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1. Symptoms
What are the symptoms of Osteitis Pubis? What does OP feel like? We will cover a list of symptoms, methods of diagnosis, self-treatment and rehabilitation in the rest of the site. For now let’s describe a common story we hear from OP patients.
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Stage 1: Early onset Osteitis Pubis
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OP usually starts as just some stiffness and tightness in the adductors (groin) during exercise. You might feel some dull pain and stiffness the next day but with some heat, rest and gentle stretching you’re fine for your next training session. Except 20 minutes into training it starts again. You go through the same process of rest and stretching, except it keeps coming back. The pain will probably get a little worse, the stiffness might take longer to stretch out; but you just keep on training just the same. None of it strikes you as a ‘serious’ problem. The pain isn’t agonising and as long as you warm up properly before exercise, you can get through it. You probably assume it will ‘sort itself out’ at some point.
We refer to this is early stage OP. The pain and stiffness is present, but it’s minimal and doesn’t change your exercising/training habits substantially.
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Stage 2: Fully developed Osteitis Pubis
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You keep training but now the pain is worse. You wake up in the morning with stiff, heavy adductors. Stretching doesn’t help anymore, it might even make the pain worse. Pain often starts immediately upon exercise. It’s becoming harder to train, and if you do train, it takes twice as long to recover. At this stage you might see a physio or get a massage. They tell you to rest, stretch and might give you some exercises to strengthen your hips (pilates clams, theraband exercises etc.). You’ll see some improvement, but the minute you return to a full training load the pain is back, often worse than before.
No matter what you do, you can seem to get rid of that stiffness in your groin.
At this point you have full developed Osteitis Pubis. Rest helps but it also lets your adductors become weak, so that when you return they are susceptible to re-injury. Clams and theraband exercises might deal with a few biomechanical issues, but as you will learn if you keep reading they are a band aid for the bullet wound that is OP.
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Stage 3: Final stage Osteitis Pubis
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The final stage of OP I call late stage OP; and its not pretty. This is when you start feeling pain on the pubic bone and pubic symphysis when you exercise. The stiffness is ever present in your life. It might even migrate to your hip flexors, glutes and lower back. It feels as if your entire pelvis is breaking down on you. Coughing might even bring on pain.
At this stage you might be sent off for scans. These show scelorsis, widening of the pubic symphysis or other serious issues in your pelvis. Now you’re being told to completely rest. And to consider different surgical options, one of which includes burning off the ends of your pain receptors in your groin!
And all the while no one is talking about or explaining how you developed Osteitis Pubis to begin with. If no one can actually provide you with an answer to why you develop OP to begin with, how can they provide you with an effective solution? How can they ensure that your OP wont come back at another stage?
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Symptoms of Osteitis Pubis
Stage 1 Symptoms
Stage 2 Symptoms
Tightness/sore in adductors: Your adductors feel rigid and tight most of the time.
Dull pain on exercise.
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Feeling of heaviness: your groins feel even when not training.
Rest improves pain: but the minute you train it returns and you need to rest again to recover.
Loss of flexibility/mobility: you’ve notice a distinct lack of mobility in the groins.
Slow onset: You don’t feel groin at the beginning of a workout. The pain comes on slowly.
Pain if you touch pubic bone
Numbness: in the adductors, hip or pubic area.
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Weakness during exercise: a noticeable loss of strength.
Pain in pubic bone during movement.
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Migration: Symptoms begin migrating to the hip flexors, lower back.
More rest required: Long periods of rest between exercise needed for groin to recover.
Pain immediately upon movement.
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2. Self Diagnosis
Amongst the medical community Osteitis Pubis is a poorly understood injury. The first steps on the road to recovery are;
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Determining if you actually have OP
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Determining how far (what stage) your OP has progressed
Determining how far your OP has progressed is vital to developing an effective intervention strategy. The stage/progression of your OP will determine the:
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Type/style of treatment
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Rehabilitation exercises
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Period of rest between exercise
This page will demonstrate and provide you with the tools to accurately diagnose whether you have OP and how severe it is.
Osteitis Pubis Self Diagnosis: a simple guide
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There are three main tools used to diagnose Osteitis Pubis.
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Radiological Scans: XRays and MRI
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Symptoms/case presentation: type and level of pain you feel, on what movements etc.
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Orthopaedic tests: A set of movements which test the integrity of the adductors, hip and pelvis.
