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Use of Pubic Symphysis Curettage for Treatment-Resistant Osteitis Pubis in Athletes

Authors:
  • Perth Orthopaedic and Sports Medicine Centre, Perth ,Western Australia

Abstract

In athletes, osteitis pubis is regarded as a problem of overuse, with instability and movement of the anterior pelvis. There is no evidence to conclusively support any treatment modality. Recovery with nonoperative management can take an extended period of time, often unsatisfactory for professional athletes. Curettage of the pubic symphysis is a viable option for nonoperative treatment of resistant osteitis pubis in athletes. Case series; Level of evidence, 4. This retrospective study presents the results of curettage of the pubic symphysis in 23 athletes with osteitis pubis that was refractory to initial nonoperative therapies. Patients met the criteria for the study if they had symptoms suggestive of osteitis pubis and underwent isolated pubic symphysis curettage. The discomfort had been present for a mean of 13.22 months before presentation. Patients were reviewed at 24.31 months (range, 12.5-59.6 months) postoperatively. Twelve of the patients also underwent a postoperative magnetic resonance imaging scan at 19.10 months; any findings of residual osteitis pubis were noted. Mean visual analog scale for pain improved from 6.9 preoperatively to 2.8 postoperatively (P = .36). Twenty-one patients returned to pain-free running by 3.14 months (range, 1.5-6 months), 17 to training by 4.44 months (range, 2.5-7 months), and 16 to full activity by 5.63 months (range, 2.5-12 months). Overall, 61% of patients reported an activity grade of 4 at postoperative review, defined as no pain with full activity. There were no significant postoperative complications in the study group. Marrow edema improved in most cases for which magnetic resonance imaging was available preoperatively and postoperatively. Patient satisfaction with the procedure was high, with 78% of participants feeling their symptoms were better or much better than preoperatively. The authors suggest that this relatively simple procedure can be of significant benefit to those athletes wishing to return to their previous levels of physical activity when more nonoperative measures have proven unsuccessful.
122
Osteitis pubis in athletes is generally regarded as a result of
overuse and functional anterior instability of the pelvis.3,7-9,14,23
Sports most commonly implicated include soccer, Australian
Rules football, rugby, ice hockey, American football, and dis-
tance running.2,4,6,8,9,12,13,15,22 The typical history is of gradu-
ally increasing unilateral or bilateral discomfort or pain in
the pubic area, 1 or both groins (adductor areas), and the
area of the lower rectus abdominis muscle.1,2,6-9,16,17
Diagnosis of osteitis pubis can be obtained from the typical
history of gradually increasing unilateral or bilateral dis-
comfort or pain in the pubic area, 1 or both groins (adduc-
tor areas), and the area of the lower rectus abdominis
muscle.1,2,6-9,16,17,21,23 Additional signs of osteitis pubis
include tenderness of the symphysis pubis and adjacent
pubic bodies and rami, as well as pain on adductor muscle
stretch.6,8,13,21,23 Various imaging techniques such as plain
radiographs, bone scans, and MRI have been used to aug-
ment this diagnosis.2,6-8,20,23 Radiographic changes in the
more severe (or acute) situations may include rarefaction
or cystic changes of the margins of the symphysis with
widening of the joint. In the more chronic or asymptomatic
forms of the disease, variable degrees of sclerosis and joint
narrowing may be visible.5Instability of the symphysis
pubis may be seen on an AP radiograph of the pelvis while
the patient stands on 1 leg (the “flamingo” view).8,23
However, as with other bone and joint problems, the sever-
ity of the disease may not correlate with radiographic
changes, and it is not uncommon for radiographs to be nor-
mal in the presence of disease.6,8,13,14,21 Bone scans have
shown that increased uptake in the symphysis pubis
region can be associated with osteitis pubis, although
scans may not become positive for some months after the
Use of Pubic Symphysis Curettage
for Treatment-Resistant Osteitis
Pubis in Athletes
Ross Radic,* MBBS, and Peter Annear, MBBS, FRACS(Orthopaedics)
From Perth Orthopaedic and Sports Medical Centre, West Perth, Australia
Background: In athletes, osteitis pubis is regarded as a problem of overuse, with instability and movement of the anterior pelvis.
There is no evidence to conclusively support any treatment modality. Recovery with nonoperative management can take an
extended period of time, often unsatisfactory for professional athletes.
Hypothesis: Curettage of the pubic symphysis is a viable option for nonoperative treatment of resistant osteitis pubis in athletes.
Study Design: Case series; Level of evidence, 4.
Methods: This retrospective study presents the results of curettage of the pubic symphysis in 23 athletes with osteitis pubis that
was refractory to initial nonoperative therapies. Patients met the criteria for the study if they had symptoms suggestive of osteitis
pubis and underwent isolated pubic symphysis curettage. The discomfort had been present for a mean of 13.22 months before
presentation. Patients were reviewed at 24.31 months (range, 12.5-59.6 months) postoperatively. Twelve of the patients also
underwent a postoperative magnetic resonance imaging scan at 19.10 months; any findings of residual osteitis pubis were noted.
