Osteitis Pubis - Chronic Inflammation of the Pubis Symphysis

Introduction

Osteitis pubis was first found in individuals who had undergone suprapubic surgery due to the complication of the invasive procedure on the pelvis. Sometimes it may occur as an inflammatory process in athletes. However, the incidence and cause of osteitis pubis remain controversial among physicians.

What Is Osteitis Pubis?

Osteitis pubis is a chronic inflammation of pubis symphysis and surrounding soft tissue. It causes abdominal and pelvic pain.

What Are the Stages of Osteitis Pubis?

• Stage 1: The pain is unilateral and dominant. The pain is felt in the inguinal region and may radiate to muscles on the inner thigh.

• Stage 2: The pain is bilateral and is felt in the inguinal and inner thigh muscles.

• Stage 3: The pain is bilateral and is felt in the groin, superior to the symphysis pubis, inner thigh muscles, and abdomen.

What Are the Symptoms of Osteitis Pubis?

The symptoms of osteitis pubis include:

• Loss of flexibility in the groin region.

• Dull aching pain in the groin region.

• In severe cases, sharp stabbing pain in the groin while running, kicking, standing, and changing directions.

• Tenderness in front of the thigh region.

• Pain while coughing and sneezing.

• Popping and clicking sound when rising from a seating position.

• Fever or chills.

• Irregular walk or gait.

What Are the Causes of Osteitis Pubis?

The causes of osteitis pubis are as follows:

• Pregnancy or childbirth.

• Gynecologic (uterus) surgery.

• Urologic (kidney) surgery.

• Playing athletic sports such as running, ice hockey, football, American football, and tennis.

• Major trauma.

• Repeated minor trauma.

• Rheumatological (disorders in muscles, joints, and bone) disorders.

• A complication of pubic surgery.

• Overload and training errors include exercising on hard surfaces and uneven grounds, too quickly increasing the exercise intensity or duration, beginning exercises after a long gap or rest, and exercising with ill-fitting shoes.

• Gait disturbances.

• Due to improper walking or running mechanisms.

• Presence of tight and stiff muscles in the hips, groin, and buttocks region.

• Imbalance in the body musculature.

• Differences in the leg length.

What Is the Pathophysiology of Osteitis Pubis?

The symphysis pubis joint has minimal motion and serves as an insertion point of the abdominal muscles and thigh muscles. The antagonistic nature of the abdominal muscles, which elevates the pubis symphysis while the thigh muscles depress the joint- results in the development of osteitis pubis.

Who Is Prone to Osteitis Pubis?

• Post-operative Patients: Individuals who have undergone suprapubic (region above pubis) surgery and other surgical procedures in the pelvic area are more prone to develop osteitis pubis.

• Pregnancy: During pregnancy, the hormone relaxin is produced, which causes the widening of the pelvis for childbirth. Due to delivery positioning, there may be damage to joints and ligaments after birth. Also, the relaxin hormone will be in the body for twelve months postpartum, increasing the risk of ligament injury.

• Athletes: It is an inflammatory response in athletes, especially football players. It is due to overuse injury, gradual in onset, and at later stages develops into osteitis pubis.

How to Diagnose Osteitis Pubis?

X-rays and magnetic resonance imaging (MRI) are essential in diagnosing osteitis pubis.

1. X-ray

• In the early stage, plain radiographs appear normal.

• In chronic osteitis pubis, there appear lytic (resorption) changes, sclerosis (hardening of tissues), and widening.

• The flamingo view determines the dynamic instability of the pubis symphysis. Greater than two mm of the subluxation is considered pubis symphysis instability.

2. Magnetic Resonance Imaging (MRI)

• In the acute stage, magnetic resonance imaging demonstrates subchondral bone edema with bilateral involvement.

• In chronic cases, magnetic resonance imaging shows bone resorption, the irregular contour of the articulating surfaces, and subchondral cyst formation.

• Magnetic resonance imaging helps to distinguish between acute and chronic cases.

• Findings obtained from this scan help in predicting the clinical outcome of the individual suffering from osteitis pubis.

• Scan showing edema involving the pubic bone and surrounding musculature has a lower percentage for recovery.

• Whereas a scan showing edema just confined to the pubic bone has a higher percentage of complete recovery within eighteen months.

What Is the Treatment?

1. Non-surgical Treatment: Conservative treatment takes three to six months for recovery.

• Rest.

• Ice compression.

• Physical therapy.

• Taking painkiller medications.

2. Surgical Treatment: Surgical management includes:

• Curettage (surgical scraping or cleaning) of symphysis fibrocartilage.

• Wedge resection of the symphysis pubis.

• Symphyseal fusion.

All these surgical procedures take a more extended period for recovery and are done to repair the abdominal and pelvic floor musculature. Athletes can return to physical activity after six months.

How to Prevent Osteitis Pubis?

• Do stretching and warm-up exercises before starting physical activity.

• Taking recovery and rest time after doing heavy workouts.

• Wear proper clothes and shoes during exercise.

• Avoid doing exercises on hard ground and uneven surfaces.

When Can Athletes Return to Physical Activity?

It takes almost two to three months to recover from osteitis pubis and resume physical activity. While recovering, the individual should not do activities that put too much pressure on the symphysis.

What Are the Exercises for Osteitis Pubis?

1. Transversus Abdominis Retraining: The transverse abdominis is the abdomen muscle that helps stabilize the pelvis.

• While lying on the back, contract the abdominal muscles, pulling the belly button back to the spine.

• Should hold this position for several minutes.

• Should not lift the rib cage.

• Should keep the rest of the body relaxed other than the abdominal muscles.

• Should repeat the exercise three to four times per day.

2. Adductor Stretch: The adductor muscles are present in the thigh.

• Standing with the back straight and legs wider than shoulder width, lunge to the left while keeping the right leg straight. The individual should feel the stretch in the right leg.

• Hold for ten to fifteen seconds without lunging too far.

• Then slowly return to the starting position.

• Then lunge to the right while keeping the left leg straight.

• Hold until a stretch is felt, and then return to the original position.

Conclusion

If an individual is experiencing symptoms of osteitis pubis, the person should contact a medical professional and be treated. The physician will guide them with strengthening exercises and stretches. Physical therapy and a progressive sport-specific program are indicated before returning to the sports activity.