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Osteitis Pubis

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Other Names

  • Osteitis Pubis

Background

  • This page refers to 'osteitis pubis', a painful, chronic overuse syndrome affecting the Pubic Symphysis and surrounding soft tissue

History

Epidemiology

  • Incidence is estimated to be 0.5% - 8% among athletes[1]
  • In male soccer players, accounts for between 10% - 18% of injuries per year[2]

Pathophysiology

  • Overuse syndrome of the pubic symphysis, surrounding soft tissue structures
    • Characterized by pelvic pain, tenderness over the pubic symphysis
    • Common in sports that involve kicking, turning, twisting, cutting, pivoting, sprinting, rapid acceleration and deceleration or sudden directional changes[3]

Etiology

  • Not completely clear, still debated
  • Typically related to overuse or trauma
    • Most commonly occurs in athletes, but can occur in non-athletes with pelvic stress
    • Opposing shearing forces across the pubic symphysis is likely the main contributing factor
  • Muscle imbalance is the leading hypothesis
    • Between the abdominal and hip adductor muscles[4]
    • Abdominal muscles: work with paravertebral muscles to stabilize the torso
    • Adductors: stabilize the hip

Pathoanatomy

Associated Conditions


Risk Factors

  • Pregnancy
  • Childbirth
  • Gynecologic Surgery
  • Urologic Surgery
  • Pelvic Trauma
  • Rheumatological Disorders
  • Sports
    • Running
    • Swimming
    • Soccer
    • Tennis
    • Ruby
    • Australian Rules football

Differential Diagnosis


Clinical Features

  • History
    • Pain is most commonly insidious
    • Typically athletes will complain of anterior or medial grown pain
    • It may radiate to adductor musculature, lower abdominal muscles, perineal region, inguinal region or scrotum
    • Can be unilateral or bilateral
    • Worse with running, kicking, hip adduction, flexion or ecentric loads to abdominal muscles[5]
  • Physical Exam: Physical Exam Hip
    • Tenderness to palpation of the pubic symphysis
    • Pain with resisted hip adduction, abdominal flexion
    • Gait exam may include a limp or be wide-based
  • Special Tests

Evaluation

Radiographs

  • Standard Radiographs Pelvis is initial imaging modality of choice
  • Findings at pubic symphysis[6]
    • Bony sclerosis
    • Erosions
    • Widening or narrowing of the joint
    • Bony absorption or remodeling
    • Osteopenia
  • Flamingo view: AP view with patient standing on one leg
    • Can give evidence of pelvic instability
    • Positive findings: vertical subluxation greater than 2 mm widening of the symphysis greater than 7 mm[7]

MRI

  • Gold standard for osteitis pubis
  • Findings < 6 months symptoms
    • Hyper-intense signal on T2-weighted images within the symphysis, adjacent parasymphyseal structures
  • Findings in chronic cases
    • Subchondral sclerosis
    • Subchondral resorption with bony irregularity
    • Osteophytosis or pubic beaking
    • Subchondral marrow edema
  • Note can find marrow edema in asymptomatic patients, must correlate to clinic exam[8]

Ultrasound

  • May be used to evaluate for osteitis pubis among other causes of groin pain
  • Need reference/ citation

Bone Scintography

  • Positive findings[9]
    • Increased tracer uptake in the pubic symphysis region and parasymphyseal bone
  • Note: degree of uptake is poorly correlated with duration and severity of symptoms
  • Useful adjunct in which MRI or ultrasound or nondiagnostic

Classification

Rodriguez Classification

Stages Laterality Site of pain Characteristics
1 Unilateral, dominant Inguinal with radiation to adductors Pain alleviated after wam up, exacerbated after training
2 Bilateral Inguinal and adductors Pain exacerbation after training
3 Bilateral Groowin, adductor region, suprapubic, abdominal During training, kicking, sprinting, turning. Cannont achieve training goals, forced to withdraw
4 Generalized Generalized, radiation to lumbar region Walking, getting up, straining at stool, simple activities of daily living*
  • Note this classification system is not validated, only empiric[10]

Management

Prognosis

  • Typically considered a self-limiting condition that improves with rest
    • Can be challenging for athletes who require prolonged periods of rest
  • Most athletes return to pre-injury levels within 3 months (4 - 14 weeks)
    • In one study, successful long term follow up was reported for all patients (range 6 - 48 months)[11]
  • Approximately 5-10% of athletes will require surgical intervention (need citation)