Results: Mean visual analog scale for pain improved from 6.9 preoperatively to 2.8 postoperatively (P=.36). Twenty-one patients
returned to pain-free running by 3.14 months (range, 1.5-6 months), 17 to training by 4.44 months (range, 2.5-7 months), and 16 to
full activity by 5.63 months (range, 2.5-12 months). Overall, 61% of patients reported an activity grade of 4 at postoperative review,
defined as no pain with full activity. There were no significant postoperative complications in the study group. Marrow edema
improved in most cases for which magnetic resonance imaging was available preoperatively and postoperatively. Patient satisfaction
with the procedure was high, with 78% of participants feeling their symptoms were better or much better than preoperatively.
Conclusion: The authors suggest that this relatively simple procedure can be of significant benefit to those athletes wishing to
return to their previous levels of physical activity when more nonoperative measures have proven unsuccessful.
Keywords: osteitis pubis; pubic symphysis curettage; groin pain; athletes; recovery for osteitis pubis in athletes
*Address correspondence to Ross Radic, MBBS, 31 Outram Street,
West Perth, WA, Australia 6005 (e-mail: rossradic@hotmail.com).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 36, No. 1
DOI: 10.1177/0363546507306160
© 2008 American Orthopaedic Society for Sports Medicine
Vol. 36, No. 1, 2008 Treatment-Resistant Osteitis Pubis in Athletes 123
onset of symptoms.6,8 Studies have shown that MRI is a use-
ful tool in diagnosing osteitis pubis and in assessing its clin-
ical features in relation to scan changes.6,20,21 Verrall et al20
found that there was a significant correlation between cur-
rently symptomatic athletes with marrow edema graded as
severe (also with marrow edema graded as severe and an
affected area size equal to or larger than 2 cm) and between
previously symptomatic athletes with changes on MRI scan
consistent with previous injury to the pubic bone area.
Nonoperative management has become the preferred
method of treating the condition. Typically, treatment
includes physical therapy, involving strengthening the
abdominal and hip muscles to improve core stability;
improving range of motion of the hip, particularly the mus-
cles of internal rotation; and modification of activity to
minimize pain and associated debility.6-8,14,16,21,23 Although
osteitis pubis is considered a self-limiting condition, recov-
ery can be lengthy, averaging 9.6 months for men and 7
months for women, with a general range of 3 to 12
months.1,2,6,8,16,21 Drug therapy has traditionally been
directed at providing anti-inflammatory and analgesic
effect with the use of nonsteroidal anti-inflammatory
drugs (NSAIDs) and/or cyclooxygenase-2 inhibitors.6-8
Corticosteroid injection has been used for relief of symp-
toms with good effect, particularly in the case of athletes
for whom it is unacceptable to spend extended periods of
time away from physical activity2,6,13; however, this has not
been conclusively shown to promote recovery.8
Surgery has historically not been recommended as a
method of treatment for osteitis pubis.6-8,21 However, various
procedures have been undertaken, including wedge resec-
tion and symphysiodesis of the pubic symphysis, with incon-
clusive results.17,19,23 More recently, curettage of the pubic
symphysis has been performed with some success; however,
limited data are available regarding the efficacy of this
method.18 It is less extensive than previously described pro-
cedures, perhaps leading to reduced risks and a shorter
recovery to full participation in physical activities.18
The present study presents the results of curettage of the
pubic symphysis in 23 athletes with osteitis pubis that was
refractory to initial nonoperative therapies. Specifically, we
looked at the successfulness of curettage as a treatment
option for athletes with osteitis pubis and the recovery
time before the patients could recommence sporting activ-
ities at their desired level.
METHODS
The details of athletes who were seen at the Perth
Orthopaedic and Sports Management Centre and under-
went pubic symphysis curettage surgery for osteitis pubis
during the period from January 14, 2000, to February 24,
2005, were reviewed. All surgery was conducted by Mr P
Annear, consultant orthopaedic surgeon. Patients met the
criteria for the study if they had symptoms suggestive of
osteitis pubis as described in the introduction and under-
went isolated pubic symphysis curettage. Patients with
symptoms suggestive of osteitis pubis plus conjoint ten-
dinitis or adductor tendinitis and had corrective surgery
for these conditions were excluded from this study. From the
medical records, 41 patients with isolated osteitis pubis
were identified who underwent surgery for correction of the
condition after failure of traditional nonoperative therapies.
Eighteen patients were lost to follow-up for various reasons,
the majority because of loss of contact details. The remain-
ing 23 patients are the basis of this study.
The medical charts of these patients were reviewed to
determine which sporting activity the patient regularly
undertook. The history of all patients was reviewed to
determine the presenting complaint, duration of symp-
toms, severity of symptoms, and mode of onset. Of these
athletes, 22 were men and 1 was a woman, with a mean
age at presentation of 27.04 years (range, 19.9-56.7 years).
The most common sporting activities associated with the
presentation were Australian Rules football (15 patients)
and soccer (5 patients). