Osteitis Pubis 

Updated: Jun 01, 2018
Author: Henry T Goitz, MD; Chief Editor: Craig C Young, MD 

Overview

Practice Essentials

Osteitis pubis is an inflammation of the pubic symphysis and surrounding muscle insertions. First described in patients who underwent suprapubic surgery, it remains a well-known complication of invasive procedures about the pelvis. It may also occur as an inflammatory process in athletes. See the image below.

Radiograph in 19-year-old athlete who presented wi 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.

Signs and symptoms

The presenting symptoms of osteitis pubis can be almost any complaint about the groin or lower abdomen. Common complaints include the following:

  • Pain localized over the symphysis and radiating outward

  • Adductor pain or lower abdominal pain that then localizes to the pubic area (often unilaterally)

  • Pain 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 occurring with walking, climbing stairs, coughing, or sneezing

  • A sensation of clicking or popping upon rising from a seated position, turning over in bed, or walking on uneven ground

  • Weakness and difficulty ambulating

  • Fever, chills, or rigors along with pubic pain (osteomyelitis must be ruled out)

Physical findings for osteitis pubis can vary greatly.[1] Such findings may include the following:

  • Tenderness to palpation in the area over the superior pubic ramus

  • When sacral innominate dysfunction is a cause, pain over one or both sacroiliac (SI) joints, often in conjunction with piriformis spasm and resultant sciatic-type pain

  • With discrepancies of leg length (anatomic or functional), hip pain in the longer limb

The most specific test for osteitis pubis is a direct-pressure spring test, performed 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

The examination may also include the following as appropriate:

  • Checking for inguinal hernia

  • Assessment of muscle weakness, especially in hip adductors or flexors

  • Gait assessment

  • Gynecologic examination, if other symptoms suggest possible pelvic inflammatory disease (PID)

  • Rectal examination, if symptoms suggest possible prostatitis

Diagnosis

Laboratory studies are not required to make the diagnosis, but some may be helpful in eliminating other causes, including the following:

  • Complete blood count (CBC)

  • Erythrocyte sedimentation rate (ESR)

  • Urinalysis

  • If the patient is febrile, a blood culture

Imaging studies that may be helpful include the following:

  • Plain radiography

  • Bone scanning (technetium-99m)

  • Single-photon emission computed tomography (SPECT)

  • Magnetic resonance imaging (MRI)

  • Computed tomography (CT)

Other studies that may be considered are as follows:

  • Aspiration of the pubic symphysis for culture, when the patient is febrile but blood cultures are negative

  • Herniography, when a sports hernia is a strong consideration

Treatment

Rest and time are the primary healing mechanisms. Physical therapy (PT) may be useful during the early stage and has the following goals:

  • To help alleviate pain

  • To start correcting the mechanical problems that precipitated the injury

Elements of therapy may include the following:

  • Heat or ice may provide symptomatic relief

  • Progressive ambulation with the aid of an assistive device and possible orthoses

  • Avoidance of any exercise that may place stress on the pelvic ring

  • Dynamic stabilization techniques

  • Manipulation

  • Ultrasound and electrical stimulation

Once the patient is free of pain, strengthening therapy can begin. Further PT measures may include the following:

  • Exercises for the hip flexors, hip adductors, lumbar stabilizers, and abdominal muscles

  • Hamstring and quadriceps exercises

  • Stretching (daily or more often)

  • Aquatic conditioning (except frog kicking)

  • Stair-stepping machines (as tolerated)

  • Sports-specific activities, with offending motions added last

  • Manipulation

Pharmacologic therapy may include the following:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Steroids (oral or injected)

  • Prolotherapy with dextrose and lidocaine

Surgery is rarely warranted for osteitis pubis and is generally reserved for failure of conservative management. Surgical approaches, if indicated, include the following:

  • Curettage

  • Arthroscopic curettage combined with adductor debridement and reattachment

  • Arthrodesis

  • Wedge resection

  • Wide resection

Background

Osteitis pubis is an inflammation of the pubic symphysis and surrounding muscle insertions.[2, 3, 4, 5, 6] It 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.[7]

