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Shockwave Therapy: Alternative for Osteitis Pubis


Osteitis pubis is a painful condition and it is difficult to handle without a comprehensive treatment method. The majority of the people affected by this condition are young athletes. However, women also get this condition during pregnancy or after birth. Conservative and surgical methods are used to manage this condition.

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Conservative treatment should be the first form of treatment in managing Osteitis before considering surgery. Conservative treatment commonly used includes physiotherapy treatment and rest. Recent research reveals that Osteitis pubis can be successfully treated with a series of strengthening exercises.1 Extracorporeal Shockwave Therapy (ESWT) has become a preferred treatment method in recent years. ESWT is effective and has low risks compared to surgical treatment.

Anatomy of the pelvic structures

The pelvic structure joins the abdomen and the lower limbs. The pelvic structure comprises many ligaments, tendons, and muscles fixed on the symphysis pubis. The inguinal area comprises parts such as the rectus abdominis and parts of the inguinal canal. The inguinal canal slants in a direction and joins the abdomen and the pelvic region. Moreover, the inguinal canal has a boundary of four walls and four ports.

The pubis symphysis is a joint with restrained movement. However, with the help of hyaline and cartilage, it can withstand heavyweight.2 The abdominal and paravertebral muscles work cooperatively to support the pubic symphysis when in motion.

The adductor muscles apply opposing friction on the pubic symphysis. The femoral triangle is positioned on the upper thigh and several structures run inside it.

Pathophysiology of Osteitis pubis

Osteitis pubis is an inflammation described by pain in the pelvis and bone damage of the pubic symphysis. It is a self-limiting condition. The symptoms arise eight weeks after the beginning of the condition. Symptoms of this condition are a painful walk, rise in body temperature, waddling gait, and painful hip movement.

A patient will also have increased levels of acute-phase proteins. For diagnostic purposes, scintigraphy will indicate any disorder at the pubis. In addition, MRI scans can indicate inflammation in the bone.3 At the early stages the symptoms can be noted after engaging in sports. However, the condition is progressive and is worsened by physical movement. Later, the condition advances and affects ordinary activities such as getting up from a chair.

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Predisposing factors

The imbalance between the adductor and abdominal muscles has been noted to cause Osteitis pubis. This condition is linked to recurring traumas in the abdomen and adductor muscles. People engaged in sporty activities involving an abrupt change of movement are at more risk of getting Osteitis pubis. The weight imbalance on the pubic symphysis and insertional tendons can develop Osteitis pubis.4 Research shows that both internal and external factors can cause Osteitis pubis.

Examples of Internal factors are flaws of plantar support, irregularity in the lower limbs, and decreased mobility of iliopsoas. External factors include poor training in sports, wrong footgear, and harsh playing conditions. This condition can occur in pregnancy because of extreme ligament laxity. Softening of the pelvic muscles due to hormones can cause the broadening of the symphysis pubis.

Treatment of osteitis pubis in athletes using conservative therapy -the use of rehabilitation and/or oral anti-inflammatory medication use in their course of treatment

The treatment of Osteitis pubis comprises conservative therapies such as rehabilitation and oral drugs. Rehabilitation therapies are divided into three levels, acute, sub-acute, and go-to-sport. The role of the acute phase is to reduce the pain. Rehabilitation therapies especially in the acute stage include postural balance exercises.

These exercises are important for relaxing and strengthening muscles. In the sub-acute level, concentric and eccentric workouts are introduced which strengthen the muscles. In chronic conditions, a friction massage helps to prevent fibrosis.5 The athlete is advised to use a treadmill when jogging. At the final stage, the athlete can engage in vigorous pieces of training such as aerobics. Exercises involving sprints and jumps are initiated. Athletes train with the ball to regain the neuromotor knowledge of particular sports acts.

The use of compression shorts in an attempt to limit groin pain and increase athletic performance in athletes with Osteitis pubis

Another conservative method is the use of compression shorts in reducing groin pain and enhancing performance in sports. The utilization of compression shorts in pain relief and therapy has become famous in the last few years. The role of compression shorts is to give compression and resist motion in the pelvic structure. A study was done on athletes already receiving rehabilitation treatment.6 They were fixed with compression shorts during specific agility drills.

