Dear all,
             I would like to  thank warmly all those who have responded to
my request for information and help regarding my posting. I have compiled a
summary of replies below. I have passed on your replies to the athlete who
made the original request for help and I'm sure he will benefit from your
advice once he has consulted with those responsible for his care and
treatment.

I will be contacting individual respondents in due course.

Regards,
              Ian

Original message:

From: CARMEL SPITERI <[log in to unmask]>
Organization: University of Malta
To: [log in to unmask]
Subject: Re:Osteitis Pubis

Dear Ian,

I am a young soccer player and have been diagnosed as having osteitis pubis
The diagnosis has been substantiated with the use of X-Rays and a Bone Scan.
The pain in the right groin region had started growing slowly. At first the
pain occurred after having played a match. I used to go for physiotherapy
sessions in a heated pool. The injury seemed to improve and I started
running. At this time the pain was practically inexistent. After this period
the club doctor instructed me to start normal training schedules, at which
point, the pain came back. This whole period took me around six months.
>From there, I had to start all over again since the pain was quite intense.
The main problem I have now is that the pain, (after around three months of
physiotherapy in the pool) has moved to the left groin area and does not
seem to be decreasing. Also, the pain I now encounter is different, in that
the pain occurs when I try to open my left foot outwards, and not when
pressing my knees together.
Also different doctors have advocated different procedures. The club doctor
has advised me to continue with the physiotherapy. Another sports doctor has
advised me to take corticosteroid injections, whilst a third foreign doctor
who works in Malta and whom my club took me to see opted for an operation.
If anyone on the list knows something about the condition and the pros and
cons of the different treatments, could he forward this information to me.
Thanks a lot.
C.S.


Summary:

Reply-To: “American Medical Soc. of Sports Medicine” <[log in to unmask]>
From: Matt McQueen MD <[log in to unmask]>
Subject: Re: Osteitis Pubis

Give consideration to an undiagnosed Inguinal Hernia - “Gilmore’s Groin”

******
From: “Scott Grindel, M.D.” <[log in to unmask]>
Subject: Re: Osteitis Pubis
To: [log in to unmask]

Ian,

I agree, Gilmore’s groin may be the culprit.  It sounds as though the
physician who wanted to do an operation may have thought the same (?).  Also
consider stress fracture, osteitis pubis, subacute testicular torsion (make
sure he’s wearing supportive jockstrap), nerve entrapments, and back/hip
pathology (may be referred pain).  I would make sure a thorough exam was
done.  If it is adductor/abdominal pain you can try Vulcan pants (Bar-1
brace by Brace International).  These essentially compress, warm, and
stabilize the groin and hamstrings.  I have had good success with them for
groin and hamstring strains in combination with an aggressive abdominal
strengthening program and stretching/strengthening of the thigh/buttocks.  I
am very reluctant to inject adductors of the groin as I have seen (from a
distance, thank goodness) an American football lineman avulse his adductor
magnus due to this.  If it is inguinal pain (Gilmore’s groin), surgical
options may be in order if rest, PT, and NSAIDs have failed.  There will be
no guarantee the surgery will be successful if no obvious exam findings.  It
depends on how frustrated the patient is with the pain.
Here are some responses from the list on Gilmore’s groin from back in
November (including your response Ian):
Good review on Gilmore’s Groin in Clinics in Sports Medicine October 1998 -
“Groin Pain in the Soccer Athlete: Fact, Fiction, and Treatment” by Jerry
Gilmore.
David Ross, MD

This is the type of groin pain about which the Australians have been
talking and studying for several years, as Margot notes there are
precious few Americans with expertise here. The Australians have
identified several causes including occult abdominal/inguinal hernias
and ilioinguinal nerve entrapments, as well as all the usual stress
fractures, osteitis pubis, etc.  In the absence of sending the patient
to Australian, I would suggest at least an email or phone call to the
Olympic Park Sports Medicine Centre, Drs. Chris Bradshaw, Paul McCrory
([log in to unmask]) or
Peter Brukner ([log in to unmask]).
Tom
Thomas L. Schwenk, MD


