published 05/09/09
Widespread Chronic Pelvic Pain In a Runner With a Surprising Cause
Separation of the pubic symphysis (diastasis symphysis pubis), strangely painless at the site
by Paul Ingraham, Vancouver, Canada MOREclose
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
For years I’ve been working with a patient who has flare-ups of moderate pain throughout the low back, hips (back and front), and legs. I’ve never been able to interpret her pain as anything but stubborn myofascial pain syndrome — a lot of muscle knots — aggravated and sustained by a variety of overuse injuries and other old problems, such as a decade-old lumbar fusion, and a nerve injury from giving birth. These factors alone seemed mostly adequate to explain her situation.
Treatment efficacy for her always varied wildly. She kept coming back because, sometimes, she felt a lot better for a little while. But, just as often, the hour seemed almost wasted, the surface barely scratched. We often speculated about possible causes for the complexity and persistence of her symptoms, but I never felt confident of anything except the obvious: that she has a great many severe muscle knots.
Recently, her seemingly infinite supply of symptoms was substantially explained.
Following a severe flare-up of pain — much worse than the usual — her physician diagnosed a large separation of the pubic bones (diastasis symphysis pubis, DSP), where they meet in the front. Some diastasis is normal during and following childbirth. But this was a more dramatic separation, more of a dislocation. Almost certainly, this has been the ultimate source of a great many of her symptoms for years now.
What is remarkable about this, I think, is that she never experienced any clear, well-defined pain at the joint itself — and thus I never suspected the presence of DSP. It never even crossed my mind. Here we have what is essentially a dislocated joint that was not clearly producing symptoms at the location of the joint — in a marathon runner, no less, someone who puts in long hours pounding pavement — and I just didn’t realize that was possible. Not only does it surprise me, but I have recent experience with another case of DSP in a runner that certainly did hurt right at the joint — very much, with every impact! So apparently it can go either way. Just what determines whether or not someone with diastasis feels pain at the joint or not I cannot begin to claim to know.
Here we have a dislocated joint that was not producing symptoms at the location of the joint — in a marathon runner, no less.
Obviously this was a diagnostic failure on my part, though I don’t quite know how I might do better in the future. When one rare problem drives complex and shifting symptoms throughout an entire region, but without actually obviously hurting at the site of injury, it’s hardly surprising that it would elude detection.
There are so many possible factors contributing to a complex case of musculoskeletal pain that one can quite easily waste a great deal of time and money on wild diagnostic goose chases. On the other hand, it’s possible I could have identified this DSP long ago with some relatively straightforward assessments — not a wild goose chase, but just a little diligent checking.
It now makes more sense to me to thoroughly check the integrity of every tissue and structure in a problem area, regardless of whether or not there are any obvious reason for doing so. A complex pattern of extremely persistent pain in a region is justification enough for checking every checkable thing, however improbable it might seem. Evidently, myofascial pain syndrome can quite easily be powered by a non-obvious epicentre: like stars swirling around a black hole, symptoms can orbit an otherwise invisible problem.
Fascinating.