[ resident’s case problem ]

ANDREW P. HAWKINS, PT, DPT, ATC1 • JONATHAN C. SUM, PT, DPT, OCS, SCS2
DANIEL KIRAGES, PT, DPT, OCS, FAAOMPT2 • ERICA SIGMAN, PT, DPT, OCS2 • SOMA SAHAI-SRIVASTAVA, MD3

Pelvic Osteomyelitis Presenting as

Groin and Medial Thigh Pain:
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A Resident’s Case Problem

G
roin pain presents a challenging differential diagnosis due to gastrointestinal and visceral organ con-
the often vague symptoms and the multiple structures that can ditions; abdominal or pelvic infections;
urologic diseases; lumbopelvic plexus
refer pain to this region.4,8,22,28,38 While physical examination for
and peripheral nerve lesions; and bony
groin pain in active populations has been described, the value disease of the lumbar spine, pelvis, and
of clinical examination procedures in individuals with atraumatic, hip.8,16,20,22,28,45 Musculoskeletal dysfunc-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

nonspecific groin pain is less clear.3,8,32,38 The diagnostic triage in such tions of the lumbar spine, sacroiliac joint,
cases requires first exploring the more serious and life-threatening pelvis, hip, and knee may present with
secondary symptoms of groin pain.3,4,8,11,22
causes of groin pain. This process can medications.1,7,11,14,19,30,40 Many systemic The differential diagnosis process re-
be further challenged by surgical proce- and medical conditions can present with quires careful clinical examination and
dures in and around the pelvis, postsur- groin pain, including cancerous tumors collaborative care with the referring pro-
gical complications, comorbidities, and of the spinal cord, prostate, and testicles; vider to maximize diagnostic accuracy.
While clinical signs and symptoms may
have limited accuracy in determining the
TTSTUDY DESIGN: Resident’s case problem. nerve palsy. The physical therapist’s examination
Journal of Orthopaedic & Sports Physical Therapy®

anatomical source of groin pain, combin-

TTBACKGROUND: Groin pain represents a diag-
nostic challenge and requires a diagnostic process
that rules out life-threatening illness or disease
processes. Osteomyelitis is a potential fatal
disease process that requires accurate diagnosis
and medical management. Osteomyelitis presents
a problem for the outpatient physical therapist, as
the described physical findings for the diagnosis of
osteomyelitis are nonspecific.
TTDIAGNOSIS: A 67-year-old man with groin
and bilateral medial thigh pain was referred for
physical therapy care to address right adductor
weakness and generalized deconditioning. He
had undergone extensive treatment for bladder
cancer, with a recent radical cystoprostatectomy
and cutaneous urinary diversion with an Indiana
pouch. Postsurgical magnetic resonance imaging
indicated normal findings, and the patient was cur-
rently being managed by an orthopaedic surgeon,
who diagnosed the patient as having obturator
produced findings inconsistent with this diagnosis.
Subsequently, nuclear medicine studies revealed
pubic symphysitis/osteomyelitis with secondary
myositis, predominantly affecting the right adduc-
tor muscles.
TTDISCUSSION: Osteomyelitis represents a dif-
ficult problem for the outpatient physical therapist.
Careful consideration of red-flag symptoms and
inconclusive physical testing indicate the need for
further medical work-up. In this case, appropri-
ate medical management led to improvement in
patient function, highlighting the need for early
diagnosis.
TTLEVEL OF EVIDENCE: Differential diagnosis,
level 4. J Orthop Sports Phys Ther 2015;45(4):
306-315. Epub 10 Jan 2015. doi:10.2519/
jospt.2015.5546
TTKEY WORDS: adductor pain, adductor
weakness, differential diagnosis, pubic
symphysitis, red flags
ing risk-factor assessment with the clini-
cal evaluation and medical testing, such
as diagnostic imaging and laboratory
studies, can help increase accuracy and
improve clinical decision making.6,21,34
Osteomyelitis is a bony infection, most
commonly caused by the pathogen Staph-
ylococcus aureus, often occurring in the
spine, pelvis, or small bones in skeletally
mature adults.6 The risk of bony infec-
tion following surgery varies but has been
reported to occur in up to 3% of cases
following radical cystectomy.7,19 It may
present as acute, subacute, or chronic
infection. Chronic infections are a more
common entity in adults, representing
up to 44% of cases of bony infection, and
may present without systemic signs of in-

1
California Rehabilitation and Sports Therapy, Yorba Linda, CA. 2Division of Biokinesiology and Physical Therapy, Herman Ostrow School of Dentistry, University of Southern
California, Los Angeles, CA. 3Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA. The patient gave verbal consent for
publication of the information related to the case. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article. Address correspondence to Dr Andrew P. Hawkins, California Rehabilitation and Sports Therapy, 19768 Yorba
Linda Boulevard, Yorba Linda, CA 92886. E-mail: aphawkin@gmail.com t Copyright ©2015 Journal of Orthopaedic & Sports Physical Therapy®

