Osteitis pubis

INTRODUCTION — 

Osteitis pubis is an inflammatory condition of the pubic symphysis and surrounding structures that occurs most often in athletes but may also occur in nonathletes from pelvic stress (eg, trauma, pelvic surgery, pregnancy).

The epidemiology, clinical presentation, diagnosis, and management of osteitis pubis are reviewed here. Other injuries and conditions affecting the pubis and groin region, including pelvic osteomyelitis, are discussed separately.

●Diagnosis of hip and groin pain (see "Approach to hip and groin pain in the athlete and active adult" and "Musculoskeletal examination of the hip and groin" and "Musculoskeletal ultrasound of the hip")

●Other sports-related injuries involving the hip or groin (see "Sports-related groin pain or 'sports hernia'" and "Hip adductor muscle and tendon injury" and "Femoroacetabular impingement syndrome")

●Pelvic osteomyelitis (see "Pelvic osteomyelitis and other infections of the bony pelvis in adults")

DEFINITION — 

Osteitis pubis is an inflammatory condition of the pubic symphysis and surrounding soft tissues. It is most likely related to overuse or trauma [1-3]. Osteitis pubis develops most often in athletes but may also occur in nonathletes who sustain stress at the pelvis (eg, trauma, pelvic surgery, pregnancy). (See 'Clinical presentation' below.)

Experts met in Doha in 2015 to address problems with unclear terminology related to groin pain in athletes [4]. To develop standard terminology, they agreed on the following basic classification scheme for sport-related groin pain.

●Clinical entities for groin pain, including the following:

•Adductor-related groin pain

•Iliopsoas-related groin pain

•Inguinal-related groin pain

•Pubic-related groin pain

●Hip-related groin pain

●Other causes of groin pain

While the publication did not include the term, "osteitis pubis" would presumably fall within the "pubic-related groin pain" category.

CLINICAL ANATOMY — 

Osteitis pubis is a chronic inflammatory process involving the pubic symphysis and its surrounding attachments, including cartilage, ligaments, muscles, and the pubic rami (figure 1). The pubic symphysis is mainly composed of fibrocartilage and is a nonsynovial, nonvascular joint. Four major ligaments provide structural integrity of the pubic symphysis. Most of the strength and support is provided by the superior and inferior ligaments, while the anterior and posterior ligaments are of less structural importance.

The pelvic floor musculature is composed of multiple muscles including some that insert on the pubic symphysis, such as the levator ani and coccygeus (figure 2 and figure 3). The pectineus, rectus abdominis, obturator internus, obturator externus, pyramidalis, and external oblique muscles, as well as the inguinal ligament, insert near the superior portion of the pubic symphysis (figure 4). The pubic rami give rise to several muscle origins (figure 5): adductor magnus, adductor longus, adductor brevis, and gracilis. These muscles make up the adductors of the hip [5].

The attachment sites of the abdominopelvic musculature and pubic ligaments are closely intertwined. A complex involving the pyramidalis, anterior pubic ligament, and adductor longus, which are often implicated in groin pain, has been proposed [6,7].

EPIDEMIOLOGY — 

The prevalence of osteitis pubis in the general athletic population ranges from 0.5 to 6.2 percent [1,8,9]. Athletes whose sport requires rapid changes in direction or kicking are at higher risk [10,11]. Thus, although many sports may be associated with the condition, those with a higher risk include soccer (football), American and Australian football, ice hockey, and rugby [12,13]. Male soccer players may account for up to 18 percent of cases among athletes [11].

The incidence of osteitis pubis is approximately two to five times higher in male than female athletes, although this difference may be due to discrepancies in sports participation between the sexes when the studies were performed [1].

The following conditions are also associated with osteitis pubis: osteoarthritis, pregnancy, pelvic trauma, and female pelvic surgery [14]. Although the incidence is not well described for surgical causes, the incidence of osteitis pubis after retropubic urethropexy has been reported to be up to 2 to 3 percent [15], and following female pelvic reconstruction surgery (eg, transvaginal sling) under 1 percent [16].

PATHOGENESIS — 

While the precise etiology of osteitis pubis remains uncertain and may vary among patients, mechanical and degenerative processes appear to be important contributors [3,17]. Repetitive trauma alone or in conjunction with shearing forces across the pubic symphysis are likely the main factors in athletes [18-22]. The opposing forces of the adductor longus and rectus abdominis are thought to contribute to this shear, which may occur during a range of movements, including kicking, rapid acceleration or deceleration, and rapid change of direction (ie, "cutting") [23]. Functional or anatomic leg-length discrepancy may increase forces exerted at the pubic ramus [24], possibly leading to increased shear stress at the pubic symphysis, with subsequent inflammation and degenerative changes.

