Osteitis- Pubis


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Osteitis Pubis is a condition that many consider rare, however, it is probably more common than you may think. The incidence of groin pain, in some sports, is as high as 13% (Ekstrand and Ringbord, 2001). Thus, it is highly likely that as a sports physiotherapist you will encounter may athletes with a diagnosis of osteitis pubis. Therefore, as is frequently stated on this site, you need to be aware of the current research and evidence based practice, even in a world with limited research.

 
OVERVIEW
Osteitis pubis is defined as a painful inflammatory process involving the pubic symphysis and surrounding structures including the pubic rami, cartilage, musculotendinous and ligamentous pelvic structures (Batt et al, 1995). It is suggested that this is caused by repetitive stresses of the pubic symphysis during strenuous physical activity, most commonly secondary to reduced hip range of motion (LeBlanc and LeBlanc, 2003).
 
DIAGNOSIS

Subjective:
CHx: The athlete will often report an insidious onset of groin pain, with nil major traumatic incident. 

Pain:  Will usually be present in the groin and lower abdominal region.
Agg: Aggravating activities will likely include running, stepping, jumping and kicking. 
 
Objective:
  • AROM: generally reduced hip range of motion, particularly abduction and rotations 
  • RIMT: adduction and lower abdominal activation will reproduce pain 
  • Palp: there will be tenderness around the groin and lower abdominal musculature with marked tenderness on palpation of the pubic symphysis. 
  • NB: A cornerstone of successful conservative osteitis pubis treatment will be addressing biomechanical and functional deviations at both the hip and lumbosacral complex, therefore these regions should be appropriately assessed and treated (Wollin and Lovell, 2006). This is further discussed below.
  • DDx: Some important and common competing hypotheses are listed below (Choi et al, 2011):
Strain 
Sportsman’s Hernia
Stress #
Hip Pathology (FAI)
LBP Referral 
 
RADIOGRAPHY
X-Ray: normal radiographic findings may include:
loss of the smooth cortical periphery
reactive sclerosis
rarefaction
superficial bone destruction with occasional heterotopic ossification
greater than 10-mm separation of the symphysis
symphyseal instability as demonstrated by movement of the symphysis of more than 2 mm on step films (Lentz, 1995)
Bone Scan: has greater sensitivity than plain film X-ray.
MRI/CT: Also diagnostic of osteitis pubis. Also particularly useful in exclusion of competing hypotheses.
 
TREATMENT
The following discussion regarding treatment decisions is guided by the systematic review by Choi et al (2011). Whilst they searched for the best available evidence, they were unable to identify any RCTs regarding treatment decisions for osteitis pubis. Therefore, the following recommendations are based on clinical experience and case studies/series. Hint, hint… not a lot of rock solid evidence going around.
 
CONSERVATIVE MANAGEMENT
This generally involves the three mainstays of an inflammatory musculoskeletal condition: relative rest, NSAIDs, and physiotherapy!
 
Physiotherapy treatment, as always, should be based on the individual athlete and their assessment findings. Thus, as stated above, you should assess for biomechanical and functional impairments and treat accordingly. The components of a successful conservative rehabilitation program included (Wollin and Lovell, 2006):
 
Manual techniques to restore full range of motion in the lumbar, sacral and hip joints. This included soft tissue, MET, mobilisation and manipulative techniques. 

Core Control Exercises (TrA and Pelvic Floor Training)
Adductor Strengthening (Progression of gentle isometric through to loaded isotonic strengthening)
Gluteal Strengthening
PNF patterns
Stationary Bike
Return to running program
Graduated and progressive return to play
Whilst this is by no means a recipe for your patients, it should serve as an indicator of the components of a successful rehabilitation program. In this small case series (n=4) all players returned to play at a mean time of 13 weeks.
 
The results of this study mirrored the overall findings of Choi et al (2011) who found that the mean return to play for all patients undergoing conservative management was 9.55 weeks! Not bad…
 
INJECTIONAL THERAPY
The studies examined two types of injectional therapy corticosteroid or prolotherapy.
 
Corticosteroid Injections: Overall 58.6% of patients RTP in 8 weeks, whilst there was no response in approximately 20% of patients. 
Prolotherapy Injections: Topol et al (2005) examined prolotherapy injections in patients with chronic groin pain and found much more promising than the corticosteroid injections! 91.7% of the athletes RTP in 9 weeks, and there was a 8.3% no response rate. Be warned, I have been told it hurts…a lot.

