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Osteitis pubis

Osteitis pubis
Literature review current through: Jan 2024.
This topic last updated: Jun 04, 2021.

INTRODUCTION — Osteitis pubis is defined as an idiopathic, inflammatory condition of the pubic symphysis and surrounding structures, but it is most likely related to overuse or trauma [1,2]. Osteitis pubis most commonly occurs among athletes but can also occur among non-athletes as a result of any pelvic stress (eg, trauma, pelvic surgery, pregnancy).

This topic will discuss the epidemiology, diagnosis, and management of osteitis pubis. Other sports-related injuries and pelvic osteomyelitis are discussed elsewhere. (See "Sports-related groin pain or 'sports hernia'" and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Pelvic osteomyelitis and other infections of the bony pelvis in adults".)

ANATOMY — Osteitis pubis is an 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. The pubic symphysis is reliant on four ligaments to maintain its supportive integrity. Most of the strength and support arise from the superior and inferior ligaments, whereas the anterior and posterior ligaments are of less supportive importance. The pelvic floor musculature, composed of the levator ani and coccygeus, insert posteriorly at the pubic symphysis. The pectineus, rectus abdominis, and oblique externus muscles, as well as the inguinal ligament, insert near the superior portion of the pubic symphysis. The pubic rami give rise to several muscle origins: adductor magnus, adductor longus, adductor brevis, and gracilis. These muscles make up the adductors of the hip [3].

EPIDEMIOLOGY — The prevalence of osteitis pubis among the general population of athletes ranges from 0.5 to 6.2 percent [1,4,5]. Although many different sports may be associated with osteitis pubis, sports with a higher risk include soccer, football, ice hockey, and rugby [6,7].

Many factors are known to play a role in developing osteitis pubis. Repetitive movements within the pelvis, such as those associated with athletic activity, predispose to osteitis pubis. The following conditions are also associated with osteitis pubis: osteoarthritis, pregnancy, pelvic trauma, and pelvic surgery [8].

PATHOGENESIS — Although the etiology of osteitis pubis is unknown, repetitive trauma alone or in conjunction with opposing shearing forces across the pubic symphysis is likely the main contributing factor in many athletes [9-13]. This may be due to different types of movements, including rapid acceleration/deceleration, kicking, and changes in direction. Overuse of the adductor muscles and imbalances between abdominal wall and hip adductor strength may be other contributing factors [10]. The underlying cause of osteitis pubis may be a combination of contributing factors, including microtrauma and/or microstrains at the origins of the adductor muscles, avascular necrosis of the pubic symphysis, osteochondritis dissecans at the symphysis, and/or fatigue fracture (fracture resulting from excessive activity rather than a specific injury).

CLINICAL PRESENTATION — The clinical presentation of a patient with osteitis pubis can vary but generally includes the gradual onset of pelvic pain in the absence of systemic symptoms [1,14]. Pain may be localized to the lower abdomen, hip, thigh, testicle, or perineum. The pain may be exacerbated by playing a particular sport or by a certain position or activity (eg, moving from sitting to standing). The pain can be midline, unilateral, or bilateral. The pain may have an acute onset, particularly after an injury. However, it is often more insidious in nature. Pain may be accompanied by a limp and a wide-based gait (similar to other causes of pelvic or hip pain). (See "Approach to the adult with unspecified hip pain".)

Differential diagnosis — Other causes of groin pain that can present similarly to osteitis pubis include osteomyelitis, musculotendinous strain, hernia, stress fracture, intraarticular hip disease, genitourinary disease, and referred low back pain. Osteomyelitis of the pubic symphysis is one of the diseases most commonly confused with osteitis pubis [2,15]. However, there are some characteristics that differentiate the two entities. As the etiology of osteomyelitis is infectious, osteomyelitis is typically sudden in onset, more likely to be accompanied by fever, and may lead to more severe, escalating pain [6]. However, many bony infections of the pelvis present subacutely with or without associated fever. (See 'Clinical presentation' above and "Pelvic osteomyelitis and other infections of the bony pelvis in adults", section on 'Clinical manifestations' and "Sports-related groin pain or 'sports hernia'" and "Approach to the adult with unspecified hip pain" and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

Long-term sequelae — There are few long-term sequelae associated with osteitis pubis. Sustained injury to the pubic symphysis and adductor muscles (specifically at the muscle-tendon junction) is a known complication which can lead to chronic pain and disability. Most cases of osteitis pubis resolve with rest. Osteitis pubis does not lead to significant bone deformity, unlike osteomyelitis that can result in severe bone erosion and necrosis, along with surrounding soft tissue destruction. Thus, it is important to consider osteomyelitis in the differential diagnosis along with osteitis pubis.

DIAGNOSIS — The diagnosis of osteitis pubis is often determined by history and physical examination alone. Gradual onset of pelvic pain, along with pubic symphysis tenderness or resisted adductor testing, is characteristic of osteitis pubis [7].

Conversely, osteomyelitis is sudden in onset and usually associated with fever [6]. If infection is suspected, a complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), urinalysis, and blood cultures should be performed. Other laboratory testing, diagnostic imaging, and joint aspiration are adjunctive tests.

