What is Osteitis Pubis?
Osteitis Pubis is an inflammation of the pubic symphysis, the cartilage that joins the two pubic bones, of the pelvis. The inflammation can also extend to muscle insertions in the surrounding area. First described in 1924 by a urologist who noticed inflammation in post suprapubic surgical patients, it is characterised by a loss of flexibility in the groin region accompanied by dull, aching pain in the lower abdomen and pelvic region, or a sharp, stabbing pain when running (especially changing directions) or performing actions such as kicking. Pain can also be present when performing mundane tasks like getting out of a car or stepping into a bath. On examination, there is often tenderness on palpation along the adductor longus (one of the main groin muscles) point of origin.
Diagnosis can be confirmed with the assistance of the following investigations:
- X-ray – a widening of the pubic symphysis is often seen
- More detail can be found in a CT scan
- Ultrasound (US) imaging is sometimes used to assess any thickening of the joint capsule as well as potential tendonosis (deterioration of collagen) in the adductor muscles (especially adductor longus) and lower abdominal muscles. Radiologists may also use US to rule out a hernia which can cause similar symptoms to Osteitis Pubis
- MRI is the gold standard of investigation as it does not use radiation like x-ray and CT and can be used for diagnosis and also to determine treatment planning
Who suffers from Osteitis Pubis?
Post-operative patients
The condition can occur in people who have undergone suprapubic (the region above the pubic region) surgery, or other surgical procedures in the pelvic region. These include gynaecological and urological procedures.
Pregnancy
Due to a hormone called relaxin, the ligaments in the body increase in laxity and the pelvis widens in preparation for child birth. There can be some damage to joints and ligaments after childbirth due to delivery positioning and women can also injure themselves during slips, trips or fall while pregnant or post-delivery. Relaxin is in the body for 12 months after child birth, increasing the risk of ligament injury. During pregnancy and delivery, women can also suffer from pubic symphysis diastasis where the cartilage separates. This is usually reasonably painful and is often associated with pelvic girdle pain which is quite common in pregnant women.
Athletes
Osteitis Pubis also occurs as an inflammatory response in athletes especially when asymmetrical forces are placed through the pelvis such as those experienced in football codes when kicking, tackling and being tackled. It is usually an overuse injury and gradual in nature, meaning it isn’t due to one specific sustained injury. However, an injury can result in a predisposition to developing Osteitis Pubis at a later date.
Australian Football League
The incidence of Osteitis Pubis has increased drastically in the last decade due to three reasons:
- As players become bigger and stronger, there is pressure on young aspiring footballers to add size and mass to their bodies before they are mature enough to manage the load. This is especially significant with those trying to develop abdominal muscles, placing increased strain on the pubic bone.
- As the game has become more professional, time spent training and playing has increased. The nature of the game that requires, running, kicking, tackling, changing direction and jumping for marks places great amounts of strain through the pubic symphysis and groin.
- Less rain, better drainage at stadiums and local grounds as well as roofed stadiums has resulted in dryer and therefore firmer playing surfaces. The harder surfaces have been linked with an increase in soft tissue and bony injuries.
Other playing factors that increase the risk of developing Osteitis Pubis include;
- Poorly fitted football boots
- Running long distances in football boots that aren’t cushioned like a running shoe
- Excessive playing load or sudden increase in load and/or intensity
- Uneven playing surfaces e.g. divots and pot holes.
The AFL has taken steps to reduce the incidence of Osteitis Pubis in players by recommending that strength training, especially of a bodybuilding nature, in younger players is kept to an appropriate level until their bodies have a chance to mature to meet the demands of training. If not managed correctly, Osteitis Pubis can become a career ending condition.
How is Osteitis Pubis Treated?
During the initial stage, standard anti-inflammatory measures such as resting, icing and compression as well as anti-inflammatory medication can be used. Once the acute phase has passed then patient can commence gentle stretching and strengthening of the stabilising muscles of the pelvis. A physiotherapist will assess and address any biomechanical imbalances such as incorrect gait pattern, foot biomechanics and leg length discrepancies as well as tight or stiff hamstring and gluteal muscles.
If symptoms do not respond to therapy, a corticosteroid injection can be made into the pubic symphysis by a medical professional.
An Argentinian study(1) has looked into regenerative therapy, an injection of lidocaine and glucose to facilitate the healing process and connective tissue regeneration. A trial involving 72 athletes who have had unsuccessful conservative management, saw subjects having monthly injections to the pubic ligaments. Results showed that pain improved by 82%, 6 athletes did not improve and 66 returned to playing unrestricted sport in an average of 3 months.
Surgical management can involve a wedge resection of the pubic symphysis in the most severe of cases that haven’t responded to conservative management. An alternative intervention is an endoscopic technique which has fewer complications.
References:
(1) Topol GA, Reeves KD (2008). “Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series”. Am J Phys Med Rehabil. 87 (11): 890–902.