Pubic symphysis in Male Athletes | Caring Medical Sports
This article will deal with the treatment of injury to the pubic symphysis in male athletes, for treatment in women please see our companion article: Symphysis Pubis Dysfunction Treatment in Women. Pubic symphysis injury is very treatable with Prolotherapy, see below.
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The pubic symphysis is actually a disc. It is a fibrocartilaginous disc that, like any other disc in the body, can be damaged, disrupted and displaced. In union with the sacroiliac joints the symphysis pubis forms a stable pelvic girdle.
Because the pubic symphysis and the sacroiliac joint are the only two joints connecting the two halves of the pelvis, an injury to one can affect the other. Thus, anyone sustaining injury to a sacroiliac joint should also have the pubic symphysis examined. This may help alleviate chronic low back pain in some athletes.
The pubic symphysis is supported on top by the superior pubic ligaments. Typically, people with groin pain are assumed to have a groin strain. This refers to a strain of the adductor muscles that attach to the pubic bone. Chronic pain that does not respond to exercise, massage, or manipulation is most likely a ligament problem.
In the case of pain reproduced by palpating the pubic symphysis, the cause of the pain is pubic symphysis diathesis. This means a loose pubic symphysis area. Unfortunately, mild laxity in the joints can only be diagnosed by palpation. There is no x-ray study that can be done to confirm it. This is also why many physicians do not diagnose it. The diagnosis of ligament laxity can generally only be made by a listening ear and palpation.
The pubic symphysis joint is stressed when the leg is pulled out from underneath, such as a slip and fall accident. In sports, pubic symphysis injuries are relatively frequent. Swimmers who do the breast stroke often suffer groin pain from a pubic symphysis injury.
The pubic symphysis role in muscle strength
The pubic symphysis plays a role very similar to that of the sacroiliac joint by enhancing overall pelvic mobility. It also is the site of attachment of the powerful adductor muscles, which move the leg inward, and the abdominal muscles whose strength helps keep force off of the lower back and discs.
Pubic symphysis dysfunction or injury is often overlooked and blamed on the more “glamorous,” abdominal muscles and adductor muscles which attach in this area. When there is pain attributable to this area, the diagnosis is called “abdominal muscle pull” or “adductor tendonitis.”
How the Pubic symphysis injured
The pubic symphysis joint may be stressed whenever the leg is pulled out from underneath . On overextended strike in soccer players can also cause injury. Swimmers who swim the breast stroke often suffer groin pain from a pubic symphysis injury.
The pubic symphysis widens slightly whenever the legs are stretched far apart, and therefore activities requiring this type of movement have a higher risk of causing injury to the pubic symphysis. This widening leads to misalignment and instability of the symphysis pubis joint.
An injury to the pubic symphysis can cause severe groin pain. In the case of pain in the pubic symphysis, the cause is pubic symphysis diathesis or laxity, that is a weakening of the supportive structures causing excessive movement and instability.
Symptoms of pubic symphysis pain in male athletes
Pain and tenderness is localized over the pubic symphysis and radiates outward to the upper thighs and perineum (the area between the anus and the scrotum).
- Pubic symphysis pain may be mild or severe, and can develop into a chronic condition.
- It can be a burning, shooting, grinding or stabbing pain.
- Pain is experienced while performing such activities as running, doing sit-ups and squatting.
- In more severe cases, the pain affects activities of daily living and causes the sufferer to walk with a waddling gait, as pain is experienced while walking, climbing stairs, coughing, and sneezing. The person also experiences exquisite tenderness to touch in the pubic symphysis area.
Cortisone injections into the pubic symphysis
Doctors from Ohio State University writing in the British Journal of Sports Medicine discussed the use of cortisone injections into athletes with public symphysis pain. Here are their findings:
The doctors examined three studies which documented corticosteroid injections into the pubic symphysis. They note that they could not come up with a definitive conclusions on an ideal strategy for cortisone because each study did not use a consistent type, strength or quantity of medication for injection
In the studied research, an average 1.24 injections (range of 1–3 injections) was performed.
- Overall success rates for return to sport following corticosteroid injections were moderate (58.6% with a mean of 8 weeks from the first injection).
- There was also a high number of athletes who did not respond to injection (20.7%) and were unable to return to sport at all.
- Timing of injection from the start of symptom onset may play a role in the overall success rate.
- The results of one study suggest that injection of corticosteroid in athletes with chronic symptoms after 16 weeks does not promote as rapid a recovery as injection in athletes with acute symptoms less than 2 weeks.1
The same research team also examined a 2005 study using Prolotherapy (dextrose and lidocaine) to treat osteitis pubis.2 They note that numerous injection sites were targeted across the pubic rami and into the pubis symphysis rather than one single injection into the pubic symphysis.
- An average 2.8 treatments (range 2–6 treatments) were performed which is more than the reported number of corticosteroid injections. Similar to corticosteroid therapy, Prolotherapy also appears to demonstrate a high safety profile with no reports of postinjection complication in the 24 athletes that received at least one treatment course.
- Interestingly, prolotherapy did produce high success rates for return to sport (91.7% with a mean of 9 weeks from the first injection series) in this study, suggesting that this treatment option should be investigated further.1
Pubic Symphysis Pain Treatment with Prolotherapy
Prolotherapy for pubic symphysis injury and instability are injections into the fibro-osseous junction of the superior pubic symphysis ligament and injections into the pubic symphysis itself.
Prolotherapy is extremely effective in strengthening the pubic symphysis and relieving chronic groin pain in this area. Prolotherapy solutions injected into the affected ligaments, tendons, and/or joints causes a local inflammation in the injected area. The mild, localized inflammation boosts blood supply and regenerative cells to the weakened area. This results in the deposition of new collagen, the material that the symphysis pubis is made of. The new collagen tightens the weakened, unstable joint and makes it stronger.
As mentioned above, the pubic symphysis is the front joint of the pelvic bone and the sacroiliac joint is in the back. The doctor should check for sacroiliac joint instability and treat it at the same time.
In patients with groin pain due to abdominal wall abnormalities, one finds a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles, such as sit-ups.
On physical examination there is tenderness of the pubic tubercle and a positive jump sign is elicited. In this instance, Prolotherapy to the muscle attachments onto the pubic symphysis is often curative.
All of the other muscle attachments to the groin area, including the rectus femoris, gracilis, rectus abdominis, and adductor group, can all be treated with Prolotherapy if there is tenderness and reproduction of the man’s pain upon palpation of the area where the muscle attaches to the bone. If a positive jump sign is elicited, the diagnosis is made and Prolotherapy is given.
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1 Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. British journal of sports medicine. 2010 Nov 1:bjsports50989. [Pubmed] [Google Scholar]
2 Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Archives of physical medicine and rehabilitation. 2005 Apr 30;86(4):697-702. [Pubmed] [Google Scholar]