Conjoined tendon injury/ Traumatic osteitis pubis symphosis(TOPS)

Conjoined tendon injury

Findings

There is a history of a groin pain and suprapubic or low abdominal pain. This may be severe enough to cause the athlete bend over double, and there may be an accompanying adductor lesion. However, palpation at the adductor origin, although resisted adduction does produce the symptoms. Besides breaststroke, even swimming backstroke or front crawl hurts. Turning over in bed may produce pain in lower abdomen.

Resisted abdominal hurts, as does palpation of the external ring through the invaginated scrotum. If external diagnosis cannot be made, the over a 2 week period, one may have to run the athlete daily and provoke an injury with rehabilitation ladder. Sometimes after 2 weeks external ring will become more painful to palpation and diagnosis is confirmed. Often the contralateral side may produce symptoms after the primary side has been treated.

Cause

There is disruption or degeneration of the conjoined tendon of the abdominal muscles at their attachment to the pubic tubercle. A crypt hernia might be presented. Because the pelvis might be considered as a ring, there may be two or more injury sites in conjuction, such as the sacroiliac joint and the pubic symphisis. The cause may be from performing excessive sit-ups, or from twisting and backing off movements, such as in basketball, or in midfield soccer players who, whilst defending, may have the ball played back and forth across this condition because, if the body’s rotation is limited at the hip, the stress is forced onto the next link in the chain – pelvis.

Treatment

a)      Inject the pubic tubercle with a local anaesthetic and hydrocortisone for short-term relief

b)      Surgical application for the conjoined tendon

c)      Rest, which may take 12-18 months to bring about healing, but with controlled exercise may be the treatment of choice when surgery is not available

d)     Controlled exercise. Cross- training on a bike, Achilles ladder, then add cross- over, side step runs, plus figure-of-eight and kicking ladder. Reduce sit-ups and certainly avoid rotational sit-ups such as “crunches”

Sports

This lesion has been reported as TOPS in many sports. However, there might be a continuum – the
conjoined tendon being the precursor of TOPS. The overall impression is that twisting and turning
 movements with one foot fixed, such as stretching out for a ball, side stepping, or kicking is the major problem, for with good, small-step footwork, the conjoined tendon sufferer can often play squash.

This is still a difficult diagnosis to make, and sometimes comes down to no other diagnosis being available, plus the patient fails to rehabilitate. There seems to be an increase diagnosis to this problem. Some sportsmen if return too fast after this injury on the pitch, might suffer down again or get a collateral injury.

Traumatic osteitis pubis symphosis(TOPS)    

Findings

Same like conjoined tendon injury. The TOPS sufferer may describe the pain as radiating into the perineum or rectum.

Cause

Degenerative changes are found in the pubis or pubic symphisis, which may be a part of a disturbance of the pelvic ring. The pubic symphisis  becomes unstable.

Treatment

a)      Local anaesthetic and hydrocortisone into the pubic symphisis for temporary relief

b)      Rest and cross train for 12-18 months

c)      Try conjoined tendon repair, if less than 3 mm shift on stork views

d)     Sclerosants to the sacroiliac joints to strengthen the pelvic ring

e)      Pamindronate infusion or intramuscular injection may reduce the bone oedema and pain

f)       Rarely, surgery to fuse the pubic symphisis if it remains unstable after the appropriate rest

g)      Treat any systematic cause

h)      Controlled rehabilitation and core stability

Sports

a)      Change of direction sports may cause the problems if side to side and rotational movements are not accompanied by good footwork. When the play goes from side to side across the player, as in midfield footballer, then the player has to stretch for the ball or to make a tackle. An extreme stretch will force external rotation of the hip to its end range. Because the hip can no longer contribute to abduction,  the abduction force reaches the pelvis and the weakest point, the pubic symphisis, comes under load. Athletes with a limited hip range may be more liable to injury. Players may have to channel the opposition in one direction to avoid the ball being played across them

b)      When TOPS has occurred swimming is painful, and not just breaststroke but also backstroke and front crawl produce abdominal pain

c)      Cross- training should be on a rowing ergo to maintain equal pressure on both sides of the pelvic ring, and then asymmetry of load, by cycling and running, can be added later

d)     Sit-ups should be avoided

e)      Running probably should not start for 12-18 months, and sprinting and high knee raises may be difficult until truly stable

TOPS may be the end of point of an unstable pelvic ring, where the conjoined tendon strain is the early phase.

"Concise guide to sports injuries, 2^nd edition",Churchill Livingstone, Malcolm T.F. Read,  foreword by Bryan English