eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions
Osteitis Pubis
Updated: Jul 28, 2009
Introduction
Background
Since 1924, osteitis pubis has been known as a noninfectious inflammation of the pubis symphysis (also known as the pubic symphysis, symphysis pubis, or symphysis pubica) causing varying degrees of lower abdominal and pelvic pain. Osteitis pubis was first described in patients who had undergone suprapubic surgery and remains a well-known complication of invasive procedures about the pelvis. However, it may occur as an inflammatory process in athletes. The incidence and etiology of osteitis pubis as an inflammatory process versus an infectious process continues to fuel debate among physicians when confronted by a patient who presents complaining of abdominal pain or pelvic pain and overlapping symptoms. (See image below and Image 1.)
Radiograph in a 19-year-old athlete who presented with a 3-week history of a groin pull that was not resolving. This radiograph shows the classic sclerosis and lysis findings of osteitis pubis around the pubis symphysis, with widening of the symphysis.
Pathophysiology
Osteitis pubis is thought to result from inflammation of the pubis symphysis and is characterized by sclerosis and bony changes of the pubis symphysis.1 (See image below and Image 2.)
Pelvis, frontal view.
Frequency
United States
No available statistics are found in the literature for this condition.
International
No available international data exist; however, osteitis pubis may be more common in Europe due to the popularity of kicking sports such as soccer.
Mortality/Morbidity
While rare instances of mortality have been reported in the obstetric literature from femoral artery involvement, morbidity is observed more commonly secondary to pain and difficulty with ambulation.
Sex
The literature suggests that osteitis pubis is more prevalent in men. However, as women continue to lead more active lifestyles, and become more involved in sports such as soccer, the incidence and prevalence of the condition may change.
Age
Although osteitis pubis can affect all age groups, it is rarely encountered in the pediatric population. The disorder occurs most commonly in men aged 30-50 years. Women are more frequently affected in their mid-30s.
Clinical
History
- Pain generally is localized over the symphysis and may radiate to the groin, medial thigh, or abdomen.
- Onset can be abrupt or insidious (more than 1 mo).
- Pain is exacerbated by activities such as running, pivoting on 1 leg, and kicking.
- Lying on one's side also may exacerbate the pain.
- Pain can occur with walking, climbing stairs, coughing, or sneezing.
- The patient may experience a sensation of clicking or popping when rising from a seated position, turning over in bed, or walking on uneven ground.
- The patient may report weakness and difficulty ambulating.
Physical
- Tenderness to palpation is noted directly over the pubis symphysis with bilateral compression of the greater trochanters.
- The patient may report weakness, chiefly in the hip adductors, but there also may be involvement within the hip flexors.
- A waddling gait may be observed.
Causes
- Pregnancy/childbirth
- Gynecologic surgery
- Urologic surgery
- Athletic activities (eg, running, football, soccer, ice hockey, tennis)
- Major trauma
- Repeated minor trauma
- Rheumatologic disorders
- Unknown etiology
Differential Diagnoses
Adductor Strain
Other Problems to Be Considered
Osteomyelitis of the pubis symphysis
Ischial intersection syndrome
Snapping hip syndrome
Stress fracture
Groin strain
Pelvic and hip fracture
Muscle contusions
Tendon injuries
Acetabular labral tears
Bursitis
Chronic symphyseal injury
Workup
Laboratory Studies
- Laboratory studies are not required to make the diagnosis, but some authorities suggest testing for an elevated WBC count and/or erythrocyte sedimentation rate. This testing may eliminate other causes.
Imaging Studies
- Plain radiographs
- Plain radiographs demonstrate sclerosis, cystic changes, or rarefaction of the medial portions of the pubic rami (ie, marginal irregularity).
- Instability is defined as more than 2 mm of cephalad translation of the superior pubic ramus on each side, with the patient standing on 1 leg in turn.
- Widening of the cleft usually is measured to greater than 10 mm.
- The sacroiliac joints also should be evaluated since laxity of one or both may contribute to pubis symphysis instability.
- Positive findings usually are not apparent until 4 weeks after the onset of symptoms.
- Bone scans may be negative but can demonstrate intense signal uptake at the pubis symphysis.
- Ultrasonography may show abnormal widening of the cleft.
- Computed tomography (CT) scanning is also used for evaluation of the pubis symphysis and the posterior pelvic ring.
