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Osteitis pubis is characterised by pain and inflammation of the joint at the front of the pelvis “pubic symphysis” and surrounding area of the bone where the muscles attach in the groin. The pubic symphysis is a joint that is designed to have only a few degrees of movement, its main function is to act as a shock absorber within the pelvis. Weakness in any of the muscles around the hip or lower spine can cause an imbalance between the two sides of the pubic joint. Any movement of the legs where one moves relative to the other (for example when we walk) would cause a shearing motion across the pubic symphysis. This shearing motion irritates the joint stimulating inflammation of the joint and surrounding muscle attachments. The inflammation causes pain and can alter how the muscles work; making the problem worse if the pain is ignored. Players involved in sports that require lots of running, kicking and rapid changes in direction are more at risk of developing Osteitis Pubis. For this reason Osteitis Pubis is commonly seen in AFL and soccer players. An individualised treatment/recovery program is important to prevent Osteitis Pubis becoming a long-term debilitating condition. Consultation with a physiotherapist will allow them to assess any contributing factors such as muscle weakness or joint stiffness and provide you with appropriate treatment and an exercise program. An individualised program is the best way to get back to sport quicker and reduce the risk of having a recurrence down the track. How do we diagnose Osteitis Pubis?The diagnosis of Osteitis Pubis is based on three main factors: 1. Information that you tell the physiotherapist Typically people with Osteitis Pubis complain of insidious onset of groin pain, usually felt in the adductor muscle but may be centred on the lower abdomenUsually aggravated by exercise at the start of their warm-up but then it reduces or goes away, only to return again once you have stopped exercisingShort periods of rest reduce the severity but on resumption of exercise the pain returns to its original intensity and severityGroin pain and stiffness the morning after a game/exercise sessionThe natural history is one of progressive deterioration until sporting activity cannot be performed “Early Warning signs” ‘tightness/stiffness’ during or after activity, stretching = temporary or no reliefLoss of accelerationLoss of speed when sprintingVague discomfort in decelerationLoss of distance in kicking sports2. Physical testing performed by the physiotherapist Your physiotherapist will take you through a number of tests to assess whether you have Osteitis Pubis or another similar groin problem. They will also do a number of tests to find out any contributing factors, these may vary from patient to patient. Some of these tests are as follows: They will have a feel of the pubic symphysis joint and areas where key muscles attach.Pain with resisted groin adduction (knee squeezed together or squeeze test) Pain on resisted hip flexion (knee to chest) Adductor muscle guarding Pain on resisted hip flexion and adduction in the Thomas test position (Pubic symphasis stress test)If it is still unclear whether you have Osteitis Pubis or not they may send you off to get either a bone scan (see article on stress fractures), CT scan or an MRI. A bone scan in the early stage may show increased uptake, however this may not be diagnosed as Osteitis Pubis as many other conditions will display similar resultsplain X-rays in a chronic presentation may show a moth eaten appearance.CT scanning is the most sensitive investigation and may show cystic changes.MRI is considered to be the ‘gold standard’, however it may show bone marrow oedema but not necessarily the bony architecture in as much detail as CT.What would my treatment for osteitis pubis involve?Treatment for osteitis pubis has a number of different components. It is now recognised that a conservative rehabilitation program should be the first line of treatment. Rest is a key component in the treatment for osteitis pubis. Without rest from the activities that cause your groin pain, inflammation will continue. This will lead to increasing pain and a slower recovery. Commencing activities too early will also predispose you to a recurrence of Osteitis Pubis. During this period your physiotherapist may advise you of alternative activities that may be suitable for you to maintain your fitness.No Pain philosophy, pain is warning sign, avoid no pain – no gain philosophy. Pain = poor compliance = poor outcome.In addition to resting from sport your physiotherapist will design an individualised strengthening program based on your assessment