In late stage OP morphological changes take place in the pubic symphysis (click here for more info…landing page). These changes can be picked up in an Xray or MRI and give a definitive diagnosis of OP. Unfortunately scans at this stage of OP are unnecessary; the pain and dysfunction is so severe that it’s obvious that you have OP.
Diagnosis for OP uses a combination of symptom history and orthopedic tests. These tools establish whether you have OP and what stage it has progressed to.
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2 Stages of Osteitis Pubis
For simplicity we have broken OP down into two distinct stages. In stage 1 OP, the pain in your adductors (anatomical name for your groin muscles) may have been around for a while. You’ve likely managed it with a combination of conservative treatment, such as ice, heat and massage. But no matter how much you rest or stretch, the tightness, lack of mobility and dull pain in the groin won’t go away.
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In stage 2 your symptoms are becoming severe and your stage 1 symptoms are becoming more intense. Your groins are extremely tight all the time, pain comes on immediately during exercise and you need longer periods of rest between exercise to reduce the pain. Alarming symptoms such as numbness and tingling may present.
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MRI and Xrays during stage 2 often show dysfunction and changes in the pubic bone and symphysis. Essentially the problem in your adductors has become so serious that its affecting bones.
The checklist here will use the symptoms you have to categorise whether you have stage 1 or 2 OP. If your symptom history is inconclusive, you can perform orthopedic tests to clarify.
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Interpreting the symptoms of Osteitis Pubis (OP)
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If you suffer from any of the symptoms in stage 2; do not proceed to orthopedic testing. You have OP. Though you can cure OP by yourself using this guide, I highly recommend you consider engaging Mindful Myo or another health professional to help with the treatment of Stage 2 OP.
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If you have 3 or more symptoms from the stage 1 checklist you have OP. Perform the Squeeze and Palpation test to confirm. If there is no pain in the Palpation test and minor pain from the squeeze test continue on to the FABERS test.
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If you have less than 3 symptoms from stage 1 continue to all three orthopedic tests.
Orthopaedic testing: confirming early stage Osteitis Pubis (OP)
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If you have 3 or less stage 1 symptoms there is a good chance that you have early onset OP. We can confirm a diagnosis of OP with some orthopedic testing.
The palpation, Squeeze and FABERS test will attempt to elicit/reproduce the symptoms of OP by placing the adductors and pubic symphysis in a compromised mechanical position. In simple terms we put the adductors/pubic symphysis under pressure highlighting any pain or dysfunction present. Reproduction of your symptoms would be a ‘positive’ sign (confirmation) of OP.
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Orthopedic tests for Osteitis Pubis; can they make things worse?
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Orthopedic tests can aggravate the adductors. This is why we only perform them when we are unsure of an OP diagnosis. In stage 1 your OP has not progressed; brief testing will not cause significant issues. However in stage 2 the adductors may be extremely weak; which is why the symptoms are severe (numbness, tingling, weakness etc.). If you have experienced any stage 2 symptoms you should avoid all orthopedic tests, as they constitute an unnecessary risk to your adductors.
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Palpation test
The adductors attach to the pubic bone. In OP the adductors are over contracted; placing excessive pressure at their attachment on the pubic bone and pubic symphysis. Overtime this area of bone will become inflamed and painful. In stage 1 the inflammation can only be felt through manual pressure on the bone. By stage 2 the inflammation increases; simply moving the adductors aggravates the area. The palpation test will help highlight the presence of inflammation.
Squeeze Test
The squeeze test measures the strength, function and integrity of the adductor muscles. If the squeeze test reproduces any stage 1 or 2 symptoms you have OP. The severity of these symptoms will determine whether you are in stage 1 or 2 (refer to the ‘interpreting the symptoms’ section).
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FABERS Test
I’m diagnosed, now what?
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Now you need to learn what causes OP, so you can go about making the best decisions regarding treatment and rehab to overcome your OP. Keep working through the rest of this site, as we explain what causes OP, how to treat and rehab it.
3. Biomechanical Issues
So we know that Osteitis Pubis develops when biomechanical weaknesses in the lower body overload the adductors.
Overused adductors; the true cause of Osteitis Pubis.
The major biomechanical weaknesses that cause Osteitis Pubis are:
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Hip drop whilst running
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Over pronation/supination
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Anterior pelvic tilt
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Knocked knees/bowed legs
These are not isolated issues; weakness in one area increases the likelihood of having a weakness in another. If you over pronate your tibia will be internally rotated, increasing the likelihood of having knocked knees. Furthermore the arch muscles; which stabilize your foot to prevent over pronation connect in the same muscular/fascial chain to the stabilizing muscles of the pelvis, which help prevent an anterior pelvic tilt.