- Magnetic resonance imaging (MRI) studies2,3 may indicate bone marrow edema at the pubis symphysis, but this finding may also be seen in asymptomatic individuals.4 (See image below and Image 3.)
Magnetic resonance imaging (MRI) scan from a 20-year-old National Hockey League (NHL) player who presented with a complaint of testicle pain, which became worse with skating and with the performance of off-ice plyometric conditioning. The MRI scan of the player's pelvis, combined with the patient's history and physical examination, indicated a diagnosis of osteitis pubis.
Treatment
Rehabilitation Program
Physical Therapy
Rest and time are the primary healing mechanisms. Physical therapy (PT) may be useful during the early stage. Modalities, such as heat or ice, may provide symptomatic relief. Progressive ambulation with the aid of an assistive device (eg, cane, crutches) and possible orthoses (eg, lumbar/sacral corset, sacroiliac belt) to unload the pelvis for pain relief and to maintain correct anatomical alignment may be necessary.5
Avoidance of any therapeutic exercise that may place stress on the pelvic ring is prudent. A home exercise program that includes pelvic tilts may be prescribed. Experienced therapists may attempt dynamic stabilization techniques.
Surgical Intervention
Different surgical approaches have been described, including curettage, arthrodesis, wedge resection, and wide resection.5,6 A report by Radic and Annear suggested that curettage is an effective treatment for athletes with osteitis pubis in whom nonoperative therapy has been unsuccessful.7 The investigators found that 21 of the study's 23 athletes were able to run without pain one and a half to 6 months following curettage of the pubis symphysis, while 17 of them returned to training two and half to 7 months after the procedure, and 16 of the athletes resumed full activity two and a half to 12 months after curettage.
Wedge resection of the pubis symphysis is another technique that can be performed on patients in whom conservative management has failed; however, the natural progression of osteitis pubis may require months, and in some cases years, to improve. Surgical intervention is associated with early improvement of symptoms but may lead to later posterior pelvic instability. This instability may then require a second surgical procedure for stabilization.
Other Treatment
- Manipulation is performed in some instances to correct anterior translation of the symphysis.
- Intra-articular glucocorticoid injections are controversial.
Medication
Nonsteroidal anti-inflammatory agents (NSAIDs) are the DOCs for treatment of osteitis pubis. Narcotics also are employed for pain control in some cases, usually in the obstetric or postsurgical patient. Limited case reports suggest that use of antibiotics and heparin also has been successful.
Nonsteroidal anti-inflammatory drugs
Most commonly used for relief of mild to moderate pain. Although ibuprofen is the DOC for initial therapy, other options include, but are not limited to, ketoprofen and naproxen.
Ibuprofen (Advil, Motrin, Midol, Nuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Dosing
Adult
200-400 mg PO q4-6h; some patients may require doses as large as 800 mg PO q8h; not to exceed 3.2 g/d
Pediatric
<12 Months: Not established
12 months to 12 years: 10 mg/kg q6-8h; not to exceed 40 mg/kg/d
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; renal insufficiency; peptic ulcer disease; recent GI bleeding; high risk of bleeding
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; caution in congestive heart failure; renal and hepatic dysfunction; hypertension; anticoagulation therapy (monitor levels)
Ketoprofen (Actron, Orudis, Oruvail)
For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Dosing
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Dosing
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Cyclooxygenase-2 (COX-2) inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Dosing
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Interactions
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
Follow-up
Further Outpatient Care
- Rest is the primary treatment for osteitis pubis. Recommended duration of rest can vary from 2 weeks to 3 months. Athletes are advised to refrain from sporting activities for 3-6 months.
- Return to sports should be discussed between the patient, physical therapist, and physician.
- Regular use of anti-inflammatory medications can help with pain control and lessen recovery time. Narcotics have been used after initial injury, especially after lesions of the pubis symphysis resulting from obstetric, surgical, or traumatic conditions.
- Recommend participation in a physical therapy treatment program, including a gradual program for return to sports.
- Use of local corticosteroid injections remains controversial.
- Reserve surgery for those who fail conservative management. Surgical intervention rarely is indicated.
