Osteitis Pubis

By admin On Oct 11, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Osteitis Pubis

Nadya Volsky

Robert L. Jones

Basics

Description

Chronic inflammatory, painful condition secondary to stress forces through the anterior pelvis involving the pubic bones, pubic symphysis, and adjacent structures as a result of either chronic overloading or impaction trauma
Anterior pelvic ache or sharp pain that is worse with activities involving twisting/kicking
Located over the symphysis
May radiate into the lower abdominal muscles, perineum, and thigh adductors
May have associated adductor spasm
Can be provoked by standing on one leg or resisted hip adduction
Synonym(s): Pubic symphysis enthesopathy; Pubic symphysitis; Osteochondritis of pubic symphysis; Athletic pubalgia

Epidemiology

Incidence

Depends on type of sport; groin pain in general is seen in 2–5% of all sports injuries.
In sports that involve excessive twisting and turning movements such as soccer, ice and field hockey, tennis, and Australian-rules football, groin injuries may rise to 5–7% of all injuries.
Difficult to separate from possible coexisting conditions and to diagnose
Pure incidence for osteitis pubis alone is not clear.

Risk Factors

Sports involving kicking, interval sprinting, and rapid changes of direction such as soccer, ice and field hockey, Australian-rules football, tennis
Skeletal immaturity, especially coupled with high training volume/competition demands
Hip adductor/abductor muscle imbalance (abductors normally are ∼20% stronger than adductors)
Possibly hip stiffness and decreased range of motion (ROM) in the hip joint
Sacroiliac (SI) joint dysfunction
Pelvic asymmetry
History of prior groin injury
Pregnancy and/or postpartum
Rheumatologic disorders, such as ankylosing spondylitis or rheumatoid arthritis involving SI joint
Infection following urologic or gynecologic procedure

Etiology

Poorly understood; poorly studied
Likely includes combination of following: Adductor muscles injury or overuse, anterior pelvic instability
Possible correlation between decreased preseason hip rotational ROM and the development of osteitis pubis

Diagnosis

Physical Exam

Tenderness with palpation over the symphysis and pubic rami
Pain with resisted adduction, stretching hip flexors, and rising from a seated position

Diagnostic Tests & Interpretation

Imaging

X-rays:
- Anteroposterior view of pelvis
- 1-legged stance
- In relatively acute cases, plain radiographs may be normal; in chronic cases, radiographs can show cystic changes, sclerosis, and widening or narrowing at the symphysis, osteophytes, bony irregularities, or resorption.
- Instability may be evident on a 1-legged stance film (step-off >2 mm between the pubic rami in the vertical plane and/or symphyseal gap >7 mm between the pubic bones).
MRI:
- Bone edema spanning the symphysis with cystic or other degenerative changes, adductor microtears, and fluid in symphysis area may be visible.
- Associated pathologies such as tendon injuries, stress fractures, and SI or sacral injuries may be evident.
Bone scan: May show increased uptake at the symphysis, although it can take months to become positive

Differential Diagnosis

Most common:
- Adductor dysfunction (adductor complex tendinopathy, adductor tendinitis, adductor strain) and sports hernia
- Both also could coexist or proceed osteitis pubis.
Other:
- Femoral neck stress fracture
- Labral tear of hip
- Sacroiliitis
- Lumbar disk pathology
- Inguinal hernia
- Genitourinary disorders: Prostatitis in males, UTI in females, passing renal stones
- Gynecologic problems in females: Ovarian cyst, endometriosis
- Pelvic soft tissue tumors

P.423

Treatment

Treatment modalities: No randomized, controlled trials with level 4 evidence for any treatment regimen
Rest, ice, and NSAIDs are the 1st-line treatment.
Physical therapy including hip ROM and pelvic and core stabilization modalities
Manual therapy/massage
Corticosteroid injection in the symphysis
Prolotherapy with dextrose solution
Surgery is reserved for refractory cases.
Surgery:
- Wedge resection at the symphysis
- Symphysiodesis
- Posterior wall mesh repair
- Pubic symphysis curettage
- Polypropylene mesh repair has provided the quickest return to play with level 4 evidence studies only.
Rehabilitation:
- Core stabilization
- Hip ROM
- Correction of biomechanical errors such as poor/inefficient kicking technique in soccer player
- Correction of pelvic asymmetry
- Correction of SI joint dysfunction

In-Patient Considerations

Initial Stabilization

Rest, ice, and NSAIDs
Work on the biomechanical weakness, hip ROM, abdominal strengthening, and pelvic stabilizers.
Corticosteroid injection into the symphysis pubis and surrounding tissue can be beneficial.
Functional progress back to sport
General return to sport in 4–8 wks

Additional Reading

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. 2008.

Cunningham PM, Brennan D, O'Connell M, et al. Patterns of bone and soft-tissue injury at the symphysis pubis in soccer players: observations at MRI. AJR Am J Roentgenol. 2007;188:W291–W296.

Kunduracioglu B, Yilmaz C, Yorubulut M, et al. Magnetic resonance findings of osteitis pubis. J Magn Reson Imaging. 2007;25:535–539.

Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. 2007.

Pizzari T, Coburn PT, Crow JF. Prevention and management of osteitis pubis in the Australian football league: a qualitative analysis. Phys Ther Sport. 2008;9:117–125.

Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24:1407–1421.

Codes

ICD9

733.5 Osteitis pubis

Clinical Pearls

Return to play depends on how long the condition persisted prior to starting treatment (average time frame is 8–10 wks) and when the patient is pain free or mostly pain free with sports-specific activities (range of recovery between 2 wks and 5 mos).
To speed up recovery and to prevent this from happening again, work on hip ROM and flexibility and strengthening of muscles around hip joint, and core and pelvic stabilization exercises; maintain good and efficient sport-specific body mechanics (kicking for soccer, skating for hockey, etc.); and make sure to progress slowly and only if pain free with sport-specific activities.
Surgery is reserved for athletes who have failed to show improvement with a consistent trial of nonoperative treatment for at least 8 wks. Main reasons include the perioperative risks; just as with any other surgery, success rate, on average, is 80%, although techniques continue to improve. Recovery after surgery is also long and demands adherence to physical therapy regimen.
Recovery from surgery generally lasts 8 wks at a minimum with gradual return to play, but it may vary based on surgeon and the type of surgery.