Physical Therapy Rehabilitation for Osteitis Pubis (Hip adductor pain)

Introduction

Osteitis Pubis is an inflammatory condition affecting the pubic symphysis, the joint where the two halves of the pelvis meet at the front. It is commonly associated with sports that involve running, kicking, or rapid directional changes, leading to overuse or injury. This condition can cause significant pain and limitation in movement, affecting an athlete’s performance and quality of life. Physical therapy rehabilitation plays a crucial role in the management and recovery from Osteitis Pubis, aiming to reduce pain, restore function, and prevent recurrence.

Clinical Symptoms

• Pain localized over the symphysis and radiating outward/ downwards
• Hip adductor (medial side of thigh) muscle pain or lower abdominal pain
• Pain is exacerbated by activities such as running and pivoting movement
• Pain occurring with walking, climbing stairs, coughing, or sneezing

A sensation of clicking or popping upon rising from a seated position or turning over in bed. Patients will have point tenderness to palpation directly over the symphysis pubis.

Causes and Risk Factors

Osteitis Pubis is primarily caused by repetitive stress on the pubic symphysis and surrounding muscular and fascial structures. The most important muscles are the hip adductor group. This muscle group is progressively getting tight and creates abnormal tensile force resulting in inflammation on the pubic symphysis and insertion of hip adductor tendons

Athletes participating in sports such as soccer, hockey, football, and running are at higher risk due to the dynamic and high-impact nature of these activities. Factors ontributing to the development of Osteitis Pubis include muscle imbalance, poor biomechanics, inadequate warm-up and stretching, and previous pelvic or groin injuries.

Diagnosis

Diagnosis of Osteitis Pubis involves a detailed medical history, physical examination, and imaging studies such as X-rays or MRI to rule out other conditions and confirm inflammation of the pubic symphysis.

Comparison of MRI images taken before and after the treatment program

The patient took the first MRI image before having his first treatment. It showed moderate to severe inflammation in symphysis pubis (Left picture where the arrows are pointing).

He had 9 sessions of comprehensive treatment with Focused shockwave therapy. The session consists of focused shockwave therapy on hip adductors and symphysis pubis, manual therapy, myofascial trigger point release, stretching and mobility program, electrical stimulation and red light therapy. After having 9 sessions, he didn’t have pain any more and only felt occasional tightness in the upper adductor area. He has been performing stretching/flexibility exercise program and his hip and back mobility have improved significantly. He took an MRI again and it presents with minimal inflammation in the symphysis pubis area.

Our Rehabilitation Program

Initial Phase: Pain Management and Rest

• Rest: Avoid activities that exacerbate symptoms.
• Ice Therapy: Apply ice packs to the affected area to reduce inflammation and pain.
• Electrotherapy: Modalities like TENS can provide short-term pain relief.
• Soft tissue mobilization: slowly release tight muscles in hip adductors, and flexors
• Myofascial release: releasing lower abdomen fascia increase blood circulation

Intermediate Phase: Release dysfunctional tissues and improve Mobility and Flexibility

• Focused Shockwave Therapy: One of the best modality for adductor tendinitis and symphysis pubis pain
• Manual Therapy: Techniques such as myofascial trigger point therapy and deep tissue release to improve tissue flexibility and decrease pain.
• Flexibility Exercises: Stretching and mobility exercises for the hip flexors, adductors, and hamstrings to relieve tension and improve range of motion.

Advanced Phase: Functional Training and Gradual Return to Sport

• Functional Training: Exercises that mimic sport-specific activities to prepare the athlete for return to sport.
• Gradual Return to Sport: A stepwise increase in activity level based on symptoms and functional capacity.

Benefits of Focused Shockwave Therapy

Focused Shockwave Therapy (FSWT) is a non-invasive treatment option that has shown promise in the management of Osteitis Pubis. It works by delivering high-energy sound waves to the affected area, promoting healing and reducing pain through several mechanisms:

• Pain Reduction: FSWT can interrupt the pain cycle by reducing nerve sensitivity.
• Increased Blood Flow: The therapy promotes neovascularization, improving blood supply to the area and accelerating healing.
• Tissue Repair: FSWT stimulates the body’s natural healing processes, encouraging tissue regeneration and repair.
• Mobility Improvement: By reducing pain and inflammation, FSWT can help restore mobility, allowing for more effective participation in rehabilitation exercises.

Conclusion

Osteitis Pubis is a challenging condition for athletes, significantly impacting their ability to perform. A comprehensive physical therapy rehabilitation program, incorporating focused shockwave therapy, manual therapy, strengthening, flexibility, and functional training, is critical for recovery