Recovery from Osteitis Pubis

My recovery from this Osteitis Pubis injury has been more involved than any other injury I've ever had. To recap, I have a partially torn adductor with "moderately severe" Osteitis Pubis according to my MRI from April 25. You can read my previous post for all the details. 

Physical Therapy
I started seeing a pelvic floor physical therapist in the middle of April, twice per week. Each time I go she gives me a new set of exercises to do. She started with simple, easy exercises such as the Kegel (pelvic floor contraction) and abdominal squeezes. I don't know the official term, but it's basically just sucking in on the lower abs. Over time she has given me more strengthening exercises like squats, adductor raises, clams, and more. 

In terms of treatment she's done dry needling which hurt so, so much, as well as blood flow restriction therapy. Blood flow restriction therapy wraps a tight band around your quad that feels like a blood pressure machine. It squeezes just like a blood pressure machine while you perform squats to help make greater strength gains with a lighter load. The dry needling, painful as it is, has really helped me feel more normal when walking around. 

I do the exercises nearly every day, in combination with the other items below. These exercises are designed to build strength in the areas around the injury so that when I start running again, everything will be strong enough. 

Strength Training
While the physical therapy exercises are designed to rehab anyone with this injury, I am working with the same strength coach I've had for over a year on making sure I maintain my overall body strength during this time. I would be doing this even if I didn't have an injury, and she has tailored the program to focus on the areas that need the most help: deep core, glutes, adductors. These exercises are more challenging than the PT exercises, involving weights and resistance.

The OP Clinic
I was referred to the OP Clinic in Australia by a friend who also had this injury. He does virtual sessions over Skype. He specializes in OP and the purpose of his program is to rewire your mechanics and movement patterns so that you don't overload your pubic bone. The sessions are a very small part of the program. He has given me a self-guided program with "homework" exercises that I learn through videos. I send the videos to him as soon as I am able to complete the exercises properly and he reviews them and lets me know if my form is correct or where I need to improve.

The program starts with basic core breathing, establishing a strong center of gravity, and having correct form for basic exercises like the deadlift. It's an extremely intense program and so far I've spent over an hour each day watching all the videos and going through each exercise. Stability is the key focus, and in order to be stable you have to engage your core and glutes. It's challenging to upload videos to this blogging platform but if you follow me on Instagram, I post videos to my story all the time. 

Right now I'm focused on learning how to do the perfect deadlift. This involves breathing properly, having the right center of gravity, engaging the glutes, moving slowly, keeping a straight back (not hunched or arched), and feeling the "fascial tension" as I slowly perform the movement. I am doing deadlifts with bands and on my forefeet to ensure I am not rocking back into my heels. 

The OP Clinic is a 10-stage program and by the end of it, I should be able to run as much as I did pre-injury. Because my mechanics will have changed, I will no longer be overloading my adductors. There is no timeline for how long this will take. I can get through the program at whatever pace I am able to. The program isn't necessarily designed to heal; the body does that on its own. It's designed to help patients stop overloading their adductors and pubic bone. Here's how I see all of these working together:

• Physical Therapy: Helps the injury heal with different therapies and exercises
• Strength Training: Ensures I have the strength needed to support an intense training load
• OP Clinic: Overhaul of my running mechanics so I don't keep injuring the area

Cardio
In addition to the above, of course I want to maintain some level cardiovascular fitness. I started swimming two weeks ago, once I felt like it would be safe to kick my legs. It turns out I don't have a great freestyle kick to begin with so swimming is 100% fine. Due to Covid, I have to reserve a lane a few weeks in advance so planning has been tricky. 

Swimming
I've been swimming 3-4 times per week. I swim freestyle, and that's my only stroke! I know how to do the others but the breast stroke kick wouldn't be good for my injury and I'm only good for about two laps of butterfly before I fatigue. My typical swim is 20-25 laps, lasting about 30-40 minutes.Yesterday I introduced pool running with the belt. I did 5 minutes yesterday and 10 minutes today after my swim. My plan is to very gradually ramp up the pool running because I do not want to strain the adductors. 

