Groin Pain In A Collegiate Sprinter

HISTORY: A 20 y/o male collegiate sprinter presented to sports medicine clinic with left groin and posteromedial hip pain. His symptoms started 5 months prior during a 200 m race at a track meet. His pain was sharp and aching in quality and worse with running, squatting, prolonged standing or with adductor exercises. He denied back pain, radiating pain, or numbness/tingling distally. Prior to evaluation, he had discontinued running and completed 2 months of physical therapy without significant benefit. PHYSICAL EXAMINATION: Tenderness to palpation elicited over the anterior inferior pubic ramus with reproduction of pain on resisted thigh adduction. No pain was elicited over other bony landmarks. Hip IROM was full and painless. Special tests including FABER, FADIR, bent knee stretch test, and resisted cross-body sit-up were negative. Lumbar spine exam revealed painless ROM, intact strength and sensory testing L2-S1 distribution, negative neurotension signs, and 2+ DTRs. DIFFERENTIAL DIAGNOSES: Stress fracture of pelvis Osteitis pubis Groin pain in the athlete Adductor or proximal hamstring tendinopathy Intra-articular hip pain Lumbosacral radicular pain Ilioinguinal neuralgia TESTS AND RESULTS: Initial left hip MRI without contrast revealed T2 changes of the left superior pubic ramus adjacent to the pubic symphysis with mild irregularity of the pubic symphysis. FINAL/WORKING DIAGNOSIS: Initial diagnosis was left superior pubic ramus stress injury with component of adductor magnus enthesopathy. We recommended non-impact exercise and physical therapy. He underwent ultrasound-guided trigger point injection to the adductor longus and injection targeting the adductor longus entheseal pubic cleft and rectus-adductor enthesis without benefit. Despite three months of activity modification and PT, he continued to have symptoms. Repeat left hip MRI demonstrated interval resolution of left superior pubic ramus edema with persistent mild irregularity of the pubic symphysis consistent with osteitis pubis. TREATMENT AND OUTCOMES: Due to refractory symptoms and desire to avoid additional injections, he elected to complete four sessions of extracorporeal shockwave therapy to the myotendinous region of the adductors, pubic symphysis, and site of osteitis pubis and continue his physical therapy progression.