SURGICAL MANAGEMENT
As you may expect surgical management should only be considered as a last resort. Dependant on the choice of surgery, which is widely variable in clinical practice, it can be a season ending operation. Therefore, it is not a decision to make lightly. The case series literature describes three surgical techniques (Choi et al, 2011). These are discussed below:
 
Curettage of Pubic Symphysis: 72% RTP at an average of 5.6 months
Arthrodesis of the Pubic Symphysis: 87% RTP at an average of 6.6 months, with a 25% complication rate.
Polypropylene Mesh Placement into the Preperitoneal Retropubic Space: 92.3% RTP at an average of 7.2 weeks.

TAKE HOME MESSAGES
There is a dearth of quality research to guide treatment decisions for osteitis pubis.
Conservative management should always be the first line of treatment for osteitis pubis.
Optimal management is individualised and always looks “beyond the groin”!
Prolotherapy could be used if physiotherapy fails (but it hurts!).
Surgery is a last resort only! 
 
REFERENCES
  • Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc 1995;27:629–33.
  • Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med 2011 45: 57-64
  • Ekstrand J, Ringborg S. Surgery versus conservative treatment in soccer players with chronic groin pain: a prospective randomised study in soccer players. Eur J Sports Traumatol 2001;23:141–5.
  • LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia 2003;7:68–7
  • Lentz, Samuel S. Osteitis Pubis: A Review. Obstetrical & Gynecological Survey 1995;50(4):310-315
  • Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil 2005;86:697–702.
  • Wollin M, Lovell G. Osteitis pubis in four young football players: a case series demonstrating successful rehabilitation. Phys Ther Sport 2006;7:153–60

Warning: The reader of this article should exercise all precautionary measures while following instructions on the home remedies from this article. Avoid using any of these products if you are allergic to it. The responsibility lies with the reader and not with the site or the writer.This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE and should not be treated as a substitute for the medical advice of your own doctor. 



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Gift of Anger


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The Gift of Anger 
  
A tale is told about the Buddha, Gautama (563-483BC), the Indian prince and spiritual leader whose teachings founded Buddhism. This short story illustrates that every one of us has the choice whether or not to take personal offense from another person’s behavior.
It is said that on an occasion when the Buddha was teaching a group of people, he found himself on the receiving end of a fierce outburst of abuse from a bystander, who was for some reason very angry.
The Buddha listened patiently while the stranger vented his rage, and then the Buddha said to the group and to the stranger, “If someone gives a gift to another person, who then chooses to decline it, tell me, who would then own the gift? The giver or the person who refuses to accept the gift?”
“The giver,” said the group after a little thought. “Any fool can see that,” added the angry stranger.
“Then it follows, does it not,” said the Buddha, “Whenever a person tries to abuse us, or to unload their anger on us, we can each choose to decline or to accept the abuse; whether to make it ours or not. By our personal response to the abuse from another, we can choose who owns and keeps the bad feelings.”

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Osteitis – Pubis


 
Osteitis Pubis is a condition that many consider rare, however, it is probably more common than you may think. The incidence of groin pain, in some sports, is as high as 13% (Ekstrand and Ringbord, 2001). Thus, it is highly likely that as a sports physiotherapist you will encounter may athletes with a diagnosis of osteitis pubis. Therefore, as is frequently stated on this site, you need to be aware of the current research and evidence based practice, even in a world with limited research.
 
OVERVIEW
Osteitis pubis is defined as a painful inflammatory process involving the pubic symphysis and surrounding structures including the pubic rami, cartilage, musculotendinous and ligamentous pelvic structures (Batt et al, 1995). It is suggested that this is caused by repetitive stresses of the pubic symphysis during strenuous physical activity, most commonly secondary to reduced hip range of motion (LeBlanc and LeBlanc, 2003).
 
DIAGNOSIS
 
Subjective:
CHx: The athlete will often report an insidious onset of groin pain, with nil major traumatic incident. 
Pain:  Will usually be present in the groin and lower abdominal region. 
Agg: Aggravating activities will likely include running, stepping, jumping and kicking. 
 
Objective:
  • AROM: generally reduced hip range of motion, particularly abduction and rotations 
  • RIMT: adduction and lower abdominal activation will reproduce pain 
  • Palp: there will be tenderness around the groin and lower abdominal musculature with marked tenderness on palpation of the pubic symphysis. 
  • NB: A cornerstone of successful conservative osteitis pubis treatment will be addressing biomechanical and functional deviations at both the hip and lumbosacral complex, therefore these regions should be appropriately assessed and treated (Wollin and Lovell, 2006). This is further discussed below.
  • DDx: Some important and common competing hypotheses are listed below (Choi et al, 2011):
Strain 
Sportsman’s Hernia 
Stress # 
Hip Pathology (FAI) 
LBP Referral 
 
RADIOGRAPHY
X-Ray: normal radiographic findings may include:
loss of the smooth cortical periphery 
reactive sclerosis 
rarefaction 
superficial bone destruction with occasional heterotopic ossification 
greater than 10-mm separation of the symphysis 
symphyseal instability as demonstrated by movement of the symphysis of more than 2 mm on step films (Lentz, 1995) 

Bone Scan: has greater sensitivity than plain film X-ray.
MRI/CT: Also diagnostic of osteitis pubis. Also particularly useful in exclusion of competing hypotheses.
 
