Findings in the Clinic: A Case of Osteitis Pubis

Assessment findings and implications of findings in a ongoing case of osteitis pubis in an NHL athlete.

San Jose Sharks captain Logan Couture is another NHL athlete who is dealing with osteitis pubis. Source

This past week, we received a referral for a physical assessment of an NHL athlete dealing with a persistent case of osteitis pubis. This referral came from another NHL athlete, a teammate whom we've managed the treatment and training of for years. The athlete sought a physical assessment, hoping to gain an understanding of why their initially minor case of osteitis pubis had progressed to a chronic state and worsened over the course of the season despite adhering diligently to the prescribed training regimen. In the following article, we present our clinical notes, hypotheses regarding the underlying cause of the osteitis pubis, and our recommendations for treatment and training.

First, the definition of osteitis pubis:

Osteitis pubis is inflammation of the joint between the left and right pubic bones (pubic symphysis - see image above).¹ It causes pain and swelling in the groin and/or lower abdomen.

The anterior pubic ligament, highlighted in green, is the location of inflammation from osteitis pubis and subsequent pain.

Joint-Specific Accommodation + Compensation in High Performance

Before getting into the assessment findings let’s consider two physiological facts.

1. Joint-Specific Accommodation is a real phenomenon that occurs in professional athletes who do not implement and execute joint-specific training work.

2. High-level athletes are the best at compensating for specific movement prerequisites they may lack but are required to perform - more on this later.

In our opinion, both of these physiological factors contribute to the ongoing and worsening case of osteitis pubis in this athlete.

Hip Joint Workspace: Physical Demands for Skating

Considering the physical demands of the athlete, who is a defenseman, it is paramount for him to possess the appropriate active joint ranges of motion in his hip joints that enable him to generate the basic movement requirement during skating. For example, during skating forward acceleration, the hip will start from a position of bent knee hip flexion and then moves rapidly into hip extension, abduction, and external rotation. Once the athlete is up to speed, the hip requirements change. During the full skating stride, the hip will be required to start in a position of deeper hip flexion and move into further abduction with internal rotation. There are other more than basic skating techniques, such as crossovers, pivots, transitions, and backwards skating, that will all have requirements of the hip to be performed at a high level regarding this athlete.

These macro requirements will be dependent on the available relative micro motion that exists between the femoral head and the acetabulum. Also, keep in mind that in addition to these range requirements, there are strength requirements that determine the behavior of each range.

Hip Joint Functional Range Assessment [FRA]

When performing the local Functional Range Assessment (FRA) on this athlete's hip joints (including table tests and Controlled Articular Rotations analysis), we focused on the basic macro ranges of motion necessary for skating. Given the specific physical demands of skating and our aim to correlate them with osteitis pubis, we prioritized the assessment of bent knee hip flexion and hip internal/external rotation during the FRA.

Note: For clarity in communicating with Absolute subscribers, it's important to note that the assessment findings were very similar for both legs. Therefore, we will not detail the findings for each individual leg but rather summarize them for each macro range of motion.

Bent Knee Hip Flexion

During the passive range of motion assessment, there was a closing-angle block at the end range of motion in bent knee hip flexion. In addition, when the hip was moved to the end range of motion in bent knee hip flexion while internally rotating the thigh (replicating the skating mechanism of the hip), the athlete pointed to his groin and mentioned feeling both a block and pinch - with a block first and then a pinch when the joint was challenged. He said this painful sensation was what he experienced during skating.

Continuing the assessment and trying to create feedback loops, when the hip was passively assessed at the end range of motion in bent knee hip flexion, the athlete was asked if he felt a stretch in the back of his hip. He stated that he felt no stretch in the back of the hip (posterior hip joint capsule), only the block that escalated into a pinch in the front of his hip.

Active range of motion was assessed, not expecting a 1:1 ratio to passive but to observe where the compensatory motions may occur. When moving through bent knee hip flexion it was obvious to see where the hip stopped moving and the pelvis carried on, hiking upwards to his rib cage even while the pain from the dysfunctional arthrokinematics was present.