We have had two athletes recently who I would consider classic “Gilmore’s
Groin” problems.  One a soccer player, and the second a decathlete.  They
both presented similarly with diffuse, generalized complaints consistent
with a variety of adductor, abdominal and sartorius type muscle patterns,
minimal to mild pain at the symphysis pubis, and pain on inguinal ring
palpation during hernia check.  Dr. Bill Myers at UMass Worcester (formerly
trained at Duke with US Soccer’s Bill Garrett) is who has performed the
surgery.  He is likely one of the few  American “experts”, and has operated
on several US National Team soccer players as well as hockey and track
athletes from around the country.  From what he has described to me the
procedure involves an inguinal floor repair (herniorraphy) along with
adductor tendon release.  Dont have enough follow-up to give you an opinion
on the success or recurrence rate.
[log in to unmask]
Margot Putukian, MD


Hi, a quick search of the web using the subject gave up this
reference as the first hit (Alta Vista). It appears to be common to
Rugby players. I’ve cut the rest of the contents.Hope this helps!
I’m also forwarding this message to amssmnet in the hope that someone will
have other references/information.
Intermittent High Intensity Exercise : Preparation, Stress and Damage
Limitation Back to Rugby Books
Sports Medicine Congress 1991 Editorial Board and Speakers Organizing
Committee
Foreword
By Princess Royal
Introduction
By I. R. Vanderfield, D. A. D. Macleod
“Gilmore’s Groin”: a previously unsolved problem in sportsmen
By O. J. A. Gilmore
Regards,
Ian Rogers M.Med.Sci.

> ----------
> From:         IAN ROGERS[SMTP:[log in to unmask]]
> Sent:         Tuesday, February 23, 1999 2:18 PM
> To:   [log in to unmask]
> Subject:      Re: Osteitis Pubis
>
> I am forwarding this request to the list for your consideration and help.
> I
> am a Sport and Exercise Science Master’s graduate who offered the person
> below some references and web sites where he might find further
> information.
> Clearly he needs some practical, medical advice which I can’t offer.
>
> If you reply to me directly, or to the list, whichever you feel is most
> appropriate, I will compile a summary to forward to the person.
>
> Regards,
>               Ian
> Ian Rogers
> 232, Broomhall St,
> SHEFFIELD S3 7SQ
> UK
>
> Tel. 0114 276 1018
> E-mail [log in to unmask]


*****
From: “Jim Crosby” <[log in to unmask]>
To: [log in to unmask]
Subject: Osteitis Pubis

Hi,

I am physio with on of the Scottish Premier League soccer clubs,  and
obviously had some experience of the various groin problems occurring in
soccer players.
I would be interested to know the age of your ‘patient’ and also the level /
frequency /intensity at which they participate in their sport.
I would also recommend that he undergo a radio-isotope bone scan (sounds
BAD... actually pretty simple!!) to determine the extent of the absorption
hot-spots’ of bone inflammation.  Given the information from such a scan it
should be possible to differentially diagnose pain caused or influenced by
bone inflammation, or from other factors.
Osteits pubis can often be mis-diagnosed and the pain be referred from back
/ sacro-illiac problems.
If osteitis pubis is the clinically diagnosed condition then a follow-up
bone scan taken 5-6 months later can provide objective information relating
to the progress or otherwise of the condition.
A common problem encountered in the rehabilitation process is of
over-exuberance from both the patient and the medical / physio staff.  Being
sent for ‘physiotherapy’ can have drawbacks... (speaking as a physio  :-))
We tend to concentrate exercises on rehabilitation of the injured area.
Sometimes rest and time is the best (?only) way to make effective progress.
Osteitis pubis is an active bone inflammation in the area where the
principle lower limb adductors have their individual and common insertions.
Gentle exercise, even in a heated pool,  can (with the best intentions) give
rise to a continuation of symptoms.
I would be interested if you could keep me informed of the responses you get
with your request.  If you have a fax number I have an article (not the one
you refer to) from one of the sports medicine journals which might be of
interest.
best wishes,