This is why flat feet are often associated with an Anterior Pelvic tilt; and why OP patients present with varying degrees of the 4 major biomechanical weaknesses.
Click here if you would like to book in for a free, 20 minute Skype consultation to discuss your case.
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Individual Muscles aren’t necessarily weak
The first reaction patients have is to want to strength each weak muscle; their gluteus medius for a hip drop, their glut max for an anterior pelvic tilt etc. to fix their biomechanical weaknesses. But there is a major problem with this theory; these muscles aren’t necessarily weak.
When we test the strength of muscles in isolation (1 muscle at a time) OP patients don’t always show strength deficits. In fact most OP patients, being athletes demonstrate strong powerful muscles… when each is tested individually.
However functional, whole body tests (multiple muscles at once) tell a different story. 1 legged squats, lunges, deadlifts, balance work, Osteitis Pubis patients do poorly in. In fact a wide variety of exercises that demand muscular co-ordination and balance challenge OP patients. This is because they struggle activate their muscles/fascia in their correct ‘chains’. Each muscle is strong enough on its own; but they have no idea how to work together.
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Osteitis Pubis patients move clunky
When we slow down OP patients during movements they often appear stiff, rigid and well…. Clunky. Their movements are often powerful; a lot of patients are great athletes. But they never move ‘smoothly’. This makes changes in direction particularly difficult; as the more off balance you are the harder you have to contract your muscles to counter balance.
The muscles aren’t communicating and working together, they’re fighting each other. They’re bracing and contracting, doing their best to maintain balance without any help. No muscle more so than the adductors.
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A simple test?
Stand on one foot and close your eyes. You should be able to maintain your balance without shaking too much for 20 seconds. This sounds easier than it is. Most OP patients will find themselves touching the ground regularly.
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So which Muscular/Fascial systems are faulty?
The million dollar question. There are three specific systems. Click on the links below to find out more about each, or return to the Osteitis Pubis guide landing page to move straight onto the treatment and rehab methods to fix your Osteitis Pubis forever!
The functional chains that fail you:
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Deep front line and Osteitis Pubis; what happens when the major fascial chain fails
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Weak core and glutes and Osteitis Pubis
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Poor balance causing Osteitis Pubis? The invisible cause.
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3 functional systems fail in Osteitis Pubis
3 functional fascial, muscular and neural chains are dysfunctional in OP patients. These 3 chains can explain all of the biomechanical issues present in OP; and explain how they are all interconnected. The 3 chains are:
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The Deep Front Line: A fascial/muscular chain which includes the muscles of your arch (which affect pronation/supination and bowed/knocked knees), your adductors and your hip flexors (which strongly affect an anterior pelvic tilt) becomes weak and stops functioning effectively.
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Weak core and glutes: Your core muscles and gluteus medius are responsible for keeping your pelvis stable. Failure to stabilize the pelvis effectively forces the body to stabilize from the adductors.
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Vetibular/Proprioceptive system (balance): Whilst not a muscular system on its own, your balance is vital to the function of every muscle in the body. OP patients present with reduced balanced and body awareness; their movements tend to be clunky and rigid. This clunky, rigid movements create more friction and force through the lower body; putting more load on the already overloaded adductors.
The longer these systems remain weak, the harder the adductors work. Overworked muscles become tired, fatigued and tight. They develop trigger points and refer pain. They jam up joints and restrict mobility.
4. Adductors
Over Worked, Weak Adductors
Let’s start with a big statement; The underlying cause of all Osteitis Pubis cases is overused, over worked adductors. Whilst each individual case will have different associated issues, in the end, every OP patient’s adductors are extremely fatigued and dysfunctional due to being overused.
This should make sense; why else have your adductors become so stiff, dysfunctional and riddled with trigger points? However the better question is… Why your adductors? Why do you have OP, when no one else on your team; who probably train in the exact same conditions, does? To answer this question we need to start at the beginning, with the anatomy of the adductors.
Click here if you would like to book in for a free, 20 minute Skype consultation to discuss your case.
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Anatomy of the Adductors: a quick review
Your adductors do not work in isolation. Your adductors are connected to your tibialis posterior (the muscle that controls the arch of your foot) and actually continues up into your pelvic floor, core and further. We can this your Deep Front Line. We cover this in depth in part 6.