findings. It will likely contain exercises for your back, core, hip and lower limb muscles. This is aimed at restoring normal balance across the pelvis, particularly across the pubic symphysis.Your physio will also provide you with local tissue therapy in the form of massage and other treatment modalities.Education about the condition is really important, there should be rehab goals and good communication between coach, fitness staff and medical staff.Once your physiotherapist thinks you have sufficient strength and balance through the pelvis they will start you on a graduated running program. This will usually be about 6 – 8 weeks into your strengthening program, depending on your clinical findings.You may also be advised to speak to your doctor about taking some medication to help reduce the inflammation depending on the severity, usually in the early stages of rehab only.How long will it be before I can play sport again?Recovery from osteitis pubis can take 4-6 months or more. It is important not to rush recovery of Osteitis Pubis as it can be very common for athletes to have a recurrence of Osteitis Pubis. Your physiotherapist will monitor your groin symptoms as you begin to return to sport to assess whether you are progressing at an appropriate pace. What other treatments are available for osteitis pubis?If after a month or so of treatment your symptoms have not improved some alternative treatments may be considered. Your physiotherapist may send you to speak to your doctor to discuss the possibility and appropriateness of getting a corticosteroid injection. The purpose of these injections is to quickly settle the inflammation in order to progress with recovery. In some very severe cases of osteitis pubis, or cases that have just not responded to a thorough physiotherapy program and corticosteroid injections, an orthopaedic surgeon review may be an option. The surgeon may decide to do a “tenotomy” where they cut the adductor tendons to relieve the tightness. Discuss these options with your physiotherapist and or doctor for more information. It is important to note that this information is not intended to replace any form of physiotherapy management and a reminder that groin pain is a very complex region and an accurate assessment and diagnosis is required in order to effectively manage any groin pain condition. Please consult a physiotherapist for more information regarding Osteitis Pubis or any other groin pain. ReferencesFricker, P., Taunton, J., & Ammann, W. (1991) Osteitis pubis in athletes: Infection, inflammation, or injury? Sports medicine, 12, 266-279.Holmich, P., Uhrskou, P., Ulnits, L., Kanstrup, I., Nielsen, M., & Bjerg, A. (1999). Effectiveness of physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet, 353(9151, 439-443.Holt, M., Keene, J., Graf, B., & Helwig, D. (1995) Treatment of osteitis pubis in athletes. Results of corticosteroid injections. American journal of sports medicine, 23(5), 601-606.McCarthy, A., & Vicenzino, B. (2003) Treatment of osteitis pubis via the pelvic muscles. Manual therapy: an international journal of musculoskeletal therapy, 8(4), 257-260.McKim, K., Traunton, J. (2001). The effectiveness of compression shorts in the treatment of athletes with osteitis pubis. New Zealand journal of sports medicine, 29(4), 70-73Morelli, V., & Smith, V. (2001). Groin injuries in athletes. American Family Physician, 64, 1405-1414.Mullhall, K., McKenna, J., Walsh, A., & McCormack, D. (2002). Osteitis pubis in professional soccer players: a report of outcome with symphyseal curettage in cases refractory to conservative management. Clinical journal of sports medicine, 12(3), 179-181.Two people, case report.Paajanen, H., Heikkinen, J., Hermunen, H., & Airo, I. (2005) Successful treatment of osteitis pubis by using totally extraperitoneal endoscopic technique. International journal of sports medicine, 26(4), 303-306. Preliminary report, only five people, no proper outcome measures or demographic information.. Seidenberg, P., & Childress, M. (2005). Managing hip pain in athletes. The Journal of Musculoskeletal Medicine, 22, 246-254.Topol, A., Reeves, D., & Mohammed, K. (2005). Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Archives of physical medicine and rehabilitation, 86(4), 697-702.Wollin, M., & Lovell, G. (2006). Osteitis Pubis in four young football players: A case series demonstrating a successful rehabilitation. Physical Therapy in Sport, 7, 153-160.If you would like to know more about osteitis pubis or would like to make an appointment for an assessment and diagnosis please contact us at beleura Sports and Spinal Centre. Click here to return to articles page
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