Jim
[log in to unmask]

*****
Subject: Re: Osteitis Pubis
From: [log in to unmask]
To: [log in to unmask]

In a message dated 2/26/99 5:06:05 PM Eastern Standard Time,
[log in to unmask] writes:
<< Also different doctors have advocated different procedures. The club
doctor
has advised me to continue with the physiotherapy. Another sports doctor,
has advised me to take corticosteroid injections, whilst a third foreign
doctor who works in Malta and whom my club took me to see opted for an
operation. >>

Not mentioned in the above is very likely the least invasive procedure, that
of manipulation.  Fixated or immobile/dysfunctional sacroiliac joints or
pelvic imbalance may manifest in pubic symphysis stress, and quite possibly,
osteitis pubis.  I’ve provided many patients relief from groin related
complaints with manipulation and associated therapies.
Randy Conger, DC, CCSP
(Chiropractic Sports Physician) Date: Sat, 27 Feb 1999


*****
Subject: Re: Osteitis Pubis
From: David Felhendler <[log in to unmask]>
To: [log in to unmask]

Hi Ian,

> If anyone can offer anything in the way of advice and information for
> this athlete he would be very grateful.

In my opinion this sounds very much like a referred pain. Areas that can
refer pain to that region starts around T11 and ends with the SIJs.
My suggestion is that he is seen by some kind of manual therapist (PT,DC,DO)
who can assess and treat this.
That’s something to start with.
All the best,

David


*****
Subject: Re: Osteitis Pubis
From: [log in to unmask]

I have had the opportunity to treat two patient’s with this diagnosis. Both
incidence were caused by splits or a sudden strain of the adductors. This
injury in my opinion can cause:
1. an adductor muscle strain at the origin
2. a separation of the pubis and ligametious sprain.

I have found muscle strains can take up to 6 months to completely resolve.
Continued stretching and strengthening are required and progressed to
tolerance.  Initiating full athletic activity before restoration of strength
will provoke recurrence.
If separation is the primary problem weight bearing exercise such as squats
are helpful. Exercise or activity provoking separation should be avoided for
up to 3 months.
In both cases dependent upon acuteness either Phonphoresis or Pulsed US is
effective, prior to gentle stretching and exercise.
I have not read any literature concerning this diagnosis.
Charlie Filippone PT OCS

*****
Subject: Re: Osteitis Pubis
From: “Bernadette Sangeelee” <[log in to unmask]>
To: <[log in to unmask]>


Dear Ian,
Last summer I went to a one day seminar, about injuries of hip and groin.
Graham Smith (tutor) told us the following:
Osteitis pubis is sclerosis of symphysis pubis, but pts. have that long
before they get problems. Symptoms: vague aches and pains in pubic area and
inside legs, very tight adductors, recurrent groin injuries over a long
period of time. Main problem: low endurance of adductors causing fatigue,
which causes high tone in adductors.
Treatment: Conditioning of adductor endurance: Repetitative adduction and
abduction in sling suspension with pulley over symphysis pubis. Do this
until patient needs rest. After the rest he has to continue until he has
done 200 repetitions. Carry on this programme until pt. can do 200 reps
without a rest. (Make sure pt. does not lift his legs, it should be done in
the hor. plane.
This Rx does not cure the osteitis pubis, but cures the symptoms.  Hope this
is helpful. I have never come across a pt. with this problem, so I do not
know if it actually works.
Good Luck,
Bernadette.

