Management of a nonathlete with a traumatic groin strain and osteitis pubis using manual therapy and therapeutic exercise: A case report.

INTRODUCTION: Without a definitive single pathoanatomical origin for groin pain, management is difficult. The purpose of this case report is to describe the differential diagnosis and management of an individual with a traumatic groin strain. Case Description: A 47-year-old sedentary male truck driver presented to physical therapy with a 2-month history of right medial groin pain. Pushing the gas pedal and sitting were painful activities. Pain was 3-8/10 on the Numeric Pain Rating Scale (NPRS). The patient reported 46/80 on the Lower Extremity Functional Scale. Examination: Tenderness was noted along the adductor longus muscle belly, right pubic ramus and hip range of motion was limited. Special tests directed at the hip and pelvic region indicated intraarticular and pelvic dysfunction. Treatment included hip and pubic symphysis joint mobilizations, lumbopelvic manipulation, adductor longus soft-tissue mobilization, and core strengthening. Outcome: 12 sessions of physical therapy resulted in LEFS to 80/80, Global Rating of Change (GROC) + 7, and NPRS 0/10 at worst. The patient returned to full work without restriction. Discussion: Groin pain has many pathoanatomical drivers. Management of a traumatic groin injury requires a thorough evaluation and a global treatment approach, in order to improve outcomes and reduce the risk of the pathology becoming chronic.

Edema óseo idiopático: evolución de 3 casos tratados con denosumab / Idiopathic bone marrow oedema: Outcome of 3 cases treated with denosumab

El edema óseo idiopático se considera una entidad de fisiopatología no aclarada y origen multifactorial que afecta a personas de mediana edad; se caracteriza por dolor e impotencia funcional en extremidades inferiores asociados a hallazgos característicos en resonancia magnética: imágenes hipointensas en T1 e hiperintensas en T2 en las articulaciones afectadas. Presentamos 3 casos clínicos de varones (edad: 45-64), 2 en rodillas y uno en cadera. Inicio con dolor intenso (EVA ≥ 5), sin desencadenante claro e impotencia funcional con imágenes características en resonancia magnética. Tratamiento: vitamina D (20.000 UI/semana vía oral) y dosis única subcutánea de denosumab (60mg) (indicación fuera de ficha técnica), descarga de articulación afectada y ejercicios autoasistidos de mantenimiento de recorrido articular. Evolución favorable con resolución clínica y del edema óseo, sin complicaciones reseñables. El denosumab se muestra como una opción de tratamiento para la resolución clínico-radiológica del edema óseo idiopático y parece acortar la evolución natural del proceso

Idiopathic bone marrow oedema is considered an unclarified pathophysiological entity of multifactorial origin affecting middle-aged persons; it is characterised by pain and functional limitation of the lower extremities. Characteristic findings on magnetic resonance imaging are hypointense T1 and hyperintense T2 images in the affected joints. We present 3clinical cases of BMO in men (age: 45-64 years), involving 2knees and one hip. Onset occurred with intense pain (VAS ≥ 5), with no clear cause and functional limitation with characteristic images on magnetic resonance imaging. Treatment consisted of vitamin D 20,000 IU/week orally and a single subcutaneous dose of denosumab 60mg (off label use). The patients avoided weight bearing on affected joints and conducted self-assisted exercises to maintain range of movement. Outcome was favourable with clinical and bone oedema resolution, with no notable complications. This report demonstrates that denosumab is a treatment option for the clinical/radiological resolution of bone marrow oedema and seems to shorten the clinical course of the process

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.

The Effectiveness of Nonoperative Rehabilitation Programs for Athletes Diagnosed With Osteitis Pubis.