The athletes did not get improved performance in their sports. In addition, they did not experience a considerable reduction in groin pain during exercise. Though no improved athletic performance was noted, the decrease in pain is crucial in the treatment of Osteitis pubis. The risk of using compression short is that the resistance exerted by the compression shorts will tire muscles faster, increasing the chances of an injury.

Injection therapy- Cortisone for treatment of osteitis pubis

If Osteitis pubis is treated and the symptoms remain, injection therapy becomes the best option. Studies have revealed that if an athlete wants to recover quickly and resume sports, then corticosteroid injection is the best choice. Pubic symphysis injections can be administered in a room without the need for fluoroscopic control.

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These injections are used for both therapeutic and diagnostic purposes.7 Injection therapy depends on feeling the position of the pubic symphysis to allow the flow of injection as it penetrates the joint. If the injection is done improperly, an injury may occur on the spermatic cord and urinary bladder.

Treatment of Osteitis pubis in athletes using surgical correction

If the conservative therapies fail to work after three months of therapy, surgical correction may be considered. When patients have undergone surgery, they should engage in sports after three months period. There are two major surgical methods each with advantages and disadvantages.

The advantage of the trapezoidal wedge resection is that it is reliable, has minimal risks, and is quick to operate.8 One risk involved with this surgery is the likelihood of late pelvis instability because of anterior pelvis disruption. On the other hand, compression plate fusion gives the best stability by reducing the occurrence of stress fracture and the risk of pelvis instability. Before the surgical process, a specialist surgeon in sports hernias examines an athlete. If the athlete does not qualify for the surgery then pubic symphysis stabilization becomes the best option.

Extracorporeal shock wave therapy (ESWT)

Extracorporeal shockwave therapy (ESWT) started as a minor study of osteoblastic behavior patterns in animals in the 1980s. The study increased interest in the application of ESWT to muscle disorders. Shockwaves are applied to influence the growth of new tissues. ESWT has become a preference for the treatment of various orthopedic conditions.

ESWT has been used in managing lateral epicondylitis of the elbow, calcific tendinitis of the shoulder, and deformities in bone structure. ESWT has gained fame throughout the world.9,10 The risks of ESWT are minimal and insignificant. Mild hematoma and megrim are some of the risks, which are easy to treat. ESWT is a therapy, which is effective, convenient, and secure. It can substitute surgery for many orthopedic disorders thus avoiding the risks of surgery.

Reference List

  1. Haemi C, Michael M, Thomas MB. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Journal of Sports and Medicine 2011;45(1):57–64.
  2. Romeo P, Lavanga V. Clinical application of extracorporeal shock wave therapy in musculoskeletal disorders. Journal of Alternative and Integrative Medicine 2013;2(2):1-5.
  3. Bert M, Steve AM. Osteitis pubis. Operative Techniques in Sports Medicine 2005;13:62-67.
  4. Don FP, Vittorio C, Alberto R, Angelo C, Marco P. Effectiveness of radial shock wave therapy for calcific tendinitis of the shoulder: single-blind, randomized clinical study. Journal of the American Physical Therapy 2006;86:672-682.
  5. Pauli S, Willemsen P, Declerck K, Chappel R, Vanderveken M. Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature. Journal of Sports and Medicine 2002;36:71–73.
  6. Loew M, Daecke W, Kusnierczak D, Rahmanzadeh M, Ewerbeck V. Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder. Journal of Bone and Joint Surgery 1999;81:863-7.
  7. John HJ, Yun JJ, Cheong HS. The effect of extracorporeal shock wave therapy on myofascial pain syndrome. Annals of Rehabilitation Medicine 2012;36(5):665-674.
  8. Wellock V. The ever widening gap-symphysis pubis dysfunction. British Journal of Midwifery 2002;10(6):348-353.
  9. Ching JW. Extracorporeal shockwave therapy in musculoskeletal disorders. Journal of Orthopaedic Surgery and Research 2012;(7):11-8.
  10. Cristina R, Antonio M, Horacio L. Osteitis pubis syndrome in the professional soccer athlete: a case report. Journal of Athletic Training 2001;36(4):437-440.

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