Although the exact etiology of osteitis pubis is unknown, it is most likely caused by repetitive microtrauma or shearing forces to the pubic symphysis. 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.[3]

Multiple sports-related occurrences of this condition have been reported. For instance, in a study of 502 Australian Football League (AFL) players, 161 of whom had sustained a hip or groin injury during their career with the league, Gabbe et al found that players who had had such an groin injury during their time in elite junior football had a nearly 4 times greater chance of missing games because of osteitis pubis than other players did (as well as a 9.59 times greater chance of missing games because of a hip chondral or labral lesion).[8]

Anatomy

The pelvic girdle anatomy is quite complex (see image below). The pelvis is essentially a ring, and any change in the anatomy or in the forces applied to one area of the ring may result in increased stress and pain at another. 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.

Pelvis, frontal view. Pelvis, frontal view.

In addition, it is important to understand the functions of the muscles that attach to the pubic rami. The hip adductors (ie, the gracilis, adductor longus, adductor brevis, and adductor magnus) originate at the inferior pubic ramus.[9] The pectineus and rectus abdominis muscles, along with the inguinal ligament, insert superiorly. The muscles of the peroneal floor insert posteriorly.

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 (see the image below).[10]

Radiograph in 19-year-old athlete who presented wi 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.

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[2, 4, 5, 9, 11, 12] :

  • Soccer

  • Sprinting

  • Ice hockey

  • American football

Soccer involves a great deal of running and rapid change of direction.[13, 14, 15] 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. Often, the athlete is not well balanced when planting the foot to kick, and this imbalance places a great deal of strain on the muscles that stabilizing him or her for the kick. This strain translates to abnormal forces across the pubic symphysis.

Sprinting can lead not only to repetitive microtrauma to the pelvis but also to muscle pulls, which are common consequences of the rapid acceleration inherent in sprinting. This condition, coupled with multiple repetitions, can lead to cumulative stress on the pubic symphysis.

Ice hockey 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 changes in direction that are required in ice hockey.

American football also has multiple factors conducive to a high injury rate.[3] The first is the amount of sprinting performed. The second is the frequent violent collisions that often lead to minor injuries, which many athletes may play through. Certain positions (eg, defensive secondary) also demand a great deal of backpedaling, with rapid abduction of one hip to allow the defender to turn and run with a receiver. This motion can lead to hamstring or adductor strains, which change muscle balance and forces applied across the pubic symphysis.

Etiology

The causes of osteitis pubis are multifactorial. This condition is usually caused by an abnormal shearing force across the pubic symphysis, which, as noted (see above), 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.

Conditions associated with osteitis pubis include the following:

  • Pregnancy and childbirth

  • Gynecologic surgery

  • Urologic surgery

  • Athletic activities (eg, running, football, soccer, ice hockey, and tennis)[16]

  • Major trauma

  • Repeated minor trauma

  • Rheumatologic disorders

In the case of the athlete with a fever and osteomyelitis, Staphylococcus aureus is the most commonly cultured pathogen. Pseudomonas aeruginosa and Escherichia coli have also been reported.

Epidemiology

United States statistics

The exact frequency for osteitis pubis in the United States is difficult to estimate. However, in a study performed by Lloyd-Smith et al in Canada, this condition accounted for 6.3% of the 222 overuse injuries that were studied.[17] In smaller studies, the incidence of osteitis pubis appears to be as much as 5 times more prevalent in males than in females.

International statistics

International data are limited. However, there is some reason to think that osteitis pubis may be more common in Europe, because of the popularity of kicking sports such as soccer. A study by Westlin reported that 80% of the athletes who presented to the Sports Medicine Clinic in Malmö, Sweden, had this condition.[18]

Age- and sex-related demographics

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.

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 relative sex-related incidences may change.

