In our series we have placed emphasis on a myofascial origin in nearly 90% of our patients. I am sure that some of our non-responders had other etiologies, i.e., neurogenic, visceral, etc. I believe periosteitis, in addition to enthesopathy, plays an important part in the etiology of this syndrome.
This is a unique but relatively straightforward condition affecting millions of patients. Understanding the concept that somatic pain of enthesopathy/periosteitis can manifest several inches away from bony attachments, thus mimicking visceral pain in the groin, lower abdomen and pelvis, is helpful. On physical examination of the abdomen, a thorough examination of the surrounding bony points, even during pelvic and rectal exams, and the use of the signs described helps in suspecting the diagnosis. Confirmation of the diagnosis as well as treatment objectives are achieved simultaneously with strategically placed steroid injections.
As experience with this condition is acquired and as confidence is gained, the diagnosis can be made strictly on clinical examination in the majority of these patients, without the need for expensive lab work, imaging studies and endoscopies. Literally billions of dollars are saved by making a swift diagnosis and administering appropriate conservative treatment. Pain and suffering, along with the cost of loss of productivity, are also minimized.
I feel we are still in the learning phase about this enigmatic condition, and much research, both clinical and experimental, needs to be done to streamline our approach and minimize or eliminate unnecessary investigations, invasive procedures, and sometimes unnecessary operations. The use of radiofrequency and Botox needs to be explored in the treatment of this condition.