The rectus abdominis inserts and the hip adductors originate at the pubic symphysis (figure 4 and figure 5). When contracting, these muscles create antagonistic forces. An imbalance in the strength of these muscle groups may increase shear forces across the pubic symphysis [11].

Other factors that may contribute include overuse of the adductor muscles and hip mobility restrictions [11,19]. Reduced hip internal and external rotation have been associated with chronic groin injury in athletes, but it is unclear if they contribute to osteitis pubis [10,20]. One theory proposes that motion at the pubic symphysis increases as a compensatory response to decreased motion at other joints in the mechanical chain (eg, femoroacetabular impingement), leading to increased shear [25]. Microtrauma at the adductor origins, avascular necrosis or osteochondritis dissecans of the pubic symphysis, and bone stress injury may play a role in pathogenesis [11,26,27].

CLINICAL PRESENTATION

History — The clinical presentation of a patient with osteitis pubis can vary. A history of gradual onset lower abdominal or groin pain associated with overuse during sport, a new training method, or new athletic activity, in the absence of systemic symptoms, is suggestive [1,28]. According to a 2022 systematic review, the average age of onset ranges between 22 and 40 years [25].

Although the onset of pain may be acute, particularly after an injury, it is generally more insidious. Pain may be localized to the lower abdomen, pubic symphysis, adductor origin, hip, testicle, scrotum, or perineum. It may be focused in the midline or manifest unilaterally or bilaterally. The patient may describe radiation of pain further along the groin or into the medial thigh or abdomen [29]. A review of 59 athletes with the condition reported pain at the adductor origin in 80 percent, pubic symphysis in 40 percent, lower abdomen in 30 percent, and hip in 12 percent [3].

Patients may describe increased pain when playing a sport (eg, soccer) or performing particular movements (eg, running, moving from sitting to standing). Athletic movements that commonly aggravate the condition include sprinting, kicking, twisting, and rapid change of direction (ie, "cutting") [30].

Osteitis pubis can occur during or following pregnancy, presenting with a gradual onset of pain over the pubic symphysis followed by rapid progression over several days with radiation to the thighs [31].

Physical examination — Patients with osteitis pubis may walk with a limp or a wide-based gait. Characteristic physical examination findings include [9]:

●Tenderness at the pubic symphysis

●Pain with resisted strength testing of the adductor and lower abdominal muscles

The absence of tenderness at or closely adjacent to the pubic symphysis nearly excludes the diagnosis of osteitis pubis [32]. However, such tenderness is nonspecific and can be seen in other conditions [33,34].

No specific examination maneuver has been identified that can differentiate osteitis pubis from other causes of groin pain in athletes [4]. Pain provoked by single-leg stance may suggest pelvic instability or adductor-related groin pain in athletes. However, it is not specific for osteitis pubis [35].

In patients with osteitis pubis, hip range of motion testing may exacerbate pain, and diminished internal or external rotation may be present [10,20,33,34]. However, pain felt at the anterior hip joint during internal and external rotation of the hip suggests intra-articular pathology, such as femoral acetabular impingement, osteoarthritis, or a labral tear rather than osteitis pubis. (See "Femoroacetabular impingement syndrome" and "Clinical manifestations and diagnosis of osteoarthritis", section on 'Hip'.)

In addition to simple hip internal and external rotation testing, the Flexion Abduction External Rotation (FABER) (picture 1) and Flexion Adduction Internal Rotation (FADIR) (picture 2) maneuvers should be performed to assess mobility and as provocative maneuvers to assess hip conditions. (See "Approach to hip and groin pain in the athlete and active adult" and "Approach to the adult with unspecified hip pain".)

While not specific to the diagnosis of osteitis pubis, other components of the general musculoskeletal examination that should be performed include:

●Palpation of adductor muscles and origins, rectus abdominis muscle and insertion, iliopsoas muscle and tendon, and pubic symphysis and rami

●Strength testing of the adductor, abdominal, oblique, and hip musculature

Additional maneuvers that may help to determine the etiology of groin pain in athletes include the adductor squeeze test (picture 3) and resisted sit-up test (picture 4). Leg-length discrepancy may contribute to pain at the hip or groin and should be assessed. These and other relevant tests are reviewed in detail separately. (See "Musculoskeletal examination of the hip and groin".)