306 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy

45-04 Hawkins.indd 306 3/18/2015 5:10:21 PM


7 y prior to physical therapy:
Patient diagnosed with TCC. Began
treatment with mitomycin C and
BCG.
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2 mo prior to physical therapy:
Patient undergoes right nephroureter-
ectomy with lymph node dissection,
radical cystoprostatectomy, and
cutaneous urinary diversion. MRI
shows normal post-surgical
findings, begins amoxicillin.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
2 wk prior to physical therapy:
Second pelvic ultrasound shows no
fluid collection; catheter is removed
secondary to tenderness.
FIGURE 1. Timeline of medical treatment prior to physical therapy. Abbreviations: BCG, Bacillus Calmette–Guérin vaccine; CT, computed tomography; MRI, magnetic resonance
Journal of Orthopaedic & Sports Physical Therapy®
imaging; TCC, transitional cell carcinoma.
fection (fever, chills, pain, swelling, red-
ness, or loss of function).6 Osteomyelitis
represents a potentially fatal complica-
tion following surgery and requires prop-
er medical management.7,19 Osteomyelitis
also presents as a challenging diagnosis,
as there are no universal guidelines for
definitive diagnosis, with physical ex-
amination findings providing minimal
diagnostic value.33 The classical signs
of infection—pain, redness, swelling or
edema, fever, and loss of function—may
be the only physical findings and should
be combined with a risk-factor assess-
ment.33 Risk factors that increase risk
of osteomyelitis include the chronic use
of indwelling catheters, pressure ulcers,
history of surgery, history of drug use
and blood toxicity, advanced age, treat-
ments and diseases causing decreased
immune system response, and wound
infections.23,24
journal of orthopaedic & sports physical therapy | volume 45 | number 4 | april 2015 | 307
45-04 Hawkins.indd 307
2 y prior to physical therapy:
Patient fails conservative treatment,
underwent right ureterectomy.
Diagnosed with TCC of the right
kidney, ureter, and bladder.
Managed with gemcitabine and
cisplatin.
5 wk prior to physical therapy:
Patient is walking in mall, develops
right medial thigh pain and
weakness.
1 wk prior to physical therapy:
The patient develops left medial groin
pain and weakness.
The purpose of the following case
was to describe the examination and di-
agnostic process of a patient with pelvic
osteomyelitis presenting to a private-
practice physical therapy clinic with a
chief complaint of groin pain and adduc-
tor weakness following extensive pelvic
and abdominal surgery.
DIAGNOSIS
Medical History
T
he patient was a 67-year-old
man, a retired administrator who
lived at home with his wife. He
was diagnosed with distal ureteral tran-
sitional cell carcinoma 7 years prior to
his physical therapy evaluation. He was
treated with mitomycin C and Bacil-
lus Calmette–Guérin vaccine for several
years, but ultimately failed conservative
treatment and underwent a right ureter-
9 mo prior to physical therapy:
Patient develops kidney failure.
4 wk prior to physical therapy:
Doppler ultrasound and CT scan are
negative for thrombus.
2 d prior to physical therapy:
The patient is diagnosed with
obturator neuropathy.
ectomy 2 years ago. Following the sur-
gery, the patient developed transitional
cell carcinoma of the right kidney, right
ureter, and bladder that same year. He
was managed immediately with 2 cycles
of neoadjuvant chemotherapy with gem-
citabine and cisplatin until developing
kidney failure 9 months prior to physi-
cal therapy. As a consequence of kidney
failure, he had a right nephroureterec-
tomy with retroperitoneal lymph-node
dissection, a pelvic lymph-node dissec-
tion, radical cystoprostatectomy, and the
continent cutaneous urinary diversion
with an Indiana pouch to the umbilicus
performed 2 months prior to presenting
to physical therapy. Magnetic resonance
imaging (MRI) was completed 3 days
postsurgery, and described postsurgical
inflammatory changes without lymph-
node enlargement and ill-defined infil-
tration of the omentum, mesentery, and
3/18/2015 5:10:21 PM
 [ resident’s case problem
subcutaneous soft tissues of the anterior
pelvis. No complications were reported
following the surgery, and he was pre-
scribed 500 mg of amoxicillin, twice dai-
ly prophylactically, and returned home
after several days. Five weeks prior to
physical therapy, the patient had been
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walking for 2 hours in the shopping mall
when he experienced severe right medial
thigh and groin pain. The pain increased
in intensity and progressed to profound
weakness with adduction and flexion of
the right hip over a 1-week period. The
patient contacted his primary care phy-
sician 4 weeks prior to physical therapy
with complaints of thigh and groin pain,
and received Doppler ultrasound and a
pelvic computed tomography (CT) scan,
both of which were negative for the pres-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ence of a thrombus. A left lymphocele
was identified and drained on the same
day. A second pelvic ultrasound 2 weeks
prior to physical therapy revealed no re-
sidual fluid collection, and the patient re-
quested the catheter be removed due to
severe tenderness. The week the patient
was scheduled to begin physical therapy,
the pain began to spread to his left medial
Journal of Orthopaedic & Sports Physical Therapy®
thigh and groin, progressing to weakness
with flexion and adduction of the left
hip. Two days prior to physical therapy,
the patient was diagnosed with obturator
neuropathy by an orthopaedic surgeon
based on physical examination. FIGURE 1
provides a timeline of medical examina-
tion prior to physical therapy.
Initial Examination
History  The patient was evaluated for a
5-week history of groin pain, after refer-
ral from his physician for right adductor
weakness and general postoperative de-
conditioning. The patient’s chief com-
plaint was weakness with hip flexion and
adduction bilaterally, with bilateral me-
dial thigh pain occurring less frequently
than at the initial onset of symptoms.
Pain was described as beginning in the
groin, radiating to the bilateral medial
thighs above the knees (FIGURE 2). Pain
was rated as 0/10 at rest and increasing
to 9/10 with aggravating factors of stand-
308 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy
45-04 Hawkins.indd 308
P1: Deep, throbbing
groin pain. Rest,
0/10; worst, 9/10.
P2: Radiating thigh
pain (occurs
only when groin
pain is present).
FIGURE 2. Body chart: location and description of
the patient's symptoms at initial evaluation by the
physical therapist. Abbreviations: P1, pain 1; P2,
pain 2.
ing, walking, or hitting objects with his
foot while walking. Movement of both
limbs into hip flexion or adduction in
either weight bearing or non–weight
bearing was inconsistently painful. On
the patient’s intake form, he reported
weight loss, loss of appetite, fatigue, fever,
numbness and tingling, and shortness of
breath with or without activity. The pa-
tient reported intermittent numbness of
the plantar and dorsal aspect of his bi-
lateral feet for 4 years without a known
mechanism of onset or aggravating fac-
tors, but denied any temporal relation-
ship to the groin pain. The patient also
reported fatigue and shortness of breath
with moderate to heavy activity that had
been occurring for several years, with no
change since the recent surgery. The pa-
tient described a loss of appetite, which
he attributed to the recent surgery and
medications, and weight loss of 2 kg since
the surgery. The patient reported a fever
with prior illnesses, but denied any fever
since the surgery.
Vital Signs  The patient had a blood pres-
sure of 134/79 mmHg, pulse of 83 beats
per minute, respiratory rate of 16 breaths
per minute, and a temperature of 96.3°F.
Observation and Range of Motion Based
on visual observation, the patient had
marked atrophy of the medial thigh in
both lower extremities. The patient am-
bulated with a single-point cane and
displayed an antalgic gait pattern with
]
decreased bilateral hip flexion during
swing, right hip circumduction for foot
clearance, and decreased hip extension
bilaterally during late stance. Passive
and active range of motion of the hip in
supine was normal into flexion, internal
and external rotation in neutral and flex-
ion, and abduction, with pain into the
groin at end-range abduction. The pa-
tient had –20° of hip extension for both
hips when tested in the Thomas test posi-
tion, with the knee in flexion, and –5° of
hip extension when tested with the knee
in extension.
Manual Muscle Testing  Muscle weakness
was assessed with manual resistance, as
described by Reese.31 Quadriceps, anteri-
or tibialis, and the extensor hallucis lon-
gus muscles had normal strength (5/5)
and were pain free bilaterally. Weakness
and pain were noted for hip flexion (3/5
bilaterally) and hip adduction (2/5 bilat-
erally), whereas hip abduction was weak
but pain free (2+/5 right, 3/5 left).
Neurologic Testing  Sensory assessment
for light touch and vibration for the low-
er and upper extremities was completed
and was considered normal bilaterally.31
Deep tendon reflexes were 2+ bilaterally
for the patellar and Achilles tendons, and
the patient was negative for Babinski re-
flex, clonus, and spasticity. Slump and
femoral nerve tension tests with neural
sensitizing maneuvers were negative
bilaterally.
Outcome Measures The patient com-
pleted the Lower Extremity Functional
Scale and had an initial score of 11/80,
reporting a little bit of difficulty with
standing for 1 hour and moderate diffi-
culty walking between rooms and with
light household activities, with all other
items being rated as quite a bit of diffi-
culty or extreme difficulty/unable to per-
form activity.2,47
Initial Assessment
TABLE 1 provides diagnostic features for
common sources of groin pain. Rapid
onset of groin pain and severe weak-
ness indicated the need to rule out se-
vere complications following invasive
3/18/2015 5:10:23 PM
 TABLE 1 Differential Diagnosis of Groin Pain

