What is osteitis pubis?

Osteitis pubis is an overuse injury at the front of the pelvis at the symphysis pubis joint. The symphysis pubis joint joins two of the main bones of the pelvis and is made up of the pubic bones (portion of the pelvis), cartilage, a joint capsule and joint fluid. The ends of the pubic bones reabsorb a slow dissolving process. The cause is unclear, but it may be a reaction to stress or a stress fracture of the end of the pelvic bones (the pubis symphysis).

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How does osteitis pubis occur?

The cause of osteitis pubis is unclear, but it is believed to be due to excessive or repeated stress to the pubic symphysis with vigorous activities or to repeated tension from muscles that attach to the area.

What increases the risk?

• Sports that require repetitive kicking, such as soccer or football kicking
• Sports that require repetitive jumping; also commonly seen in distance runners, fencers, ice hockey players and weightlifters
• Poor physical conditioning (strength and flexibility)
• Previous osteitis pubis
• Previous sprain or injury to the pelvis
• Stiffness or loss of motion of the hip
• Previous hip injury
• Ankylosing spondylitis
• Bladder or prostate surgery

What are the symptoms of osteitis pubis?

• Pain, discomfort or ache, tenderness and swelling at the front of the pelvis at the pubic symphysis
• Pain possibly extending to the groin, inner thigh or lower belly
• Symptoms that start slowly and insidiously following the activity and progress to affect the whole activity, becoming constant pain
• Pain that is worsened with pivoting on one leg, kicking a ball, sprinting, jumping, climbing stairs or suddenly changing direction while running; also pain that is worse with stretching, particularly separating the legs and thighs or with bringing the thighs and legs together against resistance
• Walking or running with a limp
• Weakness when bending the hip or kicking

Occasionally, clicking in the front of the pelvis

There is also the possibility of having osteitis pubis with no symptoms.

How is osteitis pubis diagnosed?

• Physical exam shows tenderness to palpation directly over the symphasis, where the pubic bones come together

• X-ray shows abnormal appearance to the symphasis, usually with sclerotic changes (increased bone density) and sometimes an irregular appearance at the joint

• MRI shows abnormal bone changes, joint irregularity and often, fluid in the joint

Are there any special tests?

Definitive tests include

• MRI

• Bone scan

• Diagnostic/therapeutic injection of local anesthetic/cortisone

MRI

MRI provides a detailed look at the joint, including the bone directly under the joint surfaces (the subchondral bone). The disadvantage of this test is its’ sensitivity. Some patients have changes in this joint that are not related to their symptoms.

Bone scan

Bone scan is very sensitive and specific for this condition. In this test, a very small amount of a radioactive tracer is injected intravenously, and the pubic area is scanned for the emitted radioactivity following the injection. Because some level of activity is normal, the patient is scanned both prior to and following the injection. Care is necessary when performing this test because dye accumulation in the bladder can prevent visualization of uptake of the tracer in the overlying joint. A positive bone scan is very accurate for diagnosing osteitis pubis.

Diagnostic/therapeutic injection of local anesthetic/cortisone

For cases in which there is clinical suspicion but underwhelming diagnostic imaging data, patients should be injected using local anesthetic. Although this can be performed under fluoroscopy (live X-ray), injection can usually be successfully accomplished in the office, directing a small needle with local anesthetic directly into the joint. A small “pop” is usually felt as the needle penetrates the overlying soft tissue. Improvement in the symptoms after the injection confirms the diagnosis. Usually a small amount of cortisone is added to the injection, as a therapeutic strategy if the local injection confirms the diagnosis. This approach avoids having to otherwise potentially inject a second time to instill cortisone.

How is osteitis pubis treated?

Non-operative treatment

Initial treatment consists of medications and ice to relieve pain and reduce inflammation. Modify the activities that initially caused the problem by eliminating those activities or substituting them with other activities that do not cause symptoms. Stretching and strengthening exercises of the hip muscles are important. These can be carried out at home, although referral to an athletic trainer or physical therapist for further evaluation and treatment may be helpful. Cortisone, by injection or by pills, may be attempted to relieve the symptoms and inflammation. Very slow and gradual return to sports is attempted after all symptoms have disappeared

Operative treatment

Surgery is rarely necessary. If symptoms persist despite at least 6 months of conservative treatment and the athlete is unwilling or unable to give up participating in the sport, surgery may be necessary. Surgical options include fusing the joint (removing all motion at the joint) or cleaning out the joint and removing inflamed or scarred tissue.

What are the complications of treatment?

Possible complications of non-operative treatment include:

• Persistent pain
• Impairment of activity

Possible complications of operative treatment include:

• Surgical complications not specifically associated with symphasis pubis, such as pain, bleeding (uncommon), infection (<1 percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.
• Complications specific to surgical treatment of this condition, including persistent symptoms, increased pain and instability of the symphasis pubis. 

When can you return to your sport or activity?

This condition is curable by avoiding the exacerbating activity. Continued activity results in persistent pain and disability. It may take 3 to 8 months or more to return to sports.

How can osteitis pubis be prevented?

• Avoid trauma to the hip
• Maintain appropriate conditioning:
  • Cardiovascular fitness
  • Pelvis and hip strength
  • Endurance and flexibility
  • Use proper technique