Pubic symphysis injury in Male Athletes does this ever heal?

Ross Hauser, MD
Danielle R. Steilen-Matias, MMS, PA-C

Pubic symphysis injury in Male Athletes – Does this ever heal?

We see many male athletes who have confusing and frustrating groin pain. They will come into our clinics after bouncing from doctor to doctor to doctor looking for some answer that will let them get back to his game without pain. This is a problem that they have been dealing with for years.

If you are looking for answers for your groin pain, you may be on similar paths to others we have seen.

These are some of the things we will typically hear from a young male athlete:
- “My doctors don’t know what it is. I have severe pain. It is either my pubic symphysis or something in my groin area. I don’t know. It is only on the one side. The NSAIDS does not help at all, it is a waste of time taking them. I have stopped icing, that doesn’t help either.“
- Another patient may say: “My doctor thinks it is my SI joint or Sacroiliac joint dysfunction.” In our clinics, we do see this problem very often. Sacroiliac joint dysfunction sending pain into the pubic symphysis or groin area. We also find that a reduction in hip range of motion is usually a supportive clue in understanding that this is a pubic symphysis problem.

If you are reading this article it is very likely that you are very well educated about your problem because it has gone on for some time. You have also likely not had success with the standard of care treatments you have been prescribed.

So one day you had groin pain

You were on the soccer field, you had an obvious scoring opportunity, you lunged as you struck at the ball. You felt something happen. You have not been the same since.
You are the punter on your High School football team. You are deep in the end zone and need to get the punt off fast, you punt it away, you felt something happen. You have not been the same since.
You play hockey, while you may not be able to pinpoint a particular play when the groin pain started, you know now that you cannot skate and how this started will only be of interest to you if you can prevent it in the future and if it helps heal you now.
You compete in the breast stroke, during a meet you felt something happen. You have not been the same since.
You have been using an exercise bike with a poorly adjusted saddle and suddenly something popped in your groin.

Symptoms that we may suspect is causing pubic symphysis pain in male athletes

Pain and tenderness are localized over the pubic symphysis and radiates outward to the upper thighs and perineum (the area between the anus and the scrotum). It can be mild or severe and is chronic.

Patient complains of burning, shooting, grinding or stabbing pain while 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 or pain while climbing stairs, coughing, and sneezing. The person also experiences exquisite tenderness to touch in the pubic symphysis area.

Why nothing is working for you

In this section we are going to talk about the standard of care options doctors typically offer. We will also talk about why these treatments work very well for some people and why they are not working for you.

Let’s introduce the idea that you have a ligament problem causing pelvic instability and stress on the pubic symphysis and this is why you have pain.

In sports injuries, the glamorous ligaments are those of the knee, the ACL, MCL, and sometimes PCL and the UCL of the elbow made so famous by the Tommy John procedure. Rarely however, do patients who have pubic symphysis dysfunction have a discussion with their health care provider about the problems of the ligaments of pelvic, hip, and low back region.

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. When all is well and the balance between the sacroiliac joints and the pubic symphysis is maintained, you have a pain-free stable pelvic girdle.

So what happened that caused your pain?

The pubic symphysis widens slightly whenever the legs are stretched far apart, and therefore activities requiring this type of movement (kicking, lunging, leg kick in butterfly stroke) have a higher risk of causing injury to the pubic symphysis. This widening leads to misalignment and instability of the symphysis pubis joint. You have a slipped disc.

Where do ligaments fit in?

Pain in the pubic symphysis can be caused by micro-tearing and subsequent weakening of the ligaments of the supportive structures causing excessive movement and instability.
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.

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.

“abdominal muscle pull” or “adductor injuries” or pubic symphysis degeneration and slippage

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.”

Cortisone injections into the pubic symphysis

Doctors from Ohio State University writing in the British Journal of Sports Medicine (1) 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 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.

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.

Do you have a question about Pubic symphysis pain? Get help and information from Caring Medical staff

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. [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. [Google Scholar]

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