A focused abdominal, genitourinary, and musculoskeletal examination is important for assessing other possible causes of groin pain and should be tailored to the history. Such causes may include inguinal hernia, intra-articular hip joint disorders, gastrointestinal disease (eg, diverticulitis), genitourinary tract disease (eg, cystitis), and lumbar radiculopathy, among others [30,36]. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Evaluation of the adult with abdominal pain".)

DIAGNOSTIC IMAGING

Approach to imaging — Imaging studies in the diagnostic workup of osteitis pubis may include plain radiographs, magnetic resonance imaging (MRI), ultrasound, bone scan (nuclear scintigraphy), and computed tomography (CT) scan [1,37]. If clinical suspicion for osteitis pubis is high, we begin with plain radiographs. Clinicians adept at diagnostic ultrasound often perform a bedside sonographic examination of the regions of interest in addition to radiographs. If the findings of these initial studies are consistent with the clinical diagnosis, as determined by the history and physical examination, no further imaging is needed.

While the diagnosis of osteitis pubis does not require imaging, given the multiple potential causes for groin pain, imaging is often performed early to rule out conditions that may necessitate different treatment (eg, bone stress injury). The initial imaging study is typically plain radiographs of the hip and pelvis (possibly including flamingo views). Clinicians proficient in musculoskeletal ultrasound often perform such an examination. In pregnant patients, radiographs may be deferred and ultrasound performed instead.

For patients whose symptoms persist beyond six weeks despite appropriate conservative management, or if diagnostic uncertainty persists for other reasons, ultrasound examination by an experienced musculoskeletal sonographer or MRI of the pelvis can be performed. MRI may be ordered sooner in competitive athletes or if there is concern for other diagnoses (eg, pelvic stress fracture) necessitating an immediate change in management. Anatomy in the region of the symphysis pubis is complex, and difficulty distinguishing among adductor strain, rectus abdominis strain, rectus-adductor aponeurosis tear ('sports' hernia), inguinal hernia, and other conditions may reasonably prompt clinicians to obtain an MRI.

Plain radiographs — Plain radiographs are often obtained when the etiology of pain is unclear or if symptoms persist despite treatment. If plain radiographs are performed, an anteroposterior pelvis image should be obtained. Abnormal findings are often absent in patients with osteitis pubis until the patient has experienced symptoms for several weeks to months. Findings may include those seen in this radiograph (image 1) or any of the following [38]:

●Widening of the pubic symphysis

●Bone resorption or remodeling at the pubic symphysis

●Osteopenia (generalized loss of bone density) at the pubic rami (image 2)

Negative radiographs do not rule out a diagnosis of osteitis pubis [39]. In addition, particularly in adolescents, some findings that appear abnormal, such as a "fuzzy" irregular symphyseal joint surface, may reflect normal development of the maturing pelvis [39]. Other findings, including an "apple bite" shaped lucency, sclerosis, or a visible ossicle are of unclear clinical significance.

If pelvic instability is suspected based on examination findings (eg, difficulty walking, waddling gait, pain with single-leg stance, clicking sensation of pelvic joints), flamingo views should be obtained. Flamingo views are anterior stress views of the pubic symphysis obtained while the patient performs a single-leg stance (image 3). These views may reveal instability (>2 mm of vertical displacement) or widening (≥8 mm diastasis) of the symphysis pubis [40].

Ultrasound

Utility — While ultrasound findings alone are not sufficient to establish a diagnosis of osteitis pubis, ultrasound may reveal confirmatory findings, such as the following [41-43]:

●Cortical irregularity or widening of pubic symphysis

●Fluid within pubic symphysis

●Parasymphyseal capsular thickening

●Hyper- or hypoechoic changes within pubic symphysis (this can be difficult to identify as there is no contralateral structure for comparison)

Increased Doppler flow around the joint suggests more active arthropathy [43].

Nevertheless, when assessing sport-related groin pain, ultrasound is probably most useful for assessing soft tissue pathologies (eg, rectus abdominis-adductor aponeurosis tears) and to help rule out inguinal hernia. Ultrasound examination of the patient with suspected osteitis pubis should include evaluation of the proximal adductor and distal rectus abdominis tendons, as injury to either can present similarly to or coexist with osteitis pubis. Ultrasound findings for these conditions are discussed separately.