Prognosis

With definitive diagnosis and treatment, the prognosis for osteitis pubis is excellent. Although rare instances of mortality from femoral artery involvement have been reported in the obstetric literature, morbidity is more commonly observed secondary to pain and difficulty with ambulation.

In most cases, osteitis pubis resolves with rest. 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. More aggressive therapy is often needed when an athlete refuses to modify activities or rest.[19] With aggressive physical therapy and judicious use of medications, the athlete often returns to the previous level of activity.

Patient Education

Osteitis pubis is a frustrating condition both for the patient and for the physician; therefore, patient education cannot be overemphasized. Rest is advised. Any activity or exercise that may place stress on the pelvic ring should be avoided. Athletes are advised to refrain from sporting activities for 3-6 months and then to return on a gradual supervised basis.

The most important information to present to athletes and coaches is the importance of incorporating flexibility training into the athlete’s daily routine. In addition, athletes, coaches, and athletic trainers must understand that early identification and treatment of osteitis pubis are crucial.[1] Any groin pull that does not resolve or show marked improvement in 5-7 days should be referred to the team physician. The entire sports medicine team must not only maintain a high index of suspicion but also be thorough in evaluating groin pain.

For patient education resources, see the Men’s Health Center and the Women’s Health Center.

 

Presentation

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.

 

DDx

Diagnostic Considerations

The only real diagnostic pitfall in the management of osteitis pubis is missing a medical condition during the evaluation. Genitourinary diagnoses are the most likely to be missed. Obtaining a thorough patient history and performing a physical examination should help the physician rule out other conditions (see Presentation), along with ordering baseline laboratory and imaging studies (see Workup).

In the adolescent and young adult population, it is important to rule out gynecologic complications. Tubal pregnancies and pelvic inflammatory disease (PID) can often present as groin or suprapubic pain, though patients with these conditions usually appear acutely ill, whereas patients with osteitis pubis do not. In rare situations, prostatitis in male athletes and prostate cancer in older males can present with pubic pain. These conditions must be excluded in the initial clinical evaluation.

In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Abdominal muscle pull

  • Acetabular labral tears

  • Bursitis

  • Chronic symphyseal injury

  • Groin strain

  • Inguinal hernia

  • Ischial intersection syndrome

  • Muscle contusions

  • Pelvic and hip fracture

  • Pubic stress fracture

  • Reiter syndrome (rare)

  • Snapping hip syndrome

  • Sports hernia

  • Tendon injuries

Differentials

Adductor Strain

Ankylosing spondylitis (rare)

Femoral neck fracture

Osteomyelitis

Pelvic inflammatory disease

Prostatitis

Sacroiliac Joint Injury

Urinary tract infection, Female

Urinary tract infection, Male

 

Workup

Laboratory Studies

Laboratory studies are not required to make the diagnosis, but some may be helpful in eliminating other causes. A complete blood count (CBC) should be obtained to rule out systemic infection. Leukocyte counts should be normal; if not, infectious causes should be sought. The 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 will be negative, unless the patient presents as clinically septic. Patients with osteomyelitis will most likely have blood cultures that are positive for S aureus.

Plain Radiography

Radiographs are often negative early in osteitis pubis. After a few (typically approximately 4) weeks, some widening of the pubic symphysis may be seen on anteroposterior (AP) films (see the image below). As osteitis pubis progresses, sclerosis and osteolysis can be seen. In the case of osteomyelitis, bone erosions can be seen on plain films.

Radiograph in 19-year-old athlete who presented wi 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.

If pelvic inequity is suspected as a cause, flamingo views can expose a pubic instability. 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. The sacroiliac joints also should be evaluated; since laxity of one or both may contribute to pubis symphysis instability.

