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Osteitis Pubis
From WikiSM
Contents
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
- 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
Associated Conditions
- Avascular necrosis of the pubic symphysis
- Osteochondritis dissecans at the symphysis
- Pelvic Stress Fracture
Risk Factors
- Pregnancy
- Childbirth
- Gynecologic Surgery
- Urologic Surgery
- Pelvic Trauma
- Rheumatological Disorders
- Sports
- Running
- Swimming
- Soccer
- Tennis
- Ruby
- Australian Rules football
Differential Diagnosis
- Muscle And Tendon
- Adductor Tendonitis
- Adductor Strain
- Hip Flexor Tendonitis
- Snapping Hip Syndrome
- Rectus Femoris Strain
- Rectus Abdominus Strain
- Myositis Ossificans
- Sports Hernia
- Hip Etiology
- Acetabular Labrum Tear
- Femoral Acetabular Impingement
- Avulsion Fractures
- Avascular Necrosis of the Hip
- Acetabular Labrum Tear
- Ligamentum Teres Injury
- Osteochondritis Dissecans
- Pelvic Stress Fracture
- Neuropathies
- Ilioinguinal Nerve Injury
- Genitofemoral Nerve Injury
- Iliohypogastric Nerve Injury
- Obturator Nerve Injury
- Meralgia Paresthetica (Lateral Femoral Cutaneous Nerve)
- Spine
- Pelvis
- Athletica Pubalgia
- Osteitis Pubis
- Inguinal Hernia
- Femoral Hernia
- Sports Hernia
- Pediatric Considerations
- Genitourinary & Reproductive
- Ovarian or testicular torsion
- Nephrolithiasis
- Epididymo Orchitis
- Ovarian Cyst
- Pelvic Inflammatory Disease
- Urinary Tract Infection
- Endometriosis
- Prostatitis
- Gastrointestinal
- Appendicitis
- Diverticulitis
- Lymphadenitis
- Inflammatory Bowel Disease
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
- One study showed accelerated return to play when combined with Shock Wave Therapy[12]
- 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
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Braun P, Jensen S. Hip pain – a focus on the sporting population. Aust Fam Physician. 2007;36(6):410–413.
- ↑ Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J. 1974;4(5938):211–214.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.