“Athletic pubalgia” is a general term that encompasses a wide range of injuries at the symphysis pubis that share a similar injury mechanism and clinical presentation of exertional pubic and groin pain 5 . Groin pain most commonly develops insidiously, but may present acutely with a clinical history of a sudden tearing sensation. Symptoms are most often unilateral but may be bilateral. The patient typically experiences pain during exercise, complaining of discomfort in the inguinal region over the distal rectus abdominis, in the perineum, or radiating to the testicles. On physical examination, the patient may experience pain with resisted hip adduction or resisted sit-ups 4 . Local tenderness may be elicited at the attachments of the adductor longus or rectus abdominis or over the external inguinal ring, and Valsalva maneuver may cause pain.
Bisphosphonate therapy is a proven method of preventing femoral head collapse in patients with avascular necrosis and subchondral lucency.
Lai et al evaluated the effect of alendronate on patients with Steinberg stage-II or III osteonecrosis of the femoral head. They found that alendronate prevented early collapse of the femoral head at twenty-four months.
Agarwala et al evaluated the effect of bisphosphonate therapy on patient reported and radiographic outcomes in femoral head avascular necrosis. They found alendronate reduces pain, improves function and may prevent disease progression at 5 year followup.
Nishii et al evaluated the effect of alendronate on 20 hips with osteonecrosis of the femoral head without collapse. They found a lower frequency of collapse and less patient reported pain in patients treated with bisphosphonate therapy compared to controls at 12 month follow up.
Thanks to Dr. Chris Rice at UW Madison:
"Recent level 1 evidence seems to cast doubt on the efficacy of bisphosphonate treatment in precolapse AVN with medium to large lesions. There is also some thought that the supposed success seen in smaller lesions is due to the natural history of these lesions which often do not progress to collapse even in the absence of any treatment. "
Lee YK, Ha YC, Cho YJ, Suh KT, Kim SY, Won YY, Min BW, Yoon TR, Kim HJ, Koo KH Does Zoledronate Prevent Femoral Head Collapse from Osteonecrosis? A Prospective, Randomized, Open-Label, Multicenter Study. J Bone Joint Surg Am. 2015 Jul 15.
Answer 1: Cyclic parathyroid hormone therapy is used in osteoporosis treatment, and not in the treatment of femoral head avascular necrosis.
Answer 3 & 4: Neither RANK nor RANK ligand are being used in therapeutic forms currently. Denosumab, an anti-RANK ligand antibody, has shown early success in the treatment of bone lysis in oncologic applications.
Answer 5: Selective estrogen receptor modulator therapy is used in osteoporosis, and not in the treatment of femoral head avascular necrosis.