●Adductor injury (see "Hip adductor muscle and tendon injury", section on 'Musculoskeletal ultrasound')

●Rectus abdominis injury (see "Soft tissue musculoskeletal injuries of the abdomen, flank, and lumbar region in adults and adolescents", section on 'Rectus abdominus enthesopathy')

●Inguinal hernia (see "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Diagnostic evaluation')

Ultrasound may also be used to identify iliopsoas injury, iliopectineal bursitis, nerve entrapment (eg, ilioinguinal, iliohypogastric, or genitofemoral nerves), and other pathologies [41].

Examination — When performing the ultrasound examination for suspected osteitis pubis, the patient lies supine in a frog-leg position (hips flexed, abducted, and externally rotated). This allows better visualization of the adductor tendon origins. A linear, high-frequency transducer provides high-resolution images for superficial structures. For patients with a larger body habitus, a lower-frequency curvilinear transducer may improve visualization of tendons and underlying tissues.

Performance of the musculoskeletal ultrasound examination of the hip region is discussed in detail separately. All structures examined should be visualized in both longitudinal and transverse planes. (See "Musculoskeletal ultrasound of the hip".)

Magnetic resonance imaging — If the diagnosis remains in question after the history, physical examination, and plain radiographs are performed, further imaging may be required, most often MRI [1,44].

In acute cases, MRI may demonstrate fluid in the pubic symphysis joint, subchondral bone marrow edema, or periarticular edema of the symphysis; and possibly small tears of the adductor muscles. Intense signal within the symphysis pubis and adjacent tissues on T2-weighted images is the most common finding in osteitis pubis of less than six-month duration (image 4) [11,45]. Subchondral sclerosis and bone resorption may be seen with chronic osteitis pubis (image 5).

MRI is used with increasing frequency due to its high sensitivity for signs of osteitis pubis and availability [1,26,46,47]. Small, observational studies suggest that the sensitivity and specificity of MRI for detecting bone marrow edema in osteitis pubis are above 90 percent [47]. MRI also helps to distinguish between osteitis pubis and pelvic osteomyelitis, in which cortical destruction, marrow abnormalities, and soft tissue inflammation are present. (See "Pelvic osteomyelitis and other infections of the bony pelvis in adults", section on 'Diagnosis'.)

Other advanced imaging studies

●Bone scan – Bone scan (nuclear scintigraphy) is typically reserved for patients in whom MRI and ultrasound are equivocal. Bone scan should not be a first-line imaging technique because it requires injection of a radioactive tracer and increased uptake is a nonspecific finding [48,49]. Bone scan may reveal subtle stress reactions not seen with other imaging studies. In patients with osteitis pubis, a large area of bone uptake may be evident near the pubic symphysis. (See "Imaging techniques for evaluation of the painful joint", section on 'Bone scan'.)

●CT scan – CT scan can evaluate the integrity of the pubic symphysis and associated skeletal structures but is rarely helpful in making a definitive diagnosis of osteitis pubis.

OTHER DIAGNOSTIC STUDIES — 

Laboratory testing is not required for the diagnosis of osteitis pubis, as abnormalities are not expected. However, testing for inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), complete blood count with differential, urinalysis, and blood cultures can be obtained if an infectious process is suspected or the diagnosis is unclear [50,51]. Blood testing should be performed for patients presenting with fever and at high risk for infection (eg, diabetes, immunocompromised state, recent surgery or procedure). Joint aspiration or bone biopsy is performed as indicated if suspicion for osteomyelitis is high. (See "Osteomyelitis in the absence of hardware: Approach to diagnosis in adults", section on 'Diagnosis'.)

If the diagnosis remains in question despite appropriate imaging studies, diagnostic injection of an anesthetic agent with or without glucocorticoid may be helpful in some instances [40].

DIAGNOSIS — 

The diagnosis of osteitis pubis can be made by history and physical examination. Gradual onset of pain at or around the pubic symphysis associated with tenderness and pain with resisted adductor testing is characteristic. The condition occurs most often in susceptible athletes (eg, soccer players) but may occur among nonathletes who have sustained pelvic stress from trauma, surgery, or pregnancy. While some clinicians obtain imaging at presentation to avoid missing other pathology (eg, bone stress injury), others prefer to delay imaging unless the clinical presentation remains unclear, or symptoms fail to improve with conservative management. If the diagnosis cannot be established clinically, initial imaging studies (plain radiographs, musculoskeletal ultrasound) often reveal suggestive findings as noted above, but no finding or study alone is definitive. When a definitive diagnosis is needed, MRI is typically performed. (See 'Diagnostic imaging' above.)

