Chronic Groin Pain Presenting As Osteitis Pubis

Abstract

HISTORY: 23-year-old college football receiver who felt a pop in his right groin followed by pain during drills 18 months ago. Initially diagnosed with adductor strain and referred to P.T. Continued pain with drills and running. Rest, NSAIDs, P.T., prednisone, and 3 pubic symphysis steroid injections provided no long term relief. Experienced complete but temporary relief with symphysis injections. Since feeling pop 6 weeks ago now notes left groin pain. Pain worse with lateral movements. History of right inguinal hernia repair 8 y/a. Previous interventions: Pelvis MRI 2/06: Signal abnormality at right inferior rami Pelvis MRI 6/06: Secondary cleft sign at symphysis Symphysis pubis injection 2/07: Secondary cleft at insertion of right adductor longus Bone scan 4/07: Negative Pelvis MRI 5/07: Increased signal at insertion of left adductor Pelvic US 6/07: Negative for hernia bilaterally Symphysis injection 6/07: Same result Symphysis injection 7/07: Bilateral secondary cleft sign Left hip arthrogram 8/07: Normal hip. Cystic changes within symphysis. Bilateral cleft sign, partial tears of adductor brevis and obturator externus muscles bilaterally. Partial tear of adductor longus muscle. PHYSICAL EXAMINATION: FROM of lower back without pain. FROM of hips with mild pain on left hip internal rotation. Mild tenderness over left adductor tendon and pain with resisted adduction. No tenderness over pubic body or symphysis. Tender over inferior lateral rectus abdominis (L>R). Pain with valsalva. Negative straight leg raise and Patrick's sign. No inguinal hernia. 5/5 strength lower extremities. DIFFERENTIAL DIAGNOSIS: Adductor strain Distal rectus abdominus strain Inguinal hernia Osteitis pubis Sports hernia TEST AND RESULTS: Pelvis Radiograph 8/07: cystic changes within symphysis. Reevaluation of MRI suspicious for sports hernia FINAL WORKING DIAGNOSIS: Sports hernia with concurrent osteitis pubis TREATMENT AND OUTCOMES: Referred for surgical consideration. Underwent bilateral pelvic floor repair and adductor releases. Patient running pain free and pleased with results. We feel this case represents delay in diagnosis of a sports hernia due to concurrent osteitis pubis and improvement with therapeutic interventions (e.g. symphysis pubis injection) that are not necessarily specific to a single diagnosis.