History — The gradual onset of pain with history of overuse, new training method, or new activity is indicative of osteitis pubis. In addition to lower abdominal pain, the patient may also complain of radiation of pain into the groin, medial thigh, or abdomen [16]. It is crucial to ask the patient about sports and exercise activities, as well as when the pain is most prominent. Specific athletic activities that commonly aggravate this condition include sprinting, kicking, twisting, and cutting.

Physical examination — Characteristic physical examination findings include tenderness to palpation of the pubic symphysis and pain with resisted strength testing of the adductor and lower abdominal muscle groups [5]. To assess the adductor and lower abdominal muscles, the patient should be placed supine on the examining table with hips and knees flexed 90 degrees (picture 1). The athlete then performs an isometric adductor muscle contraction against the examiner’s fist. A painful isometric muscle contraction is considered a positive test.

Thorough abdominal, genitourinary, and musculoskeletal examination is important in assessing for other causes of pain. These causes include but are not limited to hernias, gastrointestinal disease (eg, diverticulitis), and genitourinary tract disease (eg, prostatitis, cystitis).

Diagnostic imaging — Imaging studies in the diagnostic workup of osteitis pubis may include plain radiographs, magnetic resonance imaging (MRI), ultrasound, bone scan, and/or computed tomography (CT) scan [1].

Plain radiographs are often obtained when the etiology of pain is unclear or if symptoms persist despite treatment. If plain radiograph is performed, an anteroposterior pelvic film should be obtained. Abnormal findings on plain radiograph in patients with osteitis pubis are often not present until the patient has experienced several weeks to months of symptoms. These findings may include (image 1) [17]:

Widening of the pubic symphysis

Bone resorption or remodelling 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.

If pelvic instability is suspected (eg, difficulty walking, waddling gait, pain with one legged stance, clicking sensation of pelvic joints), flamingo views should be obtained which can reveal vertical instability (>2 mm of vertical displacement). Flamingo views are anterior stress views of the pubic symphysis where the patient performs a single leg stance, one side at a time (image 3).

If the diagnosis is still in question after history, physical examination, and plain radiograph, further imaging may be required [1,18]:

MRI in acute cases may demonstrate fluid in the pubic symphysis joint, subchondral bone marrow edema, or periarticular edema of the symphysis, along with possible visualization of small tears of the adductor muscles. Subchondral sclerosis may be seen with chronic osteitis pubis (image 4). MRI is used with increasing frequency due to its high sensitivity and availability. 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'.)

Ultrasound may be used to help rule out hernia as well as visualize widening at the pubic symphysis joint. This modality is limited by technician expertise. However, ultrasound does have some role for diagnosis due to its lost cost and wide availability.

Bone scan should be reserved for patients in whom MRI and/or ultrasound are equivocal. Bone scan should not be a first-line imaging technique since it requires injection of radioactive tracer. Bone scan allows for greater bony detail in difficult cases and may pick up subtle stress reactions compared with other imaging studies. In patients with osteitis pubis, a large area of bone uptake may be evident near the pubic symphysis.

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

Other studies — Blood testing for inflammatory markers (ESR and CBC with differential), urinalysis, and blood cultures can be obtained to assess for an infectious process [19,20]. Blood testing should be performed for patients presenting with fever and at high risk for infection (eg, diabetes, other immunocompromised state, recent surgical intervention). Given its invasive nature, joint aspiration and/or bone biopsy should only be performed if the suspicion for osteomyelitis of the pubic symphysis if high. (See "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

MANAGEMENT — As with most sports-related injuries, active management of osteitis pubis is a vital step towards full recovery and return to activities of daily life, including sports. There have been several studies that have examined different treatment options for athletes with groin pain, including osteitis pubis [7,13,18,21]. However, there are no randomized trials, and most studies are comprised of case reports and case series, usually in male athletes [21]. The approach to management of osteitis pubis should be stepwise, going from least invasive to most invasive if previous therapy fails. In the absence of clinical trial data and large cohort studies assessing treatment options, we suggest initial management with conservative measures (rest, ice, pain medication, physical rehabilitation), followed by injection therapy, and surgery as a last resort.

In patients who present with osteitis pubis due to surgery or trauma and in those with severe symptoms, it may be appropriate to start with more invasive therapy, including injections and surgical treatment.

Medical therapy — Medical management of osteitis pubis includes rest, ice, nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, glucocorticoid injections directly into the pubic symphysis, and oral glucocorticoids [1,22-24].

After the diagnosis of osteitis pubis is established, relative rest is essential. Relative rest refers to refraining from activities that induce any type of discomfort. This usually includes avoiding the sport that immediately preceded pain symptoms and/or offending activities that exacerbate the condition. Given low cost, wide availability, and ease of administration, we suggest the use of relative rest, application of ice, NSAIDs, and physical rehabilitation as first-line treatment for both acute and chronic cases of osteitis pubis [5,21,25]. (See "NSAIDs: Therapeutic use and variability of response in adults".)

