successfully with a nine-point programme - 1. Acute pharmacological management. 2. Tone reduction of over-active structures. 3. Improved ROM at hips, pelvis and thorax. 4. Adductor strength. 5. Functional movement assessment. 6. Core stability. 7. Lumbo-pelvic control. 8. Gym-based strengthening. 9. Field-based conditioning/rehabilitation. The evidence for these interventions is reviewed.

RESULTS

The player returned to full training and match play within 41 and 50 days, respectively, and experienced no recurrence of his symptoms in follow up at 13 months.

CONCLUSION

This case report displays a nine-point conservative management strategy for OP/PBS, with non-time dependent clinical objective markers as the progression criteria in a Premier League football player.

Endoscopic Pubic Symphysectomy for Recalcitrant Osteitis Pubis

Recalcitrant osteitis pubis presents a challenging problem for orthopaedic surgeons. Various surgical interventions have been described for treatment, including opening-wedge resection, symphysiodesis, and curettage. We propose that endoscopic pubic symphysectomy offers an effective method of treating such a challenging problem. This article describes in detail the technique used to perform endoscopic pubic symphysectomy, and a companion video demonstrating the procedure is included. Our experience suggests that removal of the interpubic fibrocartilaginous lamina and resection of approximately 1 cm of bone can successfully eliminate all sources of pain and dysfunction caused by the recalcitrant osteitis pubis.

Arthroscopic pubic symphysis debridement and adductor enthesis repair in athletes with athletic pubalgia: technical note and video illustration

We elaborately describe our novel arthroscopic technique of the symphysis pubis in athletes with osteitis pubis and concomitant adductor enthesopathy who fail to conservative treatment modalities. The symphysis pubis is debrided arthroscopically and the degenerated origin of adductor tendon (enthesis) is excised and reattached. With our surgical procedure the stability of the symphysis pubis is successfully preserved and the adductor longus enthesopathy simultaneously addressed in the same setting.

Return to sport after surgical treatment for pubalgia among professional soccer players

Objective

to evaluate the return to sport after surgical treatment for pubalgia among 30 professional soccer players and describe the surgical technique used.

Method

this case series was evaluated by means of a questionnaire and physical examination on 30 male professional soccer players of mean age 24.4 years (range: 18–30). The mean duration of the symptoms was 18.6 months (range: 13–28). The diagnosis was made through clinical investigation, special maneuvers and complementary examinations, by the same examiner. All the patients underwent surgical treatment after conservative treatment failed; all procedures were performed by the same surgeon using the same technique. Nonparametric comparisons were made to investigate the time taken to recover after the surgery, for the patients to return to their sport.

Results

five patients evolved with hematoma, with the need to remove the stitches three weeks after the operation because of a small dehiscence at the site of the operative wound. The wound healed completely in all these cases by five weeks after the surgery. Four patients presented dysuria in the first week, but improved in the second postoperative week. The mean time taken to return to training was around eight weeks (range: seven–nine). All the players returned to competitive soccer practice within 16 weeks. When asked about their degree of satisfaction after the operation (satisfied or dissatisfied), taking into consideration their return to the sport, there was 100% satisfaction, and they returned to professional practice at the same competitive level as before the injury. This degree of satisfaction continued to the last assessment, which was made after 36 months of postoperative follow-up.

Conclusion

the surgical technique presented in this case series, with trapezoidal resection of the pubic symphysis in association with bilateral partial tenotomy of the long adductor, was a fast and effective procedure with a low rate of postoperative complications. It was shown to be an excellent treatment option for refractory cases, with a return to sports activity among professional soccer players.

Sports hernia/athletic pubalgia: evaluation and management

Context:

Sports hernia/athletic pubalgia has received increasing attention as a source of disability and time lost from athletics. Studies are limited, however, lacking consistent objective criteria for making the diagnosis and assessing outcomes.

Evidence Acquisition:

PubMed database through January 2013 and hand searches of the reference lists of pertinent articles.

Study Design:

Review article.

Level of Evidence:

Level 5.

Results:

Nonsurgical outcomes have not been well reported. Various surgical approaches have return-to–athletic activity rates of >80% regardless of the approach. The variety of procedures and lack of outcomes measures in these studies make it difficult to compare one surgical approach to another. There is increasing evidence that there is an association between range of motion–limiting hip disorders (femoroacetabular impingement) and sports hernia/athletic pubalgia in a subset of athletes. This has added increased complexity to the decision-making process regarding treatment.

