Original researchPrevention and management of osteitis pubis in the Australian Football League: A qualitative analysis
Introduction
Groin pain has a high incidence in sports involving kicking, interval sprinting and rapid change of direction movements (Cowan et al., 2004; Verrall et al., 2005a). In the Australian Football League (AFL), it occurs with an incidence second only to hamstring strains with over three new injuries sustained per club during the 2006 season. This high incidence is compounded by its prevalence with around 14 games missed per club per season (Orchard & Seward, 2007) in a season of 22 games. As a proportion of total player payments, it can therefore be estimated that during the 2006 season, groin pain cost the 16 AFL clubs over AU$1.7 million in player unavailability.
Although the pathogenesis and diagnostic criteria for chronic groin pain in athletes remains unclear (Biedert, Warnke, & Meyer, 2003; Mandelbaum & Mora, 2005) symptoms are believed to be secondary to stress forces through the anterior pelvis (Robinson et al., 2004; Verrall, Slavotinek, & Fon, 2001).
When used in a sports medicine context, “osteitis pubis” refers to a painful inflammatory condition involving the pubic bones, pubic symphysis, and adjacent structures (Williams, Thomas, & Downes, 2000). It is an injury that is characterized by chronicity (Verrall et al., 2001), and can run a prolonged and disabling course if misdiagnosed or mismanaged (Rodriguez, Miguel, Lima, & Heinrichs, 2001). The use of the term osteitis pubis as an umbrella term to describe the syndrome of exercise-related groin pain has been questioned due to the variability in inflammatory findings of athletes with groin pain (Bradshaw & Holmich, 2007). At the time of this study, however, the term osteitis pubis was accepted as an appropriate term for describing exercise-related groin pain.
The current absence of reliable clinical indicators for the development of chronic groin pain makes it difficult to establish effective prophylactic strategies (Wollin & Lovell, 2006) and once entrenched, the condition is difficult to manage. It has been shown in one study of AFL players that 41% of players still experienced symptoms in the second season after their initial diagnosis despite undertaking a conservative management protocol inclusive of 3 months rest (Verrall, Slavotinek, Fon, & Barnes, 2007a).
Due to the high prevalence of groin pain in Australian football and the limited understanding about its pathogenesis and optimal management, the AFL Research and Development Board identified a need for AFL clubs to share current prevention and management strategies.
The purpose of this study was to collate information on prevention and management of osteitis pubis in the AFL and to develop a set of recommendations for the management of osteitis pubis.
Section snippets
Participants
In-depth interviews were conducted with the medical personnel of each AFL club and two key personnel in the sports medicine arena. Key personnel included a physiotherapist recognized as an expert in osteitis pubis management and a medical practitioner of a National Rugby League club in Australia. Nine medical practitioners, 20 physiotherapists, and seven fitness staff participated in the study.
Procedure
This study was commissioned and approved by the AFL Research and Development Board. Participants were
Results
Two major themes emerged in the review of the data: (1) prevention of osteitis is a product of balancing load and pelvic integrity, and that (2) early detection and intervention is the key to optimal management. Within these major themes, the perceived risk factors for the development of osteitis pubis were highlighted, the recognition and management of proposed predisposing factors, the early management of pathology, prevention programs, and surgical management were all discussed.
Discussion
Prevention of osteitis pubis as a product of balancing load and potential risk factors was a key theme that corresponds with the “envelope of function” model proposed by Dye (1996) that defines a safe range of loading for a given joint using a “load–frequency distribution” (Fig. 1). The distribution features the zone of homeostasis, defined as the safe range of joint loading. Activities that place high loads on a joint that are performed frequently are likely to reach beyond the zone of
Conclusion
Management of osteitis pubis in the AFL involves the balancing of mechanical load through the pelvis and pelvic integrity. Medical staff within AFL teams attempt to identify early warning signs of groin injury and treat accordingly as well as identifying perceived risk factors and modifying these if possible. Further research should be conducted to validate the views of the respondents in this study, particularly in the area of risk factors and the value of screening.
Acknowledgments
The authors would like to acknowledge the team medical staff who gave their time for interviews and divulged their beliefs and expertize. This study was funded by the AFL Research and Development Board.
Ethical Approval: This study was commissioned and approved by the AFL Research and Development Board. All clubs identified appropriate medical staff willing to be involved in the study. Participation was voluntary and participants provided verbal consent to be involved in the interview process.
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