Bone Scanning, SPECT, MRI, and CT

Bone scanning (technetium-99m [99m Tc]) or single-photon emission computed tomography (SPECT) may be negative but often yields positive results 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 are conclusively positive in cases of osteitis pubis. However, the degree of positivity or unilateral findings does not correlate well with the severity of the symptoms or the chronicity of the disease.[2]

As magnetic resonance imaging (MRI) becomes more widely used and the technology more sophisticated, its utility increases (see the image below).[13, 23, 24, 25, 26] MRI is especially useful when fat suppression views are obtained, in that it helps the physician distinguish among muscle, tendon, periosteal, and bony disruption. Often, inflammation of the fibrocartilaginous disk, bone marrow edema, and sclerosis at the pubic margins can be appreciated,[27, 23] though bone edema is also seen in asymptomatic individuals.[28]

Magnetic resonance image (MRI) from 20-year-old Na 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.

Computed tomography (CT) is also used for evaluation of the pubis symphysis and the posterior pelvic ring.

Other Studies

In cases where the patient is febrile but the blood cultures are negative, the pubic symphysis should be aspirated for culture. This is most commonly done with the guidance of ultrasonography or CT scanning.

 

Treatment

Approach Considerations

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, a cane or crutches) and possible orthoses (eg, a lumbar/sacral corset or a sacroiliac belt) to unload the pelvis for pain relief and to maintain correct anatomic alignment may be necessary.[29]

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. >Manipulation is performed in some instances to correct anterior translation of the symphysis.

Pharmacologic therapy may include nonsteroidal anti-inflammatory drugs (NSAIDs), steroids (oral or injected), or, possibly, prolotherapy with dextrose and lidocaine. Surgery is rarely warranted for osteitis pubis and should not be a consideration during the acute phase.

During the acute phase, possible alternative medical explanations for the occurrence of pubic pain must be considered. A blood workup and a urinalysis should be performed to rule out infectious sources. Prostatitis and pelvic inflammatory disease (PID) must be treated, if present. Osteomyelitis must be treated for 4 or more weeks before aggressive therapy can begin.

Physical and Occupational Therapy

The so-called acute phase of rehabilitation for osteitis pubis is sometimes a misnomer. During this acute phase—that is, when the patient presents to the physician—the symptoms may actually be either acute or chronic. Nevertheless, the patient should always be treated as if the onset of symptoms is acute. The goals at this point are to help alleviate the patient’s pain and to identify and correct the mechanical problems that may have precipitated the symptoms.

Athletes are initially pulled from all sporting activities.[15] They should be evaluated for gait abnormalities, leg-length discrepancies, and somatic dysfunctions, especially of the sacroiliac (SI) joints. The physical therapist can be very active in all these evaluations.

Physical therapy can be engaged at the outset of treatment and is directed 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.

Once the patient is free of pain, strengthening therapy can begin by focusing on exercises for the hip flexors, hip adductors, lumbar stabilizers, and abdominal muscles. Hamstring and quadriceps exercises are also performed, with squatting and leg presses added last (because of the increased load used in these exercises). Stretching is performed at least daily, with flexibility as the main focus of therapy.

Aquatic conditioning can also be initiated, with the exception of frog kicking, which uses the adductors extensively. Many patients can tolerate stair-stepping machines at this time. Usually, cycling is still not tolerated, because of the pressure that is caused by the saddle, though some patients can tolerate a recumbent cycle. Sports-specific activities are added late in this phase, with offending motions added last.

Manipulation may be employed on an occasional basis in this phase and may be very helpful. If any SI dysfunction or pubic shearing occurs, manipulative therapy may alleviate pain by decreasing 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.

Maintenance therapy must stress consistent and aggressive flexibility programs. Continuous strengthening and conditioning are essential, with muscle balance and core strength exercises as the mainstays of the maintenance program. In addition, plyometric and neuromuscular facilitation activities are vital for maintaining proper mechanics and body control in the athlete.

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.

A double-blinded controlled study by Schöberl et al that included 44 amateur European football players with groin pain and aseptic osteitis pubis reported earlier pain relief and return to play in the group that received shock wave therapy.[30]

Pharmacologic Therapy

During the acute phase, NSAIDs are administered to treat pain and inflammation. In rare cases—usually when the symptoms have been present for more than 4-6 weeks—oral corticosteroids can be considered. The author’s preference is a pulse dose of prednisone 40 mg/day of for 5 days, or sometimes a longer tapering dose (see Medication, below).

