Osteitis Pubis

Where is Osteitis Pubis painful? (Body Chart)

What are the classical features of Osteitis Pubis?

Best characterised as a bone stress injury

Age: All ages, more frequent in the younger population as higher activity levels, 20-50 years old

Gender: 3 to 5 times more common in males compared to females.

Activity: Running, rapid change of direction, acceleration, deceleration

Sport: long-distance runners, soccer, ice hockey, tennis, AFL, netball, basketball

Where is Osteitis Pubis painful?

– Pain on the pubic bone especially close to the pubic symphysis

– May radiate to surrounding structures but will stay localised to the lower abdomen and proximal/medial thigh

– Most commonly unilateral however can be bilateral // depends on how far progressed the pathology is and where it is on the pubic bone

Characteristics of symptoms for Osteitis Pubis

– Pain during, and after loading

– Pain increases with loading // no warm-up effect

– During the activity: sharp pain, can be described as pulling or catching

– After the activity: dull ache, deep inside

– Intermittent symptoms depend on the activity

– Report loss of function

– Reduced power production

Typical activity capability/restriction for clients with Osteitis Pubis

– Will become increasingly restrictive with loading

– Likely start with mild symptoms that do no inhibit function and can progress to the point of inability to participate in activity

– Report loss of power (ie reduced kicking distance)

– Reduced agility (unable to cut and push off of the affected side)

– Pain on activities that increase intraabdominal pressure (cough, sneeze)

Behaviour of symptoms for Osteitis Pubis

Aggravating:

– Running, change of direction, kicking, jumping, agility, variable surface, stairs, plyometric exercises, shear forces, abduction

Ease

– Stable surface, rest, NSAIDs, increased cadence, reduced speed

24-hour pattern:

– Mechanically related so will be activity dependant

– If aggravated may ache at night or the next morning

Typical history of a client with Osteitis Pubis

– Highly active individuals

– Typically a recent increase in loading // review training diary if available

– Unlikely to have a traumatic incident

– Start with dull ache and soreness after aggravation, will progress with increases to loading

– As the pathology progresses it will start to inhibit function (starts with high-level activities like power and sprinting) and will affect lower-force activities (ie running and stairs)

– If not managed will become more disabling

Pathobiological mechanisms behind Osteitis Pubis

– Nociceptive dominant

– May have a tendency to become nociplastic as the population may be hesitant to give the relative rest required for optimal healing to occur

– Also nociplastic potential as symptoms typically prolonged for 6/12 months

– Recurrence of injury is common and past experiences should be explored to identify psychosocial factors

Proposed pathology underlying Osteitis Pubis

– Best described as a bone stress injury

– Repeated trauma on the pubic bone from its muscular attachments

– Loading causes repeated damage of the bone and leads to tissue pathological changes

– The higher the contractile demand of these muscle groups the increased forces being placed on the bone

– Can cause inflammatory process and also muscle restriction

– Endpoint is sclerosis of the pubic symphysis

Physical impairments & associated structure/tissue sources (ie P/E findings)

Local:

– Tenderness on the pubic symphysis

– Tenderness on rectus abdominis insertion

– Tenderness on the pubic body and ramus

– Tenderness at the adductor insertion

– Pain on a contraction of abdominals and adductors

– Reduced internal rotation at the hip

– Reduced abduction at the hip

– Reduced hip flexor length

– Reduced strength into adduction // increased if combined with rectus abdominis activation

Remote

– Reduced balance/proprioception of the lower quarter

– Reduced lumbopelvic control

– Reduced abductor strength

General

– Running technique (reduced stability or adductor activation)

– Kicking technique (adductor load biased)

Typical contributing factors to Osteitis Pubis

– History of back dysfunction

– History of SIJ dysfunction

– Hip anterioversion

– Coxa vara

– Hip hypomobility

– Participation in high load activities

– Leg length discrepancy

– Irregular loading patterns (sporadic)

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability

– Serious pathology needs to be excluded due to the overlapping nature of symptoms