Clinical Scenario: The differential diagnosis of groin pain can be very challenging due to the many causative pathologies. Osteitis pubis is a pathology that is becoming more recognized in athletes who participate in sports such as soccer, ice hockey, rugby, and football. Conservative nonoperative treatment is often prescribed first before surgical intervention. Of particular interest are the outcomes of nonoperative rehabilitation programs and their effectiveness to return athletes to preinjury levels of participation. The most recent systematic review in 2011 examined the spectrum of treatments for osteitis pubis and found only level 4 (case report or case series) evidence with varying approaches to treatment. Due to the amount of time since the last published review, there is a need to critically appraise the recent literature to see if more high-quality research has been published that measured nonoperative interventions for athletes with osteitis pubis. Focused Clinical Question: Is there evidence to suggest that nonoperative rehabilitation programs for osteitis pubis are effective at returning athletes to their preinjury levels of participation? Summary of Key Findings: Four studies met the inclusion criteria. Only level 4 evidence was found. All studies reported using a structured nonoperative rehabilitation program with a successful return to preinjury participation between 4 and 14 wk, except for 1 study reporting a successful return at 30 wk. Successful long-term follow-up was reported at 6-48 mo for all patients. Clinical Bottom Line: There is weak evidence to support the efficacy of nonoperative rehabilitation programs at returning athletes to their preinjury levels of participation. Strength of Recommendation: There is grade D evidence that a nonoperative program for osteitis pubis is effective at helping athletes return to their preinjury level of participation. The Centre of Evidence Based Medicine recommends a grade D for level 4 evidence with consistent findings.

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.

Physical therapy management of osteitis pubis in a 10-year-old cricket fast bowler.

This case report describes a 10-year-old boy who presented with radiating pain (Visual Analog Scale score of 7.2 cm) down his left groin and was eventually diagnosed to have osteitis pubis. History revealed that he was exceeding the workload guidelines of bowling for a fast bowler. Examination findings were left sacro-iliac joint dysfunction, reduced left internal rotation of the hip, tightness of bilateral hip flexors and poor motor control of the lumbo-pelvic muscles. Physical therapy was aimed at correcting the sacro-iliac joint dysfunction, increasing the hip range of motion and muscle length along with exercises aimed at improving the lumbopelvic stability. The patient had complete resolution of pain by the ninth week and returned to fast bowling without any discomfort.

Multimodal physiotherapeutic management for stage-IV osteitis pubis in a 15-year old soccer athlete: a case report.

Osteitis pubis among soccer athletes is a disabling painful condition and it is difficult to manage without integrating a multimodal treatment approach. There is limited scientific evidence on the effectiveness of exercise in treating Osteitis pubis especially when it progress to a chronic painful condition. The purpose of this case report is to discuss the successful multimodal physiotherapeutic management for a 15-year old soccer athlete diagnosed with stage-IV Osteitis pubis. Land and water based active core muscle strengthening exercises, Proprioceptive neuromuscular facilitation techniques (PNF) and Manual Therapy are some of the essential components incorporated in multimodal intervention approach with emphasis to water based strength and endurance training exercises. The athlete was able to make progress to a successful recovery from his chronic painful condition and accomplished the clearly established clinical outcomes during each phase of rehabilitation.

Osteitis pubis in athletes.

Osteitis pubis is one of many etiologies of groin pain in athletes. It is a painful overuse injury of the pubic symphysis and the parasymphyseal bone that typically is found in athletes whose sports involve kicking, rapid accelerations, decelerations, and abrupt directional changes. Athletes most commonly present with a complaint of anterior and/or medial groin pain but also can present with lower abdominal, adductor, inguinal, perineal, and/or scrotal pain. Symptoms can be severe and can limit participation in sport until treatment is instituted. Imaging is useful for ruling out other etiologies of groin pain, identifying concomitant pathology, and confirming the diagnosis itself. Treatment is varied but usually includes nonoperative measures of rest, rehabilitation, and/or pharmacotherapy and also may include injections and/or surgical procedures. A high clinical suspicion should exist when evaluating soccer, rugby, or American football players and distance runners who present with complaints of groin pain.

Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial.

HYPOTHESIS: A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain. STUDY DESIGN: Single blinded, prospective, randomised controlled trial. PATIENTS: Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months. INTERVENTIONS: ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program. PRIMARY OUTCOME: time to return to full sports participation. SECONDARY OUTCOME MEASURES: objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks. RESULTS: Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p = 0.043). Only 50-55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p = 0.72) or VAS during sports (p = 0.12). CONCLUSIONS: The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

[The results of radical-rehabilitative surgical treatment in tuberculous osteitis of the hip joint in children]. / Rezul'taty radikal'no-vosstanovitel'nogo khirurgicheskogo lecheniia tuberkuleznogo ostita tazobedrennogo sustava u detei.

Radical restorative surgery is an operation of choice in treatment of tuberculous osteitis of the hip joint in children of all age groups irrespective of the destructive process localization and duration. The early surgical treatment provided recovery from tuberculous osteitis in 100 per cent of the patients and proper development of the operated hip joint in 90 per cent of the patients.