Conclusion:

An association between femoroacetabular impingement and athletic pubalgia has been recognized, with better outcomes reported when both are managed concurrently or in a staged manner.

Isokinetic imbalance of hip muscles in soccer players with osteitis pubis

In this study, we compared the isokinetic torques of hip flexors/extensors and abductors/adductors in soccer players suffering from osteitis pubis (OP), with normal soccer players. Twenty soccer male athletes with OP and 20 normal soccer athletes were included in this study. Peak torque/body weight (PT/BW) was recorded from hip flexor/extensor and abductor/adductor muscles during isokinetic concentric contraction modes at angular velocity of 2.1 rad · s(-1), for both groups. The results showed a significant difference between the normal and OP groups for hip flexors (P < 0.05). The normal group had significant, lower PT/BW value than the OP group for their hip flexors (P < 0.05). The hip flexor/extensor PT ratio of OP affected and non-affected limbs was significantly different from that of normal dominant and non-dominant limbs. There were no significant differences between the normal and OP groups for hip extensor, adductor and abductor muscles (P > 0.05). Regarding the hip adductor/abductor PT ratio, there was no significant difference between the normal and OP groups of athletes (P > 0.05). The OP group displayed increase in hip flexor strength that disturbed the hip flexor/extensor torque ratio of OP. Therefore, increasing the hip extensor strength should be part of rehabilitation programmes of patients with OP.

Conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain

BACKGROUND

Musculoskeletal, ligamentous and osseous groin injuries are common in athletes and may result in a delay of several months to resume sports. Even then, this may not be at the former level of sport activity. The treatment of exercise-related groin pain is mainly conservative (non-surgical), using interventions such as exercises, electrotherapy, manual therapy and steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); MEDLINE (1948 to November week 3 2011); EMBASE (1980 to Week 49 2011); CINAHL (1982 to December 2011); LILACS (1982 to December 2011); PEDro (1929 to December 2011), SPORTDiscus (1985 to December 2011), OTseeker (to December 2011), reference lists of papers and conference proceedings (2000 to 2011).

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials evaluating conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain were included. Studies comparing conservative with surgical treatments were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessments. There was no pooling of data.

MAIN RESULTS

Two studies, involving a total of 122 participants who had experienced adductor-related groin pain for at least two months, were included in this review. All but one of the participants were male athletes aged between 18 and 50 years old. Both studies were assessed as 'high risk of bias' for at least one source of bias domain. The 'successful treatment' outcome reported in both studies was based primarily on pain measures.One study, based on an intention-to-treat analysis, found a significant difference favouring exercise therapy (strengthening with an emphasis on the adductor and abdominal muscles and training muscular co-ordination) compared with 'conventional' physiotherapy (stretching exercises, electrotherapy and transverse friction massage) in successful treatment at 16-week follow-up (25/34 (74%) versus 10/34 (29%); risk ratio (RR) 2.50, 95% CI 1.43 to 4.37, P = 0.001). Similarly, of those followed-up significantly more athletes treated by exercise therapy returned to sport at the same level (23/29 (79%) versus 4/30 (13%); RR 5.95, 95% CI 2.34 to 15.09, P = 0.0002). Although still favouring the exercise group, the differences between the two groups in patients' subjective global assessment at 16 weeks and successful treatment at 8 to 12 years follow-up were not statistically significant.The second study (54 participants) found no significant differences at 16-week follow-up between a multi-modal treatment (heat, manual therapy and stretching) and exercise therapy (the same intervention as in the above study) for the outcomes of successful treatment (14/26 (54%) versus 12/22 (55%); RR 0.99, 95% CI 0.59 to 1.66, P = 0.96) and return to full sports participation (13/26 (50%) versus 12/22 (55%); RR 0.92, 95% CI 0.53 to 1.58, P = 0.75). Those returning to full sports participation returned on average 4.5 weeks earlier after receiving multi-modal therapy (mean difference -4.50 weeks, 95% CI -8.60 to -0.40, P = 0.03) than those in the exercise therapy group. This study reported that there were no complications or side effects found in either intervention group.

AUTHORS' CONCLUSIONS

The available evidence from the randomized trials is insufficient to advise on any specific conservative modality for treating exercise-related groin pain. While still low quality, the best evidence is from one trial which found that exercise therapy (strengthening of hip and abdominal muscles) in athletes improves short-term outcomes (based primarily on pain measures) and return to sports compared with physiotherapy consisting of passive modalities. Given the low quality of the available evidence from both included trials, further randomized trials are necessary to reinforce their findings.

