What is Osteitis Pubis?
Osteitis Pubis is a common cause of chronic groin pain in the football codes. It is an overuse injury. That is, it is caused by repeated trauma rather than a specific incident. However, it is not uncommon for a specific incident to trigger the symptoms.
Diagnosis is usually made in the advanced stages when the pubis bones have begun to erode at the pubic symphysis. Early diagnosis can prevent the condition progressing beyond the stage of “bone stress”.
What Causes Osteitis Pubis?
The main cause is instability of the pelvic bones and in particular the pubic symphysis.
The instability is aggravated when asymmetrical loads are placed through the pelvis such as when running or kicking. These activities are normally well accommodated in the normal “stable” athlete but with poor lumbopelvic control the additional forces are uncontrollable and will cause injury.
Due to the instability in the region it is not uncommon for the athlete to have experienced a previous history of groin strains, a “sportsman’s” hernia or low back pain.
How to Diagnose Osteitis Pubis
Pain is usually experienced over the pubic symphysis with referred pain into the inguinal region and the groin. Palpation of the pubic symphysis and the pubic ramus is acutely tender. Resisted muscle contraction of the hip adductors and flexors will elicit pain. Likewise stretching into abduction and extension can elicit pain in the acute stage. Coughing, sneezing and performing a sit up will reproduce pain. This athlete is often unable to lie flat on their back or prone.
Bone scan will highlight advanced uptake at the pubis symphysis. X-rays will shows cysts and erosion of the pubic symphysis in advanced cases. MRI will show the bone stress injury and swelling present.
Figure 1. Osteitis pubis. Plain X-ray findings in 2 separate cases:
- A. Irregular resorption of articular cortex and variable mild subcortical sclerosis is seen along both sides of the symphysis. Also note subtle soft tissue calcification in the line of the right adductor longus (white arrowhead), indicative of simultaneous pathological change at two separate anatomical structures in this case.
- B. Longstanding disease on the right side has produced prominent traction spurs at the pubic insertion of rectus abdominis (white arrow) and adductor origin (black arrow), a broad zone of bony enthesial sclerosis at the conjoint tendon insertion and adductor origin (*), and irregular resorption of articular cortex along the right side of the pubic symphysis.
(Courtesy of: Atlas of Imaging in Sports Medicine, McGraw-Hill, Sydney 1998)
Treatment for Osteitis Pubis
A thorough rehabilitation under the guidance of an experienced Sports Physiotherapist or Sports Physician is highly recommended. The return to sport should be totally guided by their experience to avoid a future reaggravation.
Stages of Rehabilitation
- Rest is essential to unload the injured region. This will almost certainly entail a cessation of running and kicking. In the acute stage, it may even require the use of crutches if walking is painful.
- Retrain stabilisation control of the pelvic girdle via extremely specific exercises. You will need to consult your physiotherapist for these unique exercises including core stabilisation exercises.
- Normalise the adjacent soft tissue and muscle flexibility to avoid excessive forces being placed through the region. Assess and improve lumbo-pelvic, hip and lower limb biomechanics. Your physio will know what to do.
- Early return to sport is via less stressful activities such as cycling, swimming with a pool buoy. These activities should be slowly progressed in consultation with your therapist. Use these activities to maintain your cardiovascular fitness.
- Once pain permits, light straight-line running drills may commence.
It is not uncommon for this rehabilitation process to take in excess of three months.
This condition is tricky to treat. Please consult your sports physician or physiotherapist for expert advice.