THE CLINIC

Is Groin Inflammation Common in Distance Runners?

I’ve written to you in the past about pain in my groin area. Last year I found a good chiropractor, who recommended exercises known as the Active Release Technique, which has helped in the healing of scar tissue in that area. However, in the last month, pain in the middle groin area became so severe that I could not perform any physical activity. After several examinations—including a CT scan, prostate exam, x-rays, and blood tests—an unusual injury was detected. It has been diagnosed as osteitis pubis, but in my case, there is a widening gap of the pubic symphysis, toward the bottom. [ed. note: the pubic symphysis is the slightly moveable joint at the front of the pelvis.] Cartilage loss and bone damage are present, causing pain in that area.

My surgeon has never seen this condition before, since there was never any trauma to that area. It is most likely the result of being a runner for 25 years. The recommendation is rest and non-impact activities. My surgeon is actually doing research on the subject, to determine the actual cause a prescribe the right rehab program. I am scheduled to be re-evaluated in two weeks.

Is the degree of this injury common among distance runners? How long will it take to heal, and when can I return to running regularly? My own limited research on the subject has introduced me to cortisone and prolotherapy injections, various drugs and surgeries, and an extended period of rest as all possible remedies.

Mark Roosevelt
Wakefield, AZ

As noted, osteitis pubis is inflammation of the joint between the two halves of the pelvis that join in the front (pubic symphysis). It’s common in women immediately after pregnancy. It is very easily diagnosed by pointed tenderness in the exact middle of the pubic bone. If there is tenderness more than 1 cm on either side of the midline, it is something other than osteitis pubis. One may or may not see widening on x-ray. A bone scan is conclusive. Treatment involves avoiding any activity that irritates it, plus simple o.t.c. anti-inflammatory medication. It usually responds within six or eight weeks of limited activity. This is one injury that you cannot “run through.” Bicycling is usually acceptable. Cross-country ski machines or rowing machines are also usually relatively comfortable. It rarely becomes a chronic problem.

G. Klaud Miller, MD
Rochester, MN

The pain in this condition manifests in the pubic region and lower abdomen, as well as along the inner thigh region, usually on both sides. It may occur for no identifiable reason, but is often due to overuse. Specifically, the repetitive back and forth or up and down shearing movements between the two halves of the pelvis. Because they are joined infront by the pubic symphysis, it can become swollen and painful. Running sports that involve abrupt cutting and pivoting are often associated with the development of this condition. Unfortunately, it can sometimes become chronic. 

Tight hip adductor (inner thigh) muscles especially, but also hamstrings and weak lower abdominal muscles have been implicated as being responsible for osteitis pubis. I have not heard that it occurs in distance runners any more often than in other running athletes. For most musculoskeletal conditions, the longer the symptoms have been present, the longer it takes for them to improve. Since you have had groin pain symptoms for more than a year, improvement in your pain is most likely going to be gradual; it may require months, rather than weeks, before you can cautiously try to resume short-distance, slow running without aggravating your symptoms.

If you haven’t already doen so, a course of physical therapy is appropriate. This would involve your therapist finding and correcting any imbalances in muscle strength or flexibility that the initial evaluation may have revealed.

Brian Bowyer, MD
Cincinnati, OH

Contemplating a Bone Graft

I am 52 years old, and have run for 22 years and played all kinds of other sports. I no longer run on pavement. My right knee was diagnosed with osteochondritis dissecans (OCD) and I had meniscus surgery on the same knee a year and a half ago. At the follow-up my surgeon recommended that I have Osteochondral Allograft Transplant Surgery (OATS). I still play volleyball regularly and occasionally will play a game of basketball. I can still jog slowly on a treadmill.

Wayne Marseus
Williamsburg, VA

[Ed. notes: In OCD, which usually affects knees and elbows, a loose piece of bone and cartilage separates from the end of the bone because of a loss of blood supply. The loose piece may fall into the joint space, making the joint unstable. This causes pain and feelings that the joint "sticks."

During OATS, a size-matched donor graft (allograft) is obtained and the diseased cartilage is mapped, and a single, large cylinder of the poor cartilage and underlying bone is removed. The allograft donor cylinder is then inserted into the socket, restoring a normal joint contour.]

There are many issues with osteochondritis and OATS procedure brings more into play. I assume that if allograft is anticipated there must be large OCD lesions, otherwise autograft tissue might be preferable.

I would probably avoid surgery until you do not have other options. Patella-centering braces, NSAIDS, quadriceps strengthening exercises, and cross-training would all likely be helpful. I would avoid stairs, hills, and the like and never train to excess. Some use glucosamine to their advantage and also injections of viscous material like Synvics.

In the right circumstances OATS is a good procedure. However, if the lesion is small with intact articular cartilage, the bone scan normal, and your symptoms minor, then the real value of the procedure is less evident.

Larry D. Hull, MD
Centralia, WA

In order to make an assessment we’d have to see your MRI as well as an A/P longstanding view of both lower extremities to determine the size of the OCD defect, your weight-bearing alignment, and associated intraarticular knee disease.

My experience with allograft osteochondral grafting have been very encouraging. Results, at least in the short term, are excellent.

