eMedicine Specialties > Sports Medicine > Hip

Osteitis Pubis

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

Updated: Feb 4, 2008

Introduction

Background

Osteitis pubis is an inflammation of the pubic symphysis and surrounding muscle insertions.^1,2,3,4,5 Although the exact etiology of osteitis pubis is unknown, it is most likely caused by repetitive microtrauma or shearing forces to the pubic symphysis.

In 1924, Beer described inflammation of the pubic symphysis as a result of urologic surgery. He called it an orthopedic disease sponsored by urologic surgery. In 1932, Spinelli wrote about osteitis pubis in athletes. Since that time, multiple sports-related occurrences of this condition have been reported. As shown by Alderink, sacroiliac (SI) joint motion has a very large impact on the motion about the pubic symphysis. Batt et al postulated that osteitis pubis is a result of muscle injury to the hip adductors or abdominal musculature, causing muscle spasm, which, in turn, produces increased shearing forces across the pubic symphysis.²

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Related Medscape topics:
Resource Center Exercise and Sports Medicine
Musculoskeletal Problems in the Female Athlete

Frequency

United States

The exact frequency for osteitis pubis is difficult to estimate; however, in a study performed by Lloyd-Smith et al in Canada, this condition comprised 6.3% of the 222 overuse injuries that were studied.⁶ In smaller studies, the incidence of osteitis pubis appears to be up to 5 times more prevalent in males than in females.

International

A study by Westlin reported that 80% of the athletes that presented to the Sports Medicine Clinic in Malmo, Sweden, had this condition.⁷

Functional Anatomy

The anatomy around the pelvic girdle is quite complex. The pelvis is a ring, and any change in anatomy or applied forces to one area will be compensated throughout the ring. This simple fact makes it easier to understand why a leg-length discrepancy or SI dysfunction can greatly change the shear forces across the pubic symphysis. In addition, understanding the functions of the muscles that attach to the pubic rami is important. The hip adductors (ie, gracilis, adductor longus, adductor brevis, and adductor magnus) originate at the inferior pubic ramus.⁸ The pectineus and rectus abdominis muscles, along with the inguinal ligament, insert superiorly. The muscles of the peroneal floor insert posteriorly.

Sport-Specific Biomechanics

Osteitis pubis seems to be more prevalent in sports that involve running, kicking, or rapid lateral movements. Sports in which participants develop osteitis pubis more often include the following^1,3,4,8,9 :

• Soccer^10,11 : This sport involves a great deal of running and rapid change of direction. These movements can lead to strains of the adductor muscles, which change the forces directed on the pelvis during recovery. Kicking is another inciting motion in soccer. Many times the athlete is not well balanced when planting the foot to kick, placing a great deal of strain on the muscles stabilizing that is stabilizing him or her to perform the kick. This translates to abnormal forces across the pubic symphysis.
• Sprinting: This activity can lead not only to repetitive microtrauma to the pelvis, but also to muscle pulls, which are common occurrences due to the rapid acceleration in sprinting. This condition, coupled with multiple repetitions, can lead to cumulative stress on the pubic symphysis.
• Ice hockey: This sport has multiple risk factors, including the skating motion and the contact with other players and the dasher boards. Ice hockey players may sustain minor adductor strains, but the continued play and resultant changes in flexibility lead to abnormal forces across the pubic symphysis. This condition can often be aggravated by the rapid change in direction that is required in ice hockey.
• American football² : This sport also has multiple reasons for a high rate of injury. The first factor is the amount of sprinting that is performed. The second factor is the amount of violent collisions that often lead to minor injuries, which many athletes may play through. Certain positions (eg, defensive backfield) also demand a great deal of back pedaling, with a rapid abduction of one hip to turn and run with a receiver. This motion can lead to hamstring or adductor strains, which change the muscle balance and forces across the pubic symphysis.

