eMedicine Specialties > Sports Medicine > Hip

Osteitis Pubis: Differential Diagnoses & Workup

Author: Vincent N Disabella, DO, FAOASM, Team Physician, Student Health Service, University of Delaware
Contributor Information and Disclosures

Updated: Feb 4, 2008

Differential Diagnoses

Sacroiliac Joint Injury

Other Problems to Be Considered

Abdominal muscle pull
Adductor strain
Ankylosing spondylitis (rare)
Femoral neck fracture
Inguinal hernia
Osteomyelitis
Pelvic inflammatory disease
Prostatitis
Pubic stress fracture
Reiter syndrome (rare)
Sports hernia
Urinary tract infection, Female [in the Emergency Medicine section]
Urinary Tract Infection, Females [in the Infectious Diseases section]
Urinary tract infection, Male [in the Emergency Medicine section]
Urinary Tract Infection, Males [in the Infectious Diseases section]

Workup

Laboratory Studies

  • A complete blood cell (CBC) count level should be obtained to rule out systemic infection. The leukocyte counts should be normal; if not, infectious causes should be sought.
  • An erythrocyte sedimentation rate (ESR) should be measured to rule out possible inflammatory and rheumatologic disorders.
  • A urinalysis should be performed to rule out an etiology of a urinary tract infection (UTI) or prostatitis.
  • If the patient is febrile, perform a blood culture. Most of the time, the blood culture is negative, unless the patient presents as clinically septic. Patients with osteomyelitis will most likely have blood cultures that are positive for S aureus.

Related eMedicine topic:
Sepsis, Bacterial

Related Medscape topic:
Resource Center Sepsis: Pathophysiology and Treatment

Imaging Studies

  • Radiographs
    • Radiographs are often negative early in osteitis pubis.
    • After a few weeks, some widening of the pubic symphysis may be seen on anteroposterior (AP) films (see Image 1).
    • As osteitis pubis progresses, sclerosis and osteolysis can be seen (see Image 1).
    • If pelvic inequity is suspected as a cause, flamingo views can expose a pubic instability.
      • In the case of osteomyelitis, bone erosions can be seen on plain films.
  • Bone scans (technetium-99m [99m Tc]) or single-photon emission computerized tomography (SPECT) scans are often positive early in the disease. These studies show increased radionuclide uptake directly over the pubic symphysis or unilaterally at the pubic margin. The delayed views of the triple-phase bone scan will be conclusively positive in cases of osteitis pubis. However, as stated by Fricker, the degree of positivity or unilateral findings does not correlate well with the severity of the symptoms or the chronicity of the disease.1
  • As magnetic resonance imaging (MRI) becomes more widely used and the technology becomes more sophisticated, it is becoming a very useful study to obtain.10,14,15,16 MRI is especially useful when fat suppression views are obtained; this imaging modality helps the physician distinguish between muscle, tendon, periosteal, or bony disruption. Many times, inflammation of the fibrocartilaginous disk, bone edema, and sclerosis at the pubic margins can be appreciated.

Procedures

  • In cases in which the patient is febrile but the blood cultures are negative, perform an aspiration of the pubic symphysis for cultures. This is most commonly done with the guidance of ultrasound or computed (CT) scanning.
  • Herniography may be needed in cases in which a sports hernia is a strong consideration.9

Related eMedicine topic:
Ultrasonography, Pelvic

More on Osteitis Pubis

Overview: Osteitis Pubis
Differential Diagnoses & Workup: Osteitis Pubis
Treatment & Medication: Osteitis Pubis
Follow-up: Osteitis Pubis
Multimedia: Osteitis Pubis
References
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References

  1. Fricker PA. Osteitis pubis. Sports Med Arthrosc Rev. 1997;5:305-12.

  2. Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc. May 1995;27(5):629-33. [Medline].

  3. Karpos PA, Spindler KP, Pierce MA, Shull HJ Jr. Osteomyelitis of the pubic symphysis in athletes: a case report and literature review. Med Sci Sports Exerc. Apr 1995;27(4):473-9. [Medline].

  4. Sing R. Osteitis pubis in the active patient. Phys Sportsmed. 1995;23(12):67-73.

  5. Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill-Livingstone; 1992:633-9.

  6. Lloyd-Smith R, Clement DB, McKenzie DC, Taunton JE. A survey of overuse and traumatic hip and pelvic injuries in athletics. Phys Sportsmed. 1985;18(10):131-41.

  7. Westlin N. Groin pain in athletes from southern Sweden. Sports Med Arthroscopy Rev. 1997;5:280-4.

  8. Holmich P. Adductor-related groin pain in athletes. Sports Med Arthrosc Rev. 1997;5:285-91.

  9. Lynch SA, Renström PA. Groin injuries in sport: treatment strategies. Sports Med. Aug 1999;28(2):137-44. [Medline].

  10. Cunningham PM, Brennan D, O'Connell M, et al. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol. Mar 2007;188(3):W291-6. [Medline]. [Full Text].

  11. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. Oct 1998;17(4):787-93, vii. [Medline].

  12. Braun P, Jensen S. Hip pain - a focus on the sporting population. Aust Fam Physician. Jun 2007;36(6):406-8, 410-3. [Medline].

  13. Ruane JJ, Rossi TA. When groin pain is more than "just a strain": navigating a broad differential. Phys Sportsmed. 1998;26(4):78-103. [Full Text].

  14. 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].

  15. Kunduracioglu B, Yilmaz C, Yorubulut M, Kudas S. Magnetic resonance findings of osteitis pubis. J Magn Reson Imaging. Mar 2007;25(3):535-9. [Medline].

  16. Kneeland JB. MR imaging of sports injuries of the hip. Magn Reson Imaging Clin N Am. Feb 1999;7(1):105-15, viii. [Medline].

  17. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med. Sep-Oct 1995;23(5):601-6. [Medline].

  18. King JB. Treatment of osteitis pubis in athletes: results of corticosteroid injections. Am J Sports Med. Mar-Apr 1996;24(2):248. [Medline].

  19. Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. Apr 2005;86(4):697-702. [Medline].

  20. 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].

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Further Reading

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Keywords

pubic instability, pubic symphysitis, pubalgia, traumatic aseptic osteitis pubis, Pierson syndrome, chondritis pubis, posttraumatic osteonecrosis of the pubis, groin pain, groin pull, groin injury

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Contributor Information and Disclosures

Author

Vincent N Disabella, DO, FAOASM, Team Physician, Student Health Service, University of Delaware
Vincent N Disabella, DO, FAOASM is a member of the following medical societies: American College of Sports Medicine, American Medical Society for Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, Assistant Professor, Departments of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami
Andrew L Sherman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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