Every person that suffers from OP will have at least 1 (if not multiple or all) of the following postural issues;
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Hip drop whilst running
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Over pronation/supination
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Anterior pelvic tilt
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Knocked knees/bowed legs
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Dysfunctional foot muscles; the true cause of pronation (and why orthotics don’t work)
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These are all biomechanical dysfunctions; a failure of the muscular chains responsible for stabilising the pelvis (hip drop), feet (pronation/supination), lower back (anterior pelvic tilt) and knees (knocked/bowed legs). These conditions create excessive wear and tear on the joints of the body; increasing the force and friction that goes through the body.
This is where your broad, strong adductors come in; they compensate for the poor stability in the feet, knees, pelvis or lower back by over stabilising the femur. Unfortunately this wears down the adductors. Your adductors are overused and overworked; constantly compensating for the other weaknesses on your body. Over worked, over used muscles become dysfunctional. They develop trigger points, refer pain and start to break down. They start to hurt and complain all the time.
Over worked adductors essentially feel like….. Osteitis Pubis!
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Why does OP treatment ‘wear off’?
So you get your groins massaged and it feels great…. For a little while. Then after a bit of training that pain creeps back in; and your back to square one. When you massage overworked muscles they relax. Your reduce inflammation and the muscle can start working again. Then the second you go back to training you overwork them again, and the cycle continues. The same process applies to rest; you give your adductors a chance to heal but once you return to activity the pain comes back… often worse than before!
5. Deep Front Line
The Deep Front Line (DFL): a break down in the core of your body
Osteitis Pubis develops when biomechanical weaknesses in the body overload the adductors. The most common biomechanical flaws that we see to some OP patients are
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Hip drop whilst running
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Over pronation/supination
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Anterior pelvic tilt
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Knocked knees/bowed legs
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Unfortunately these conditions are treated as separate problems. Tight hip flexors cause your APT, flat feet causes over pronation, a weak gluteus medius causes a hip drop.
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But what if there was a common thread that tied all these conditions together?
What if this same ‘thread’ is at the center of Osteitis Pubis? This thread is the deep front line; the most important fascial/muscular chain in your body
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The Deep Front Line: the rails of your body
Your body is a moving machine. Like a train on its tracks our ‘moving machine’ only works well when it moves within its limits. If you pull your leg back to kick a ball, and your hip slightly dislocates out of its socket, that ball isn’t going very far. Your DFL sits in your central axis; it is a fascial connection of all the muscles responsible for keeping your entire body stable and upright. It holds you in the ‘rails’ of good posture. Within these ‘rails’ your joints, ligaments, muscles and tendons are balanced. Joints remain firmly in their sockets, load is distributed evenly across the body and no one area is overused.
Parts of the DFL
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The arch of your foot (deep toe flexors),
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Knee/femur (adductors),
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Pelvic girdle (pelvic floor and hip flexors)
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Lower back (top of hip flexors and diaphragm)
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Ribcage (thoracic core and diaphragm)
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Neck and skull (deep neck flexors, TMJ muscle).
The muscles in brackets individually stabilise a specific joint; leading to the common misconception that you can strengthen one muscle to fix a joint problem. However it’s the DFL which connects and co-ordinates all the muscles together.
None of these muscles are actually strong enough to stabilise their individual joints without help. If your arch collapses (weak toe flexors) than your adductors will be unable to stabilise your femur; and your knee will suffer. If your pelvis is unstable (pelvic floor and hip flexor weakness) than your adductors will struggle to stabilise your hip in the socket.
It is the fascial connection between all these stabilising muscles; the DFL, which ensure the stability of all these joints. The sum is greater than its parts. The DFL enables you to move your body smoothly and efficiently, as a whole. When you stabilise your neck it’s the DFL, automatically pulling your ribcage and lower back into position to de-load the neck vertebrae and advantage the deep neck flexors.
The relative weakness of each stabilising muscle is negated when connected by the DFL.
How a collapsed Deep Front Line causes Osteitis Pubis
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The Deep Front Line stabilises your body towards your central axis; keeping you balanced and in good posture. This helps distribute load evenly across your entire body. When its dysfunctional your body, and your posture begin to collapse. Where moving ‘outside the rails’ of our body. Now muscles and joints are being moved in unstable, overloaded patterns. Joints get worn out, muscle fatigue, Osteitis Pubis develops.
