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Manual Therapy (2003) 8(4), 257260 r 2003 Elsevier Ltd. All rights reserved. 1356-689X/03/$ - see front matter doi:10.1016/S1356-689X(03)00054-7

Case report

Treatment of osteitis pubis via the pelvic muscles

A. McCarthy, B. Vicenzino Department of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, Queensland, Australia

INTRODUCTION Osteitis pubis is an entity that has been discussed greatly in the orthopaedic and sporting literature from the perspective of medical intervention (Fricker et al. 1991; Batt et al. 1995; Holt et al. 1995). Many studies recommend injection of the symphysis pubis with corticosteroid as early as possible, although the outcome reported is variable (Batt et al. 1995; Holt et al. 1995). Fricker et al. (1991) found that the average time to recovery was 9.6 months. Rest is the most common treatment prescribed, but a programme of aggressive stretching of the adductors has also been recommended (Batt et al. 1995, Holt et al. 1995). The rehabilitation of this disorder was not discussed in these papers. The purpose of this case report is to describe an alternate approach to assessment and treatment looking at the athletes motion patterns in provocative activities, in addition to focussing on the local signs.

CASE REPORT A 20-year-old male Gaelic football player attended the physiotherapy clinic having experienced low central abdominal pain, which had been present for 6 weeks, (Fig. 1). Three weeks prior to attendance, he had taken a tumble forwards after scoring a goal and experienced an immediate increase in pain, which
Received: 7 April 2003 Accepted: 7 April 2003 Ann McCarthy MCSP, MPhty Studies (Sports), Head, Musculoskeletal Physiotherapy, Royal Free Hospital, London, Bill Vicenzino, PhD, MSc, Grad Dip Sports Phty, BPhty, Senior Lecturer, Director Musculoskeletal Pain and Injury Research Unit, Coordinator of Masters of Physiotherapy Studies (Sports), Department of Physiotherapy, University of Queensland, Australia. Correspondence to: B.V. Department of Physiotherapy, School of Health and Rehabilitation Sciences, University of Queensland, 4072 Queensland, Australia. Tel.: +61 7 3365 2781; Fax: +61 7 3365 2775; E-mail: b.vicenzino@shrs.uq.edu.au 257

lasted for 2 days, and then eased slightly. He had avoided exercise since. Pain was localized over the lower part of the rectus abdominus muscle. Running, kicking the ball, sit-up exercises and leg lifting exercises aggravated it. He was able to continue with a weight programme. Even split lunge exercises were not provocative. Only the aforementioned abdominal exercises were sore. One year previously the athlete had experienced a lower back injury, which had resolved with a physiotherapy regime concentrating on stabilizing exercises for the lumbar spine. The athlete had not sustained a maintenance routine of those exercises. Pain at that time had been central in a band across the low lumbar spine, bilateral buttocks and posterior thigh. His pain was provoked by unilateral weight bearing and hopping. For the current problem the athlete required no analgesic medication, and had not used anti-inammatory drugs of his own recourse. There had been no imaging of either the lumbar spine or pelvis. Running was his most limited functional activity; therefore it was examined as the rst priority. A visual analysis of the athletes running gait showed the following abnormalities: markedly limited trunk motion about the waist/lumbar spine, that is, little extension or rotation; decreased hip extension, internal and external rotation; and decreased stride length. In order to discover why these movement patterns were present, an examination of the lumbar spine, sacroiliac joints and hips was undertaken. The lumbar spine and sacroiliac joints were grossly normal. At the hips, there was a xed exion deformity of 51 bilaterally on Thomas testing (Magee 1997). The athlete was unable to isolate active hip extension from lumbar extension. Hip rotations were limited to approximately 251 and this was more apparent at the limit of extension, suggesting that anterior hip structures lacked adequate extensibility. External rotation was most reduced. The Thomas test

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Fig. 1Body chart depicting the pain presentation.