Corticosteroid injection is often necessary to speed recovery in athletes with osteitis pubis, but this therapy should be used with caution.[19, 31] Osteitis pubis often resolves without the need for steroid injection.[1] If the athlete can take the time to allow the condition to resolve without an injection, this therapy may not be warranted. The athlete, the coach, and other involved persons must be informed; rehabilitation can take up to 9.6 months.[2]

It is believed that early corticosteroid injection can be beneficial.[19] If injection is indicated, it 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 can be administered 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 anteroposterior (AP) direction. The needle is advanced approximately 1 in. until a pop is felt as it enters the space. The author typically uses a 1.5-in. 20-gauge needle with a 3-mL syringe filled with 1 mL of betamethasone injectable suspension (6 mg/mL), 1 mL of 2% lidocaine, and 1 mL of 0.5% bupivacaine. Paraben-free anesthetic is used so that the betamethasone does not precipitate out of the mixture.

After the injection, the patient remains away from activity for 1 week. Occasionally, a second injection, or even a third (rare), is required after intervals of 2-3 weeks.

In a study by Topol et al, athletes with chronic groin pain showed symptomatic improvement after prolotherapy,[32] which involved injecting a 1:1 mixture of 12.5% dextrose and 0.5% lidocaine into the patients’ pubic symphysis, adductor origins, and superior pubic ramus area. Although the study had limitations, the symptomatic improvement and long-term pain relief (mean, 2.8 treatments; average follow-up, 17.2 months) suggested that prolotherapy might be another possible treatment for osteitis pubis.

Tapering the dose of any NSAID can be attempted in an effort to prevent gastrointestinal (GI) and renal complications. Although such tapering often proves impossible, the idea that the lowest effective dosage should be given for the shortest duration possible is always a good rule of thumb.

Surgical Intervention

Surgery is rarely warranted for osteitis pubis and should not be a consideration during the acute phase. Surgical intervention is generally reserved for those in whom conservative management fails. When surgery is performed, various approaches are available, including curettage, arthrodesis, wedge resection, and wide resection.[29, 33]

A report by Radic and Annear suggested that curettage of the pubis symphysis is effective for athletes with osteitis pubis in whom nonoperative therapy has been unsuccessful.[34] The investigators found that 21 of the study’s 23 athletes were able to run without pain 1.5-6 months postoperatively, whereas 17 of them returned to training in 2.5-7 months and 16 resumed full activity in 2.5-12 months.

In a small case series of 7 patients with athletic osteitis pubis with concurrent femoroacetabular impingement, Matsuda et al saw encouraging early outcomes in pain visual analog scale (VAS) scores as well as Non-Arthritic Hip Score (NAHS) after treatment with endoscopic pubic symphysectomy.[35]

A small German study used a novel surgical technique of arthroscopic pubic symphysis curettage combined with adductor debridement and reattachment to treat competitive soccer players with degenerative osteitis pubis and concomitant adductor pathology in whom conservative treatment had failed.[36] All of the patients were able to resume full sports activity after an average of 14.4 weeks. One intraoperative bleeding episode occurred, necessitating revision surgery, but none of the patients developed pubic instability.

Wedge resection of the pubis symphysis can also be performed on patients in whom conservative management has failed; however, the natural progression of osteitis pubis is such that months, and in some cases years, may be required for improvement. Surgical intervention is associated with early improvement of symptoms but may lead to later posterior pelvic instability, and this subsequent instability may then necessitate a second surgical procedure for stabilization.

Activity

Ideally, return to play should occur only when the patient is pain-free with all activity; however, athletes often return to play when they feel minimal pain with the aggravating activity. The condition is usually self-limited and generally resolves in 6-12 months. Note, however, that although recurrence rates are as high as 25%, the athlete often experiences residual pain that does not require activity modification.[3] The importance of flexibility training must be stressed for the athlete to be able to continue full activity.