Obturator Entrapment/
Pelvic Osteomyelitis6,28 Osteitis Pubis28 Adductor Strain13,37 Pubalgia37 Hip Osteoarthritis4 Neuropathy25,39
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Age of onset Variable 30-49 y <45 y <45 y >45 y Variable

Etiology Infection of the pelvic Inflammatory process Tearing of the adductor Weakening of the Degeneration of the Adductor fascial com-
bone. Most com- of pubic symphysis. muscles. Decreased rectus abdominis, articular cartilage. pression (younger pa-
monly from pelvic Surgical trauma hip adductor pyramidalis, internal/ May be traumatic tients), surgical mass
surgery, malignancy, and childbirth are strength, decreased external obliques, or nontraumatic in effect or stretching,
or IV drug use. May the most common hip abduction range transverse abdomi- origin neoplasm infiltration
occur spontaneously causes. Also com- of motion, and par- nis, or tendons (elderly patients)
in athletes mon in sprinting, ticipation in sports
cutting, and kicking are risk factors
sports
Duration and May be acute or chronic. Average of 9 mo. Duration: 1 wk to 4 mo. Usually >6 mo. Degeneration is progres- Variable; may be
progression Progressive without Nonprogressive Nonprogressive May progress sive over several progressive
treatment years; may have incit-
ing event
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Subjective Vague unilateral or Vague unilateral or Groin or medial thigh History of chronic groin Slowly progressive groin Pain in groin radiating
history bilateral symptoms bilateral symptoms pain with sporting pain that radiates or lateral thigh pain down the medial
of abdominal, pelvic, of abdominal, pelvic, activity, history of to hip adductors worse with weight- thigh. May complain
or groin pain. Use of or groin pain. Use of groin strains and unresponsive to bearing activities. of weakness if
abdominal or adduc- abdominal or adduc- treatment. Pain with Stiffness is present significant neural
tor muscles increases tor muscles increases twisting and turning with prolonged compression or injury
pain. Patient may pain movements positions is present
complain of fever,
nausea/vomiting, and
anorexia
Physical exami- Elevated body Antalgic gait may be Pain and decreased No detectable hernia. Antalgic gait present. Pain exacerbated with
Journal of Orthopaedic & Sports Physical Therapy®

nation temperature and present. Pain with hip strength with resisted May be tender to Limited hip flexion hip extension, abduc-
lymphadenopathy motion; range may hip adduction, limited palpation at con- and internal rotation tion, and internal
present. Tenderness be restricted. Tender- hip abduction range joined tendon, pubic range of motion, with rotation. Altered
of the pubic bone, ness of the pubic of motion tubercle, superficial pain on internal rota- sensation at medial
superior or inferior bone, superior or inguinal ring, or pos- tion. Hip extension is knee and weakness
pubic rami inferior pubic rami terior inguinal canal. usually limited of the adductors may
Pain with resisted sit- be present
ups, hip adduction, or
Valsalva
Imaging MRI and CT may show Radiographs may show MRI used to confirm Used to rule out other Confirmed on radio- Used to assess for
bony abnormalities. irregular borders over diagnosis, show causes of groin pain graphs with presence neoplastic infiltration
Nuclear medicine is pubic symphysis or extent of injury of joint-space or mass effect
used to evaluate flow rami. MRI may show narrowing entrapment
uptakes bone marrow edema
Medical Erythrocyte sedimenta- Not required Not required Not required Not required EMG and nerve conduc-
diagnostic tion rate and tion testing may be
testing biopsy can be used to used to assess nerve
confirm infection status
Abbreviations: CT, computed tomography; EMG, electromyography; IV, intravenous; MRI, magnetic resonance imaging.

abdominal surgery. Cancer and visceral
disease were considered less likely than
other causes secondary to the patient’s
extensive medical evaluation.7,16,20,35,45
Infection needed to be ruled out due to
the elevated risk associated with a history
of surgery, the use of an indwelling cath-
eter, and advanced age. Lack of cardinal
physical signs of infection other than lo-
cal pain lowered the initial clinical suspi-
cion of infection.7,33
Other potential causes of pain includ-
ed intra-articular pathology of the hip,
which may cause symptoms in the groin
and pain that increases with strength

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45-04 Hawkins.indd 309 3/18/2015 5:10:23 PM