TREATMENT
The following discussion regarding treatment decisions is guided by the systematic review by Choi et al (2011). Whilst they searched for the best available evidence, they were unable to identify any RCTs regarding treatment decisions for osteitis pubis. Therefore, the following recommendations are based on clinical experience and case studies/series. Hint, hint… not a lot of rock solid evidence going around.
 
CONSERVATIVE MANAGEMENT
This generally involves the three mainstays of an inflammatory musculoskeletal condition: relative rest, NSAIDs, and physiotherapy!
 
Physiotherapy treatment, as always, should be based on the individual athlete and their assessment findings. Thus, as stated above, you should assess for biomechanical and functional impairments and treat accordingly. The components of a successful conservative rehabilitation program included (Wollin and Lovell, 2006):
 
Manual techniques to restore full range of motion in the lumbar, sacral and hip joints. This included soft tissue, MET, mobilisation and manipulative techniques. 
Core Control Exercises (TrA and Pelvic Floor Training) 
Adductor Strengthening (Progression of gentle isometric through to loaded isotonic strengthening) 
Gluteal Strengthening 
PNF patterns 
Stationary Bike 
Return to running program 
Graduated and progressive return to play 
Whilst this is by no means a recipe for your patients, it should serve as an indicator of the components of a successful rehabilitation program. In this small case series (n=4) all players returned to play at a mean time of 13 weeks.
 
The results of this study mirrored the overall findings of Choi et al (2011) who found that the mean return to play for all patients undergoing conservative management was 9.55 weeks! Not bad…
 
INJECTIONAL THERAPY
The studies examined two types of injectional therapy corticosteroid or prolotherapy.
 
Corticosteroid Injections: Overall 58.6% of patients RTP in 8 weeks, whilst there was no response in approximately 20% of patients. 

Prolotherapy Injections: Topol et al (2005) examined prolotherapy injections in patients with chronic groin pain and found much more promising than the corticosteroid injections! 91.7% of the athletes RTP in 9 weeks, and there was a 8.3% no response rate. Be warned, I have been told it hurts…a lot.

SURGICAL MANAGEMENT
As you may expect surgical management should only be considered as a last resort. Dependant on the choice of surgery, which is widely variable in clinical practice, it can be a season ending operation. Therefore, it is not a decision to make lightly. The case series literature describes three surgical techniques (Choi et al, 2011). These are discussed below:
 
Curettage of Pubic Symphysis: 72% RTP at an average of 5.6 months 
Arthrodesis of the Pubic Symphysis: 87% RTP at an average of 6.6 months, with a 25% complication rate. 

Polypropylene Mesh Placement into the Preperitoneal Retropubic Space: 92.3% RTP at an average of 7.2 weeks.
TAKE HOME MESSAGES
There is a dearth of quality research to guide treatment decisions for osteitis pubis. 
Conservative management should always be the first line of treatment for osteitis pubis. 
Optimal management is individualised and always looks “beyond the groin”! 
Prolotherapy could be used if physiotherapy fails (but it hurts!). 
Surgery is a last resort only! 
 
REFERENCES
  • Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc 1995;27:629–33.
  • Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med 2011 45: 57-64
  • Ekstrand J, Ringborg S. Surgery versus conservative treatment in soccer players with chronic groin pain: a prospective randomised study in soccer players. Eur J Sports Traumatol 2001;23:141–5.
  • LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia 2003;7:68–7
  • Lentz, Samuel S. Osteitis Pubis: A Review. Obstetrical & Gynecological Survey 1995;50(4):310-315
  • Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil 2005;86:697–702.
  • Wollin M, Lovell G. Osteitis pubis in four young football players: a case series demonstrating successful rehabilitation. Phys Ther Sport 2006;7:153–60
Warning: The reader of this article should exercise all precautionary measures while following instructions on the home remedies from this article. Avoid using any of these products if you are allergic to it. The responsibility lies with the reader and not with the site or the writer.
This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE and should not be treated as a substitute for the medical advice of your own doctor.
 