*****
Subject: Re: Osteitis Pubis
From: Herb Silver <[log in to unmask]>
To: [log in to unmask]

>Dear Ian,
>Last summer I went to a one day seminar, about injuries of hip and groin.
>Graham Smith (tutor) told us the following:
>Osteitis pubis is sclerosis of symphysis pubis, but pts. have that long
>before they get problems. Symptoms: vague aches and pains in pubic area and
>inside legs, very tight adductors, recurrent groin injuries over a long
>period of time. Main problem: low endurance of adductors causing fatigue,
>which causes high tone in adductors.
>Treatment: Conditioning of adductor endurance: Repetitative adduction and
>abduction in sling suspension with pulley over symphysis pubis. Do this
>until patient needs rest. After the rest he has to continue until he has
>done 200 repetitions. Carry on this programme until pt. can do 200 reps
>without a rest. (Make sure pt. does not lift his legs, it should be done in
>the hor. plane.
>This Rx does not cure the osteitis pubis, but cures the symptoms.  >Hope
this is helpful. I have never come across a pt. with this problem, so I >do
not know if it actually works.
>Good Luck,
>Bernadette.
>
I am interested in this treatment but can’t visualize where the pulley is.
This is my attempt at a drawing without doing an attachment to the file—see
drawing below.  The person is in sidelying (please reference the smiling
face).  Is the “X” located where you are suggesting the pulley is—ie above
the pubis?  If that is correct, the next question is “where is the
resistance—at the ankle or above the knee?  And I imagine this is very light
resistance in the range of not reproducing any symptoms after at least 20
reps—correct?
\   X
           \
            \
      _______\__________(:



Herb Silver
[log in to unmask]


*****
Subject: Re: Osteitis Pubis
From: Nicola PHILLIPS <[log in to unmask]>
To: [log in to unmask]


Dear Ian,
I have treated a number of rugby players with this problem - some responded
to conservative management with physiotherapy alone, some with rehab after
steroid injection. 2 players went through the above process but the pain
returned on resuming training. They were eventually managed by fusing the
symphysis pubis with bone graft and plate. They both returned to
professional level rugby union after rehab.
If this footballer hasn’t responded to conservative management and you’re
confident he has tried the right exercises I would suggest he  tries a more
aggressive approach after what must now be 8 months of  treatment. Although
some medical opinion suggests waiting  up to a  year before considering
surgery as these injuries are notoriously slow to settle.
Nicola Phillips


*****
From: Nicola Cockarill <[log in to unmask]>
Subject: RE: Osteitis Pubis

A copy of the Jerry Gilmore “Groin pain....” article is held in NSMI
Library.
Here are a couple more articles on the subject of osteitis pubis:
When groin pain is more than “just a strain” :navigating a broad
differential
Ruane J and Rossi T
Physician and Sportsmedicine 26 (4), Apr 1998, P78-103

Osteitus pubis
Fricker P
Sports medicine and arthroscopy review, 5(4), Oct/Dec 1997 305-312

For more details of a complete literature search, please contact Nicola
Cockarill  e-mail - [log in to unmask]

*****
Subject: Re: Osteitis Pubis
From: john spencer <[log in to unmask]>
To: [log in to unmask]

Dear Ian,
I have had some good results on these symptoms in footballers by employing
Transversus Abdominus and Multifidus stability work. Paul Hodges from
Brisbane who has done a lot of work on the area believes these muscles are
important in stabilising the SI and hence Pubic Symphysis. (an an unstable
SI may well be responsible for an inflammed, irritated pubis with the
symptoms you describe).
If you want to follow-up this line then do write back and I can tell you
more (there is a new book on the subject). I believe that these exercises
have been used on sports people prophylactically and may be responsible for
dramatically reducing injury rates. If you wanted to talk on the phone I
could forward you a number as I am pretty local (Manchester)
--
john spencer (MCSP)

*****
To: [log in to unmask], [log in to unmask],
From: Garry Alison <[log in to unmask]>
Subject: Re: Osteitis Pubis

Following from the comments/ questions on Pubis Osteitis by Ian Rogers &
John Spencer. I would like to add some anecdotal information - when I refer
to Football I mean Australian Rules football..Soccer  - Association
football.
Working with a football team I see what I call a trilogy of conditions
a) Lumbar segmental spine dysfunction - more of a instability pattern (eg
Spondylolythesis / Pars # worst case senarios)
b) variable pattern groin pain +/- adductor ‘strains’
c) Pubis Osteitis