demonstrated an early anterior pelvic tilt and decreased length of iliopsoas and the quadriceps muscles. The test position became painful if the pelvis was manually stabilized by the examiner. Tests reproducing the presenting pain were: stretch and contraction of the adductor groups; an abdominal crunch exercise; palpation of the rectus abdominus insertion on to the pubis and the adjacent inguinal ligaments. In general, the athlete demonstrated a decreased ability to stabilize his lower trunk and pelvis whilst using his legs independently. Treatment was based on a progressive staged graduated therapeutic exercise programme in which isolated protective muscle function was rst established and then rapidly progressed to incorporate elements of functional tasks, rst in stable positions progressing to less stable higher demand dynamic movement patterns. Various facilitation techniques such as visual and tactile feedback of correct movement patterns and muscle activation, use of rehabilitation ball as a form of unstable base to facilitate higher level trunk stability control and repetition of staged movement patterns (kicking and running) were used. Initially, specic re-education of underactive muscles was undertaken. Gluteus medius work was developed to stabilize the hip in stance, and transversus abdominus to stabilize the low lumbar spine and pelvis. Muscles that exhibited decreased compliance on length tests (e.g., hip exor and rotator muscles) were released passively with massage techniques and inhibitory stretch techniques, but only after the client had achieved adequate activation of the gluteus medius and transversus abdominus. A home exercise programme of quadriceps, hip exor and adductor stretches was performed. In the end stages of rehabilitation, the athlete performed highlevel stability work using a large rehabilitation ball in which appropriate contraction of muscles of the pelvis and lower back was encouraged (Figs. 2a and b).
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The athlete attended for seven sessions over a period of 5 weeks. He was able to jog after three sessions and had performed a 2 km run prior to discharge, without pain and had returned to full participation of his chosen sport. At 3 months postdischarge the athlete reported being pain-free and not limited in any way by his previous symptoms.

DISCUSSION Osteitis pubis is a condition affecting the pubic symphysis in mainly athletic groups, although it has been reported post-partum and after surgery (Fricker et al. 1991). The largest incidences are reported in the football codes, but it has been reported in several other sports (Holt et al. 1995). The most frequent symptoms reported are pubic pain, lower abdominal pain and adductor pain. Commonly reported examination signs are: pubic symphysis tenderness, adductor longus muscle insertional tenderness, decreased hip external rotation, pelvic malalignment/sacroiliac joint dysfunction, and restricted hip abduction (Fricker et al. 1991). Radiographs show periosteal reaction, sclerosis and in advanced cases demineralisation of the cortical bone (Zachezewski et al. 1996). The symphysis may appear widened in the acute case, but chronic cases may demonstrate joint narrowing. Bone scan conrms the diagnosis, with increased uptake in the area of the symphysis. This must be differentiated from a pubic stress fracture (Fricker et al. 1991). Fricker et al. (1991) state that there appears to be no correlation between the bone scan or radiograph results and the severity or duration of symptoms. Although there was no imaging in the case described, the symptoms, signs and history are of a classic presentation of osteitis pubis.
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Treatment of osteitis pubis 259

Fig. 2(a and b) High level stabilizing exercises using a large rehabilitation ball.

The aetiology of the condition is still the subject of debate. In the athletic population the condition has been described as overuse in nature. Repetitive microtrauma due to the pull of the rectus abdominus muscle has been suggested. With chronic cases, instability of the symphysis and/or sacroiliac joints ilial portion has been noted (Fricker et al. 1991). This instability may be an additional cause of stress at the symphysis. Bowerman (1977) suggested that repetiManual Therapy (2003) 8(4), 257260

