ATHLETIC HERNIA and OSTEITIS PUBIS as RUNNING INJURIES

All throughout the running and sports medicine blogospheres, both professional and amateur, there is a plethora of information and comments on the common running injuries. Runner’s world names these seven as the most common:  Runner’s knee, Achilles tendonitis, Hamstring issues, Plantar fasciitis, Shinsplints, IT band syndrome, and stress fractures.

I had none of that.

Last February (2013) I ran my first Marathon at Surf City Huntington Beach. It was awesome and hard and I ran my perfect race with a negative split pace. I suffered the usual post race pain in the quads especially and had difficulty going up and down stairs and getting up from a sitting position. That was expected. All was fine until about a month later, during a training run, that a felt some acute pain in the front of my pelvis. I hadn’t any problem with cycling, but the quick change in direction  of the leg from its most posterior position to accelerate it forward brought on a most unusual pain. Like my pelvis was unstable. It was worst at the beginning of this run and seemed to loosen up a little later, a couple of miles in. Over the next few months, with less running, it was not getitng better, but instead worse. It was also very difficult and painful the first thing in the morning after a run the previous day. The pain radiated into the medial adductors (groin muscles) and it was intense.

As a doctor, I am reluctant to visit other doctors and do so only reluctantly. I did visit the local hernia specialist after I “self-diagnosed athletic pubalgia or “athletic hernia” (AH). The AH is not listed as common running injury.

Here is a good summary:

A sports hernia is a tear to the oblique abdominal muscles in the pelvic region of the abdomen. Unlike other hernias, the sports hernia has no visible bulge under the skin. The pain associated with a sports hernia resembles a groin strain, but doesn’t respond as well to rest, ice and anti-inflammatory medications. The pain tends to return with a vengeance once the athlete returns to the sport.
A sports hernia occurs with the weakening of the muscles or tendons in a thin region of the lower abdominal wall. Once overexerted, a muscle tear occurs inside the groin. The oblique muscles attach at the top of the pubic bone while stronger hip muscles attach to the bottom of the pelvic bone. When both contract simultaneously and with a lot of force, a tug-of-war of the pelvis ensues.

Because the thigh muscles tend to be stronger than trunk, the weaker abdominal oblique muscles tear, resulting in a sports hernia. Sports hernias occur most commonly among football, hockey, soccer and tennis players. However, weekend warriors and athletes making extreme and repeated twisting-and-turning movements are also susceptible.
(http://www.philly.com/philly/blogs/sportsdoc/Preventing-the-dreaded-sports-hernia.html#fdMkSxw2xjCxz9Fd.99)

So in June, I had (essentially) a hernia operation to repair a torn left external oblique muscle attachment to my pelvis. Recovery was about as expected, but after several weeks, the pain in both the medial groin muscles did not seem to abate.  I gave it more time and nearly stopped running or competing all through the Spring and Summer months, unfortunately. Biking and swimming, no problem, so I continued trying to stay fit, just not with triathlons or racing.

So I went back to Google to try t5o make sense of my continued pain and difficulty and then came across another, related diagnosis that just hit the nail on the head, Osteitis Pubis (OP). OP is a chronic inflammation and/or weakening of the pubic symphysis joint, the non-articulating , ligamentous joint that holds the two halves of the pelvic bones together up front. This area seems to be the “core of the core”. It is where many important core stabilizing muscles all come together as opposing vector forces.

Pelvic muscle attachments

Pelvic muscle attachments

There really doesn’t appear to be much in the way of surgical intervention, and I wasn’t to keen on having another surgery. So I waited it out. I kept the aggravating activities (well, running) to am minimum and tried to be patient. I mean, hey, I’m not a professional and my livelihood does not depend on competition and I could still bike and swim, so who am I to complain. Well that patience lasted a few months and I decided for another visit to an orthopaedic specialist in LA known to specialize in non-surgical intervention. After a couple of minutes of telling him what I thought I had, he agreed to do a steroid anti-inflammatory injection. He injected dexamethasone into the adductor muscle attachments and home I went. Honestly, I didn’t really notice much of a difference at all.

Withing a few weeks I had a patient of my own (I am an eye doctor) who was telling me about his treatment for his shoulder problems with prolotherapy. Now prolotherapy is pretty much the opposite of steroids. With steroids, you assume the primary problem is inflammation that needs treatment. With prolotherapy, you make the assumption that the connective tissues need healing by strengthening them. The problem with ligaments and tendons is that they are not very vascular and just don’t recover very quickly from injury. There are essentially two approaches to prolotherapy, 1) Platelet Rich Plasma (PRP), and 2) the cheaper stuff.  PRP involves drawing the patient’s blood, spinning it down in a centrifuge to separate out the components, and then re-injecting the plasma (rich with platelets) into the area of interest. The poor man’s version is simply a mixture of a hypertonic solutions that causes some of the locale cells to be injured (or dies) with the activation of the release of local growth and regenerative factors.

With the previous injection, I had to take a half day off, and drive to LA to get the injection. The doctor-patient interaction was less than impressive and the previous treatment didn’t work. In addition, the office billed my insurance over $900 for 25 cents worth of medicine, of which I had to contribute about $225.

Screw that. Doctor, heal thyself.

I ordered dextrose solution, already had lidocaine, and started doing my own injections right into the symphysis pubic joint. I have done 5 injections, about 2 weeks apart. Other than the very slight pinch on breaking the skin, the injections are painless. I calculated that, with injection supplies, the injections are costing me less than 5 cents per treatment. Money well spent, because I estimate to be about 95% recovered. I can run without pain during or afterwards, and other than a little “awareness” , this injury is not holding me back at all, even when racing.

Overall, I am still pretty new to running and I was sedentary for many years. I think that my muscles adapted to the many new stresses of regular, vigorous exercise, but the ligaments and tendons just hadn’t had the years and years of thickening and strengthening and general adaptation to the chronic and acute stresses. It is just one of those things. I’m no spring chicken, but now…

aging-grouper

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One Response to ATHLETIC HERNIA and OSTEITIS PUBIS as RUNNING INJURIES

  1. Pingback: WILDFLOWER TRIATHLON RECAP AND REVIEW (OLYMPIC DIST.) | iSWIMBIKERUNSTRONG

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