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Osteitis Pubis

From WikiSM

Other Names

  • Osteitis Pubis
  • Athletic Osteitis Pubis
  • Pubic Symphysis Stress Injury
  • Pubic Symphysis Stress Reaction
  • Pubic Symphysis Inflammation
  • Symphysis Pubis Osteitis
  • Pubic Symphysitis
  • Noninfectious Pubic Symphysitis
  • Athletic Osteitis Pubis
  • Inflammatory Pubic Symphysis Condition

Background

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

History

  • First documented as a postoperative complication by Beer in 1924[1]
  • Renamed athletic osteitis pubis by Spinelly in 1932[2]

Epidemiology

  • Incidence is estimated to be 0.5% - 8% among athletes[3]
  • In male soccer players, accounts for between 10% - 18% of injuries per year[4]

Introduction

Pubic Symphysis[5]
One proposed injury mechanism for osteitis pubis[6]

General

  • Overuse syndrome of the pubic symphysis, surrounding soft tissue structures
  • Generally considered an idiopathic inflammatory condition seen in athletes
  • Common in sports that involve kicking, turning, twisting, cutting, pivoting, sprinting, rapid acceleration and deceleration or sudden directional changes[7]
  • Characterized by pelvic pain, tenderness over the pubic symphysis
  • Can be diagnostically challenging due to overlapping symptoms with multiple other conditions
  • A self limited condition which improves with activity modification and targeted treatment

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[8]
    • Abdominal muscles: work with paravertebral muscles to stabilize the torso
    • Adductors: stabilize the hip
  • Increased compensatory motion of the pubic symphysis theory[9]
    • Pubic symphysis increases motion to compensate for the less movement of another part of the chain movement
    • For example, patients with femoroacetabular syndrome

Anatomy of the Pubic Symphysis

  • Nonsynovial amphiarthrodial joint connecting the left and right superior rami of the pelvis.
  • Anterior portion of the joint is 3–5 mm wider than the posterior portion
  • Joint connected by fibrocartilage, surrounded by ligaments
  • Superior and inferior ligaments provide most of the joint’s stability
  • Normal adults: approximately 2 mm of translation, 1 degree of rotation
  • Numerus muscle attachments
  • Movement: very little, max 2 mm shift, 1° rotation[10]

Associated Conditions

Histology

  • Samples obtained from surgery demonstrate[12]
    • Woven immature bone with neovascularization
    • Osteoblasts
    • Fibroblasts
    • Degenerative cartilage free of inflammatory cells
    • Signs of osteonecrosis

Risk Factors

General

Sports

  • Running
  • Swimming
  • Soccer
  • Tennis
  • Ruby
  • Australian Rules football

Differential Diagnosis

Differential Diagnosis Osteitis Pubis

Differential Diagnosis Groin Pain

Clinical Features

Demonstration of Resisted Bilateral Adductor Test[13]

History

  • Pain is most commonly insidious
  • Typically athletes will complain of anterior or medial groin pain
  • 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[14]

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

Pelvis XR. Osteitis pubis with subchondral erosive change, joint irregularity and sclerosis of the pubic symphysis. [15]
Pelvis CT.Subchondral erosive changes along symphysis pubis articular surfaces with irregular articular surfaces, subchondral sclerosis and cystic changes.[16]
Pelvis MRI.Bone marrow edema around the symphysis pubis congruent with osteitis pubis. High signal intensity in the adductor attachments on the right side of the symphysis are in keeping with the symptoms of adductor tendinopathy. [17]

Radiographs

  • Standard Radiographs Pelvis
    • Initial imaging modality of choice
    • Often normal early on in the disease process
  • Findings at pubic symphysis[18]
    • 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[19]

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[20]

Ultrasound

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

Bone Scintography

  • Positive findings[21]
    • 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

Diagnostic Corticosteroid Injection

  • Can be used in cases where other modalities are equivocal and diagnosis is uncertain

Classification

Rodriguez Classification

  • Stage 1
    • Laterality: Unilateral, dominant
    • Site of pain: Inguinal with radiation to adductors
    • Characteristics: Pain alleviated after wam up, exacerbated after training
  • Stage 2
    • Laterality: Bilateral
    • Site of pain: Inguinal and adductors
    • Characteristics: Pain exacerbation after training
  • Stage 3
    • Laterality: Bilateral
    • Site of pain: Groin, adductor region, suprapubic, abdominal
    • Characteristics: During training, kicking, sprinting, turning. Cannont achieve training goals, forced to withdraw
  • Stage 4
    • Laterality: Generalized
    • Site of pain: Generalized, radiation to lumbar region
    • Characteristics: Walking, getting up, straining at stool, simple activities of daily living
  • Note this classification system is not validated, only empiric[22]

Krüger’s Classification (based on MRI and clinical findings)[23]

