|Journal of Occupational and Environmental Medicine
Volume 40 Number 5 May 2022
|Letters to the Editor
Pelvic Joint Dysfunctions, Lifting Injuries, and Testicular Pain
|To the Editor:
|I read your recent Occupational Medicine Forum entitled "Can Heavy
Lifting Cause Epididymitis?" with interest.  I have seen and treated
cases of so-called "sterile epididymitis" in the past and have discussed
this with urologic colleagues. Until your article, however, I was unable
to find any references in the literature to corroborate this
diagnosis. This article by Dr. Lerner is a welcome addition to my
|The issue of testicular pain from lifting raises the important issue of
an alternative pathology often misdiagnosed as epididymitis or other
conditions. To illustrate, a 41-year-old male was lifting and twisting
heavy lawn ornaments when he experienced sudden severe right testicular
pain. When it worsened, he was evaluated at an emergency department,
diagnosed presumptively with epididymitis, and started on a course of
antibiotics. Two days later, he returned to the emergency department
with unrelenting pain, and was started on a different course of
antibiotics. His symptoms persisted. He also had developed right-sided
low back pain and bloody diarrhea.
|He was admitted to the hospital one week later in extreme distress, and
a diagnostic workup ensued. A urology consult documented no
epididymitis, and cystoscopy and prostate evaluation results were
negative. Barium enema, colonoscopy, colon biopsy, and magnetic
resonance imaging (MRI) results of the back and pelvis were all
negative. He was diagnosed and treated for an iatrogenic case of
Clostridium difficile diarrhea. An orthopedic surgeon did not feel that
there was a surgical back lesion. After a two-week hospital course
costing tens of thousands of dollars, he was discharged home without a
diagnosis. At that point his testicle pain was not improved and his low
back pain was increasing. He was later referred to me, and the diagnosis
of a pelvic joint dysfunction was made. He was treated, with eventual
resolution of all symptoms.
|In the osteopathic literature, there is a variety of dysfunctions within
the joints of the pelvis, including the symphysis pubis  joint.
Often, symphysis pubis dysfunctions are accompanied by dysfunctions
within the sacroiliac (SI) joints. These combined dysfunctions usually
manifest as a rotation (anterior or posterior) or a shear (superior or
inferior) of the entire bony hemipelvis (inominate).
|When there is a dysfunctional symphysis pubis, pain is often referred to
the testicle or vagina, and sometimes down the medial thigh toward the
knee on the affected side. If only the symphysis is dysfunctional, the
scenario of testicle pain after heavy lifting occurs. When the SI joints
are also involved, low back pain occurs.
|The examination of the pelvic joints involves a number of
otion-palpation maneuvers, which have been previously described in
detail.  These skills require some training and are offered at
various institutions. Studies have shown high interobserver consistency
among trained examiners in evaluating pelvic joints.  Ballotment is a
simple diagnostic test, easily performed by an examiner, regardless of
training. The examiner places the heel of the palm on either the
symphysis pubis (with the patient supine) or the SI joints (prone
patient). Pushing and releasing to ballot the joint will cause pain if
the joints are dysfunctional or inflamed.
|Diagnosis and Treatment
|Diagnosis is primarily by history and physical but may be confirmed with
plain radiographs using special stress views,    and with bone
scans.  One of my patients had an edema signal detected within the
symphysis pubis on a pelvic MRI. MRI may thus be an additional
| Treatment involves manipulative techniques that are easily learned.
Occasionally, repeat manipulations may be necessary until the joint
stabilizes and the surrounding soft tissues tighten. A home program of
directed stretching and strengthening is also advisable. An excellent
discussion of treatment principles for pelvic joint dysfunctions is
extensively covered elsewhere. 
| Expeditious treatment improves the clinical outcome. Delay of diagnosis
allows the joint to stay in a dysfunctional position, prolonging the
attended stretch of supporting ligaments, muscles, and tendons. This
leads to joint instability, muscle imbalance, and muscle weakness.
Presumably, chronic inflammation and possible adhesions within the
joint may also be a factor in the chronic pain and prolonged impairment
that may result.
|Since patients presenting with pelvic joint dysfunctions do not fit the
standard medical paradigms regarding low back or groin pain, this
clinical picture poses a diagnostic dilemma to physicians not trained in
manual medicine techniques. Misdiagnosis is common. The pain does not
follow a radicular pattern, and radiculopathy can be excluded with a
thorough neurologic evaluation. Further complicating the presentation,
secondary trigger points within the gluteus medius, piriformis, and
other pelvic muscles may exist as a consequence of the joint imbalances.
These trigger points refer symptoms down the leg in nonradicular
patterns classic for myofascial pain, as described by Travell
and Simons. 
Epdidymitis is also often confused with symphysis dysfunction. The pain
is distinctly different in these two conditions. The pain of sterile
epididymitis is a burning ache. The testicles and scrotum may be too
tender to allow the wearing of underwear. Oral antibiotic treatment can
result in marked improvement in as little as 24 hours.
|In contrast, the pain with symphysis dysfunction tends to be sharper.