As we’ve established, OP is an overuse injury caused by flawed biomechanics. In OP we see a breakdown in two specific areas of the DFL; the Deep Toe Flexors which control he arch of the foot and the Pelvic Floor/Hip Flexors/Diaphragm which control the pelvis and lower back. Dysfunction in these areas lead to the common biomechanical flaws of OP
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Hip drop whilst running
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Over pronation/supination
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Anterior pelvic tilt
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Knocked knees/bowed legs
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Weak arches cause Osteitis Pubis
The deep toe flexors are a group of muscles which live deep under the calves on the back of the tibia. The foot is not a solid structure like your femur. It is made up of 26 floating bones held together by ligaments and tendons. The tendons of the deep toe flexors attach to 8 of these bones, most of which live in the mid foot (where your arch is). Your deep toe flexors are responsible for drawing up and releasing your arch.
The deep toe flexors are vital to running and walking. When you’re running at full speed, your foot strikes the ground at a force of approximately 2.5 times your body weight. If you weigh 70kg that’s 175kg per foot strike. Your feet, your calves and particularly your deep toe flexors play a vital first stage in dissipating that load. Unfortunately when the deep toe flexors are dysfunctional that load simply transfers further up the leg to your adductors.
The two most common types of deep toe flexor dysfunction are over pronation and over supination. In over pronation the deep toe flexors are stretched and weak. Failing to draw up the arch, the ankle rolls in at high speed, dragging the knee with it.
In over supination the opposite occurs. The deep toe flexors are short and tight, making the arch high and rigid. Now when the foot hits the ground the arch cannot release, unable to take the pressure of your body like a spring. Instead the rigid arch forces you to roll onto the outside of the foot, dragging the knee outwards as well.
Whether its over pronation or supination the problem is the same. The deep toe flexors are not stretching, contracting and distributing foot striking ground force effectively. Instead they are just sending the load towards the adductors. Additionally by dragging the knee out of position they are increasing the load on the adductors, as they now need to also help pull the knee back into alignment.
This is all bad news for your adductors, which buckle under this increased workload and eventually develop OP.
Unstable pelvis and Osteitis Pubis
An Anterior pelvic tilt is when the front of your pelvis dips forward, increasing curve (and pressure) in your lower back and jamming your sacroiliac joint. This increased arch is usually caused by over tightening in the psoas muscle (hip flexor) and weakness in the glutes and core.
As your pelvis dips forward it jams the hip joint. In response you will turn out your feet, opening up your hips and reducing pressure on the hip joint. Unfortunately turning out your feet over stretches your adductors. Additionally because the pelvis is dipping forward, the majority of the weight of the spine and upper body is now being sent into the front of the body. Unfortunately again it’s your adductors which is left to bear the burden of this load.
Everything is inter-connected
An anterior pelvic tilt encourages you to turn out your feet. Turning out your feet whilst running will encourage you to over-pronate. Of course if you have poor proprioception (balance), you may turn your feet out to provide more balance. Of course turning out your feet reduces tension in the pelvis; causing it to tip into an anterior pelvic tilt.
And now you can see the folly in trying to fix one area on its own. The moves in functional chains; fixing one area will only create issues further up and down the chain. Full functional rehab which focuses on re-establishing the stabiliSing role of the deep front line is one of the most important steps in recovering from Osteitis Pubis.
6. Core / Abdominals
We’ve covered how Osteitis Pubis is caused by the biomechanical flaws which overload your adductors, eventually causing OP. We’ve also covered that the issue is not weaknesses in one individual muscle, but rather weakness in the co-ordination and firing of groups of muscles across functional movement chains across the body. Finally we discussed that the deep front line is the true ‘core’ of your body and the most important functional chain to address when treating Osteitis Pubis.
Well then what role does your core play? If the DFL is the core of your body, what are the ‘core muscles’ that every physio, osteo and pilates expert you’ve visited has mentioned? Let’s address that now.
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Deep Front Line: the rails of your body
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Your body is a moving machine. Like a train on its tracks our ‘moving machine’ only works well when it moves within its limits. If you pull your leg back to kick a ball, and your hip slightly dislocates out of its socket, that ball isn’t going very far. Your DFL is a primarily fascial line whose job is to help maintain the stability of the major joints across your body. The adductors and hip flexors help keep the hip in its socket. The hip flexors and diaphragm help stabilize the spine. Most importantly the DFL works as one. As you stabilize your hip socket through the adductors you automatically stabilize your pelvis and lower back. The DFL is fascially connected web, pull on one part (the adductors) and you start to provide tension (support) to the other parts (the lower back).