 [ resident’s case problem
testing of the hip musculature. But a lack
of pain with hip range of motion, particu-
larly flexion and internal rotation, made
hip joint pathology less likely.4 Osteitis
pubis was considered secondary to the
location of symptoms, high association
with pelvic surgeries, and pain with ad-
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ductor muscle contraction. However,
widening of the pubic symphysis on the
pelvic CT scan and bone marrow edema
on MRI would have typically been ex-
pected with this condition.28
The pattern of weakness and pain,
combined with reported typical compli-
cations following abdominal and pelvic
surgeries, matched the referral diagno-
sis of obturator nerve palsy.25,39,42 How-
ever, the patient had no sensory changes
when compared to the upper extremity,
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
which would likely be present in a neural
injury significant enough to cause gross
weakness.
Stretching into hip abduction and ac-
tive movement of the patient toward hip
adduction reproduced the patient’s pain,
though neural tensioning maneuvers
were negative, which suggested a muscu-
lar source of pain.8,32 Based on the results
Journal of Orthopaedic & Sports Physical Therapy®
of previously performed medical testing
and the clinical examination, a working
diagnosis of bilateral adductor strain
secondary to surgical irritation and de-
conditioning was made. The patient was
given a home exercise program of gentle
adductor stretching and self–soft tissue
mobilization for management of adduc-
tor muscular pain.12,13,37,41
The prior medical examination and
current physical examination did not re-
veal findings that would have precluded
further physical therapy evaluation and
treatment. Despite initiating treatment,
the rapid onset of symptoms, the patient’s
high risk profile, and the presence of mul-
tiple red flags (recent surgery, history of
cancer, bilateral symptoms), it was de-
termined that potentially more serious
pathologies needed to be medically ruled
out. The patient was referred back to the
physician for further medical evaluation,
with recommendation for the patient to
obtain electromyography (EMG) with a
310 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy
45-04 Hawkins.indd 310
nerve conduction study, as the significant
levels of weakness could have been due to
a systemic neuromuscular disease.
First Follow-up Evaluation
Three days following the initial evalu-
ation, the patient returned to physical
therapy, ambulating with a front-wheel
walker that he began using after the
previous appointment. The patient re-
ported increased pain and weakness over
the weekend and was now unable to flex
or abduct the hip enough to enter his
bathtub or ambulate around the house.
He attributed the decline in function
to the active hip adduction movements
performed at the previous session and
reported that he had too much pain to
complete the home exercise program.
Observation of gait showed the patient
with a forward-flexed posture, excessive
upper extremity support, decreased bilat-
eral hip flexion, and poor foot clearance
during swing. During sidestepping, the
patient used excessive trunk contralat-
eral sidebend to lift the lower extremity
into abduction and used excessive upper
extremity support. There was weakness
(2/5) without pain during manual mus-
cle testing for hip flexion bilaterally, with
the patient using a posterior trunk lean
to flex the hip in sitting. Hip adduction
strength testing was withheld to avoid
further irritation.
The rapid decrease in muscle func-
tion and walking ability increased the
suspicion of a neuromuscular disease as
the cause, and it was determined that fur-
ther physical therapy would be withheld
until results of EMG and nerve conduc-
tion studies were completed.18 Treatment
during this session included education
on use of the front-wheel walker and fall
precautions, with light soft tissue mobi-
lization and stretching applied to the hip
adductors bilaterally.12,13,17,37,41
Second Follow-up Evaluation
The patient returned 3 days following
his follow-up visit, after completing the
EMG and nerve conduction studies.
Motor nerve conduction studies showed
]
decreased left tibial nerve conduction
velocity, decreased bilateral peroneal
nerve conduction velocity, and dimin-
ished compound muscle action poten-
tial amplitude in the extensor digitorum
brevis muscle. Prolonged H-waves were
present bilaterally for the tibial nerve,
and F-wave velocities were prolonged
for the tibial nerve and absent for the
peroneal nerve bilaterally. Sensory nerve
conduction showed decreased amplitude
and conduction velocity of the sural
nerves, with prolonged peak latencies
bilaterally, whereas the EMG study
showed no acute or active denervation.
The patient was diagnosed with distal
symmetric, predominantly axonal, sen-
sory polyneuropathy with demyelinating
features.
The patient had seen no improvement
in pain or function since the previous
therapy session, and noted that he was
now having low back pain with move-
ments such as walking or standing. Sen-
sations to light touch, sharp touch, and
vibration were tested for clinical correla-
tion with the EMG and nerve conduction
velocity study findings, and sensation was
considered normal, compared to the up-
per extremities, bilaterally.
Due to the seemingly progressive
nature of the signs and symptoms, lack
of improvement with rest and soft tis-
sue mobilization, and the findings of
the EMG and nerve conduction studies,
it was determined that the patient was
