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Perineum Pain with Pubic Symphisis Degeneration

Exit forum ID Forum Discussion Perineum Pain with Pubic Symphisis Degeneration

This topic contains 6 replies, has 3 voices, and was last updated by   Christopher Stepien January 30, 2020 at 4:46 pm.

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    Christopher Stepien

      Looking to get eyes on this case and the exam I’m going to do.

      I also can’t find what the “crossover test” is. Is this Faber’s?

      Anything else I should be examining for?

      Dx Hypothesis:

      1. Pubic symphysis degeneration

      36 YO Male
      Lx: Perineum (currently wrapping around right lateral hip and right glute area – sometimes down right proximal lateral thigh)
      Q: sharp
      I: 4/10
      P+: running 5 minutes, running and abducting hips while changing direction
      P-: Rest

      Onset: 4 YA (sudden, no apparent cause) – was 9/10 before getting below injection
      2.5 YA after March 2017 MRI – Sports Hernia surgery – 10% relief
      2 YA – 100% relief for 18 months after injection into pubic symphysis
      Came back 6 months ago with running
      Rec Hx: played soccer all life through college and beyond
      Occupation: Phys ed teacher

      MRI 11/1/16:
      moderate degeneration in pubic symphysis with spurring and mild reactive edema in right pubic body.
      Partial tear of Rectus femoris abdominal separate aponeurosis
      Mild signal consistent with mild bone marrow edema in left acetabular roof – likely degenerative

      MRI 1/2/17:
      bilateral L5 spondylolysis with grade 1 anterolisthesis
      bulging of annulus at L5-S1 with bilateral neural foraminal narrowing and abutment of each exiting L5 nerve root
      Moderate lumbar levoscoliosis

      MRI 3/2/17:
      marrow edema in right symphysis pubis – marginal osteophyte formation at symphysis consistent with osteitis pubis.
      Cleft/fluid with peeled left adductor aponeurosis and small peeled RA aponeurosis at symphysis consistent with sports hernia.

      Here’s the exam I’m going to do:

      Functional Testing:

      Lumbar and Hip Testing
      Supine Hip Abduction (passive)


      Restricted structures of Level 1 Testing
      Distal RA (Tenderness (ie, pain with palpation) of the rectus abdominis insertion to the superomedial aspect of the pubic bone (figure below). )
      Adductor longus
      Adductor brevis

      Inflamed/Torn Muscles:

      Adductor squeeze test – sensitive but not specific (Pain (at the pubic insertion of rectus abdominis) on squeeze test)
      Curl Up
      positive crossover test


      Carl Nottoli, DC

        With that symptom location and quality, what brings you to the conclusion that the pain generator is the pubic symphysis rather than the victim?

        There are many problems seen on the MRI that all appear to be compensations from what I can tell.

        Can you screen shot a picture of the pain diagram so we can get a better look at the location?


        Christopher Stepien

          I appreciate that Carl.

          LOL – I have no idea. Haven’t seen this before.

          Since his symptoms in his perineum went away with the cortisone shot for 2 years with load, I figured load on the pubic joint would make it come back prior to 2 years.

          Will screen shot tomorrow in the office.

          After looking at spondylo, I want if this can be a compensation for that?

          TY for getting back to me.


          Keith Puri, DC

            Do you know what type of spondylolisthesis he has (ie dysplastic, traumatic, isthmic)?

            Is it possible for a dysplastic spondylolisthesis to chronically overload the anterior core and pubic symphysis creating muscle weakness/tearing and reactive/degenerative changes, respectively? If so, flex/ext XR might be helpful to ddx between this and a local pubic symphysis d/o.

            If flex/ext XR do not show evidence of instability an US-guided diagnostic injection to the pubic symphysis should help to rule this in or out as the primary pain generator. I would just make sure the patient performs the provocative activity within 1 hour of the injection and it no longer provokes his C/C.


            Christopher Stepien

              Carl – pic attached.

              Keith – degenerative.

              I’m not completely following? You’re saying overload of rectus abdominus and EO attaching to PS? I checked RA and felt no adhesion – although he did have that previous hernia.

              I’m not sure how the spondylo would overload those tissues though.

              Doesn’t the cortisone into the PS with 2 years of relief satisfy what you’re saying with the US guided diagnostic injection?

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              Keith Puri, DC

                36 yo is pretty young to already have a degenerative spondylolisthesis. These are more commonly seen in the 6th or 7th decade of life causing more central or lateral canal stenosis. At 36 I would certainly look into flex/ext XR to assess for instability. If the spondy is unstable something in the lumbar spine or pelvis has to work more in a protective response to stabilize the spine and prevent the disc from shearing. My question was could the anterior core or pubic symphysis compensate for this? Like Carl mentioned, is the pubic symphysis the pain generator or is it the victim?

                2 years of relief post cortisone injection in the pubic symphysis is fantastic. However, with his return of symptoms is the primary generator still the pubic symphysis or it is something else.

                As for your patient’s perineum pain, I would have him try to identify his exact pain location and see if there is any overlap with any of the cutaneous nerves in the pelvis and perineum, spinal dermatomes or pubic symphysis pain referral pattern.

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                Christopher Stepien

                  TY so much Keith.

                  It’s dead center between the anus and testicles, so a branch of posterior femoral cutaneous nerve or S1, S2, or S3 nerve roots.

                  Patient mentioned after exam and palpation he had suprising amount of relief from one palpation pass.

                  I’m going to focus on QLF and SHF treatments to see how he progresses and what clears out. With that out of the way, I’ll start palpating the PFCN at that time.

                  TY for helping me think through this.

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