The deep front line does an excellent job of keeping the joints of your body stable, especially when they are already in good position/alignment. The problem is when you are in unstable positions. When you twist to tackle someone, or jump and land on an angle. Your deep front line is important, but it can only do so much. When life throws some more extreme physical challenges, the DFL needs some extra support to keep your body in its ‘tracks’. Or more importantly sometimes it needs something to pull your body back into its tracks. This is where your ‘core’ comes in.
What are my ‘core’ muscles
The DFL is our train track, the fascial alignment which best maintains safe posture and stability through movement. If we stay on the DFL, we remain healthy and injury free. Unfortunately the pelvis and especially the spine are not solid objects. The vertebrae, each side of the pelvis, the sacrum and the rib cage can all move in their own directions. Keeping our ‘train’ on its tracks can be extremely difficult for our pelvis and lower back.
This is the ‘cores’ job. It is a system of muscles designed to help stabilise and control the movement of the spine and pelvis. You can think of it as a box (figure 1), with the pelvic floor (figure 3) at the bottom, the transverse abdominus (figure 2) on the sides (with the multifidus as the back) and the diaphragm (figure 4) as the top. If you look closely at the Transversus Abdominis (TA) you will see that its fibres connect directly on each side of each of the lower back (lumbar) vertabrae.
The core is effective. The Transverse abdominus contracts, pulling around the sides of the stomach at their attachments on each side of the lumbar verterbae. By pulling the spine in both directions the spine is pulled backwards, flattening and becoming still like in the image above (posterior view of the spine)
To increase the effect of the TA the diaphragm contracts; which pushes down the abdominal contents. Its as if a balloon is placed inside the transverse abdominis, as the abdominal contents push against the TA it contracts harder, increasing its stabilising affect on the spine. The pelvic floor also contracts, pulling up the pelvic floor to add to this effect.
In the end the core keep the spine stable, and firmly in the tracks of the DFL.
When the ‘Core’ Fails
What happens when the ‘core’ fails? The hip flexors (part of the DFL) will tighten, stabilising the lower back whilst also pulling you into an Anterior Pelvic Tilt.
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Core activation and Osteitis Pubis
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Obviously if your core is not activating you’re not stabilising your pelvis and particularly your spine effectively. Whether this leads to an Anterior Pelvic Tilt or not, the load and force of your upper body needs to be sent somewhere. For OP patients that’s your adductors.
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In Summation
Core issues constitute another piece of the complicated Osteitis Pubis puzzle. Keep reading through the rest of the pages and you’ll have a seriously good understanding of how to kick your OP for good.
7. Glute Activation
We’ve covered how Osteitis Pubis is caused by the biomechanical flaws which overload your adductors, eventually causing OP. We’ve also covered that the issue is not weaknesses in one individual muscle, but rather weakness in the co-ordination and firing of groups of muscles across functional movement chains across the body. Finally we discussed that the deep front line the true ‘core’ of your body. And how this was the most important functional chain to address when treating Osteitis Pubis.
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Deep Front Line: like the rails of your body
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Your body is a moving machine. Like a train on its tracks our ‘moving machine’ only works well when it moves within its limits. If you pull your leg back to kick a ball, and your hip slightly dislocates out of its socket, that ball isn’t going very far. Your DFL is a primarily fascial line whose job is to help maintain the stability of the major joints across your body. The adductors, hip flexors and deep lateral rotators help keep the hip in its socket. The hip flexors and diaphragm help stabilise the spine. Most importantly the DFL works as one. As you stabilize your hip socket through the adductors you automatically stabilise your pelvis and lower back. The DFL is fascially connected web, pull on one part (the adductors) and you start to provide tension (support) to the other parts (the lower back).
The deep front line does an excellent job of keeping the joints of your body stable, especially when they are already in good position/alignment. The problem is when your are in unstable positions. When you twist to tackle someone, or jump and land on an angle. Your deep front line is important, but it can only do so much. When life throws some more extreme physical challenges, the DFL needs some extra support to keep your body in its ‘tracks’. Or more importantly sometimes it needs something to pull your body back into its tracks. This is where your glutes come in.
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What are your glutes?
Most people are familiar with their gluteus maximus; the strongest muscle in your body. The glutes however are made up of 9 muscles, which is why your bum curves of your body. You can break these muscles down into 3 groups.
Primary hip extension: The Gluteus Maximus
The most important movement to human beings is hip extension. Hip extension is when you pull your leg behind you; the motion that provides the power in running! Hence your body designed its most powerful muscle; the gluteus maximus to complete its most important movement job, hip extension!
