What is Osteitis Pubis?
Osteitis pubis, often shortened to OP, refers to consistent inflammation of the pubic symphysis, which is the joint at the front of the pelvis, and the tissues surrounding it. This condition is not caused by any kind of infection. OP can have multiple causes and it often leads to discomfort or pain in the lower abdomen or groin area.
What Causes Osteitis Pubis?
Osteitis pubis is a condition that is not fully understood, but it is often believed to be a result of repetitive stress injury to a certain area in the pelvis known as the pubic symphysis. The pubic symphysis is a central point for the muscles in the front part of the pelvis, including muscles like the rectus abdominis (the “abs” muscles) and the adductor muscle complex (the muscles that pull the legs together).
When these muscles are used repetitively, it can cause tiny injuries or imbalances. This leads to unequal force distribution across the pubic symphysis (the joint between the two pubic bones), which changes the way the joint functions. This shift in joint function can result in stress injuries to the pubic bone which eventually leads to the damage of the cartilage, a flexible connective tissue found in many areas of the body.
The condition can also be linked to changes in hip joint mechanics, such as those seen with FAI (a condition where the hip bones are not shaped normally and rub against each other). Although this relationship is less defined. Other less common causes of osteitis pubis may include rheumatic diseases (conditions affecting the joints and muscles), surgeries involving the urinary or reproductive systems, or pregnancy.
Risk Factors and Frequency for Osteitis Pubis
Osteitis pubis is a condition that has not been well studied, so there’s no clear information about how frequently it occurs in the general population. We do know that it appears more frequently in certain athletic activities, especially among long distance runners, athletes who perform a lot of kicking, and particularly male soccer players. Additionally, men are generally more prone to osteitis pubis than women, but the gap seems to be closing as more women engage in athletics. Some studies have shown connections between other health conditions and osteitis pubis. For example, having a hip condition known as Femoroacetabular Impingement (FAI) or having received certain urological procedures can increase your chances of developing osteitis pubis.
- Osteitis pubis occurs in 0.5% to 8% of athletes, especially distance runners and kickers.
- Male soccer players account for 10% to 18% of these injuries annually.
- In a study of 189 athletes with groin pain, osteitis pubis was the primary cause in 14% of cases.
- An MRI study revealed that 9.3% of 97 athletes with groin pain had osteitis pubis, with another 42.3% showing osteitis pubis in addition to small tears in their adductor muscles.
- The condition is 2 to 5 times more common in men, although women’s risk seems to be increasing.
- About 86% of osteitis pubis patients who underwent surgery showed signs of FAI on their radiographs.
- People with FAI are nearly 14 times more likely to have osteitis pubis.
- About 68% of soccer players with symptomatic FAI showed signs of osteitis pubis on their radiographs.
- Those with a specific kind of hip deformity have a higher occurrence of osteitis pubis symptoms.
- A urological procedure known as MMK urethropexy has a 2.5% incidence rate for osteitis pubis, while less than 1% of those undergoing urological procedures in general are affected.
Signs and Symptoms of Osteitis Pubis
Osteitis pubis is a condition often faced by athletes. This tricky-to-diagnose condition involves the inflammation and subsequent pain in the front and inside of the groin area. It can result from issues in several parts of the body including the sacroiliac joint, hip labrum, hip’s rotary cuff, adductor and abdominal muscles, and the lower extremity kinetic chain. Activities related to sports frequently trigger the symptoms. They may become noticeable during athletic participation, specific movements or stretches that affect the area, or when moving from a seated to a standing position.
Besides, the patient’s prior surgical or procedural history may be relevant, especially if they’re not involved in sport activities. The discomfort from osteitis pubis tends to develop gradually and can greatly affect athletes’ capabilities due to the intensity of the pain.
Through physical exams, health professionals can identify osteitis pubis by causing pain with direct touch over the joint at the front of the pelvis. The ‘spring test’ is another strategy where pressure is applied to the side of the joint causing discomfort. There are also three provocation tests: the single adductor test, the squeeze test, and bilateral adductor test. Positive results on these tests strongly suggest osteitis pubis, especially if the patient has inflamed bone marrow in the pelvic bone as seen on an MRI. These patients may walk with a waddling gait due to the pain and feel tightness in the adductor muscles.
Due to the condition’s links with issues in the rotating cuff of the hip, examining the hip joint can be essential. If there is limited flexibility in any direction or rotation of the hip joint, this should be evaluated. Patients with either issues in the sacroiliac or hip’s rotary cuff may experience discomfort when performing the FABER test, which checks for pain during flexion, abduction, and external hip rotation.
- Pain in the front and inside groin area
- Triggered by athletic activities and certain movements
- Gardual onset of pain
- Pain when touched over the joint at the front of the pelvis
- Discomfort when performing the ‘spring test’
- Positive results on the single adductor, squeeze, and bilateral adductor tests
- A waddling gait
- Tightness in the adductor muscles
- Limited flexibility of hip joint
- Pain with FABER test (flexion, abduction, external hip rotation)
Testing for Osteitis Pubis
X-rays and MRIs are both useful for diagnosing osteitis pubis, a condition that causes inflammation in the area of your body where your two pelvic bones come together. Initially, normal x-rays may not catch early stages of osteitis pubis. However, when the condition becomes chronic, your doctor can detect changes in your pubic bones such as thinning, hardening, and widening.