DIFFERENTIAL DIAGNOSIS — 

Groin pain in active adults and adolescents involves complex anatomy and many possible causes. The approach to this complex clinical scenario is discussed in detail separately, while common diagnoses are summarized in the following tables (table 1 and table 2). Below, we discuss the conditions most often confused with osteitis pubis and how to distinguish among them. (See "Approach to hip and groin pain in the athlete and active adult".)

Causes of groin pain that can present similarly to osteitis pubis include osteomyelitis; musculotendinous strains of the rectus abdominis insertion or hip adductor origin; injury of the external oblique aponeurosis; injury to the pyramidalis, anterior pubic ligament, and adductor longus complex (PLAC); inguinal hernia; stress fracture of the femoral neck or pubic ramus; intra-articular hip disease; genitourinary disease (eg, urinary tract infections, nephrolithiasis, prostatitis); and referred low back pain [4,11]. Patients with groin pain may have simultaneous ongoing pathologies [4,30].

●Osteomyelitis – Infectious osteomyelitis of the pubic symphysis may be confused with osteitis pubis [2,52]. Osteomyelitis is often acute in onset (while osteitis pubis is usually more gradual), is more likely to be accompanied by fever, and may cause more severe, escalating pain [12]. However, bone infections of the pelvis may present subacutely and without associated fever. Osteomyelitis occurs most often following surgical procedures in the affected region [30]. If obtained, laboratory investigations are usually unremarkable with osteitis pubis, but with osteomyelitis, abnormalities consistent with infection may be seen in the complete blood count with differential, inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), and blood cultures. (See "Pelvic osteomyelitis and other infections of the bony pelvis in adults", section on 'Clinical manifestations'.)

●Musculotendinous injury – Differentiating among the musculotendinous conditions capable of causing groin pain in athletes can be challenging, as many present with common features (eg, pain with running or cutting, tenderness over the pubic symphysis, pain with resisted hip adduction, or resisted sit-up). Injury may involve the muscle, tendon, or aponeurosis of the adductor, rectus abdominis muscles, or the PLAC. The examination and workup are the same as for osteitis pubis. Ultrasound examination is often helpful. When a definitive diagnosis is required, advanced imaging (usually MRI) is often necessary. (See "Hip adductor muscle and tendon injury" and "Soft tissue musculoskeletal injuries of the abdomen, flank, and lumbar region in adults and adolescents", section on 'Abdominal wall injuries'.)

●Inguinal hernia – Inguinal hernia typically presents with groin discomfort that increases with Valsalva and may be worse at the end of the day or after prolonged standing. A palpable defect at the groin or in the inguinal canal is often present in males. Without palpable defects, imaging studies (eg, ultrasound) are often needed to distinguish between these diagnoses. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

●Stress fracture of the femoral neck or pubic ramus – Stress fractures of the femur and pelvis develop most often in distance runners and often cause vague pain in the groin or proximal thigh. Pain is typically of insidious onset and worse with weightbearing, particularly when running or hopping. A positive single-leg hop test is suggestive. MRI is often indicated to establish the diagnosis of a stress fracture. (See "Femoral stress fractures in adults" and "Overview of bone stress injuries and stress fractures".)

●Femoroacetabular impingement – Femoroacetabular impingement typically causes groin pain of insidious onset that is often worse after prolonged hip flexion (eg, sitting) and exacerbated by deep hip flexion, such as when squatting. Hip impingement maneuvers, such as the Flexion Adduction Internal Rotation (FADIR) test (picture 2), often reproduce the patient's symptoms. Plain radiographs including the necessary special views often reveal structural abnormalities, but advanced imaging may be needed. (See "Femoroacetabular impingement syndrome".)

●Genitourinary conditions – Cystitis can cause lower abdominal and pelvic pain but is often associated with lower urinary tract symptoms such as dysuria, frequency, and malodorous or discolored urine. Positive urinalysis findings, including elevated white blood cell count and positive leukocyte esterase, distinguish infection from osteitis pubis. (See "Acute simple cystitis in female adults" and "Acute simple cystitis in male adults".)

