What is the treatment for an athlete with bone marrow edema of the symphysis pubis, soft tissue edema of the abductor musculature, and likely athletic pubalgia/strain?

Treatment of Athletic Pubalgia with Bone Marrow Edema and Soft Tissue Changes

Initial management should focus on conservative treatment with activity modification, progressive physical therapy targeting the pelvic floor and core musculature, and gradual return to sport over 1-3 months, with surgical intervention reserved for cases failing conservative management after at least 12 months. 1, 2

Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Immediate reduction in high-impact activities is essential, as bone marrow edema at the pubic symphysis can occur in asymptomatic athletes but progresses with continued loading 3
• Athletes with lower pre-injury training loads have significantly higher risk of developing symptomatic osteitis pubis (odds ratio 0.003 per 4 training sessions), suggesting gradual load progression is critical 3

Physical Therapy Approach

• Manual physical therapy should target pelvic floor tenderness, resolve muscular trigger points in the pelvic, abdominal, and hip regions, lengthen muscle contractures, and release painful scars 4
• Focus on the adductor musculature, rectus abdominis, and posterior inguinal wall, as these structures are commonly involved in athletic pubalgia 2, 5
• Address any hip range of motion limitations, particularly in flexion, as femoroacetabular impingement may cause pathologic transfer stress to the pubic symphysis 2

Energy Availability and Nutritional Support

• Increase energy availability to promote bone healing, as energy deficiency impairs bone metabolism and delays recovery 1
• Metabolic hormone profiles can improve within days to weeks with increased energy availability, though bone marrow edema resolution takes months 1

Stress Management

• Implement stress management practices including meditation and imagery techniques to manage stress-induced symptom exacerbations 4

Timeline for Conservative Treatment

Expected Recovery Phases

• Metabolic and hormonal improvements occur within weeks to months, but bone marrow edema resolution typically requires several months to over one year 1
• Return to sport activities can occur between 1-2 months in responsive cases, though complete bone marrow edema resolution on MRI may lag behind clinical improvement 6

Monitoring Response

• Athletes with periarticular soft tissue edema, muscle edema extending around the symphyseal joint, or higher signal intensity on STIR sequences have significantly worse long-term outcomes and should be counseled accordingly 7
• These findings are negative prognostic factors for complete recovery (p=0.042 for soft tissue edema, p=0.036 for muscle edema, p=0.0019 for higher STIR signal intensity) 7

Surgical Intervention

Indications for Surgery

• Failure of conservative management after at least 12 months 1
• Persistent symptoms preventing return to sport despite adequate conservative treatment 6

Surgical Options

• Video-assisted placement of extraperitoneal retropubic synthetic mesh (10 x 15 cm polypropylene) can hasten healing in selected cases 6
• Alternative procedures include open or laparoscopic mesh hernia repair, adductor tenotomy, primary tissue repair, rectus abdominis repair, or endoscopic surgery for osteitis pubis 2
• Concurrent treatment of femoroacetabular impingement may be necessary if hip pathology is contributing to transfer stress 2

Surgical Outcomes

• All athletes in one series returned to sport 1-2 months post-surgery with resolution of pain at 12 months 6
• Postoperative MRI showed decreased bone marrow edema on T2-weighted sequences 6

Multidisciplinary Team Approach

Treatment requires coordination between sports medicine physician, sports dietitian, physical therapist, and potentially general surgeon for surgical cases 1, 2

Key Team Members

• Sports medicine physician for diagnosis and medical management 1
• Sports dietitian for nutritional optimization and energy availability 1
• Physical therapist with expertise in pelvic floor and core dysfunction 4
• General surgeon for hernia repair or mesh placement if indicated 2, 6

Common Pitfalls to Avoid

• Do not continue high-impact training in the presence of bone marrow edema, as this significantly increases risk of progression to symptomatic osteitis pubis 3
• Avoid premature return to sport before adequate soft tissue and bone healing, typically requiring minimum 1-3 months 6, 7
• Do not overlook concurrent hip pathology (FAI) that may be causing transfer stress to the pubic symphysis 2
• Recognize that substantial bone marrow edema can exist in asymptomatic athletes, so imaging findings must be correlated with clinical presentation 3