not appropriate for physical therapy un-
til further medical evaluation had been
completed to determine the nature of
the underlying pathology.8,15,18,29 The pa-
tient was scheduled by the physician for
a follow-up pelvic MRI to evaluate for
lumbosacral plexopathy and would re-
turn to physical therapy if cleared by the
physician.18
Third Follow-up Evaluation
At 6 weeks after the initial evaluation,
the patient returned to physical therapy
following several follow-up studies co-
ordinated by his physician. Magnetic
resonance imaging of the lumbar spine
3/18/2015 5:10:24 PM
 showed multisegmental lumbar disc
desiccation with mild neuroforaminal
narrowing bilaterally at L1-2, L2-3, and
L3-4, and severe neuroforaminal narrow-
ing on the left at L4-5 and L5-S1. Mag-
netic resonance imaging of the pelvis
(FIGURES 3A and 3B) showed nonspecific
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edema of the pubic symphysis and hip
adductors bilaterally.
Based on the nonspecific findings
of the pelvic MRI, a nuclear medicine
3-phase bone scan with bone mar-
row imaging and indium oxine injec-
tion for white blood cell tagging was
ordered by the physician. The nuclear
medicine studies (FIGURES 4A and 4B)
revealed increased uptake at the pubic
symphysis and blood-pooling activity at
the hip adductor muscles. The patient
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
was diagnosed with pubic symphysitis/
osteomyelitis with secondary myositis,
predominantly affecting the right hip
adductor muscles.6,21,23,24 Blood cultures
obtained 1 week later showed a Stenotro-
phomonas maltophilia strain that was
sensitive to levofloxacin. The patient was
to continue his course of amoxicillin and
was prescribed Levaquin (500 mg daily),
Journal of Orthopaedic & Sports Physical Therapy®
and scheduled for follow-up examina-
tions to determine if surgical debride-
ment was required. He was referred back
to physical therapy with restrictions to
avoid painful hip motion.
At the third follow-up 6 weeks fol-
lowing the initial evaluation, the patient
reported less pain in frequency and in-
tensity, and reported that his strength
and function had improved, as he was
able to get in and out of the bathtub in-
dependently. The patient attributed the
improvement to beginning Levaquin
therapy 2 weeks prior, as he began feel-
ing improvement in pain and function
over the past week. Observation of his
gait revealed that the patient continued
to utilize excessive upper extremity sup-
port with his front-wheel walker, but
had greater hip flexion with less trunk
motion compensation. TABLE 2 provides a
full timeline of the medical and physical
examination findings after initiation of
physical therapy.
journal of orthopaedic & sports physical therapy | volume 45 | number 4 | april 2015 | 311
45-04 Hawkins.indd 311
A
B
FIGURE 3. (A) Short T1 inversion recovery, axial
magnetic resonance image showing nonspecific
edema at the pubic bones. (B) T1 pelvic coronal
magnetic resonance image showing nonspecific
edema at the pubic bones and proximal insertion of
the hip adductors bilaterally.
Outcomes
At the time of the third follow-up evalu-
ation, 6 weeks after the initial evalua-
tion, the patient’s biggest concerns were
his inability to walk with his wife for 20
minutes due to fatigue, his fear of falling,
and overall weakness. During this visit,
the patient completed the six-minute
walk test, covering a distance of 420
m.27 A functional gait assessment was
performed to determine fall risk. The
patient received a score of 26/30, the
greatest difficulty being a narrow base of
support and walking backward.43,44 Treat-
ment included exercise for 10 minutes at
an intensity of 3.0 on the upper extremity
ergometer to train cardiovascular endur-
ance and a lower extremity strengthen-
ing program, with balance activities to
decrease fall risk.9,10,17,26,36 The patient was
provided with instructions on a home
walking program to further train cardio-
vascular endurance.5,26,46
Two weeks later, the patient had
continued with his Levaquin therapy
and showed gradual improvement in
pain and function. The patient had pro-
gressed to walking without the use of
an assistive device and reported walk-
ing 30 minutes 3 times a week with his
FIGURE 4. (A) Three-phase bone scan with delayed
flow demonstrating increased uptake at the pubic
bones and pubic symphysis, consistent with
osteomyelitis and symphysitis. (B) Indium-oxide
labeling showing focal white blood cell accumulation
at the pubic bones and pubic symphysis, consistent
with osteomyelitis and symphysitis.
wife. The patient was readministered the
Lower Extremity Functional Scale, for
which he scored 54/80. The patient con-
tinued with therapy to progress balance,
focusing on high-level dynamic balance
activities and trunk control in standing
and walking.
Four months following the initial
evaluation, the patient had discontin-
ued Levaquin therapy. Follow-up imag-
ing showed a reduction of the infection,
without complete resolution. The patient
was scheduled to discuss further treat-
ment options with the physician, includ-
ing possible surgical debridement. At
this time, the patient had met all func-
tional goals and was discharged from
physical therapy with a score of 29/30
on the functional gait assessment and
64/80 on the Lower Extremity Func-
tional Scale. The patient reported that
he continued to have pain with moving
the hip in adduction, but the intensity
was decreased and he no longer had pain
with hip flexion.
3/18/2015 5:10:25 PM
 [ resident’s case problem ]