– If unsure send for imaging prior to local treatment

– Care with stretching and shear forces at the pubic symphysis as likely cause irritation

Relevant diagnostic imaging for Osteitis Pubis

– Shortly after onset imaging may be negative, isotope scintigraphy will demonstrate intensive uptake at this stage of the lession

– Changes start to occur over time including becoming sclerotic and “motheaten” in appearance

– Changes on imaging typically will persist even after the symptoms have resolved

– X-ray will identify bone changes if present for a period of time // minimum 2 weeks

– CT will have better detail however provides a similar value as an x-ray

– MRI is the gold standard for detail and diagnosis. Provides evidence of edema which the other options will not display

Typical prognosis for Osteitis Pubis

– Good prognosis if the patient is unloaded aggressively

– 6-8 weeks of pain-free activity minimum prior to returning to activity

– Estimated to take between 6-12 months for full symptoms resolution

– Can resume activity prior to that point however requires monitoring

– No correlation between imaging and return to sport, should be function/criteria dependant

Management/treatment selection for Osteitis Pubis

Unloading (high-level evidence)

– Need to have a period of relative rest just like with other boney injuries

– Minimum of 6-8 weeks of pain-free activity

– Limit shearing and stretching forces during this time

Local

– Abdominal and hip joint stretches (low-level evidence)

– Reconditioning adductors (high-level evidence)

– Pacing to progressively reintroduce load in the affected area (high-level evidence)

Remote

– Lumbopelvic control with aggravating activities

– Optimise mechanics // abductor conditioning and ratio to adductors

Hyperbaric chamber (low-level evidence)

General

– Gait analysis // biomechanical review to minimise adductor strain

– Orthotics for leg length

– Pacing with a return to activity (high-level evidence)

Pharmacology

– Refer to doctor for NSAID’s if required

– Will assist with pain in the early stages of rehabilitation

Hydrotherapy

– Can assist in the early stages to maintain CV fitness

– No frog kicking to minimise stress on the affected area

Shock wave therapy

– High-level evidence for reduced pain however no difference in function

Surgery

– Send for referral if failed conservative

Differential Diagnosis for Osteitis Pubis

– SIJ // palpation, symptoms differentiation

– FAI // hip assessment,

– Adductor enthesopathy // palpation, imaging

– Rectus abdominis enthesopathy // palpation, imaging

– Inguinal hernia // palpation with cough

– Inguinal impingement // neuro symptoms, palpation

– Lower back referral // lumbar range and PAMS

– Somatic referral

– Osteomyelitis // constitutional symptoms

– Labral pathology // labral tests

– Fracture // imaging

– Visceral // palpation, B&B dysfunction

– Prostatitis // constitutional symptoms, B&B dysfunction

References

Bahr R. Th IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.

Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.

Kelm, J., Ludwig, O., Andre, J., Maas, S. and Hopp, S., 2018. What do we know about osteitis pubis in athletes?. Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-traumatologische Sportmedizin.

McAleer, S.S., Lippie, E., Norman, D. and Riepenhof, H., 2017. Nonoperative management, rehabilitation, and functional and clinical progression of osteitis pubis/pubic bone stress in professional soccer players: a case series. journal of orthopaedic & sports physical therapy, 47(9), pp.683-690.

Melegati, G. and Elli, S., 2017. Osteitis Pubis. In Groin Pain Syndrome (pp. 135-140). Springer, Cham.

Schöberl, M., Prantl, L., Loose, O., Zellner, J., Angele, P., Zeman, F., Spreitzer, M., Nerlich, M. and Krutsch, W., 2017. Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study. Knee Surgery, Sports Traumatology, Arthroscopy, 25(6), pp.1958-1966.

Via, A.G., Frizziero, A., Finotti, P., Oliva, F., Randelli, F. and Maffulli, N., 2019. Management of osteitis pubis in athletes: rehabilitation and return to training–a review of the most recent literature. Open access Journal of sports medicine, 10, p.1.