Working Diagnosis:
Osteitis pubis and adductor tendinosis

Treatment:
Treatment was initiated with a nitroglycerin patch applied to the adductor origin and an individualized exercise program to improve her running form, lumbopelvic stability, and single leg stance control. She was advised to avoid activities involving cutting, pivoting, and single leg standing such as lunges.

Outcome:
In broad strokes, the patient's groin pain resolved over 6-9 months with activity modification.

Specifically, the nitroglycerin patch was quickly discontinued due to headaches. The patient stopped running for 2 weeks at the beginning of her treatment course, which led to immediate partial improvement in her pain; thereafter, she was cleared to return to jogging as long as she remained pain-free and maintained good running form. When her lumbopelvic stability improved, she gradually returned to running at higher speeds and on inclines. Following this, she resumed cutting and pivoting motions. At 9 months, she was running, kickboxing, and cycling without pain. She did not return to Crossfit though.

Author's Comments:
Osteitis pubis is a stress injury of the pubic symphysis and can present with groin or lower abdominal pain. Exam typically reveals localized tenderness over the pubic symphysis or rami. The injury is often associated with activities involving rapid acceleration and deceleration and is precipitated by abnormal shearing forces related to muscular imbalances and poor flexibility. Sports and conditioning programs that focus predominantly on the muscle groups in the sagittal plane can predispose the athlete due to frontal plan weakness, particularly the gluteal muscles.

Editor's Comments:
The differential diagnosis for specific pain generators in athletic pubalgia may be extensive. The Doha agreement was developed recently for improved classification into the adductor-related, iliopsoas-related, inguinal-related, and pubic-related pain generators. Case Photo #3 Specifically focusing on the potential pain generators over the pubic tubercle, possible causes include the genital branch of the genitofemoral nerve and other intra-pelvic or intra-abdominal processes. It is important to differentiate between adductor longus, brevis, minimus, and magnus pain generators in order to better direct focused rehabilitation exercises and regenerative treatments, if indicated.

References:
https://www.uptodate.com/contents/osteitis-pubis

Giai Via, A., Frizziero, A., Finotti, P., Oliva, F., Randelli, F. and Maffulli, N., 2018. Management of osteitis pubis in athletes: rehabilitation and return to training- a review of the most recent literature. Open Access Journal of Sports Medicine, Volume 10, pp.1-10.

Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774.

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