History
The presenting symptoms of osteitis pubis can be almost any complaint about the groin or lower abdomen. [18, 9, 11, 14, 20, 1, 21, 22]
Pain generally is localized over the symphysis and may radiate to the groin, scrotum, [2] perineum, medial thigh, hip, or abdomen. Athletes may present with adductor pain or lower abdominal pain that then localizes to the pubic area. Often, this is unilateral and has been present for a few days to weeks. Pain can be of abrupt or insidious onset. It is exacerbated by activities such as running, pivoting on 1 leg, kicking, or pushing off to change direction, as well as by lying on the side. 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. He or she may report weakness and difficulty ambulating.
Particular caution is required if the athlete complains of fever, chills, or rigors in conjunction with the pubic pain. Although osteomyelitis is rare in athletes who have not undergone pelvic surgery, it must be ruled out in these patients. [4]
Physical Examination
Physical findings for osteitis pubis can vary greatly. [1] It is important always to consider the sport involved, as well as the chronicity of the conditions.
Early in the disease, as noted (see above), the athlete may complain of groin or testicular pain, which may be aggravated by adduction of the leg or running. Symptoms are often more unilateral at this stage. Patients may also complain of lower abdominal pain, and the area over the superior pubic ramus may be tender to palpation. When sacral innominate dysfunction is a cause, the athlete may have pain over one or both sacroiliac (SI) joints, often in conjunction with 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 complaint is also reported by runners who habitually run in the same direction and who functionally have one leg that is shorter than the other as a consequence of the camber of the running surface.
A single-leg hop test can reproduce the patient’s symptoms. However, the most specific test for osteitis pubis is a direct-pressure spring test aimed at eliciting tenderness over the pubic symphysis. The pubic spring test is fairly specific and is very simple to perform, as follows:
-
Palpate the athlete’s pubic bone directly over the pubic symphysis; tenderness to touch is often noted at that point
-
Slide your fingertips a few centimeters laterally to each side, and apply direct pressure on the pubic rami; with this pressure, the patient feels pain in the symphysis
-
To see if one side or the other produces more pain or lateral pain, apply ipsilateral pressure; if the pain is not reproduced over the pubic symphysis, other diagnoses must be entertained (eg, stress fracture or 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.
All athletes with groin pain should be check for inguinal hernias. Patients with sports-related hernias may report having had multiple adductor strains that never completely resolved and experiencing very deep pain upon palpation. During the hernia examination, an enlarged external inguinal ring is typically noted. Tenderness is observed when the posterior wall of the canal is palpated. Coughing or performing the Valsalva maneuver exacerbates the pain.
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.
In affected female athletes, a gynecologic examination should be performed if other symptoms raise the suspicion of pelvic inflammatory disease (PID). In males, a rectal examination should be performed to rule out prostatitis if the symptoms warrant.
Complications
Complications of osteitis pubis are minimal and few are reported. The major complication is a muscle-tendon injury of the adductor muscles due to muscle tightness. This complication is often prevented with correction of the biomechanical errors that caused the condition and flexibility training. A major complication of a misdiagnosed osteomyelitis is erosion of bone, which may take a very long time to remodel. Femoral artery involvement may occur but is rare.
-
Radiograph in 19-year-old athlete who presented with 3-week history of groin pull that was not resolving. On clinical examination, pubic spring test reproduced patient's pain, and radiograph was obtained. This image shows classic sclerosis and lysis findings of osteitis pubis around pubic symphysis, with widening of symphysis.
-
Magnetic resonance image (MRI) from 20-year-old National Hockey League (NHL) player who presented with complaint of pain in testicles, which was worse with skating and with performing off-ice plyometric conditioning. MRI of pelvis combined with history and physical examination indicated diagnosis of osteitis pubis.
-
Pelvis, frontal view.
