Osteitis Pubis Treatment & Management

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.

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]

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.

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.

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.

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.

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.

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.

Rehabilitation Program

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