Internal Rotation [IR]

At 90 degrees of hip flexion, the hip was passively rotated internally through the range of motion to the end range, which was a very minimal amount, suggesting very few degrees of freedom. This means he did not possess the micro range of motion between the femur and acetabulum to allow for this fundamental range of motion to occur. In addition, there was no stretching sensation in the anterior hip joint capsule, only an elevation of the pelvis upwards towards his ribcage, and then when that was challenged, there was a rotation of the pelvis off the table. It is important to note that when assessing a joint for fundamental motion, in the case of the hips, internal and external rotation, there should be the sensation of a capsular stretch by the client and an elastic capsular feel by the practitioner. This capsular barrier was not appreciated, instead it was appreciated as being a more rigid barrier, indicating that the capsular connective tissue is behaving as a limiting barrier in the hip joint - a huge issue.

When asked about his sensations, the athlete mentioned feeling nothing except the block/pinching sensation in his groin. He confirmed not feeling any stretching in his hip and said that he could feel how much his pelvis moved instead of the femur moving within the pelvis. Active range of motion on hip IR was neurological incompetent in that he did not rotate the hip femur in the acetabulum; rather, he elevated his pelvis upwards to his ribs and off the table in rotation.

External Rotation [ER]

Next, external rotation was passively assessed at 90 degrees of hip flexion. The athlete reported a pleasant stretch, specifically in the posterior hip joint capsule - a stretch that starts on the outside of the hip joint and wraps around the entire backside of the hip. He described the stretch as feeling normal. Consistent with Dr. Chivers description of an escalator sensation rather than an elevator.² When challenged at the end range of motion, the athlete experienced a more intense and satisfying stretch. Passive and active range of motion was at a 1.1 ratio - showing he was neurologically competent in this macro range of motion.

Hip FRA Findings

The physical assessment showed that the hips were in a state of dysfunction. The optimal tissue tension of an escalator detected in hip ER did not exist in bent knee hip flexion or hip IR. Passive range of motion assessment of bent knee hip flexion or hip IR did not even elicit an elevator of tissue tension in the connective tissue of the hip joint capsule - there was no connective tissue that was going to length to stop the thigh bone from moving relative to the pelvis, only compensation in the pelvis/lumbar spine.

It is important to understand that when challenged at the couple degrees of end range of hip IR, the pelvis elevated upwards towards the rib cage and then rotated up off to the table with no capsular tissue coming online to absorb, dissipate, and counteract that force. On CARs analysis, because the micro range of motion between the femur and acetabulum was absent, the athlete rotated the pelvis instead of the femur in the zone of internal rotation.

Tying the Assessment Findings to Understand the Osteitis Pubis

Let's put all these bits of information from the table tests and CARs analysis into a coherent understanding of why this athlete has an ongoing and worsening case of osteitis pubis. Understanding the macro ranges of motion required for skating enables us to be specific in assessing the micro ranges responsible for those macro ranges.

We objectively know that this athlete does not have the required amount of joint workspace between the femur and acetabulum in hip internal rotation and that he is neurologically incompetent in moving the ball relative to the socket. Due to the abnormal connective tissue in his capsule, the afferent-efferent information flow from that joint is inaccurate, and thus, his output is incorrect - meaning: he continues to move his pelvis thinking he is moving his hip. It is our belief that this excessive movement of the pelvis due to the lack of hip joint workspace is causing him to create large shearing forces at his pubic symphysis region.

It is a physiological reality that the athlete can only move through space over time - if there is no space in the hip joint, the athlete’s neurology can find other space to use. This compensation was displayed when assessing the passive-to-active ratio of hip IR and bent knee hip flexion. The athlete incorrectly thought that he was moving the femur relative to the pelvis, but the femur was not moving, and the pelvis was moving. See how this is a major issue for this athlete and his specific pathology?

Hypothesis

In Absolute nomenclature, this athlete’s joint biological accommodated to the sport of hockey, and his nervous system's ability to compensate with little space between his pubic bones is generating his pain, symptoms, and pathology.

The Roadmap to Resolving