Physical rehabilitation includes assessment of any motor strength deficits/mechanical disturbances (eg, problems with flexibility and gait), exercise therapy, and the use of local modalities (eg, massage therapy, ultrasound). The main goal of physical rehabilitation is to strengthen and stabilize the pelvis and pubic symphysis. Core strengthening, adductor stretching, and balance control are key components of the rehabilitation program (eg, abdominal exercises with use of the exercise ball, bridging exercises, and side to side lunges for adductor stretch). Physical rehabilitation, usually for six to eight weeks, has been found in multiple observational studies to be effective in reducing pain among patients with osteitis pubis [21].

Complete resolution of osteitis pubis using conservative measures can take as long as two to three months. This long time course for improvement should be discussed with patients. Continued relative rest from offending activities should be employed if the patient remains symptomatic despite initial treatment.

If the patient remains symptomatic after relative rest, ice, NSAIDs, and physical rehabilitation, a local glucocorticoid injection or an oral prednisone taper is usually the next course of action. Glucocorticoid injection at the point of maximal tenderness is a technique that is often effective without significant adverse effects [7,16,22]. Injections may involve different glucocorticoid preparations (eg, dexamethasone, betamethasone, methylprednisolone) and different adjunctive agents (eg, lidocaine, bupivacaine) in varying concentrations. We use 1 mL of dexamethasone (4 mg/mL) mixed with 1 mL of bupivacaine 0.5% and 1 mL of lidocaine 1%. We give up to three injections as needed at two to three week intervals (this is rarely needed). Local glucocorticoid injection is sometimes used at an initial visit in severe, painful cases. Oral prednisone can also be given in severe or refractory cases (prednisone 60 mg for five days or a prednisone taper of 60 mg for four days, then 40 mg for four days, then 20 mg for four days OR 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) [26]. There is no evidence to support one glucocorticoid regimen over another. In our practice, we administer glucocorticoid injections rather than oral glucocorticoids if conservative measures fail. Oral glucocorticoids can be used if patients prefer not to have injection therapy.

Other less commonly used medical therapies include cryotherapy, laser, ultrasound, and electrical stimulation [5]. If these measures are not effective, we use a platelet-rich plasma (PRP) injection, although PRP injections have not been studied for the treatment of osteitis pubis [27].

Surgical therapy — Surgical management is reserved for osteitis pubis refractory to medical treatment [23,28,29]. Small case series have found that surgical treatment can be effective in most patients who fail medical therapy [30]. There are several surgical procedures used for osteitis pubis [9,23,28,29,31]:

Curettage – Debridement of degenerative areas in and around pubic symphysis, involving limited surgical exposure

Wedge resection – Trapezoidal portion of the symphysis is resected

Wide resection – Similar to a wedge resection but with larger margins involved

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

Operative treatment is not always curative, as some patients may suffer recalcitrant pain [32]. Subsequent pelvic instability may also occur, particularly after wedge or wide resection.

One systematic review found that most athletes respond well to curettage alone without resection [28]. As with medical treatment, full recovery from surgery can be quite lengthy. Whereas recovery from curettage can take three to six months, recovery from resection and arthrodesis at the pubic symphysis may take up to one year [28,30]. The long recovery process is one reason resection and arthrodesis should be reserved for patients who fail curettage [23].

SUMMARY AND RECOMMENDATIONS

Osteitis pubis is defined as an idiopathic, inflammatory condition involving the pubic symphysis and surrounding structures; it is most likely related to overuse or trauma. (See 'Introduction' above.)

Osteitis pubis is common among athletes but can occur in non-athletes, particularly in those with osteoarthritis, pregnancy, pelvic trauma, or pelvic surgery. (See 'Epidemiology' above.)

The clinical presentation of a patient with osteitis pubis can vary but generally involves the insidious onset of pelvic pain in the absence of systemic symptoms. Osteitis pubis can be confused with osteomyelitis of the pubic symphysis. Osteomyelitis is more likely to present with acute onset of severe pain and fever. However, many bony infections of the pelvis present subacutely with or without associated fever. (See 'Clinical presentation' above and "Pelvic osteomyelitis and other infections of the bony pelvis in adults".)

The diagnosis of osteitis pubis is often determined by history and physical examination alone. The gradual onset of pelvic discomfort, in combination with tenderness over the pubic symphysis or pain with resisted adductor testing (picture 1), is sufficient for the diagnosis of osteitis pubis. Blood testing, diagnostic imaging, and biopsy are adjunctive tests that are performed when the diagnosis is uncertain after history and physical examination. (See 'Diagnosis' above.)

The approach to management of osteitis pubis should be stepwise, going from least invasive to most invasive. In patients with osteitis pubis, we suggest initial treatment with conservative measures, including relative rest (refraining from activities that induce pelvic pain), ice, nonsteroidal antiinflammatory drugs (NSAIDs), and physical rehabilitation (Grade 2C). If these conservative measures fail, we suggest administration of glucocorticoid injections of the pubic symphysis rather than an oral glucocorticoid taper (Grade 2C). (See 'Medical therapy' above.)

Surgical management is reserved for patients with osteitis pubis refractory to medical treatment. Curettage of the symphysis is considered to be the most effective and well-tolerated surgical treatment option. (See 'Surgical therapy' above.)

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