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Osteitis Pubis: Treatment & Medication
Updated: Feb 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The acute phase of rehabilitation for osteitis pubis is sometimes a misnomer. During the acute phase, that is, when the patient presents to the physician, the symptoms may actually be acute or chronic at this point. Either way, the patient should be treated as if the onset of symptoms is acute. This is a time to help alleviate the patient's pain and to start correcting the mechanical problems that precipitated the injury. The athlete is pulled from all sporting activities during this phase.
Athletes should be evaluated for gait abnormalities, leg-length discrepancies, and somatic dysfunctions, especially of the SI joints. The physical therapist can be very active in all these evaluations. The aim of therapy in this phase is toward restoring flexibility around the pelvis and implementing modalities to control pain and inflammation. Ultrasound and electrical stimulation are often very helpful during this phase. However, ultrasound should be used cautiously if there is a possibility of infection or if there is a great deal of inflammation around the pubic symphysis. Athletes may also benefit from ice massage, if it is tolerated.
Medical Issues/Complications
During the acute phase, consider any medical reasons for the occurrence of pubic pain. Perform a blood workup and a urinalysis to rule out infectious sources. Prostatitis and PID must be treated, if present. Osteomyelitis must be treated for 4 or more weeks before aggressive therapy can begin.
Surgical Intervention
Surgery is rarely warranted, if ever, for osteitis pubis and should not be a consideration during the acute phase.
Consultations
Athletes with infectious comorbidity may need to be seen by gynecology, urology, or infectious disease physicians. If poor foot mechanics are part of the cause of the patient's condition, it is favorable to have the patient evaluated by a podiatrist for orthotics because the manufacturing process often takes a few days to weeks for fabrication of the orthotic. Sports psychology can often become involved early in rehabilitative therapy because treatment can sometimes be lengthy, with slow progression. Athletes do better if they are mentally prepared for the task at hand.
Other Treatment
During the acute phase, nonsteroidal anti-inflammatory drugs (NSAIDs) are administered for pain and inflammation therapy. In rare cases, usually when the symptoms have been present for more than 4-6 weeks, oral corticosteroids are prescribed. The author's suggested preference is a pulse dose of 40 mg/d of prednisone for 5 days or sometimes a longer tapering dose (see Medication, below).
- The use of steroid injections is often necessary to speed recovery in athletes with osteitis pubis, but this therapy should be used with caution.17,18 Osteitis pubis often resolves without the use of corticosteroid injections.13 If the athlete can take the time to progress without an injection, this therapy may not be warranted. The athlete, coach, and other involved persons must be informed rehabilitation can take up to 9.6 months.1
- As shown in a study by Holt et al, it is believed that early corticosteroid injection can be beneficial.17
- The injection should be performed after the athlete completes 1 week of stretching and rest. If the athlete is currently active in the playing season, the injection will be completed on the first visit, provided no other contraindications exist.
- The area to be injected is shaved and cleansed with povidone iodine.
- The injection is placed into the middle of the pubic symphysis in an AP direction. The needle is advanced approximately 1 inch until a pop is felt as the needle enters the joint. The author's suggested preference is to use a 1.5-inch 20-gauge needle with a 3-mL syringe that is filled with 1 mL each of betamethasone injectable suspension (6 mg/mL), 2% lidocaine, and 0.5% bupivacaine. Use paraben-free anesthetic so that the betamethasone does not precipitate out of the mixture.
- Postinjection, the patient remains out of activity for 1 week.
- Occasionally, a second or third (rare) injection is required at intervals of 2-3 weeks.
- Manipulation can be a very valuable modality in this phase. If any SI dysfunction or pubic shearing occurs, manipulative therapy can alleviate some pain and decrease the shearing force that is created across the pubic symphysis. In addition, correcting any somatic dysfunction can often help resolve muscle spasms around the pelvic girdle and improve flexibility about the pubic symphysis.
- In a study by Topol et al, athletes with chronic groin pain were shown to have improvement in symptoms with prolotherapy.19 The investigators injected the patients' pubic symphysis, adductor origins, and superior pubic ramus area with a 1:1 mixture of 12.5% dextrose and 0.5% lidocaine. Although this study had some limitations, it showed marked improvement of the athlete's symptoms and long-term pain relief (mean 2.8 treatments, average 17.2 mo of follow-up) and offered another possible therapy for osteitis pubis.
Recovery Phase
Rehabilitation Program
Physical Therapy
Once the patient is free of pain, strengthening therapy can begin. Exercises for the hip flexors, hip adductors, lumbar stabilizers, and abdominal muscles are started. Hamstring and quadriceps exercises are also performed, with squatting and leg presses added last due to the increased load that is used in these exercises. Stretching is performed at least daily, with flexibility as the main focus of therapy. Aquatic conditioning can also begin at this time, with the exception of frog kicking, which extensively uses the adductors. Many patients can tolerate stair-stepping machines at this time. Cycling is usually still not tolerated because of the pressure that is caused by the saddle, although some patients can tolerate a recumbent cycle. Sports-specific activities are added late in this phase, with offending motions added last.
Occupational Therapy
If the patient performs offending movements at work, proper mechanics should be taught and stressed. Occasionally, equipment modification is needed. Work-hardening programs are helpful in industrial athletes to ensure that they are ready to return to full activity.