I enjoy swimming, but it's a high maintenance activity. I have to reserve my lane in advance due to Covid capacity restrictions at the pool. Once I get there I have to lather up with pre-swim lotion so that my skin doesn't get irritated. And then get all situated with my swim cap, googles, and waterproof mp3 player. And when I am done, I have to shower there to immediately remove the chlorine from my hair and skin. I think I spend more time driving to and from the pool + getting ready and showering than I actually do with the swim. 

Walking
For the first few weeks I was hobbling around and not properly balanced. I could feel the injury with each step even though it wasn't painful. About a week ago I got to a point where I could walk and not feel the injury! Huge progress. I have been taking 2-3 mile walks and loving it. The weather has been gorgeous and Greg and I even went to Burke Lake park one afternoon to walk. We also took a few days off work to go to Annapolis and I did a lot of walking around there. All pain free!

I'm averaging about 60-90 minutes of strength/PT each day and then another 40-60 minutes of cardio (walking and/or swimming). It's more time consuming than running but it's what I need to do to get back out there again while preserving my sanity!

Running and Osteitis Pubis

Osteitis Pubis. Sports Hernia. Athletic Pubalgia. These three terms refer to a set of conditions that result in groin pain in athletes. They all have slightly different nuances, but all of them mean you shouldn't be running.

I briefly touched on this in a previous blog post, but I will get into all the details here. 

How it started
In July 2019, I had a bike accident while on vacation in Norway. The bike tire got caught on a rail track, stopped the bike, and I fell onto the pike, bashing my pelvis into the bike bar with a ton of force. This resulted in massive bruising, a ton of pain, and 9 days off from running. I went to several doctors at the

time and they all agreed it was a hematoma and it was okay to run as tolerated.

The damage from this accident never healed completely. Sometimes I would wake up in the middle of the night with my pubic bone aching. I could never do a sit-up without my lower abdominals feeling strained. Certain adductor exercises were painful or not even possible. 

But it didn't impact my running or my daily life; it was sort of lingering in the background Since the accident I have run 4 marathons (CIM, Boston Virtual, Harrisburg, and Two Rivers). I did irritate it during CIM, but it was silent after Boston Virtual and Harrisburg. But due to the slant of the road at Two Rivers, the adductor finally said "I've had enough!" I think that was the breaking point.

I did have some warning signs before the marathon, though. After my long runs throughout March I would feel a tenderness in the groin area. And once I felt some groin pain at the end of a 22-miler. 

Post Marathon
Immediately after the marathon, the left side of my pubic bone was in a lot of pain, but it subsided within 24 hours. And then I took a week off of running and I felt 100% normal walking around. I actually did quite a bit of walking at the chess tournament (one week after the marathon), logging over 8,000 steps, and felt completely normal.

When I returned to running, my pubic bone area started to hurt right away. It wasn't severe-- it was about a 2 out of 10 on the pain scale. The lower abdominal muscles were also a bit tender. Since I was just coming back from the marathon, I kept these runs slow and short. And I didn't run every day. I think it was a total of 5 short runs over a 9 day period before cutting it off completely. The last of these runs was my longest: a 5-miler. After that run, I began to feel the pain while walking. I have not run since April 13. 

I went to a doctor and my sports chiro and ultimately ended up getting an MRI (this was after the mandatory X-ray needed by insurance). I wish I had gotten an MRI immediately after the bike accident so I would have known I needed some rehab, but I didn't advocate for myself with the doctors. And they reassured me it would heal with no problems.

MRI Results + Diagnosis
This is taken from the report:

Pelvic joints: There is joint space narrowing and marginal osteophytosis with subtle erosive centered on the pubic symphysis. Marrow edema noted at the pubic bone centered on the pubic symphysis and there is

Image from Sports Injury Bulletin

synovitis within the pubic symphyseal recesses. The hip joints are preserved. Small bilateral joint effusions are seen in the right and left hips. No prominent anterior superior superior labral tears are identified.

Muscles/Tendons: There is focal high-grade partial-thickness tearing of the rectus abdominus adductor longus aponeurotic insertion on the left pubic bone (series 2, image 10). The visualized muscles and tendons are normal.

When I first read the report, I panicked. It sounded like there was a crap ton of stuff wrong! I was particularly worried about the bone marrow edema because that can become a stress fracture. The high-grade tearing of the muscle/tendon was also alarming. 

