Journal of Occupational and Environmental Medicine Volume 40 * Number 5 * May 1998 Letters to the Editor
Pelvic Joint Dysfunction, Lifting Injury, 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 library.
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 diarrhoea.
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 diagnostic tool.
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.  Epididymitis 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 nontender.
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 regimens.
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 patients annually.
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 gain.
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 the future.
Orrin Mann MD, MPH
Medical Director Department of Occupational Health Multicare Associates of the Twin Cities Rosedale, MN
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See also Acute epididymitis: a work-related injury? J Natl Med Assoc. 1996 Jun;88(6):385-7. Sawyer EK, Anderson JR.