TABLE 2 Timeline of Physical Examination and Medical Testing

Diagnostic Testing Results Reflex Testing Manual Muscle Testing Pain Scale
Initial evaluation Pelvic CT (negative for thrombus) Patellar tendon: 2+ bilateral Hip flexion: 3/5 bilateral 9/10 with aggravating movements
Downloaded from www.jospt.org at UConn Homer Babbidge Lib on October 16, 2015. For personal use only. No other uses without permission.

Pelvic ultrasound (negative for throm- Achilles tendon: 2+ bilateral Hip adduction: 2/5 with pain, bilateral 0/10 at rest
bus, positive for left lymphocele) Babinski reflex: negative Hip abduction: 2+/5 right, 3/5 left
MRI (normal postsurgical inflam- All other lower extremity groups: 5/5
mation
First follow-up None performed Not tested Hip flexion: 2/5 bilateral 9/10 with aggravating movements
Hip adduction: not tested secondary 3/10 at rest
to pain
Second follow-up EMG and nerve conduction studies Not tested Not tested 9/10 with aggravating movements
(distal symmetric axonal sensory 2/10 at rest
polyneuropathy with demyelinat-
ing features)
Third follow-up MRI: multisegmental lumbar disc Not tested Not tested 9/10 with aggravating movements
desiccation, nonspecific pelvic 0/10 at rest
bone edema
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

NM bone scan: pubic symphysitis

and osteomyelitis with secondary
myositis
Table continues on page 313

DISCUSSION act source of each sign or symptom pre- minimal fever for 1 to 3 months, leth-
sented a challenge not uncommon when argy, anorexia and vomiting, localized