  • Stage 1
    • Bone marrow edema at one side or bilateral at the pubic bone
    • Inguinal/adductor muscles
    • Symptoms lasting up to three months
  • Stage 2
    • Edema at soft tissue around the symphyseal joint or at the muscle junction
    • Inguinal/adductor muscles
    • Symptoms lasting up to six months
  • Stage 3
    • Edema/fluid in the muscles located around the symphyseal cleft joint with or without secondary cleft sign
    • Complex/pelvic muscle complex
    • Symptoms lasting up to 12 months

Gaudino’s Classification (based on information of both severity and prognosis)[24]

  • Stage I
    • MRI: Bone marrow edema + highest mean normalized STIR SI < 3 +/- periarticular edema
    • Recovery: 100%
  • Stage II
    • MRI: Bone marrow edema + highest mean normalized STIR SI < 3 periarticular edema + edema in the muscles around the symphyseal joint
    • Recovery: 50%
  • Stage III
    • MRI: Bone marrow edema + highest mean normalized STIR SI ≥ 3 +/- one of the following: periarticular edema or edema in the muscles around the symphyseal joint
    • Recovery: 30%
  • Stage IV
    • MRI: Bone marrow edema + highest mean normalized STIR SI ≥ 3 + periarticular edema + edema in the muscles around the symphyseal joint
    • Recovery: 20%

Management

Nonoperative

  • Relative rest
  • Limited activity
  • Ice
  • NSAIDS
  • Physical Therapy
  • Pubic Symphysis 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[26]
  • Dextrose Prolotherapy
    • A single arm study found used dextrose prolotherapy in athletes who had failed other conservative measures[27]
    • They found improvement in pain with the majority returning to sport at an average of 3 months

Operative

  • Indications
    • Surgical management is required in about 5-10% of patients
    • Failure of conservative management of at least 3 months, often 6 or more
  • 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[28]

  • 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

Rehab Exercise Programs PDF

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

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)[29]
  • Approximately 5-10% of athletes will require surgical intervention (need citation)

Complications

  • Chronic pain
  • Inability to return to sport

See Also

Internal

External

References

  1. ↑ Beer E: Periostitis of the symphysis and descending rami ofthe pubis following suprapubic operations. lnt J Med Surg1924;37(5):224-225
  2. ↑ Spinelli A. Nuova malattia sportive: la pubialgia degli schernitori. Ortopedia E Traumatologia Dell Apparato Motore. 1932;4:111–27.
  3. ↑ 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.
  4. ↑ Maffulli N, Giai Via A, Oliva F. Groin Pain. In: Volpi P, editor. Football Traumatology: New Trends. Cham: Springer International Publishing; 2015:303–315.
  5. ↑ Image courtesy of kenhub.com
  6. ↑ Image courtesy of orthobullets
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ Dirkx M, Vitale C: Osteitis pubis. StatPearls Publishing, Treasure Island, FL; 2021.
  10. ↑ Becker I, Woodley SJ, Stringer MD. The adult human pubic symphysis: a systematic review. J. Anat. 2010;217 (5): 475-87.
  11. ↑ Saito M, Utsunomiya H, Hatakeyama A, et al.: Hip arthroscopic management can improve osteitis pubis and bone marrow edema in competitive soccer players with femoroacetabular impingement. Am J Sports Med. 2019, 47:408-19. 10.1177/0363546518819099
  12. ↑ CO MB, MI WC: Osteitis pubis: observations based on a study of 45 patients. JAMA. 1961, 178:898-905. 10.1001/jama.1961.03040480028006
  13. ↑ Safran, M. "Evaluation of the painful hip in tennis players." Aspetar Sports Med J 3 (2014): 516-525.
  14. ↑ Braun P, Jensen S. Hip pain – a focus on the sporting population. Aust Fam Physician. 2007;36(6):410–413.
  15. ↑ Case courtesy of Laughlin Dawes, Radiopaedia.org, rID: 36028
  16. ↑ Case courtesy of Mostafa Elfeky, Radiopaedia.org, rID: 52818
  17. ↑ Case courtesy of Stan Buckens, Radiopaedia.org, rID: 39212
  18. ↑ Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. 1974;4(5938):211–214.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ Krüger J: Osteitis pubis −a proposition of stageing based on MRI findings [Article in German]. Sport Ortho Trauma. 2012, 38:182-8.
  24. ↑ Gaudino F, Spira D, Bangert Y, et al.: Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome. Eur J Radiol. 2017, 94:46-52. 10.1016/j.ejrad.2017.07.009
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ 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.
  29. ↑ 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.
Created by:
John Kiel on 5 July 2019 08:32:19
Authors:
Last edited:
22 February 2026 23:01:44
Categories:
Lower Extremity | Groin | Hip | Thigh | Overuse
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