Pelvic Pain In A Soccer Player- Soccer

Abstract

HISTORY: A 23 year old men’s soccer player presented with left sided pubic bone pain for seventeen months. The injury occurred after collision with another player and falling onto his left side during a soccer game. He developed left sided pubic symphysis pain later that evening. He finished the season followed by complete inactivity for 2 months. At the start of the next season, the same left sided pain returned that was worse with initial steps, change of direction, and lateral movements. He was seen in a sports medicine clinic and had an MRI which showed edema in the rectus abdominis, left abductor, and pubic symphysis. He completed physical therapy with no improvement. He then developed intermittent sharp pain radiating to the left testicle with running, preventing return to play. Steroid and Platelet Rich Plasma injections did not alter symptoms. He was referred to General Surgery, Orthopedics, given NSAIDs, repeated PT, repeat MRI, and finally referred for a biomechanical evaluation and treatment. PHYSICAL EXAMINATION: Pelvic compression test is + left. Palpation: left superior pubic rami pain; mild pain in left ischial tuberosity. ASIS to umbilicus measures 12 cm left, 13 cm right. ASIS is inferior on right. PSIS is superior on left. Left leg 1.5 cm shorter. Palpation of left lower abdominal quadrant lateral to the border of pubic symphysis reproduces left sided scrotal pain. Genitourinary/Hip exam: Unremarkable. Sensation intact bilateral L4-S1 distribution. Reflexes: 2+/4 bilateral knee and ankle. Pulses: 2+/4 bilateral post tibial DIFFERENTIAL DIAGNOSIS: Stress Fracture of Pubic Ramus, Athletic pubalgia, Inguinal Hernia, Abdominal muscles strain/tear, Nerve Entrapment TEST AND RESULTS: MRI (2nd): small area of edema in the left side of the pubic symphysis and inferior pubic ramus, consistent with stress reaction/athletic pubalgia. FINAL WORKING DIAGNOSIS: Stress Fracture of the Pubic Ramus (resolving), left hemipelvis in-flare, causing pubic symphysitis and genital branch of Genitofemoral Nerve entrapment TREATMENT AND OUTCOMES: Osteopathic manipulation- one course resolved pubic symphysis pain. US-guided hydrodissection of the left genitofemoral nerve-immediate alleviation of symptoms with return to play without pain or discomfort.