Complications
- Weakness and difficulty ambulating (possible)
- Femoral artery involvement (rare)
Prognosis
- Prognosis for recovery is excellent with definitive diagnosis and treatment. Reports indicate that the average time to full recovery is 9.5 months in men and 7.0 months in women. Some reports suggest that recovery may take up to 32 months. Recurrence is more common in males.
Patient Education
- The literature suggests that osteitis pubis is a frustrating condition for the patient and for the physician; therefore, patient education cannot be overemphasized.
- Rest is advised.
- Athletes are advised to refrain from sporting activities for 3-6 months and then to return on a gradual supervised basis.
- Avoid any activity or exercise that may place stress on the pelvic ring.
Miscellaneous
Medicolegal Pitfalls
- No known literature exists about osteitis pubis occurring in work-related injuries (except for professional athletes). The clinician facing this situation may have to proceed at his/her best discretion.
Multimedia
Media file 1: Radiograph in a 19-year-old athlete who presented with a 3-week history of a groin pull that was not resolving. This radiograph shows the classic sclerosis and lysis findings of osteitis pubis around the pubis symphysis, with widening of the symphysis.
Media file 2: Pelvis, frontal view.
Media file 3: Magnetic resonance imaging (MRI) scan from a 20-year-old National Hockey League (NHL) player who presented with a complaint of testicle pain, which became worse with skating and with the performance of off-ice plyometric conditioning. The MRI scan of the player's pelvis, combined with the patient's history and physical examination, indicated a diagnosis of osteitis pubis.
References
Robertson BA, Barker PJ, Fahrer M, et al. The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes. Sports Med. 2009;39(3):225-34. [Medline].
Zoga AC, Kavanagh EC, Omar IM, et al. Athletic pubalgia and the "sports hernia": MR imaging findings. Radiology. Jun 2008;247(3):797-807. [Medline]. [Full Text].
Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. Jan 2008;36(1):117-21. [Medline].
Lovell G, Galloway H, Hopkins W, et al. Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med. Mar 2006;16(2):117-22. [Medline].
Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. Sep 30 2008;[Medline].
Mehin R, Meek R, O'Brien P, et al. Surgery for osteitis pubis. Can J Surg. Jun 2006;49(3):170-6. [Medline]. [Full Text].
Radic R, Annear P. Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med. Jan 2008;36(1):122-8. [Medline].
Andrews SK, Carek PJ. Osteitis pubis: a diagnosis for the family physician. J Am Board Fam Pract. Jul-Aug 1998;11(4):291-5. [Medline].
DiStefano VJ, Nixon JE. Osteitis pubis--a case of housemaid''s pubis?. Pa Med. Jan 1972;75(1):51-2. [Medline].
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Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. Oct 26 1974;4(5938):211-4. [Medline].
Holmgren G. The treatment of osteitis pubis with anticoagulants. A report of three cases in Africans. Cent Afr J Med. Jan 1972;18(1):10-2. [Medline].
Michiels E, Knockaert DC, Vanneste SB. Infectious osteitis pubis. Neth J Med. Jun 1990;36(5-6):297-300.
Moore RS, Stover MD, Matta JM. Late posterior instability of the pelvis after resection of the symphysis pubis for the treatment of osteitis pubis. A report of two cases. J Bone Joint Surg Am. Jul 1998;80(7):1043-8. [Medline].
Pizzarello LD, Golden GT, Shaw A. Acute abdominal pain caused by osteitis pubis. Am Surg. Nov 1974;40(11):660-1. [Medline].
Vincent C. Osteitis pubis [published erratum appears in J Am Board Fam Pract 1993 Nov-Dec;6(6):616]. J Am Board Fam Pract. Sep-Oct 1993;6(5):492-6. [Medline].
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Keywords
osteitis pubis, pelvic pain, groin pain, pubis, osteitis, symphysis, pubic symphysis, pubis symphysis, symphysis pubis, symphysis pubica, symphysis dysfunction, pubis dysfunction, symphyseal separation, pubis diathesis, gracilis syndrome
Contributor Information and Disclosures
Author
Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.
Coauthor(s)
Guy W Fried, MD, Assistant Professor, Department of Rehabilitation Medicine, Thomas Jefferson University; Outpatient Medical Director, Medical Director of Incontinence and Respiratory Care Programs, Magee Rehabilitation Hospital
Guy W Fried, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Medical Editor
Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching
CME Editor
Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.
Chief Editor
Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.