Your doctor may also suggest getting a flamingo view, a special kind of pelvic x-ray taken while you’re standing on one foot and then the other. If this testing reveals any misalignment of more than 2mm, it could indicate possible instability in the area where your pelvic bones meet.
Of all the imaging tools available, the MRI has become the go-to choice for further diagnosing osteitis pubis. In the early stages, an MRI can detect inflammation in the bone tissue, often on both sides. For chronic cases, MRIs can find changes like bone resorption (a process where your body absorbs bone tissue), irregular shaping of the bone, bone spurs, and formation of fluid-filled sac in your bones, all similar to what an X-ray can reveal.
Studies show that edema or swelling in the marrow of pubic bones can even appear in people without any symptoms. However, patients with more symptoms often show a distinct signal in the MRI scans.
In people diagnosed with a hip disorder called Femoroacetabular Impingement (FAI) who have symptoms for more than 3 months, research has found that MRIs show a high prevalence of osteitis pubis. However, the prevalence was lower in control subjects and patients with FAI but without allied factors such as age and Body Mass Index (BMI).
Notably, the MRI scans seem to connect with how well patients with osteitis pubis recover. Patients with inflammation in both the pubic bone and surrounding muscles had a lower recovery rate compared to those where inflammation was confined only to the bone.
Finally, MRIs are often used to diagnose other injuries that can contribute to osteitis pubis, such as tears in the adductor muscles, rectus femoris muscles (muscles located in thigh), and the labrum (ring of cartilage that follows the outside rim of the hip joint socket). Consequently, the presence of such injuries and abnormalities may lead to less successful surgical outcomes in patients undergoing hip surgery.
Treatment Options for Osteitis Pubis
Osteitis pubis, a condition that causes inflammation in your pubic bone, can be managed through two main methods: through conservative treatment or, if needed, surgical procedures. In most cases, conservative treatment, which includes rest, taking anti-inflammatory drugs (known as NSAIDs), and a planned course of physical therapy is the first choice. However, there’s no standard protocol for this type of treatment, which means the results can vary greatly from person to person.
Unfortunately, conservative treatment for osteitis pubis can take a while. Some athletes might take 6 months or more to return to how they were before their injury, but generally, people typically start feeling better within 3 months. Nonetheless, despite it being slow, conservative management is still the main way osteitis pubis is treated.
If conservative treatment doesn’t improve symptoms, surgery might be considered. There’s no fixed timeframe to decide when conservative treatment isn’t working; it can be a range of many months. However, most commonly, at least 6 months of conservative treatment is tried before discussing surgical options.
Surgical options can involve various operations including curettage (scraping or trimming) of the symphyseal fibrocartilage (a type of cartilage), symphyseal fusion (a process that connects two bones), wedge resection of the symphysis (removal of a portion of the bone), with or without arthrodesis (bone fusion). There are also procedures to reinforce or repair the muscles of the abdomen or pelvic floor. Research shows that athletes tend to return to unrestricted activity, roughly around 6 months after a surgery.
It’s important to note that another condition, called Femoroacetabular Impingement (FAI), can sometimes coexist with osteitis pubis. FAI is a condition where the bones of your hip are abnormally shaped, causing them to painfully rub against each other. Interestingly, some patients with both osteitis pubis and FAI have experienced total relief from their osteitis pubis symptoms when FAI is treated. This suggests that osteitis pubis might be caused by altered joint movement in the pelvis.
What else can Osteitis Pubis be?
When diagnosing osteitis pubis, doctors need to rule out other conditions that can cause similar symptoms. These conditions include:
- Athletic pubalgia
- Osteomyelitis
- Adductor strain
- Rectus Abdominus strain
What to expect with Osteitis Pubis
People with osteitis pubis generally have a very positive outcome. With conservative treatment, they can typically return to their sports activities in around 3 months with a small risk of the problem coming back. In fact, only 5% to 10% of patients with osteitis pubis need to undergo surgery.
For those few who need surgery, the results are usually very good too. They can expect to return to their athletic activities roughly 3 to 4 months after the operation.
Possible Complications When Diagnosed with Osteitis Pubis
Surgical treatment for osteitis pubis may lead to several possible complications. These include:
- Chronic pain lasting for a long period of time
- Infection occuring in the area around the operation
- Failure to heal or fuse together after surgery (“nonunion of fusion”)
- Return of the osteitis pubis condition (“recurrence”)
- Blood in semen (“haemospremia”)
- Swelling in male (scrotum) or female (labia) sexual organs
Preventing Osteitis Pubis
If you’re suffering from osteitis pubis, here are some things you should know:
Osteitis pubis, a rare cause of groin pain, is often seen in people who are involved in athletics, especially soccer, running, and rugby. If you are experiencing an aggravated groin pain during physical activity, it could be a symptom of this condition.
Doctors might use plain x-rays or Magnetic Resonance Imaging (MRI) tests to help diagnose this condition. MRI is a type of imaging test that uses magnetic fields and radio waves to create detailed images of the body.
The usual treatment for this condition includes non-steroidal anti-inflammatory drugs (NSAIDs), reduced physical activities, and physical therapy. NSAIDs are a type of medicine used to relieve pain and reduce inflammation.
In rare cases where these treatments do not work, doctors may suggest surgery to provide relief from this condition. Keep in mind that this is typically a last resort treatment if other options failed to improve your condition.