Up to one-third of pregnant patients may develop peripartum pubic symphysis pain. Conditions of the symphysis pubis related to pregnancy (also referred to as pelvic girdle pain or symphysis pubis dysfunction) generally present with suprapubic pain, tenderness, swelling, and edema. Pain is exacerbated by movement of the leg, especially walking and climbing stairs, and sometimes radiates to the proximal thigh, groin, lower abdomen, or back [53]. Peripartum status and the absence of imaging findings consistent with osteitis pubis help to distinguish these conditions. (See "Maternal adaptations to pregnancy: Musculoskeletal changes and pain", section on 'Pelvic girdle pain' and "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)

●Nerve entrapments – Entrapment of the obturator, ilioinguinal, genitofemoral, or iliohypogastric nerve can cause pain or paresthesias at the lower abdomen, inner thigh, or inguinal region [4,54]. Entrapment typically occurs following trauma or surgery, but rare atraumatic focal entrapments have been described. Sensory examination of the corresponding cutaneous distribution helps to identify such entrapments. Obturator nerve entrapment may present with hip adductor weakness, while genitofemoral neuropathy may result in loss of the cremasteric reflex. (See "Overview of lower extremity peripheral nerve syndromes" and "Nerve injury associated with pelvic surgery".)

MANAGEMENT — 

Studies of treatment for osteitis pubis are largely limited to case series performed in male athletes [9,13,22,44,55]. Thus, the guidance provided below is based on that limited evidence and the authors' clinical experience.

Approach and expectations — We take a stepwise approach to the management of osteitis pubis. For most patients, particularly athletes, we begin with basic conservative measures (eg, relative rest, ice, over-the-counter analgesics) and physical rehabilitation. Should symptoms and function fail to improve with these interventions, we proceed to injection therapy, usually including a glucocorticoid. We reserve surgery as a last resort. In patients who develop osteitis pubis following surgery or trauma and in those with severe symptoms, it may be appropriate to start with more invasive therapy, including local glucocorticoid injection and surgical referral.

While osteitis pubis is often described as a self-limiting condition that resolves over time [11], extended rest is often infeasible or impractical, particularly for elite athletes. According to a 2016 review, most athletes return to preinjury levels of performance within three months (range 4 to 14 weeks) [56]. Patients should be informed of the extended period that may be needed for healing.

Initial medical therapy

Basic interventions — Management of osteitis pubis includes rest from inciting activities, application of ice (particularly following activity), and over-the-counter analgesics, often a nonsteroidal anti-inflammatory drug (NSAID).

Relative rest is essential. Relative rest refers to refraining from all activities that cause discomfort. This usually includes avoiding the sport that provoked symptoms and any other activities that exacerbate the condition. Relative rest should be continued if the patient remains symptomatic despite initial treatment. In some cases, athletes may be able to continue limited sport-specific skill work in conjunction with tailored, low-impact cardiovascular, strength, and flexibility training.

The application of ice can help to reduce pain and swelling. One method for ensuring safe application (avoiding frostbite) consists of applying crushed ice covered by a thin, slightly damp barrier (eg, thin towel) to the injured area with a compression wrap for approximately 15 minutes at a time.

Correction of underlying biomechanical flaws is often addressed through physical therapy but can also include correction of leg-length discrepancy, if present, with orthotics.

Physical therapy — The main goal of physical rehabilitation is to strengthen and stabilize the pelvis and pubic symphysis. Physical therapy begins with an assessment of strength or mobility deficits or mechanical flaws that may have contributed to the condition. An exercise program is implemented to address the problems identified. Adjunct interventions such as soft tissue massage or release techniques may also be used.

The physical therapy program generally includes exercises to improve core strength (eg, planks, bridges), adductor flexibility, and balance. Observational evidence suggests that such physical rehabilitation can reduce symptoms and allow some athletes to return to their preinjury level of sport participation [55,56].

Typically, the initial stage of physical therapy focuses on pain control, lumbo-pelvic stability, gentle stretching, and nonaggravating aerobic exercise to maintain fitness [11,57]. The next stage entails resistance training of the abdominal, pelvic, and gluteal muscles, starting with isometric exercises and then progressing to concentric exercises. Subsequent stages introduce eccentric exercises to strengthen the hips and lateral movements followed by sport-specific training and a gradual return to sport [11,57]. However, evidence is limited, multiple protocols have been described, and no universal guidelines exist for osteitis pubis rehabilitation [56].