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Pelvic Stabilisers
The gluteus medius and gluteus minimus play an important role in keeping your pelvis level whilst walking/running. As can be seen in the second image above when the glut med/min fires, the pelvis remains level. And when it doesn’t, we see the dreaded hip drop; one of the major biomechanical flaws in OP patients.
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Obviously if the pelvis is dropping dramatically the body needs to stabilize itself somewhere. And what should be sounding familiar; as seen in the third image that role often falls on the adductors.
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In Summary
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As a group the glutes play a vital role in keeping the pelvis and hip stable; helping the body remain within the ‘tracks’ of the DFL. When they become dysfunctional the adductors will often pick up the slack. And in what is becoming a broken record, they will become overworked, tighten, develop trigger points and eventually lead to OP.
8. Balance (Proprioception)
Poor Balance: the invisible cause of Osteitis Pubis
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We have covered that the cause of OP is the biomechanical flaws which lead to the overuse of the adductors. We then covered that it’s the dysfunction of the Deep Front Line (DFL), the most important fascial/muscular movement chain that plays a major role in creating these biomechanical flaws. Finally we covered how poor activation/co-ordination of the ‘Core’ and ‘Glutes’ prevents the DFL, and therefore your movement patterns from functioning properly.
Now we are going to cover the role of your proprioceptive system; that is your sense of balance, in the development of OP.
Balance: the taken for granted sense
Of all our senses, balance is the most ignored. Yet it is vital to every movement we make. Our sense of balance is more complicated than you might think. This is because unlike your eyes or ears, your sense of balance is achieved by multiple systems across your entire body & brain. To maintain a good sense of balance; to move smoothly and safely you must have some awareness of the following.
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Where you are in relation to the ground
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Where each joint is in relation to each other
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The relative strength and weakness of every muscle
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Where you are in relation to other objects in your immediate area.
Seems complicated… it is! If we can look at it the system as a whole then we are able to simplify it. As a paleo man/woman your brain and body had keep you upright and moving through tricky, unstable environments. Additionally it wasn’t okay to just remain on your feet; you had to move, dodge and change direction in a milliseconds just to survive. To achieve this, your brain and body developed a multi-faceted system to keep us agile.
But what happens when your sense of balance isn’t as efficient as it used to be? Would you notice? Would it be obvious? The answer is yes and no.
Balance and grace: an unappreciated skill
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Balance is more complicated than simply standing on one leg with your eyes closed. It’s the ability to make complicated movements in complete control. It’s the ability to be spinning in one direction, decide to stop immediately and reverse the movement. Its obvious when someone has a great sense of balance, they seem to move effortlessly. They move with ‘grace’, never out of control.
‘Grace’ is more important to your body than you think. Moving in a balanced and effortless way means that every joint is moving proportionately. Load and strain is being transferred efficiently across the body. One muscle or joint isn’t being exposed to or suffering through more load then it needs to. Shearing, buckling, bracing forces are kept to a minimum. Simply put; you avoid beating your body up.
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OP Patients move clunky
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OP patients are generally the opposite of graceful. It’s not that they are not good athletes. Most OP patients are great, powerful athletes. But they never move smoothly. They move ‘clunky’, relying on the strength of their muscles and joints to heave themselves in different directions. Over the course of a long training session, game, season this starts to wear you down. Till eventually the idea of changing direction at speed makes you nauseous. Till your groin hurts every morning, on every jog and everytime you get out of a chair. Till you have OP.
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How did my movements become ‘clunky’
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We live in a manicured society. Whilst sport is supposed to help develop well rounded bodies most sports don’t do this effectively. We run on flat, perfect grass fields. We don’t climb trees as kids, we don’t walk on unstable ledges. We wear shoes to enhance our stability and weaken our feet. In short our balance is not challenged regularly, so it atrophies.
Modern sport and exercise (running, gym etc.) challenge our muscles and cardiovascular systems. So they get stronger. Sports like basketball, football, soccer etc challenge us to be strong and powerful; so unconsciously we develop these aspects. Strength dominates our movements. We focus on doing something faster, more powerfully. We rarely focus on exactly ‘how’ we are doing it. Whether our technique in running, jumping, kicking, changing direction maybe hurting us. That is until we get injured.
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Ligaments sprains and tears; our silent killers
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Our body sends ‘proprioceptive’ messages constantly to our brains. Proprioceptive messages tell our brain where our joints, bones and muscles are in space. We need information for any change in alignment, as well as how much weight/tension our tissue is under. Our brains integrate this proprioceptive information to create efficient movements. Our ligaments are packed densely with proprioceptors to aid this process. When we sprain or tear a ligament we are essentially disrupting this connection, cutting vital information in the planning of smooth, balanced movements.