T
his resident’s case problem de- dealing with the older population. edema and erythema, diffuse and poorly
scribes the physical examination Within the outpatient physical thera- described pain, and without neurologi-
Journal of Orthopaedic & Sports Physical Therapy®

findings and risk-factor assessment
in an individual with pelvic osteomy-
elitis seen within an outpatient physi-
cal therapy setting. Because individuals
with undiagnosed osteomyelitis may be
encountered in the outpatient setting,
an understanding of how to screen and
diagnose osteomyelitis is important to
facilitate early diagnosis and treatment.
Without the presence of typical signs of
infection, full consideration may not be
given to bony infections by clinicians,
even in cases where the risk profile war-
rants high levels of suspicion.33
No physical examination diagnostic
algorithm exists for osteomyelitis. An as-
sessment of risk factors and signs of in-
flammation constitutes the extent of the
physical examination for osseous infec-
tion, and inclusion of medical testing is
required for diagnosis.33 Due to the many
comorbidities and medical procedures
that the patient had prior to initiation
of physical therapy, delineating the ex-
py setting, screening for osteomyelitis is
achieved by combining risk-factor assess-
ment with physical examination. Several
risk factors for osteomyelitis have been
identified, including chronic use of in-
dwelling catheters, history of pressure
ulcers, history of surgery, history of drug
use and blood toxicity, advanced age,
history of treatments and diseases caus-
ing decreased immune system response,
and wound infections.7,19,23,24,33 Osteo-
myelitis occurs in approximately 3% of
patients following radical cystectomies,
with wound or superficial infections
being more common.7,19 The patient in
this case had many of these risk factors,
including history of surgery, advanced
age, concurrent superficial infection,
and catheterization. Typical osteomy-
elitis within the adult patient will often
progress to a chronic condition, as signs
and symptoms may be hard to distin-
guish from a more benign pathology.23,24
Osteomyelitis commonly presents with
cal signs.6,23,24 Patients with pelvic bone
infections can present with a limp, lower
abdominal quadrant tenderness, pain
worse with hip abduction, pain with pal-
pation of the pubic symphysis, and ingui-
nal lymphadenopathy.6,8
While the patient in this case report
was mostly consistent with the typical
presentation, his pain initially appeared
to originate from a mechanical rather
than an inflammatory or infectious ori-
gin, based on the pain intensity being
altered with local hip muscle contrac-
tion and hip motion. The lack of elevated
body temperature, lymphadenopathy,
and local erythema reduced the initial
suspicion of infection. However, light,
isolated activity of the hip adductors led
to significant progression of pain and
weakness, which was less consistent with
a mechanical source of problems. While
this was initially suspected to be a disease
of the nervous or muscular system, this
might have represented a local increase

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45-04 Hawkins.indd 312 3/18/2015 5:10:26 PM

 TABLE 2 Timeline of Physical Examination and Medical Testing (continued)

Sensation Vitals Movement Analysis Working Diagnosis

Initial evaluation Normal to light touch and vibration Blood pressure: 134/79 mmHg Gait: ambulates using single-point Hip adductor strain bilaterally
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for both lower extremities when
compared to upper extremities
First follow-up Not tested
Second follow-up Normal to light touch, vibration,
and sharp touch for both lower
extremities when compared to
upper extremities
Third follow-up Not tested
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Temperature: 96.3°F cane, decreased hip flexion in
Respiration rate: 16 BPM swing bilaterally, right hip circum-
Pulse: 83 PPM duction, decreased terminal-
stance hip extension bilaterally
Not tested Gait: ambulates with front-wheel Adductor strain versus possible
walker, forward-flexed posture, obturator nerve entrapment
excessive upper extremity support,
decreased hip flexion in swing with
poor foot clearance
Not tested Not tested Lumbosacral plexopathy
Not tested Gait: ambulates with front-wheel Pelvic osteomyelitis, pubic

walker, excessive trunk flexion symphysitis, secondary

with excessive upper extremity myositis of adductor muscles
support, increased hip flexion with
increased foot clearance
Abbreviations: BPM, breaths per minute; CT, computed tomography; EMG, electromyography; MRI, magnetic resonance imaging; NM, nuclear medicine;
PPM, pulses per minute.

in inflammation due to the attachment might have been secondary to obtain- 24 hours versus 4 hours of imaging.6 A
of the hip adductor group to the area of ing the images early in the course of the 3-phase bone scan with radionuclide tag-
bony infection, with weakness being due disease. Magnetic resonance imaging has ging is the procedure of choice in nuclear
Journal of Orthopaedic & Sports Physical Therapy®

