PFATS Articles
The Treatment and Rehabilitation of a Pubic Symphysis Diastasis
Bryan Engel, ATC
An injury to the pelvic region of the body is particularly debilitating as it disrupts movement in both the upper and lower extremities. A pubic symphysis diastasis, or the separation of the pelvis at the pubic symphysis, is one of the more serious injuries affecting this region.
The purpose of this article is to discuss the diagnosis, treatment and rehabilitation of an offensive tackle in the National Football League (NFL). This player suffered a pubic symphysis diastasis, the first such injury reported by the NFL Injury Monitoring System since its inception in 1980.
Background
This study involves a 26-year-old, 6' 5", 330-pound offensive tackle in his third year in the NFL. At the time of the injury, he had no relevant pre-existing history of a pelvic injury.
He was injured as the result of a hit from a defensive lineman during an interception return in the third quarter of a game against the Tampa Bay Buccaneers. The blow upended the player and caused him to land with all his weight on his left sacroiliac (SI) joint and gluteal group.
Anatomy
The bones of the pelvis are the sacrum, ilium, ischium and the pubis. They are joined anteriorly at the pubic symphysis and posteriorly by the sacrum. Muscles originating or crossing the pelvis are:
(Abdominal Wall)
- External obliques, transverse abdominis, rectus abdominis.
(Spinal extensors)
- Quadratus lumborum, erector spinae, multifidi.
(Muscles acting on the hip)
- Adductor longus, magnus, and brevis, sartorius, gracilius, rectus femoris, iliopsoas, piriformis and the gluteal group.1
On-Field Evaluation
The on-field evaluation was limited due to intense pain in the player's right leg and lumbar spine. After talking with the player and completing a preliminary evaluation, he was removed from the field via a long board and cart, as there was concern that he may have suffered a fracture to his femur and/or lumbar vertebra, or may have possibly dislocated his hip.
X-rays taken at the stadium revealed that the player had separated his pelvis at the pubic symphysis. As he was in intense pain, it was decided he would be transported via ambulance and admitted to a local hospital.
Diagnosis
Following two days in Tampa, he was flown via air ambulance to a hospital in Green Bay. Tests done both in Florida and during his four day hospital stay in Wisconsin, which included MRIs, a CT-Scan with contrast and plain X-rays, revealed a:
- Pubic Symphysis Diastasis
- Separation of his left SI joint
- Significant right adductor strain
- Three to four hundred cc pelvic girdle hematoma pressing up against his bladder
Treatment
Team physicians determined that surgery was not necessary to repair the pubic symphysis diastasis as the separation was less than 2.5 cm and there were no fractures associated with his injury. They determined the hematoma would be treated via Lovanox injections into his abdomen to keep it from clotting until his body could reabsorb the blood.
Rehabilitation
Phase 1 (Weeks 0 to 6)
Arrangements were made for a home hospital bed to minimize difficulty in getting in and out of bed. During this time, his mobility was also very limited and he was forced to progress from a wheelchair to a walker.
The player started treatment 17 days post injury and he arrived for his first rehabilitation session with the aid of the walker. He had significant pain in his right hip, left SI join and lower abdomen. In addition, the unresolved hematoma created an uncomfortable feeling of pressure in his abdomen. He also looked much different than he had before the injury. In just two weeks, he had lost 27 pounds and there was marked atrophy in his right leg.
Treatment Objectives
During this period, our goal was to control pain and inflammation and retrain his core musculature. We also needed to minimize the shift or widening at the pubic symphysis and his left SI Joint, while stabilizing the pelvic ring. Pain determined how quickly we were able to progress.
With those goals in mind, we treated the athlete initially with:
- Interferential stimulation
- Heat and ice
- Hot whirlpool
- Therapy pool
As his treatment program progressed, we noticed a significant waddle, or hip hike, in his gait. As this had to be eliminated before he could walk unassisted, he began walking in a Swim Ex Therapy pool. Once his normal gait pattern was reestablished, we were able to advance his rehabilitation program
Phase Two (Weeks 7 to 20)
In this phase, we wanted to re-establish core strength, increase strength and endurance in his adductor muscles and maintain flexibility of his groin, hamstring, hip flexors and back extensor muscles.
To do this, we added passive and active-assisted range of motion exercises focusing on pelvic rhythm and control to his rehab program. This included exercises focusing strictly on his core muscles that can mimic “Kegel”exercises, which are frequently done by women before and after childbirth.
Doctors performed surgery that was not related to this injury on his right knee and elbow during this time, and rehabilitation exercises specific to those conditions were added. Regular X-rays of his Pelvis ensured that his rehabilitation program was aiding in decreasing the separation at his pubic symphysis.
Phase Three (Weeks 21 to 28)
This phase was designed to progress him to functional and football specific exercises. As his strength and flexibility returned, he did sled work, heavy bag exercises and other football-specific agility drills that helped mimic the stress his body would endure once he returned to practice.
Return to Competition (Weeks 29 to 32)
He returned to competition when training camp started and gradually progressed through all phases of practice. He was limited to one practice a day and began individual and controlled contact sessions with increasing intensity based on his feedback. He did not see game action until the third week of the pre-season.
The Mental Game
The mental aspect of his return to play was at the forefront throughout his rehabilitation program. He set small personal goals that allowed him to remain focused on the big picture, but to not overlook important milestones that would be met along the way. We wanted him to attack his rehabilitation program with the same intensity he brought to his play on the field.
Conclusion
The athlete made tremendous progress throughout his eight-month rehabilitation program and went on to play all 16 regular season and two play off games during the 2003 season. He was the only offensive lineman to take every offensive snap and subsequently was rewarded for his high level of play with a lucrative long-term contract.
A big component of his rehabilitation program was the effective communication and open dialogue between the medical and strength and conditioning staffs. Ultimately, it was the player’s hard work and dedication to the well-devised rehabilitation program that allowed a full return to play.
Bryan Engel, ATC, is an assistant athletic trainer for the Green Bay Packers. He can be reached at engelb@packers.com.
Reference:
1Moore, K.L., Dalley, A.F. Clinically Oriented Anatomy, 4th Edition. Lippincott, Williams & Wilkins, 1999.