Dog Man’s Best Friend


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Fun & Info @ Keralites.net
Fun & Info @ Keralites.net
Fun & Info @ Keralites.net
Fun & Info @ Keralites.net
Fun & Info @ Keralites.net

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That’s God


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THAT’S  GOD
Have you ever been just sitting there and,
all of a sudden you feel like,
doing something nice for someone,
you care for…THAT’S GOD…
He talks to you through the Holy Spirit.
Have you ever been down and out and,
nobody seems to be around for you to talk,
to….THAT’S GOD…He wants you to talk ,
to Him.
Have you ever been thinking about somebody,
that you haven’t seen in a long time and,
then the next thing you know you see them,
or receive a phone call from them…
THAT’S GOD…
there is no such thing as coincidence.
Have you ever receive something wonderful
that you didn’t even ask for,
like money in the mail,a debt that had,
mysteriously been cleared or a coupon,
to a department store where you had just,
seen something you wanted but couldn’t
afford…THAT’S GOD.
He knowa the desires of your heart.
Have you ever been in a situation and you
had no clue how it is going to get better,
but now you look back on it…
THAT’S GOD.
He passes us through tribulation,
to see a brighter day.
PRAYER
Father God, you are awesome in might,
righteousness, and faithfulness,
No one is comparable to you,
Please bless me dear Father as I seek,
for you in the Scriptures…
Please reveal yourself to me and reconfirm
the identity and uniquenss of Your Son,
as I STUDY YOUR Word and I am guided by,
you Holy Spirit.
In the Lord’s name I pray.
Amen
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Feelings and actions


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Abdullah was sleeping in a corner of a mosque in Mecca, when he was awakened by the conversation of two angels above his head. They were preparing a list of the Blessed and one angel was telling the other that a certain Mahbub of Sikandar City deserved to be ranked first, even though he has not come on pilgrimage to the Holy City.

Hearing this, Abdullah went to Sikandar City and found out that he was a cobbler, repairing the shoes of people. He was famished and poor; for, his earnings barely sufficed to keep flesh and bone together. He had by severe sacrifice piled up a few coppers during the course of years; one day, he spent the entire treasure to prepare a special dish, which he proposed to place before his enceinte wife as a surprise gift.


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When he was proceeding home with the gift he heard the cry of a starving beggar who seemed to be in the throes of extreme hunger. Mahbub could not proceed further; he gave the pot containing the costly delicacy to the man and sat by his side, enjoying the blossoming of satisfaction on his haggard face.

The act gave him a place of honour in the register of the Blessed, a place which pilgrims to Mecca who had spent millions of Dinars in charity could not secure. The lord cares for the feeling behind the act, not the fanfare and the fuss.


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There is an ancient saying in India that goes like this: Anna daanam maha daanam; Vidya daanam mahattaram. Annena kshanika trupthihi Yaavajjeevanthu vidyaya.

It means that giving food to a hungry person is indeed a great donation, but the greatest donation of all is to give a person education. Food gives but a momentary satisfaction whereas education empowers the person for his entire life.

The Sanskrit word Annadanam literally means the offering or sharing (danam) of food (annam).In sanskrit the word “Annam” means food and “Daanam” means to donate. Thus “Annadanam” means feeding the hungry and needy.Taittiriya Upanishad declares, All life force comes from food. (annam vai pranah) and Let food be produced in plenty (annam bahu kurveet). In Bhagavad Gita, Sri Krishna declares, From food all beings are evolved (annad bhavanti bhutani).Even in Vedas, Upanishad, Ramayana, or Mahabharata during all these periods feeding a hungry person was treated as a greatest service to man kind. ANNA DAANAM MAHAA DAANAM [offering food is the best gift in the world.]is a very popular Sanskrit verse which has motivated millions of Indians to perform this divine act and in ancient India in most of the temple premises there were annadana centers.

Annam Para Brahma Swarupam. Food only can support the body to attain Dharma, Artha, Kama, Moksha. The person, who participate in this sacred Annadanam, will be blessed by divine Gods. Creatures cannot live without food, hence the donors of Annadanam are also considered as donors of pranadanam. Pranadanam means to offer all things as donation, accordingly they are blessed. Annadanam is a sacred activity. It is said that the sacred works done by the people with the energy acquired by food bestows half of its effect to the donor of food and the rest is to that person. Many positive results like this can acquire from the Annadanam.
Manu Dharma Sastra declares, regard the guest as a deity (atdhithi devo bhava) plainly expresses this worldwide tradition among ancient societies that deities may move upon the earth in human guise, and that one should therefore regard them with the utmost courtesy and respect and hospitalityincluding the offering of food items. Annadanams are conducted with this very principle in mind, for among the hungry crowd there may also be the anonymous genuine devotee, saint or even a deva or deity. Indeed, each and every poor person is regarded in this way, as expressed in the Sanskrit saying Daridra Narayana (God dwells in the poor person).
Service to human is service to God. Serving food to the hungry is equal to effect of performing ritual yagna. Human beings can only be satisfied with food but not with gold, dress and other things, as they desire to have them more and more. But in case of food a man wholeheartedly says that the food is enough for him. It is said that glory, strength and fame will be acquired in Trilokas by Annadanam.


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