tive adductor muscle pull at their inferior pubic ramus insertion could produce a shearing force across the pelvis. All of the above may be partial explanations. However, they do not address the question of why the muscular over-pull or microtrauma is occurring. There is a tendency for practitioners to focus on the inciting events or mechanism of injury itself, rather than looking for causative factors, both intrinsic and extrinsic to the athlete (Meeuwisse 1994).
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Verrall et al. (1998), have used magnetic resonance imaging (MRI) scanning to examine pubic symphyses of clinically diagnosed cases of osteitis pubis. It revealed that fracture lines were present which were described as tension stress fractures (Verrall et al. 1998). These fractures may have possibly been caused by torsional stresses across the pelvis. The MRI also demonstrated bone cysts, symphyseal disc irregularity and superior pubic ligament hypertrophy. Dalstra and Huiskes (1995) have shown that the greatest load across the pubic symphysis occurs at the beginning of swing phase of gait when there is a degree of rotation across the pelvis. Using nite element analysis techniques, they have shown that muscle forces have a considerable effect on the stress patterns. Removal of muscle forces (21 of the muscles attached to the pelvis were included in the model) from their analysis showed that the load transfer from the hip joint forces is directed almost totally through an axis from the sacroiliac joints to pubic symphysis. Muscle forces across the pelvic bone, when all are acting in concert as in their model, keep the stress distributions fairly constant during the walking cycle. Dalstra and Huiskes (1995) also suggest that stress changes being kept minimal, is a favourable state with regard to fatigue failure of the bone material. It would seem reasonable to propose therefore, that an imbalance in these muscle forces might alter stresses across the pubic symphysis, reducing the motion at the symphysis and increasing the torsion of the bone. The rehabilitation approach described herein identied motor dysfunction due to altered muscle function. This motor dysfunction could have increased the susceptibility of the athlete to osteitis pubis (Meeuwisse 1994). Improving movement patterns and muscle function enables the therapist to garner an effect on the presenting signs and symptoms relatively quickly. This approach, rather than one aimed at the local pathology at the site of pain as the rst priority, enables the therapist to better direct the rehabilitation process and perhaps lessen the chances of recurrence, which is 25% in males (Hogan 1998). In the present case there was an intrinsic lack of hip extension and to a lesser extent, external rotation. We hypothesize that by improving these motions the athlete experienced a reduction in excessive strain on the pelvis by allowing a more correct balance of muscle pulls across it. Hogan (1998) describes a similar rehabilitation approach conducted in a step-wise process. Rehabilitation programmes should indeed progress from less stressful and simple early stages to more complex and demanding later stages, eventually leading to a return to sport. However, the hierarchical model suggested by Hogan (1998), appears not to allow for any interplay between the phases. Proprioceptive and sport skills need not be left until late in the process.
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Vigorous or strenuous stretches have been recommended (Batt et al. 1995; Holt et al. 1995). In this case, it was determined that rectus abdominus and adductor over-pull was due to a dysfunction of the trunk and hip stabilizing muscles. Stretching is not likely to facilitate these muscles. There must be a prior muscular re-education programme before stretching begins in earnest. These stretches must be integrated in the re-education process by concentrating on maintaining control of the pelvic position. The stretches need not be vigorous, but should be effective. Proprioceptive neuromuscular facilitation type stretches have been shown to be the most effective (Moore and Hutton 1980; Sady et al. 1982).

CONCLUSION Osteitis pubis is a self-limiting condition that is becoming more readily identied by clinicians. Although it will eventually resolve with prolonged rest, identication and restoration of abnormal motion patterns and muscle dysfunction about the pelvis and hip may lead to a more speedy recovery. In the general treatment of sporting injuries, betterdirected rehabilitation may be achieved when identication of these factors is made a priority, with less focus of treating the signs locally at the site of pain.

References
Batt ME, McShane JM, Dillingham MF 1995 Osteitis pubis in collegiate football players. Medicine and Science in Sport and Exercise 27(5):629633 Bowerman JW 1977 Radiology and injury in sport. In: Radiology and Injury in Sport. New York: Appleton-Century-Crofts, pp 224225 Dalstra M, Huiskes R 1995 Load transfer across the pelvic bone. Journal of Biomechanics 28(6):715724 Fricker PA, Taunton JE, Ammann W 1991 Osteitis pubis in athletes: infection, inammation, or injury? Sports Medicine 12(4):266279 Hogan A 1998 A rehabilitation model for pubic symphysis injuries. In: Australian Conference of Science and Medicine in Sport, 13-16/10/1998. Sports Medicine Australia, Adelaide, p 143 Holt MA, Keene JS, Graf BK, Helwig DC 1995 Treatment of osteitis pubis in athletes. American Journal of Sports Medicine 23(5):601606 Magee DJ 1997 Orthopedic Physical Assessment, 3rd edn. W.B. Saunders Company, Philadelphia. Meeuwisse WH 1994 Assessing causation in sport injury: a multifactorial model. Clinical Journal of Sport Medicine 4:166170 Moore MA, Hutton RS 1980 Electromyographic investigation of muscle stretching techniques. Medicine and Science in Sport and Exercise 12(5):322329 Sady SP, Wortman M, Blanke D 1982 Flexibility training: Ballistic, Static or Proprioceptive Neuromuscular Facilitation? Archives of Physical Medicine and Rehabilitation 63:261263 Verrall G, Slavotinek J, Fon G 1998 Osteitis pubis in Australian rules footballers: A stress injury to the pubic bone. In: Australian Conference of Science and Medicine in Sport, 13-16/ 10/1998. Sports Medicine Australia, Adelaide, ACT, p 227 Zachezewski JE, Magee DJ, Quillen WS 1996 Athletic Injuries and Rehabilitation, 1 edn. W.B. Saunders Co., Philadelphia, PA. Manual Therapy (2003) 8(4), 257260