Clinical

History

The presenting symptoms of osteitis pubis can be almost any complaint about the groin or lower abdomen.^{7,8,9,11,12,13}

• Athletes complain about pain in their groin, hip, perineum, or testicle.
  • Fricker performed a study that involved Canadian and Australian athletes who had osteitis pubis.¹ The author reported that 8% of the males in the study had scrotum or testicular pain.
• Athletes often present with adductor pain or lower abdominal pain that then localizes to the pubic area. More often than not, the pain is unilateral and has been present for a few days to weeks.
• Most of the time, the athlete's pain increases with running, kicking, or pushing off to change direction.
• Be cautious if the athlete complains of fever, chills, or rigors with the pubic pain. Although rare in athletes who have not undergone pelvic surgery, osteomyelitis must be ruled out in these patients.³

Physical

Physical findings for osteitis pubis can vary greatly.¹³ Always consider the sport and chronicity that are involved.

• Early in the disease, the athlete may complain of groin or testicular pain. The pain is often aggravated by adduction of the leg or running. Symptoms are often more unilateral.
• Patients can also complain of lower abdominal pain, and the area over the superior pubic ramus can be tender to palpation.
• When sacral innominate dysfunction is a cause, the athlete can have pain over one or both SI joints. This pain can often be accompanied by piriformis spasm and resultant sciatic-type pain.
• When discrepancies of leg length are involved, the athlete may complain of hip pain in the longer limb. This can also be seen in runners who run in the same direction and who functionally have one leg that is shorter secondary to the caber of the running surface. A single-leg hop test can reproduce the patient's symptoms. However, the most specific test for osteitis pubis is the elicitation of tenderness over the pubic symphysis with a direct-pressure spring test. This pubic spring test has proven to be fairly specific and is very simple to perform as follows:
  • Palpate the athlete's pubic bone directly over the pubic symphysis. The athlete is often tender to touch at that point.
  • Slide your fingertips a few centimeters laterally to each side. Apply direct pressure on the pubic rami. With this pressure, the patient feels pain in the symphysis.
  • Ipsilateral pressure may be applied to see if either side produces more pain or lateral pain. If the pain is not reproduced over the pubic symphysis, other diagnoses must be entertained (eg, stress fracture, avulsion).
• If the athlete complains of pubic pain of acute onset and presents with fever and chills, a full workup for osteomyelitis must be performed. These patients often present with an antalgic gait and often appear sick.
• Check for inguinal hernias in all athletes with groin pain. Patients who have sports-related hernias may relate having had multiple adductor strains that never completely resolved and report that the pain is very deep upon palpation. During the hernia examination, these patients are noted as having an enlarged external inguinal ring. Tenderness is observed when the posterior wall of the canal is palpated. Coughing or performing the Valsalva maneuver exacerbates the pain.
• Perform a gynecologic examination in affected female athletes if other symptoms are suspicious of pelvic inflammatory disease (PID).
• If the patient's symptoms warrant, perform a rectal examination on males to rule out prostatitis.

Related eMedicine topics:
Chronic Pelvic Pain
Pelvic Fractures
Pelvic Ring Fractures
Testicular Torsion
Testicular Trauma

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Hernia
Resource Center Prostatitis
CME Global Burden of Sexually Transmitted Infections (Slides With Transcript)
CME Making Sense of the Complex: a Point of Care Approach to Managing Chronic Pelvic Pain / Interstitial Cystitis
Musculoskeletal Problems in the Female Athlete

Causes

• The causes of osteitis pubis are multifactorial. This condition is usually caused by an abnormal shearing force across the pubic symphysis, which, as previously mentioned, can itself be caused by muscle imbalance, poor flexibility, and SI joint dysfunction. These abnormalities of pelvic biomechanics — coupled with multiple repetitions of aggravating motions — cause microtrauma to the pubic symphysis, which results in inflammation and muscle spasm.
• In the case of the athlete with a fever and osteomyelitis, Staphylococcus aureus is the most commonly cultured bacteria. Pseudomonas aeruginosa and Escherichia coli have also been reported.

• Search for CME/CE on This Topic »

• Osteitis Pubis (Physical Medicine and Rehabilitation)
• Groin Injury (Sports Medicine)