Ligaments don’t heal well. Typical rehab may not help.
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Ligaments have poor blood supply; they don’t heal well. Fortunately the muscles around a joint can be strengthened, effectively taking over the lost function of the ligament, providing some sense of stability. Most rehab for a ligament injury focuses on making sure the joint is strengthened and stabilised. Balance work is usually an afterthought – a token effort not explained well.
And this is where it all goes wrong. If your ligaments are damaged then your balance and awareness of that joint is extremely compromised. It doesn’t matter when you walk or run in a straight line. It will matter when you start changing direction.
Take an ankle with poor proprioception as an example. If your body doesn’t have great awareness of where the ankle is in space it will brace and stiffen it to protect it. As you change direction it won’t rely on the ankle, instead sending the load upwards to the knee. The knee will now be responsible for transferring all the load and initiating movement in the new direction. Unfortunately the knee is not as efficient at changing direction as the ankle. Your body likes winning; you may not notice a massive change in your speed. But your efficiency suffers. Your movements become clunky. Your knee suffers the damage of completing a task it’s not designed for.
OP and balance
You will notice that we did not speak about OP specifically. This is because this pattern can occur for any injury. It’s just in the case of OP that the body begins to rely on the adductors; starting the pathological process of tension and dysfunction that leads to OP.
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Can my balance be recovered?
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If ligaments don’t heal well is there any hope? Absolutely. Muscles have proprioceptors, just not as many as ligaments. If a ligament has been damaged, the muscles around the area must be challenged and strengthened from a balance and proprioceptive perspective. They have to be stimulated to grow more proprioceptors. Balance work can’t just be an after thought, it must be a vital part of recovery.
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Even if an injury occurred years before the joints function and movement can still be corrected by improving the proprioceptors in the muscles surrounding the joint. By correctly rehabbing the proprioception of a previously injured joint the body can be taught to correctly integrate it into movements. Movements can change from clunky back to smooth. Smooth movements can deload overused muscles, like your adductors, giving them the time to heal and recover. In short everything is reversible, with the right intervention, rehab and treatment.
9. The Role of Treatment
OP is an extremely painful injury. Treatment can go a long way to reducing this pain and improving your ability to get back out on the field. The problem is when treatment becomes a stop gap measure. Most athletes stop training, get treatment to reduce the symptoms till they’re groin feels pain free and then return to training… only for their OP to return with a vengeance.
Treatment needs to go beyond symptom recovery; it needs to create biomechanical changes in how the muscles and joints in the body function. If it isn’t treatment can be the equivalent of popping pain medication; good in the short term useless in the long run.
Deep Tissue Massage for OP
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Osteitis pubis involves inflammation and dysfunction of the adductors and pubic symphysis. If you have it you know exactly how tight, uncomfortable and painful your groins feel. They don’t need to be aggravated any further.
Most conventional treatment or massage involves fast, superficial, painful strokes across the surface of the muscle. The increased blood flow to the adductors often feels good immediately after the treatment, loosening up and improving range of motion. But over the next day the groin often tightens, returning to its original state or feeling even worse. This is because this style of treatment aggravates the adductors, encouraging the body to create more inflammation as the muscle is essentially ‘assaulted’ through treatment.
OP treatment needs to be slow, deliberate and deep. Your adductors will be riddled with trigger points deep under the surface. Treatment has to slowly engage the tissue, encouraging the superficial tissue to relax before deeper trigger points can be attacked with the more deliberate pressure of an elbow.
Treatment beyond the adductors
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Obviously your pain is in your adductors. But there must be a reason that your adductors have become so overworked and tight. This is because OP patients always have particular set of biomechanical weaknesses and faults which overload the adductors. Continually treating your groins without considering the rest of the body will get you nowhere.
Your Adductors share a connection to your medial hamstring. With OP, your adductors and hamstring tissue essentially become ‘stuck’ to each other.
The majority of OP patients have dysfunctional glutes, hamstrings and hip flexors. Essentially the hip and pelvis stop moving and the adductors suffer the effects of this. Treatment needs to address the hip flexors, especially around the front of the hip and the gluteal muscles in the back of the hip. Once the hip can move freely than pressure can be reduced from the adductors and they can start healing themselves.
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If you are going to try to fix OP with treatment, you’re going to need a therapist that understands the whole picture. Isolated treatment of the groin is unlikely to yield great results.
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