Rob Meislin, MD
New York, NY

To Fix Achilles Problems, Don’t Discount a
Change of Shoe

I was diagnosed with Achilles tendonitis, and my pain is severe in the lower right leg, as well as the pain in the ankle area of my left foot. After running I can hardly walk and the pain is severe going up and down stairs; it subsides when I don’t run.

I am a weekend runner and will be 67 in August. I run four to five miles at a time, and have been doing so since 1977. I was injured in January playing tennis with a leg cramp, and then the tendonitis showed up. I had been inactive in racquet sports for years prior to the leg cramp incident.

I went to an orthopedist who found no stress fractures or breaks in the x-ray. He prescribed physical therapy, but after five visits I stopped. I saw a friend who is a podiatrist and he said that arthritis is setting in—which seemed to coalesce with the fact that in the morning I now have lower back pain and tightness in my legs.

I run on street surfaces, and am 5’ 6”, 175 lbs. I’d love to continue my running.

David Mortgensen
Fort Pierce, FL

If you have both Achilles tendonitis and arthritis, I would make sure that you are running in a stable running shoe and/or an orthotic. One of the most common reasons for both injuries is overpronation (where the arch and ankle collapse too much, increasing strain on joints and tendons). Excessively-cushioned running shoes can make these problems worse. Stable running shoes, by contrast, help align the foot and decrease the workload on certain structures.

If you already have a stability shoe, then you should focus on an orthotic. I’ve treated plenty of runners who have been able to continue training simply by changing shoes, adding orthotics, and also doing physical therapy. If you haven’t found a running-oriented physical therapist in your area, ask other sports medicine specialists who they would recommend, or call the local running stores and running clubs and see who they suggest.

Paul Langer, DPM
Minneapolis, MN

The apparent Achilles tendonitis is likely related to the tennis injury you described. Conservative treatment is the early mainstay. A course of physical therapy beyond the five visits you mentioned may be helpful, as well as use of a heel lift, as noted above, to decrease tension on the tendon. You should also incorporate Achilles stretching exercises. Ideally, symptoms should improve in several weeks with this treatment outline. If this fails, you will need a thorough biomechanical examination by a sports medicine professional.

James Gardiner, DPM
Yonkers, NY

I am a 56-year-old female, 5’ 4”, 120 lbs, and have been running for 13 years. I average 15 to 20 miles per week, usually three to five miles once or twice, then a longer run on the weekend. I also do strength training, stationary biking, and yoga several times a week.

I enjoy long distance running, doing the run/walk method mostly on concrete or asphalt. I have run 15 marathons in the last five years (averaging three or four a year), with finishing times of 5:30 to 6:00. On training runs we average about a 13- to 14-minute mile pace. While on a skiing vacation a month ago, I fell and tore the ACL in my right knee (confirmed by MRI when I got home). My orthopedist recommended physical therapy three times a week to strengthen the knee instead of ACL repair surgery, in part due to my age and the risks of surgery as one ages. He explained that surgery would be necessary if I participated in sports; I stressed to him that I wanted to be able to run again. He said that it’s possible to run without an intact ACL.

I’m finishing my second week of rehab and noticing some improvement. The knee still feels unstable, however, though I’m told to be patient. I’m wondering should I give up marathoning once it heals and focus on shorter distances? Can I realistically expect to run at all with a torn ACL, even after rehab? I just want to return to running as I was before.

Jane Forrester
Baton Rouge, LA

Yes, you can run long distance without an ACL. However, you will probably have more difficulty with tennis and other racquet sports, along with most activities that require stop, start, cut, turn, and stress. Your orthopedist’s advice is the general rule for most people aged 56, but you are much more demanding of your body than most people at that age, and so this may not be the best advice for you. Generally I would recommend giving it three to six months and see how you feel, what limitations you have, and whether you are comfortable with them. If not, return to your doctor and examine the options.

I have some 50+ patients who sound a lot like you who have been much happier after an ACL reconstruction. I often suggest an allograft. This requires less surgery and is almost completely arthroscopic. It is quicker and less painful, with a smoother recovery, and the results are equally good to autograft hamstring or patellar tendon grafts.

There is a risk having an unstable knee from an ACL tear that, since more stress is applied to the medial and lateral meniscus, you’re more likely to wind up with a cartilage tear—then your knee would become worse. A loose ACL plus torn cartilage would most likely require surgery.

While your knee is recovering, some time on the bike, stair stepper, rowing machine, and the like can keep you in tip-top shape.

Larry D. Hull, MD
Centralia, WA

You must rehab your knee prior to any surgery, therefore your surgeon is correct in this conservative approach. This takes about 90 days, and the ACL repair surgery can be done anytime up to one year from the tear, so there is no rush. One of the nice things about being over 50, by the way, is that the knee tightens up in over 70% of the cases without surgery.

Robert Erickson, MD
Canton, OH

If you have instability, you should have a reconstruction of your ACL. While recovering from an ACL reconstruction is a challenge, you should be able to recover and run without difficulty. If your knee is unstable, you will likely tear your meniscus eventually, and then you won’t be able to run. I agree that an allograft reconstruction, performed arthroscopically in about 20 to 30 minutes, is indeed the best procedure to choose. You want to be off your crutches in three to five days and out of all braces in a week. The Achilles tendon allograft is the strongest, and you can get a sterilized allograft so there is no risk of infection.

Warren King, MD
Palo Alto, CA 

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