to inhibition of the adductors to prevent
further insult. Given the patient’s high
risk profile, the vague complaints and
physical examination findings warranted
consideration of several other pathologies
(TABLE 1), which necessitated the need for
further medical evaluation.4,6,13,25,28,37,39
In many cases, medical imaging is the
primary modality of diagnosis for osteo-
myelitis. Radiologic changes, typically
widening or deformity of the pubic sym-
physis, may not occur until late stages of
the disease, indicating the need for more
advanced imaging and diagnostic tech-
niques when suspecting osteomyelitis.24
Computed tomography examination may
be used as an adjunct to radiographs and
can evaluate for cortical bone changes.
However, sensitivity and specificity of CT
scans for diagnosis of osteomyelitis are
not fully established and are reported to
be in the range of 65% to 75%.6 The pa-
tient in this case had CT findings that did
not show cortical bone changes, which
been shown to have good diagnostic test
properties for diagnosis of osteomyelitis,
with sensitivity between 82% and 100%
and specificity between 75% and 96%.6
Where short T1 inversion recovery im-
ages have negative predictive values ap-
proaching 100%, conventional T1 and T2
images can be used to differentiate causes
of fluid collection.6 While cortical bone
disruption with surrounding soft tissue
can be highly specific for osteomyelitis,
normally seen bone marrow edema is
nonspecific and may mimic other condi-
tions.6 As the patient’s pelvic MRI in the
current case had findings of bone marrow
edema that were nonspecific, inclusion of
further medical imaging was necessary
to clarify the pathology. Nuclear medi-
cine techniques can help to increase the
diagnostic accuracy for bone infections,
with white blood cell labeling being the
most common procedure, due to its high
sensitivity and specificity (80%-90%)
and its accuracy, which increases using
medicine for diagnosing osteomyelitis in
bone without underlying conditions, due
to accuracy greater than 90%. However,
areas of high signal in bone scans may
represent increased bone mineral turn-
over and not infection in particular. Oth-
er disease processes, such as metastatic
disease, fractures, and joint arthropathy,
have similar findings, leading to poor
specificity of findings if the presence of
underlying conditions is in doubt. Indi-
um-111-labeled autologous leukocytes are
often utilized as a complementary image
for nonspinal infection to improve the
specificity of findings for a diagnosis of
osteomyelitis.21 The patient in this case
did undergo a 3-phase bone scan and in-
dium oxine labeling, which ultimately led
to the diagnosis of osteomyelitis.
Serial blood cultures are commonly
used but may be positive in only 32% to
60% of cases.6 In the present case, the
patient was found to have Stenotroph-
omonas maltophilia, which is a gram-

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45-04 Hawkins.indd 313 3/18/2015 5:10:26 PM

 [ resident’s case problem
negative bacterium far less common than
the typical Staphylococcus aureus and
may be potentially problematic due to its
high rates of antibiotic-resistant strains.6
After the diagnosis was made, blood cul-
tures were used to confirm the specific
pathogen and to determine the specific
Downloaded from www.jospt.org at UConn Homer Babbidge Lib on October 16, 2015. For personal use only. No other uses without permission.
course of antibiotic therapy. Laboratory
blood testing may also be used but is not
required for diagnosis.28 White blood
cell count is usually only mildly elevated,
whereas erythrocyte sedimentation rate
and C-reactive protein are commonly el-
evated but may be normal.6,23,24 However,
laboratory findings are often nonspecific
for osteomyelitis and were not utilized in
this case.
It is important to note that osteomy-
elitis is a highly variable disease and may
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
have multiple presentations, depending
on course, cause, and location.6,28 Pre-
viously described pelvic osteomyelitis
cases have varied between spontaneous
scenarios seen in athletes and cases fol-
lowing invasive pelvic surgery. A diag-
nostic score tool for osteomyelitis used
by Schmidt et al33 includes assessment
of clinical risk factors, physical exami-
Journal of Orthopaedic & Sports Physical Therapy®
nation and laboratory results, medical
imaging techniques, microbiological
analysis, and histological analysis, where
a maximum of 6 points is possible from
each of the 5 categories. This diagnostic
tool classifies the likelihood of osteomy-
elitis as certain with a score of at least 18
points, probable with a score between 8
and 17 points, and possible with a score
of 2 to 7 points. When the patient initially
presented to physical therapy, an evalu-
ation of only 2 categories (risk factors
and physical examination) was possible.
Evaluation of the clinical risk factors as-
signed 6 points for a history of malig-
nancy and surgery and 5 points in the
clinical examination for the presence of
at least 3 classical signs of inflammation
without fever (weakness, relapsing pain,
and functional deterioration). While a
score of 11 initially would classify the pa-
tient as having probable osteomyelitis, a
reliable diagnosis may only be achieved
with 3 or more categories, resulting in a
314 | april 2015 | volume 45 | number 4 | journal of orthopaedic & sports physical therapy
45-04 Hawkins.indd 314
score of 18 or greater. This underlies the
need for further medical testing to raise
suspicion from probable to certain. Posi-
tive imaging and microbiological analysis
added an additional 6 points each. At the
conclusion of this case, the patient had a
score over 18 points and could have been
classified with a certain diagnosis.33
CONCLUSION
T
his case describes the clinical
presentation of a patient with non-
diagnosed osteomyelitis, who was
evaluated in an outpatient physical thera-
py setting and required subsequent medi-
cal evaluation for correct recognition and
treatment of the infection. While the lack
of typical cardinal signs of infection, es-
pecially the absence of fever, might have
decreased the early clinical suspicion of
bony infection, it is important to recog-
nize that risk assessment might have had
equal diagnostic value in this case.
The clinical course of osteomyelitis
can be variable and may present with
a wide range of signs or symptoms that
can make diagnosis difficult. Because
osteomyelitis represents a potentially
fatal complication of invasive abdominal
and pelvic surgery, early recognition and
proper treatment are needed to optimize
outcomes. While physical therapists are
unable to provide a diagnosis of bony
infection, recognition of factors indi-
cating the need for further medical test-
ing is vital to ensure optimal outcomes.
Though osteomyelitis represents a rela-
tively rare condition, expanding access
to physical therapy services in direct-
access settings increases the need for
proper recognition and referral for early
treatment initiation. t
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