What is osteitis pubis?

Osteitis pubis is an overuse injury affecting 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, or slowly dissolve. 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).

WOSM Hip Experts:

• Dr. Benjamin McArthur
• Dr. Andrew Wolff

How does osteitis pubis occur?

The cause of osteitis pubis is not fully understood, but it is believed to be due in part to excessive or repeated stress to the pubic symphysis with vigorous activities or from repeated tension of 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)
• History of osteitis pubis
• Previous sprain or injury to the pelvis
• Stiffness or loss of motion of the hip
• Previous hip injury
• Ankylosing spondylitis
• History of 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 abdomen
• Symptoms that start slowly and gradually following activity and progress to constant pain
• Pain worsened with pivoting on one leg, kicking a ball, sprinting, jumping, climbing stairs or suddenly changing direction while running
• Pain worsened with stretching, particularly separating the legs and thighs or with bringing the thighs and legs together against resistance
• Weakness when bending the hip or kicking
• Occasionally, clicking in the front of the pelvis
• In some cases, the condition may be present on a x-ray, but is asymptomatic

How is osteitis pubis diagnosed?

• Physical exam shows tenderness to palpation directly over the symphysis (where the pubic bones come together)

• X-ray may show abnormal appearance to the symphysis
  • Sclerotic changes (increased bone density)
  • Irregular appearance at the joint

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

Are special tests used to diagnose osteitis pubis?

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

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 inconclusive diagnostic imaging data, patients may be injected with a local anesthetic. While this can be performed under fluoroscopy (live x-ray), an injection can usually be successfully performed in the office. Your physician will direct 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.

 How is osteitis pubis treated?

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 orally, may be used to relieve the symptoms and inflammation.

Surgery is rarely indicated. If symptoms persist despite at least 6 months of conservative treatment and the patient is unwilling or unable to give up provocative activities, 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.

When can you return to your sport or activity?

Often, this condition resolves with rest and avoidance of the exacerbating activity. 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