THE CLINIC: Scar Tissue Reduction Options Limited

QUESTION:
I am 50 years old and have been running for 30 years at approximately 9- to 10-minute mile pace. I am also a triathlete. I hired a coach to help me with speedwork, and after working out with him for five months I could hardly walk. This was in May of 2008. I can't even describe the pain. My adductors were weak and would spasm. I could not 

lift my legs to get dressed. I thought I had a stress fracture in my groin. I had an MRI of my hips and pelvis in October of 2008, and it read as normal. 

 

Throughout all of this I could still swim and ride my bike. In December I 

sought out an orthopedic surgeon specializing in sports medicine who, after examining me and looking at my MRI, told me I had osteitis pubis.

 

I was sent to PT for core strengthening. Will I ever get better, 

will I ever really run again? Can I be fast again, or is this going to 

be a chronic injury?

 

Christine Black

Fort Pierce, FL

 

ANSWER:

 The first few questions right off the top of my head are: 

 

1. What special training did this coach have you do?

I would do a mile warm up, stretch, do 6 x 100m strides and then many drills involving 100's, 200's, 300's, 400's, some 800's, and a lot of hill repeats. There were many days when driving home after the workouts I could not lift my leg to push in the clutch. I would lay down and be unable to move. Within a month I was slower in my long runs, but setting PRs in his drills. 

 

2. Did the MRI show pubic symphysis inflammation?

Yes.

 

3. Do you experience any pain with kicking during your swims, particularly with a frog kick?

Yes, I do experience pain if I kick aggressively. Before my diagnosis, I had also tried water jogging, which caused almost as much pain as running.

 

4. Do you have any pain/problems with coming out of the saddle for sprint/uphill pedaling?

I never have to get out of the saddle for hills. I have a compact 

crank and am able to spin. A couple of weeks ago I did try a hard gear 

on purpose, and stood going up a hill. I did not have pain, but it just 

wasn't efficient. 

 

Something else to consider: in March of 2008 I also got 

a new bike, custom. It had a very uncomfortable lightweight carbon 

saddle, and I would tend to ride with my pelvis tilted to put most of my 

weight on my pubic symphysis. Last June I had a bike fit at Boulder 

Center of Sports Medicine and found that the seat ought to be raised almost two inches. 

 

Also of note, I do not have any problem with StairMaster.

 

Maribeth Salge, PT

Rockledge, FL

 

 

ANSWER:

Answers in italics by Christine Black

 

 

I think you may have at least two different things going on, but without actually doing a hands-on exam, it's a bit difficult to know for sure. Did a portion of your drills

included high-impact, single leg or split leg landings? These can cause

pretty significant shear forces on the pubic symphysis. 

 

Another issue with high amounts of forceful hip flexion is anterior capsular or

tendon impingement, especially as the muscles fatigue and the normal joint

mechanics alter in response.

 

Additional considerations include:

 

When you say you couldn't lift your leg, was it due

to muscle failure or due to pain? If the latter, was the pain over the

pubic symphysis or more in the direction of the hip capsule? 

 

Did your pain worsen or change when you got the uncomfortable saddle or did things stay pretty much the same as after the training? Were you

still in as much pain as when you were doing the training with the coach? 

 

Which StairMaster do you use, the one with pedals or the one also known as the Step Mill? There is an interesting biomechanical difference here that may be telling.

 

Maribeth Salge, PT

Rockledge, FL

 

 

ANSWER:

A therapist or physician who is knowledgeable in gait analysis may offer some

assistance here.

 

In runners a proposed mechanism that makes sense to me is cumulative trauma

stress incurred during the up and down and/or side to side pelvic motion that occurs with running. Some studies suggest that excessive arm swinging in running may contribute to excessive pelvic sway. 

 

The standard treatment, as in most overuse injuries, involves rest from

aggravating activities followed by a graded return to sport. The problem

with osteitis pubis is that this rehab program may require up to a year of

time. I am not clear as to when you actually stopped running, but keep this

time frame in mind. 

 

The literature suggests that in compliant patients with chronic osteitis

pubis, prognosis is good, but a considerable degree of patience is required.

I see a few patients a year with chronic osteitis pubis, and unfortunately

most are lost to follow up. I have had very good success treating the

subacute cases with relative rest, NSAIDs, and a series of cortisone

injections. The injections have been very helpful for diagnosis and

treatment, and are relatively easy to perform in the office. This

is followed by a period of PT to assist with pelvic stability.

 

I know of no cases that have gone to any surgery.

 

Robert Scott MD

San Diego, CA