Middle distance running athletic population the standard presentation
characteristics are well documented.. these are often replicated within the
football / soccer population of athletes I see. However, I feel the coaching
strategy must be part of the treatment protcol. Kicking ‘around the corner’
I believe plays an important role - especially when the athlete is fatigued
or placed under a lot of pressure from the opponent..The ‘round the corner
kick is hard to describe..but I’ll try.. the athlete is running at speed and
kicks the ball at an exaggerated angle across his body - without a slide as
happens sometimes in soccer. An example is the cross in Soccer and defenders
running out of the back pocket in Australian rules.  The individual needs to
be able to perform this task with controlled stability of the stance leg.
The stability of the pelvis is associated with appropriate coactivation
patterns including the hip abductor glut. med. The TFL tends to stabilise
the hip but does not allow the through range control. Anecdotally, I feel
that this places addition stressors on the Lx - lateral flexion and rotation
during the kicking action and the hemipelvis - shear forces across the pubis
and the soft tissues of the conjoint tendon.  The stabilising role of
Transversus Abdominus (and in my opinion parts of Int Oblique) is critical
in the whole motor pattern. We have shown to some degree the ability of
specific training regimens to alter chronic back pain attributable to
segmental instabilities (See O’Sullivan, Twomey and Allison JOSPT, SPINE)’
It doesn’t stop people making generalisation to other diagnositic groups -
which are in my opinion probably reasonable.
In summary, the presentation of the ‘trilogy’ is dependent upon the
individual’s biomechanical and motor control compensatory mechanisms. This
helps explain the heterogeniety of the presenting symptomology. In anycase
any rehabilitation program needs to be sports specific with gradual adaptive
overloads. It is important in these cases the understand that the
sympotmology reflects their inability to compensate and that they may have a
poor stability pattern before the the symptoms appear (reappear).  Therefore
COACHING is a signficant part of the treatment Cheers Garry.


GT Allison PhD
Senior Lecturer in Fiunctional Rehabilitation
The School of Physiotherapy
<[log in to unmask]>


*****
Subject: Osteitis Pubis
From: “Bernadette Sangeelee” <[log in to unmask]>

Dear Herb,
Finally I have come round to reply to your response. This patient is  meant
to lie supine, and the pulley is over the symphysis pubis. The  slings are
around the ankles, so there should be virtually no  resistance. Hope this is
clearer.
Bernadette.

*****
Subject: Re- osteitis pubis.
From: [log in to unmask] (Robert Michie)
To: [log in to unmask]

>Dear Ian,
>I have had some good results on these symptoms in footballers by
>employing Transversus Abdominus and Multifidus stability work. Paul
>Hodges from Brisbane who has done a lot of work on the area believes
>these muscles are important in stabilising the SI and hence Pubic
>Symphysis. ( an unstable SI may well be responsible for an inflammed,
>irritated pubis with the symptoms you describe).<
Me too with  2 footballers,  as with pregnant women who have rectus abdomen
diastasis and/or Symph.Pubis Disfunction/diastasis.
Myra Michie

*****
From: “Kenneth Heck” <[log in to unmask]>
To: <[log in to unmask]>
Subject: Re: Osteitis Pubis

>>> john spencer <[log in to unmask]>
Ian,
Your player probably has some type of SI movement of his innominate bone.
This may include an anterior innominate rotation, a posterior innominate
rotation, an upslip of the innominate or an inflare or outflare of the
innominate bone.
My suggestion would be to palpate the PSIS bilaterally and have him slowly
lift his knee to his chest while you assess movement of the PSIS.  The PSIS
should move on the side of the flexing leg.  If it does not move on one side
than you may have a rotation of the innominate.  The other test that you can
do is to palpate the ASIS bilaterally and stabilize the hip from rotating.
While doing this, have him stand with his feet more than shoulder width
apart.  then ask him to stand flat footed on one foot and on the heel of the
other.  Then have him rotate the “heel” foot outward as far as possible,
then in as far as possible.  Note the degree of movement and or pain with
either of those movements.  Repeat with other foot.  Should there be a
difference it is idicative of a flaring of the innominate bone.
An inflare will be unable to rotate out as far An outflare will be unable to
rotate the foot in as far Both may be painful when doing this.
To confirm the type of flare, note the leg that has a movement deficiciency
and then lie him supine.  palpate the ASIS with your thumbs.  Note if one is
higher than the other.  Have him look at your thumbs and see if he can note
a height difference.  The painful side/motion restricted side should be
noticable to be clinically significant.
This can be treated with muscle energy therapy.
Note: the rotational innominates can also be treated with muscle energy
therapy as well.
Try this.  If something significant shows up write back
I would also check the internet for Richard Jackson.  He is an SI authority
and he may have something posted in this area.  I haven’t looked.
Hope this helps
Ken Heck , MS, ATC
Asst. Prof. Athletic Training
Messiah College
Grantham, PA.