A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes

Background:

Multiple surgical procedures exist for the treatment of osteitis pubis: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments.

Hypothesis:

Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain.

Study Design:

Case series.

Methods:

Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule.

Results:

The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief.

Conclusion:

This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability.

Clinical Relevance:

This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.

The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study

BACKGROUND

A link between femoroacetabular impingement and athletic pubalgia has been reported clinically. One proposed origin of athletic pubalgia is secondary to repetitive loading of the pubic symphysis, leading to instability and parasymphyseal tendon and ligament injury. Hypothesis/

PURPOSE

The purpose of this study was to investigate the effect of simulated femoral-based femoroacetabular impingement on rotational motion at the pubic symphysis. The authors hypothesize that the presence of a cam lesion leads to increased relative symphyseal motion.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve hips from 6 fresh-frozen human cadaveric pelvises were used to simulate cam-type femoroacetabular impingement. The hips were held in a custom jig and maximally internally rotated at 90° of flexion and neutral adduction. Three-dimensional motion of the pubic symphysis was measured by a motion-tracking system for 2 states: native and simulated cam. Load-displacement plots were generated between the internal rotational torque applied to the hip and the responding motion in 3 anatomic planes of the pubic symphysis.

RESULTS

As the hip was internally rotated, the motion at the pubic symphysis increased proportionally with the degrees of the rotation as well as the applied torque measured at the distal femur for both states. The primary rotation of the symphysis was in the transverse plane and on average accounted for more than 60% of the total rotation. This primary motion caused the anterior aspect of the symphyseal joint to open or widen, whereas the posterior aspect narrowed. At the torque level of 18.0 N·m, the mean transverse rotation in degrees was 0.89° ± 0.35° for the native state and 1.20° ± 0.41° for cam state. The difference between cam and the native groups was statistically significant (P < .03).

CONCLUSION

Dynamic femoroacetabular impingement as caused by the presence of a cam lesion causes increased rotational motion at the pubic symphysis.

CLINICAL RELEVANCE

Repetitive loading of the symphysis by cam impingement is thought to lead to increased symphyseal motion, which is one possible precursor to athletic pubalgia.

Pregnancy-related pelvic girdle pain: an update

A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.

Internal fixation of symphyseal disruption resulting from childbirth

OBJECTIVES

To investigate the clinical and radiographic results after operative treatment of complete symphyseal disruption resulting from childbirth and to evaluate residual pain and implant failure in relation to the timing of surgery.

DESIGN

Retrospective study.

SETTING

Tertiary pelvis and acetabulum care unit at a general hospital.

PATIENTS

Ten consecutive women with complete symphysis disruption associated with childbirth were included from a database of 603 patients with pelvic fracture. No patients with this diagnosis were excluded. All patients were followed until clinical healing of the symphysis or union of the fusion.

INTERVENTION

Open reduction and internal fixation in acute (less than 2 weeks from childbirth, four patients) and after failed nonoperative treatment in subacute cases (2 weeks to 6 months after childbirth, three patients). Fusion of the symphysis with iliac crest bone graft and plate fixation after failed nonoperative treatment in chronic cases (greater than 6 months, three patients).

MAIN OUTCOME MEASUREMENT

Analyzed variables included the Lindahl score, maintenance of postoperative reduction, implant failure, malunion, and necessity of reoperation.

RESULTS

Mean age of the patients was 32 years (range, 24-37 years). Mean follow up was 29 months (range, 5-139 months). The mean postoperative Lindahl score was 68 ± 14.6 points (range, 38-80 points). There were three excellent, four good, two fair, and one poor result. Fair or poor results occurred in one subacute and two chronic cases. There were two revision surgeries. One patient underwent implant removal resulting from dyspareunia 3.1 years postoperatively. One subacute patient had conversion to symphyseal fusion after implant failure as a result of a fall 11 years after index surgery. Major complications occurred in two and minor complications in three patients. Radiographic loosening of implants was observed in all subacute cases. All fusions healed and symptoms improved at last follow up.

CONCLUSIONS

Operative management significantly improved the functional outcomes of all three subgroups and can be an acceptable treatment option for labor-induced complete symphysis pubis disruption.