Persistent symptoms

Glucocorticoid therapy — For patients who remain symptomatic after six weeks or longer of relative rest and appropriate medical management, glucocorticoid therapy is the next intervention in most cases. The authors prefer local glucocorticoid injection of the symphysis pubis performed under ultrasound or fluoroscopic guidance.

Injection therapy — Observational evidence suggests that glucocorticoid injection at the point of maximal tenderness at the symphysis pubis often relieves symptoms without significant adverse effects in patients with osteitis pubis [13,29,58,59].

Symphyseal injections can be performed under ultrasound or fluoroscopic guidance. Clinicians may inject any of several glucocorticoid preparations (eg, triamcinolone, dexamethasone, betamethasone, methylprednisolone), combined with an analgesic (eg, lidocaine, bupivacaine), in varying concentrations. We use 1 mL of dexamethasone (4 mg/mL) mixed with 1 mL of ropivacaine 0.5%. Local glucocorticoid injection may be given at the initial visit if the patient is in severe pain. One injection is generally sufficient. Should symptoms persist, up to three injections may be given at two- to three-week intervals.

A 2011 systematic review of evidence limited to observational studies (195 subjects) reported that 58.6 percent of athletes treated with glucocorticoid injection of the symphysis pubis returned to sport, while 20.7 percent did not experience symptomatic relief [55]. In a subsequent observational study of 45 athletes treated with fluoroscopy-guided glucocorticoid injection of the symphysis pubis, 89 percent experienced improvement in symptoms, with 58 percent experiencing sustained relief at six months [60]. No significant adverse events were reported.

Oral therapy — Oral glucocorticoid (prednisone) may be given for severe or refractory cases. While the authors prefer glucocorticoid injection, prednisone can be used if patients prefer to avoid injection.

Several treatment regimens may be followed. A 60 mg dose of prednisone may be given for five days. Alternatively, a prednisone taper may be given using either of the following sequences [61]:

●60 mg for four days, then 40 mg for four days, then 20 mg for four days

●60 mg for one day, then 50 mg for one day, then 40 mg for one day, then 30 mg for one day, then 20 mg for one day, then 10 mg for two days

No convincing evidence supports one regimen over another.

Unproven therapies — Reported but unproven therapies for osteitis pubis include cryotherapy, laser, therapeutic ultrasound, electrical stimulation, prolotherapy (dextrose injection), and platelet-rich plasma (PRP) injection [9,62]. Randomized trials are lacking, and evidence for all the above treatments is limited in number and quality. The use of PRP and other orthobiologics for soft tissue musculoskeletal injury is reviewed separately. (See "Biologic therapies for tendon and muscle injury".)

Surgical management — Surgical management of osteitis pubis is reserved for patients whose symptoms and function fail to improve after three to six months of medical treatment, including an appropriately designed and well-executed rehabilitation program [11,25,63-65]. The results reported in small case series suggest that surgical treatment may be effective in many such patients [66].

Several surgical procedures are used to treat osteitis pubis [18,25,46,63-65,67]:

●Curettage – Debridement of degenerative areas in and around pubic symphysis; involves limited surgical exposure

●Wedge resection – Resection of a trapezoidal portion of symphysis

●Wide resection – Similar to wedge resection but with larger margins

●Arthrodesis – Fusion of pubic symphysis (with or without bone grafting)

●Other procedures – To strengthen or repair abdominal or pelvic floor musculature

Curettage is the most common initial surgical intervention for refractory osteitis pubis. A systematic review of 83 cases reported that most athletes requiring surgery respond well to curettage alone without resection [63].

As with medical treatment, full recovery following surgery can be lengthy. Recovery from curettage can take three to six months, while recovery following resection or arthrodesis may require up to one year [25,46,63,66]. The long recovery is one reason resection and arthrodesis are usually reserved for patients whose symptoms persist despite treatment with curettage [65].

Operative treatment is not always curative, and some patients may suffer refractory pain [68]. Pelvic instability may develop, particularly after wedge or wide resection. Arthrodesis is associated with postoperative complications in up to 25 percent of patients [25]. Wedge resection seems to be falling out of favor. Following open resection, up to 30 percent of athletes are unable to return to full activity.

Prior to surgical intervention, the possibility of femoroacetabular impingement should be investigated, as the conditions may appear concomitantly [69]. (See "Femoroacetabular impingement syndrome".)