*****
From: MIKE NUCCIO <[log in to unmask]>
Subject: Osteitis Pubis

Go to the below web site.  The web site was constructed by some graduate
school classmates of mine for our Assessment of Athletic Injuries course.
The contact person for the Hip & Pelvis page is Stephanie Stradley
([log in to unmask]).
http://www.hhp.ufl.edu/ess/at/PET4623.htm
Once at the site click on the Hip & Pelvis Injuries link, then click on the
fractures, ... link.
Hope you get some results,
Mike Nuccio, ATC/L, LMT
Graduate Assistant
Athletic Trainer
University of Florida
University Athletic Association
[log in to unmask] or
[log in to unmask]



*****
From: [log in to unmask]
To: [log in to unmask]
Subject: Osteitis Pubis

Dear Ian:
Your comments were e-mailed to me and to me and here’s a piece I recently
wrote about your problem...
It’s tempting to assume every pain in the pubic area is just another
run-of-the-mill groin pull like you had last time, and that stretching the
area before every work-out will take care of it.  Fortunately or
unfortunately, the hip area is a little more complicated than that. And one
of the common but frequently undiagnosed ways it can object to hard training
is a condition called osteitis pubis, an irritation of the pubic bone that
can imitate a number of other things like a hernia.
It’s an inflammation of the bones where the two halves of the pelvis meet in
the front. By moving up and down and rotating a little, that pelvis joint
does its job mechanically by help-ing you to be more flexible. But nature
supplied the pubic symphysis, as the joint is called, with a stingy blood
supply and consequently a great ability to become inflamed rather than
healed after irritation. So while it’s absorbing the shocks it was meant to
take from the rest of the body, it’s not really able to deal with them after
it gets them.
The classic osteitis pubis victim I see is a runner, male or female, who’s
been pounding out the miles on a hard surface in worn shoes that no longer
cushion, or possibly had too little cushioning to begin with. Men who’ve had
prostate surgery are more vulnerable. In its early stages, a mild stretching
program to loosen all the muscles that attach to and therefore pull on the
groin area might have been enough, plus some rest or at least an exer-cise
switch to water running, swim-ming, or even cycling on smooth roads. But by
the time I see most athletes, their futile “groin pull” therapy piled on top
of a full training schedule has produced se-vere pain, with particular
tenderness right on the pubic bone. Now it hurts even worse when they
stretch, and the softening of the pubic bone from all the irritation is
obvious enough to be seen on a common x-ray.
By the time the inflammation has gone this far, it’s going to take some
medication to reverse. Two weeks on corticosteroids are usually enough to
erase the symptoms, but you can be on limited or alternate exercise for as
much as two months. Ignoring it will not make it go away. In fact if it’s
untreated long enough it becomes chronic, and the only choice left is
surgery to actually fuse the pubic bone so it no longer moves.
Lewis G. Maharam, M.D., FACSM
President, Greater NY Chapter, American College of Sports Medicine
[log in to unmask]
Office Telephone: 212-308-2348

---------------------------------------------------------------------------

Ian Rogers M.Med.Sci.
232, Broomhall St,
SHEFFIELD S3 7SQ
UK

Tel. 0114 276 1018
E-mail [log in to unmask]



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