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A 21-year-old male athlete presents with left groin pain that he reports began gradually several weeks previously but which has been progressively getting worse. Apparently, the pain is made worse with kicking type motions, hopping on the left foot, or prolonged standing on either foot. The patient has a history of groin injuries on the left and rectus abdominis muscle strains on the right. The patient recently underwent radiographic imaging of the hip and pelvis and MRI, both of which were negative. The patient's past medical and surgical history is unremarkable and his symptoms are not aggravated by forced coughing.

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What is your differential diagnosis at this point?

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The differential diagnosis for this patient should include, but may not be limited to, adductor strain, osteitis pubis, iliopsoas bursitis, stress fracture of the femoral neck, obturator muscle strain, and abdominal muscle wall strain.

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The physical examination revealed the following findings:

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  • A slightly antalgic gait was noted.
  • Palpation reveals point tenderness over the symphysis pubis, the left inguinal canal, the left adductor tendons, and the contralateral rectus abdominis. Tenderness is more prominent at the pubis than the adducted tendons.
  • Passive and active range of motion reveals pain on the left hip abduction and external rotation.
  • Strength testing for bilateral lower extremities is within normal limits.
  • Sensation and reflexes are intact throughout both lower extremities.
  • Selective tension of left hip abduction or adduction is painful, as is a resistive right straight leg raise, and resistive trunk flexion (sit-ups).
  • Positive FABER test for pain in the left groin area.

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Following the physical examination with the above positive findings, what is your best working hypothesis?

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The best working hypothesis for this patient would be osteitis pubis.

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What factors predispose a patient for the development of osteitis pubis?

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What is the best approach to treat a patient with osteitis pubis?

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Which muscle group should receive the most attention?

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At what point would you allow a patient with osteitis pubis to return to sport?

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