This pain is generally located above the penis, in the midline, and
sometimes just off to the side. The testicles are not usually as tender
to palpation, or are nontender, and there is no difficulty wearing
clothing. Response to a diagnostic-therapeutic trial of manipulation is
often immediate and complete.
|Symphysis dysfunctions are also commonly misdiagnosed as acute inguinal
hernias. This is not surprising since heavy lifting is associated with
both conditions. In fact, I have seen many patients where an incidental,
preexisting, but asymptomatic hernia was treated by herniorrhaphy. Their
"hernia" pain remained despite surgery, only to disappear after
identification and treatment of the symphysis dysfunction.
|When patients have both a symphysis dysfunction as well as a hernia,
careful palpation is helpful in distinguishing which is the painful
condition. By placing the examining digit in the inguinal canal and
gently curving the finger medially, one can palpate directly over the
symphysis. Comparing tenderness at the symphysis to that at the hernia,
it is generally easy to distinguish which is more painful. Palpation in
this manner over the normal symphysis or at an old hernia is typically
|In acute inguinal hernia, tenderness and pain usually persists for a
minimum of 3-4 weeks. If treating the symphysis, without treating the
hernia, abolishes all pain in less than 1 week, one may conclude that
the hernia was old and asymptomatic and that the symphysis dysfunction
was causing the groin pain. The painless hernia may later be addressed
as indicated. Certainly it doesn't harm the patient to proceed in this
manner,in the absence of an incarceration. Alternatively, surgical
hernia repair without addressing the painful symphysis prolongs
suffering and disability and may lead to chronic impairment.
|Symphysis dysfunctions are also misdiagnosed often as acute or chronic
prostatitis. Typically these patients have had many negative culture
results and have often been treated with multiple antibiotic regimens.
Sometimes they have been instrumented or even examined under anesthesia.
Usually these treatment approaches have failed to improve symptoms, in
some cases despite years of trying. Such patients generally report
greater improvement with manipulation of the pelvis than with prior
|As a further illustration of the potentially drastic consequences of
misdiagnosis, one unfortunate patient had so much testicle pain that he
even submitted to unilateral orchiectomy. When this did not improve his
testicle pain, even in the absence of the testis, he sought further
consultation with me. Once his symphysis pubis dysfunction was
treated, the pain disappeared. At that point, he was pleased with the
pain relief but dissatisfied with the absence of his testicle.
|These conditions are not new. The mobility of the symphysis has been
documented as far back as 1929.  Symphysis pubis dysfunctions have
been discussed and described under a variety of different terms: "pubic
stress symphysitis,"  "osteitis pubis,"  "public symphysis
instability,"  and several others.  It is commonly seen in
runners, athletes, pregnant women, and workers involved with heavy
manual materials handling. Until I learned about pelvic joint
dysfunctions, I might have argued that these conditions did not exist.
Upon greater awareness, however, I have been astounded at the frequency
with which they occur.
|Pelvic joint dysfunctions are very common in patients with acute as well
as chronic low back pain. Greenman recently looked at the incidence of
pubic dysfunction in a population of 183 patients with chronic failed
low back pain. The pubis was found to be dysfunctional in 75.4% of the
population. In his words, "it clearly is a significant, but
underrecognized, and undertreated problem with low back pain
populations." (P.E. Greenman, personal communication, 1992). I would
conservatively estimate that 30%-50% of my patients with acute low back
pain have some component of a pelvic joint dysfunction. Approximately
15% of these people have symptoms referable directly to the symphysis.
|If we assume that only 10% of patients presenting with acute low back
pain have a pelvic joint dysfunction (a very conservative estimate!), it
is easy to imagine the magnitude of this problem. Low back pain is the
second most frequent presenting complaint to primary care doctors in
this country. The yearly prevalence of back pain is 50% in working-age
adults, 15%-20% of whom seek medical care.  Recognizing that
very few physicians are trained in diagnosing pelvic joint dysfunctions,
my judgment is that these are the most frequently misdiagnosed (or
nondiagnosed) conditions in the United States, effecting millions of
|If the diagnosis is missed, why then do so many of these patients
improve? One possibility is that some of these dysfunctions are treated
with maneuvers similar to exercises commonly utilized for the low back,
such as William's flexion stretches. The patients may thus be
unwittingly manipulating themselves with standard regimens. Also,
many back pain patients with pelvic dysfunctions are accurately
diagnosed and treated by physical therapists whose clinical notes are
either ignored, never seen, or misunderstood by the treating doctor. It
is consequently no surprise that the doctor may not realize what the
true problem is. More importantly, the morbidity and consequences
of incorrect treatment are staggering.
|In writing this report, I hope that my colleagues will have a greater
awareness of a condition causing significant discomfort, dysfunction,
and morbidity. Inaccurate diagnosis is exceedingly common and often
leads to inappropriate treatment, needless and costly diagnostic
tests (some of which may be invasive), hospitalization, or even surgery.
When the diagnosis is not forthcoming because it is not part of our
typical paradigm, the physician may be tempted to improperly ascribe
symptoms to presumed psychosocial pathology or motivations of secondary
|Medicine, in addition to being both science and art, is also a belief
system. Unless we doctors believe in a disease process, we are unlikely
to diagnose it. I am convinced that if my colleagues remain open-minded,
yet appropriately skeptical, they will begin to recognize patients with
pelvic dysfunctions. If the diagnosing physician is unable to perform
the manual medicine techniques, there is an increasing number of
qualified physical therapists, physicians, doctors of osteopathy, or
chiropractors who can. Through improved diagnostic accuracy and
treatment, doctors will better relieve the pain of countless patients in
|Orrin Mann MD, MPH
Department of Occupational Health
Multicare Associates of the Twin Cities Rosedale, MN
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