- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Osteitis Pubis
- This page refers to 'osteitis pubis', a painful, chronic overuse syndrome affecting the Pubic Symphysis and surrounding soft tissue
- Incidence is estimated to be 0.5% - 8% among athletes
- In male soccer players, accounts for between 10% - 18% of injuries per year
- 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
- 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
- Abdominal muscles: work with paravertebral muscles to stabilize the torso
- Adductors: stabilize the hip
- Pubic Symphysis
- Non-synovial joint stabilizes anterior pelvic ring
- Assists with transfer of weight from thorax to lower extremities
- Abdominal muscle attachments
- Hip muscle attachments
- Pelvic floor muscles attachments
- Avascular necrosis of the pubic symphysis
- Osteochondritis dissecans at the symphysis
- Pelvic Stress Fracture
- Gynecologic Surgery
- Urologic Surgery
- Pelvic Trauma
- Rheumatological Disorders
- Australian Rules football
- Muscle And Tendon
- Hip Etiology
- Pediatric Considerations
- Genitourinary & Reproductive
- Inflammatory Bowel Disease
- 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
- 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
- Standard Radiographs Pelvis is initial imaging modality of choice
- Findings at pubic symphysis
- Bony sclerosis
- Widening or narrowing of the joint
- Bony absorption or remodeling
- 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
- 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
- May be used to evaluate for osteitis pubis among other causes of groin pain
- Need reference/ citation
- Positive findings
- 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
|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
- 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)
- Approximately 5-10% of athletes will require surgical intervention (need citation)
- Relative rest
- Limited activity
- 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
- Dextrose Prolotherapy
- A single arm study found used dextrose prolotherapy in athletes who had failed other conservative measures
- They found improvement in pain with the majority returning to sport at an average of 3 months
- Failure of conservative management of at least 3 months
- Open or endoscopic curettage of the symphysis pubis
- Arthrodesis of the symphysis with or without bone graft
- Wedge resection
Rehab and Return to Play
- Pelvic muscular strengthening program
- Progress through protocol stages until able to perform exercises pain free
- And have achieved adequate range of motion, core stability
- 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
- 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
- Chronic pain
- Inability to return to sport
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
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- Maffulli N, Giai Via A, Oliva F. Groin Pain. In: Volpi P, editor. Football Traumatology: New Trends. Cham: Springer International Publishing; 2015:303–315.
- 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.
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- 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.
- 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.
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- 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.
- 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.