Prevention

Flexibility in athletes is the most important step toward prevention of osteitis pubis. Proper body mechanics must be stressed in athletes who participate in activities that yield a higher incidence of this condition. SI dysfunction in running and skating must be aggressively treated so that the pubic symphysis does not become the victim of poor pelvic mechanics. In addition, early recognition of symptoms can prevent chronic and more severe symptoms.

Consultations

Athletes with infectious comorbid conditions may need to be seen by a gynecologist, urologist, or infectious disease specialist. If poor foot mechanics are part of the cause of the condition, it is advisable to have the patient evaluated for orthotics by a podiatrist or certified physical therapist; the process of fabricating a custom orthotic often takes a few days to weeks. Since treatment can sometimes be lengthy, with slow progression, early involvement of a sports psychologist in rehabilitative therapy may be helpful. Athletes do better if they are mentally prepared for the task at hand.

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 mechanics that are activity specific. The athlete can also use this phase to become accustomed to any new orthotic or footwear that may be prescribed.

Long-Term Monitoring

The recommended duration of rest ranges from 2 weeks to 3 months. Athletes are advised to refrain from sporting activities for 3-6 months. A gradual program for return to sports should be discussed among the patient, the physical therapist, and the 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.

Osteitis pubis often recurs. 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.

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

Content.

 

 

Medication

Medication Summary

The goals of medical intervention for osteitis pubis are to decrease inflammation and to control pain. The major concern with all the drugs that are used is the effects they have on the gastrointestinal (GI) tract with long-term use. Long-term use of corticosteroids has myriad adverse effects, which are beyond the scope of this article, but should be recognized and considered.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice for treating osteitis pubis. Narcotics also are employed for pain control in some cases, usually in the obstetric or postoperative patient. Limited case reports suggest that antibiotics and heparin have also been successful.

Nonsteroidal Anti-inflammatory Drugs

Class Summary

NSAIDs are used to help reduce inflammation and relieve mild-to-moderate pain. Multiple drugs are in this class, and every physician should be aware of the drugs in each subclass; some patients respond better to one subclass than another. Ibuprofen is the drug of choice for initial therapy. Other options include, but are not limited to, ketoprofen and naproxen.

Although increased cost can be a negative factor, the incidence of costly and potentially fatal cases of GI bleeding is clearly lower with cyclooxygenase (COX)–2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeding will further define the populations that will find COX-2 inhibitors the most beneficial.

Ketoprofen

Ketoprofen has good anti-inflammatory properties and exceptional analgesic properties. It is a first-line medication because of its daily dosing, which helps with compliance. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.

Indomethacin (Indocin)

Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis. It is not always as easily tolerated by the GI system as other NSAIDs.

Naproxen or naproxen sodium (Naprelan, Naprosyn, Aleve, Anaprox)

Naproxen is used for relief of mild-to-moderate pain and inflammation; it inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis. Naproxen is available in many dosages and delivery systems. It is fairly inexpensive and has a therapeutic profile similar to those of other NSAIDs. An oral suspension (125 mg/mL) is available.

Ibuprofen (Advil, Motrin, NeoProfen)

Ibuprofen is the drug of choice for patients with mild-to-moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Celecoxib (Celebrex)

Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to the GI toxicity of NSAIDs. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. The lowest dose that is effective in a given patient should be given.

Corticosteroids

Class Summary

Corticosteroids are among 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 (Rayos)

Prednisone is used in cases where the inflammation is severe and steroid injections are contraindicated. Because of its systemic effects, it must be used with great caution.

Prednisolone (Millipred, Orapred, Orapred ODT, Prelone)

Corticosteroids act as potent inhibitors of inflammation. They may cause profound and varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in addition to their modification of the immune response of the body. Alternative corticosteroids may be used in equivalent dosage.

Betamethasone (Celestone, Celestone Soluspan)

Betamethasone is the author's drug of choice for intra-articular injections. It does not crystallize if used with paraben-free anesthetic preparations.