Medical Issues/Complications
At this point in therapy, tapering the dose of any NSAID can be attempted to prevent gastrointestinal (GI) complications. This is often not possible, but the approach of using the minimal dose that is necessary for the shortest duration possible is always a good rule of thumb.
Consultations
During the recovery phase, it is often prudent to evaluate any biomechanical errors and equipment. This is a good time to work on the proper form for activities. The athlete can also use this phase to become accustomed to any new orthotic or footwear that may be instituted.
Other Treatment (Injection, manipulation, etc.)
Manipulative therapy is continued through recovery but usually at a lesser frequency. By the recovery phase, other physical therapy should be correcting the causes of the dysfunctions and thus decreasing the need for corrections.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The patient's maintenance therapy must stress consistent and aggressive flexibility programs. Continuous strengthening and conditioning is a must, with muscle balance and core strength exercises as the mainstay of the maintenance program. In addition, plyometric and neuromuscular facilitation activities are very important to maintain proper mechanics and body control in the athlete.
Medical Issues/Complications
Osteitis pubis can often recur. Stressing to the athlete the importance of a solid maintenance program and proper biomechanics is a must. If an athlete has multiple setbacks or recurrences, a full rheumatologic workup must be performed.
Other Treatment
Manipulation may be needed on an occasional basis to correct any somatic dysfunctions, which can lead to an exacerbation of the symptoms of osteitis pubis.
Medication
The aim of medical intervention for osteitis pubis is toward the joint goals of decreasing inflammation and controlling pain. The major concern with all the drugs that are used is their effect on the GI tract with long-term use, including the monitoring of renal function with long-term NSAID use. Long-term use of corticosteroids has a myriad of side effects, which are beyond the scope of this article.
Related eMedicine topics:
Anabolic Steroid Use and Abuse
Epidural Steroid Injections
Toxicity, Nonsteroidal Anti-inflammatory Agents
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
NSAIDs
NSAIDs are used to help reduce inflammation and pain. Multiple drugs are in this class, and every physician should be aware of the drugs in each subclass because some patients respond better to one subclass than another. A few NSAIDs are named below in order to not to belabor the wide variety of choices that are available.
Ketoprofen (Oruvail, Orudis)
Has good anti-inflammatory properties and exceptional analgesic properties. First-line medication because of daily dosing, which helps with compliance.
Oruvail [Andrx Pharmaceuticals, Inc, Ft. Lauderdale, Fla] is available in 100- and 150-mg doses for patients who do not tolerate higher doses.
Orudis [Wyeth Pharmaceuticals, Inc, Philadelphia, Pa ] has a dosing of 75 mg tid or 50 mg qid. All doses should be taken with food.
Adult
200 mg PO qd
Pediatric
Not recommended
Decreased renal excretion of potassium and sodium when used with hydrochlorothiazide; warfarin can cause an increased bleeding risk and should not be used with ketoprofen; probenecid reduces clearance, so combination therapy is not recommended; methotrexate levels are increased by NSAIDs; lithium levels are increased by NSAIDs
Documented hypersensitivity
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
Should not be used in patients with decreased renal function; patients with hepatic dysfunction can have worsening of hepatic enzyme levels.
Naproxen or naproxen sodium (Naprelan, Naprosyn, Aleve, Anaprox)
For relief of mild to moderate pain and inflammation. Available in many dosages and delivery systems. Fairly inexpensive and has a similar therapeutic profile to other NSAIDs. An oral suspension (125 mg/mL) is available.
Adult
Naproxen: 375 mg or 500 mg PO bid with food
Naproxen sodium: 275 mg PO qid or 550 mg PO bid with food
Pediatric
Oral suspension: 10 mg/kg/d divided bid
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; closely monitor PT duration (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently.
Documented hypersensitivity; can induce asthma, rhinitis, and nasal polyps
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
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 the drug.
Corticosteroids
Corticosteroids are some of the strongest anti-inflammatory agents available. The injectable preparations make it possible to deliver the drug directly to the affected joint in a concentrated dose, while greatly decreasing the systemic effects.
Prednisone (Deltasone, Orasone, Meticorten, Sterapred)
Used in cases when the inflammation is severe and the patient has contraindications to steroid injections. Use with great caution because of systemic effects.
Adult
20 mg PO bid for 5-7 d
Pediatric
Not recommended
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing the maintenance dose); monitor for hypokalemia with the coadministration of diuretics.
Documented hypersensitivity; contraindicated in the presence of viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or tubercular skin infections; GI disease
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
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use.
Betamethasone (Celestone, Soluspan)
DOC for intra-articular injections. Does not crystallize if used with paraben-free anesthetic preparations.
Adult
1 mL (6 mg/mL) mixed with 1 mL 2% lidocaine and 1 mL 0.5% bupivacaine
Pediatric
Not recommended
Effects decrease with the coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases the effect of salicylates and vaccines that are used for immunization
Documented hypersensitivity; systemic fungal infections
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
Precautions
Use in pregnancy only when the benefits outweigh the risks; increases risk of multiple complications, including severe infections; monitor for adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use; intra-articular injections can cause systemic effects
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
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Further Reading
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