After I had my PT and doctor interpret this, it didn't sound so horrible. Key findings:

• Osteitis Pubis - inflammation in the area around the pubic synthesis
• Partial tear of the adductor muscle at the insertion point
• Bone marrow edema

In the diagram, the tear is located where the adductor longus meets the pubic tubercle, and I have pain in the area around the inguinal ligament + rectus abdominus. 

The most likely scenario is that when I had the bike accident, it never healed properly and it resulted in my muscles overcompensating and "learning" how to fire incorrectly to compensate for the weakness. There was a good amount of scar tissue on the MRI and the doctor said that doesn't happen within a few weeks- it takes a long time for that much to build up. Once I tore the tendon - which could have been during the marathon or during training - then additional strain was placed on the pubic bone, causing bone marrow edema and inflammation. So we think the partially torn adductor is the culprit. . . and that was caused by muscles not properly firing, resulting in an imbalance.

So this is an overuse injury, but it would not have happened if the bike accident didn't damage that area to begin with. It was like a ticking time bomb.

Moving Forward
I have been in physical therapy for three weeks now. I am working with a pelvic floor specialist and she's given me a ton of exercises. We have done blood flow restriction and dry needling. The dry needling was like torture. She has dry needled my adductor, my pelvic floor, my abdominals, and my hamstring. OUCH!  But that needling has honestly brought about the best results. 

When I stopped running on April 13, I started talking daily walks for the next two days, but then I stopped that because I felt like it was too much. It seemed to get worse and worse, with it being painful for me to walk around the grocery store on the weekend of April 24. That's when I felt like I would never get better!

But today, on May 7th, it feels a lot better to walk. I do feel it when I walk but it's only about a "1.5" on the pain scale - a minor annoyance. Maybe enough to make me limp a bit. And my doctor actually recommended that I take a 30-minute walk each day. Anything that involves the lower abdominal muscles or the left adductor doesn't feel right, so there is a constant reminder that I have this injury. 

Now I am focused on doing PT exercises each day, and getting the dry needling twice per week + blood flow constriction therapy. I'm also using my Theragun to massage the adductor and lower abdominals. 

PT exercises include:

• Single leg deadlift (no weight yet)
• Squats with a band wrapped around my upper back, anchored to a weight rack
• Kegel exercises
• Bear stance hold
• A 3-part clamshell type exercise 
• Calf "crunches" with a band to improve ankle range of motion
• Toe yoga to improve balance
• Squeezing a soccer ball between my feet

Recovery Timeline
The doctor couldn't give me a definite timeline and he couldn't even guarantee that the tear will heal itself. He said it would likely heal without surgery if I do my PT exercises regularly. At this point, the earliest I would start running again (and by running I mean a gradual run-walk introduction) would be the end of May. Early June is probably more likely. 

Worst case scenario would be surgery or simply taking 3+ months to heal. The longest I have ever taken off for an injury was 5 weeks back in 2009 when I had peroneal tendonitis. That's maybe tied with my stress fractures from 2011. I think that was 4-5 weeks, too. 

I've taken 3 months off due to mono on multiple occasions, but I've never had to take more than 5 weeks for an injury. I guess I should be glad this isn't mono and I know it's going to heal 100%. It just requires extreme patience. The silver lining is that I will be stronger when I come back because of the daily focus I have on stability, strength, and mobility exercises. 

Attitude and Perspective
Compared to previous injuries and bouts of mono, I am not that upset about this one. Even though it's the worst injury I've had - I am tolerating it much better.  Why?

• I felt like I needed a long break after the extended training cycle for Two Rivers. I ran 3 extra weeks at 75+ miles each, and I think those 3 extra weeks took a physical and mental toll.
• I don't have any races on the calendar
• Summer is coming up, so I wasn't planning on setting any PRs in the near future
• I have always set massive PRs after coming back from mono, so I think a long break will ultimately lead to a breakthrough in fitness
• I can enjoy the extra time by honing my chess skills and tackling other projects around the house

I hope the road to recovery isn't too long. I've mentally accepted that I likely won't be back on the roads until early June. I'm also prepared for it to be longer. I am still optimistic about a late fall marathon, although I haven't chosen one yet.