Since 1924, osteitis pubis has been known as a noninfectious inflammation of the pubis symphysis (also known as the pubic symphysis, symphysis pubis, or symphysis pubica) causing varying degrees of lower abdominal and pelvic pain. Osteitis pubis was first described in patients who had undergone suprapubic surgery and remains a well-known complication of invasive procedures about the pelvis. However, it may occur as an inflammatory process in athletes. The incidence and etiology of osteitis pubis as an inflammatory process versus an infectious process continues to fuel debate among physicians when confronted by a patient who presents complaining of abdominal pain or pelvic pain and overlapping symptoms. (See image below and Image 1.)

Causes

• Pregnancy/childbirth
• Gynecologic surgery
• Urologic surgery
• Athletic activities (eg, running, football, soccer, ice hockey, tennis)
• Major trauma
• Repeated minor trauma
• Rheumatologic disorders
• Unknown etiology

In the pre-antibiotic era it was an occasional complication of pelvic surgery and in particular of retropubic prostatectomy

Prostatectomy

A prostatectomy is the surgical removal of all or part of the prostate gland. Abnormalities of the prostate, such as a tumour, or if the gland itself becomes enlarged for any reason, can restrict the normal flow of urine along the urethra....

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Overload (or training errors).

• Exercising on hard surfaces, like concrete.
• Exercising on uneven ground.
• Beginning an exercise program after a long lay-off period.
• Increasing exercise intensity or duration too quickly.
• Exercising in worn out or ill fitting shoes.

Biomechanical Inefficiencies

• Faulty foot and body mechanics and gait disturbances.
• Poor running or walking mechanics.
• Tight, stiff muscles in the hips, groin and buttocks.
• Muscular imbalances.
• Leg length differences.

Symptoms

The symptoms of osteitis pubis can include loss of flexibility in the groin region, a dull aching pain

Pain

Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...

 in the groin, or in more severe cases a sharp stabbing pain when running, kicking, changing directions, or even during routine activities such as standing up or getting out of a car.

Imaging

Osteitis pubis may be diagnosed with an X-ray

X-ray

X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...

, where irregularity and widening of the pubic symphysis

Pubic symphysis

The pubic symphysis or symphysis pubis is the midline cartilaginous joint uniting the superior rami of the left and right pubic bones. It is located anterior to the urinary bladder and superior to the external genitalia; for females it is above the vulva and for males it is above the penis...

 are hallmark findings.  Similar change is also demonstrated with Computed Tomography (CT)

Computed tomography

X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...

 however the multi-planar nature of CT has a higher sensitivity than X-rays.  Though not well visualised on ultrasound

Ultrasound

Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...

, thickening of the superior joint capsule with cyst formation is a clue to the diagnosis, as well as secondary changes (tendinosis) of the adjacent adductor muscles (particularly adductor longus) and rectus abdominis. Ultrasound is also useful for excluding a hernia

Hernia

A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm....

, which may co-exist with osteitis pubis and thus may also warrant additional treatment.  

Both ultrasound and CT may be used for injecting the pubic symphysis with corticosteroid

Corticosteroid

Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...

 as part of an athlete's treatment programme . Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging

Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...

 combines the diagnostic advantages of CT and ultrasound, also showing bone marrow oedema and has the advantages of not being operator dependent, unlike ultrasound, nor does it use radiation, such as CT and X-rays.  As such, MRI is the modality of choice .

Incidence

The incidence of osteitis pubis among Australian footballers has increased sharply over the past decade. There are believed to be three reasons for this:

• The increasing physical demands of Australian rules football. As the game has become more professionalised, with players becoming full-time athletes, such factors as running speed, kicking length, jumping and tackling have all increased, placing increasing stress on the pubic region.
• The increasing hardness of the surfaces of football grounds. Grounds are better drained than in the past, and the game is increasingly played in roofed stadiums in which the grounds receive no rain. Australian football evolved as a winter game played on soft, muddy grounds, and modern surfaces have made muscle and bone injuries more common.
• The increasing demand for size and strength among footballers. This has led young players to concentrate on building muscle mass before their bodies are fully mature. The additional strain that highly developed abdominal muscles place on the pubic bone explains the higher prevalence of osteitis pubis on young players. Some develop the condition while still playing school-level football.

Treatment and prevention

Until recently there was no specific treatment for osteitis pubis. As it frequently causes long-term problems, medication, stretching and strengthening of the stabilising muscles are usually used. Topol, in Argentina, used glucose and lidocaine injections (prolotherapy or regenerative injection therapy) to restart the healing process and generate new connective tissue in 72 elite athletes with chronic groin/abdominal pain who had failed a conservative treatment trial. The treatment consisted of monthly injections to ligament attachments on the pubis. Their pain had lasted an average of 11 months, ranging from 3–60 months. The average number of treatments received was 3, ranging from 1–6. Their pain improved by 82%. Six athletes did not improve, and the remaining 66 returned to unrestricted sport in an average of 3 months.
Surgical intervention, such as wedge resection of the pubis symphysis, is sometimes attempted in severe cases, but its success rate is not high, and surgery may lead to later pelvic problems.

The Australian Football League

Australian Football League

The Australian Football League is both the governing body and the major professional competition in the sport of Australian rules football...

 has taken some steps to reduce the incidence of osteitis pubis, in particular recommending that clubs restrict the amount of body building which young players are required to carry out, and in general reducing the physical demands on players before their bodies mature.

Osteitis Pubis if not treated early and correctly can more often than not end a sporting individuals career or give them an uncertain playing future.

Pregnancy

Damage can occur to the ligaments surrounding and bridging the pubic joint (symphysis) as a result of the hormone Relaxin which is secreted around the time of birth, to soften the pelvic ligaments for labor. At this time repetitive stress or falling, tripping, slipping can injure ligaments more easily. Usually after childbirth the hormone disappears and the ligaments become strong again. In some women the weakness persists and activities such as carrying a baby or stepping up even a small step can cause a slight but continual separation or shearing in the ligaments of the symphysis, where they attach to the joint surfaces, even causing lesions in the fibrocartilage and pubic bones. Symptoms include one or more of the following; pain in the pubic area, hips, lower back and thighs. This can take months or years to settle.
X-rays taken during the early stages of osteitis pubis can be misleading, you may feel the pain but the damage doesn't appear on the films, unless stork views are obtained (i.e. standing on one leg). As the process continues, later pictures will show evidence of bony erosion in the pubic bones. Osteitis pubis can also be associated with pelvic girdle pain

Pelvic girdle pain

Pregnancy related Pelvic Girdle Pain causes pain, instability and limitation of mobility and functioning in any of the three pelvic joints...

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External links

• MRI images of the groin demonstrating bone oedema in keeping with clinical finding of osteitis pubis