Nonoperative

  • Relative rest
  • Limited activity
  • Ice
  • NSAIDS
  • Physical Therapy
  • Corticosteroid Injection
    • Overall, evidence is weak and not enough evidence to recommend for or against
    • Some relief at short term follow up, high rate of non responders[13]
  • Dextrose Prolotherapy
    • A single arm study found used dextrose prolotherapy in athletes who had failed other conservative measures[14]
    • They found improvement in pain with the majority returning to sport at an average of 3 months

Operative

  • Indications
    • Failure of conservative management of at least 3 months
  • Technique
    • Open or endoscopic curettage of the symphysis pubis
    • Arthrodesis of the symphysis with or without bone graft
    • Wedge resection

Rehab and Return to Play

Rehabilitation

  • Goals
    • Stretching
    • Pelvic muscular strengthening program
  • Progress through protocol stages until able to perform exercises pain free
    • And have achieved adequate range of motion, core stability

Proposed Protocol

  • Stage 1 (need citation)
    • Focus on pain control, improve lumbo-levic stability
    • Gentle prolonged stretching, except for the adductors and ischiopubic muscles
    • Cardiovascular exercise: cycling
  • Stage 2
    • Introduce light resistance training
    • Swiss balls and other aids are indicated for performing resistance and strengthening exercises of the pelvis, abdominal and gluteal muscles.
    • Abdominal core isometrics targeting the transversus abdominis, abdominal crunches, gluteal bridges with and without resistance bands
    • Swiss ball exercises for abdominal core, manual hip strengthening and resistance hip strengthening with band are indicated
  • Stage 3
    • Eccentric hip exercises, side stepping with bands, lunge and squat exercises and progressive sport-specific training.
    • Running is gradually increased, and changes of pace and direction are introduced.
    • Athletes start training on the field, performing exercises mimicking their sport
  • Stage 4
    • Kicking is allowed only at the end of this stage.
    • Eccentric abdominal wall strengthening exercises are started

Proposed Program by McAleer

  • Nine-point program From Mcaleer et al emphasized[15]
    • Pain control
    • Tone reduction of over-active structures
    • Improved range of motion at hips, pelvis and thorax
    • Adductor strength
    • Functional movement assessment
    • Core stability
    • Lumbo-pelvic control
    • Gym-based strengthening
    • Field-based conditioning/rehabilitation
  • All players returned to training without symptoms with 60 days and to play within 72 days
    • During follow up ranging from 16 to 33 months, there was no recurrence of symptoms

Return to Play

  • Needs to be updated

Complications

  • Chronic pain
  • Inability to return to sport

See Also


References

  1. Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports. 1999;9(2):98–103.
  2. Maffulli N, Giai Via A, Oliva F. Groin Pain. In: Volpi P, editor. Football Traumatology: New Trends. Cham: Springer International Publishing; 2015:303–315.
  3. Verrall GM, Hamilton IA, Slavotinek JP, et al. Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. J Sci Med Sport. 2005;8(1):77–84.
  4. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics. 2008;28(5):1415–1438.
  5. Braun P, Jensen S. Hip pain – a focus on the sporting population. Aust Fam Physician. 2007;36(6):410–413.
  6. Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. 1974;4(5938):211–214.
  7. Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. Am J Sports Med. 2000;28(3):350–355.
  8. Lovell G, Galloway H, Hopkins W, Harvey A. Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sport Med. 2006;16(2):117–122.
  9. Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med. 2001;35(1):28–33.
  10. Rodriguez C, Miguel A, Lima H, Heinrichs K. Osteitis Pubis Syndrome in the Professional Soccer Athlete: A Case Report. J Athl Train. 2001;36(4):437–440.
  11. Cheatham S, Kolber MJ, Shimamura KK. The effectiveness of nonoperative rehabilitation programs for athletes diagnosed with osteitis pubis. J Sport Rehabil. 2015;25(4):399–403.
  12. Schöberl M, Prantl L, Loose O, et al. Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study. Knee Surg Sports Traumatol Arthrosc. 2017;25(6):1958–1966.
  13. Choi H, McCartney M, Best TM. Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review. Br J Sports Med. 2011;45(1):57–64.
  14. Topol GA, Reeves KD. Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil. 2008;87(11):890–902.
  15. McAleer S, Lippie E, Norman D, Riepenhof H. Management of osteitis pubis/pubic bone stress in professional soccer players using a nonoperative rehabilitation protocol with clinical and functional progression criteria. J Orthop Sports Phys Ther. 2017;47(9):683–690.
Created by:
John Kiel on 5 July 2019 08:32:19
Authors:
Last edited:
5 October 2022 13:05:08
Categories:
Lower Extremity | Groin | Hip | Thigh | Overuse