PREVENTION — 

High-quality evidence about ways to prevent osteitis pubis is lacking. However, based on our current understanding of the mechanism and approaches to physical rehabilitation, a few basic interventions may be useful, including the following:

●Develop and maintain full hip mobility

●Develop and maintain strength in the hip adductor and hip flexor musculature

●Develop and maintain strength in the musculature that contributes to the stability of the torso, including abdominal and pelvic musculature

It is important to build balanced strength between agonist and antagonist muscle groups and avoid asymmetries, particularly given the presumption that shear forces across the symphysis created by strength imbalances contribute to osteitis pubis.

As with physical rehabilitation, exercises for injury prevention should progress from isometric to concentric to eccentric strengthening, followed by sport-specific training.

Prevention strategies should include searching for biomechanical factors that may predispose to osteitis pubis, such as functional or anatomic leg-length discrepancy, and implementing appropriate treatment.

OUTCOMES — 

Most cases of osteitis pubis resolve with rest and medical management, although symptoms may persist for several months or even years [46]. Available data suggest that 5 to 10 percent of athletes will need surgical treatment [25]. (See 'Surgical management' above.)

There are few long-term sequelae associated with osteitis pubis. Chronic injury of the pubic symphysis and adductor muscle origins (specifically the muscle tendon junction) are known complications. Either can lead to chronic pain and disability. Unlike osteomyelitis, osteitis pubis does not lead to significant bone erosion and necrosis.

SUMMARY AND RECOMMENDATIONS

●Definitions, anatomy, epidemiology – Osteitis pubis is an inflammatory condition involving the pubic symphysis and surrounding structures, including cartilage, ligaments, muscles, and the pubic rami (figure 4 and figure 5 and figure 1). It is most likely related to overuse or trauma. It develops most often in athletes but can occur in non-athletes, particularly those with osteoarthritis, pregnancy, pelvic trauma, or pelvic surgery.

●Clinical presentation – The presentation of osteitis pubis varies, but generally involves the insidious onset of anterior pelvic pain in the absence of systemic symptoms. Pain is often associated with overuse during a sport, or a new training method, or a new athletic activity. Characteristic physical examination findings include tenderness at the pubic symphysis and pain with resisted strength testing of the hip adductor and lower abdominal muscles.

●Diagnostic imaging and other testing – If clinical suspicion for osteitis pubis is high, we obtain plain radiographs. Clinicians adept at diagnostic ultrasound often perform a bedside examination. If findings are consistent with the clinical diagnosis (image 1), no further imaging is needed. If symptoms persist beyond six weeks despite appropriate conservative management or diagnostic uncertainty persists, MRI of the pelvis is performed. Laboratory testing is not required for the diagnosis of osteitis pubis, as abnormalities are not expected.

●Diagnosis – The diagnosis of osteitis pubis is often determined by history and physical examination alone. The gradual onset of pelvic discomfort associated with activity, in combination with tenderness over the pubic symphysis and pain with resisted adductor testing (picture 3), and in the absence of systemic symptoms and signs, is sufficient.

●Differential diagnosis – Causes of groin pain that can present similarly to osteitis pubis include osteomyelitis; musculotendinous strains of the rectus abdominis insertion or hip adductor origin or the pyramidalis, anterior pubic ligament, and adductor longus complex; inguinal hernia; stress fracture of the femoral neck or pubic ramus; femoroacetabular impingement; and genitourinary disease (eg, cystitis). Osteomyelitis is more likely to present with acute onset of severe pain and fever. However, some bony infections of the pelvis present subacutely or without associated fever.

●Management – We follow a stepwise approach to management beginning with conservative measures, including relative rest (refraining from activities that provoke pelvic pain), application of ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical rehabilitation designed to strengthen and stabilize the pelvis and pubic symphysis. Most cases resolve with conservative management, although symptoms may persist for several months or longer.

For patients who remain symptomatic after six weeks or longer of conservative management, we suggest local glucocorticoid injection of the pubic symphysis rather than oral glucocorticoid or other therapies (Grade 2C). Local glucocorticoid injection is performed under ultrasound or fluoroscopic guidance.

Surgical management is reserved for patients whose symptoms and function fail to improve after three to six months of medical treatment, including an appropriately designed and well-executed rehabilitation program. Curettage of the symphysis is the most common surgical intervention.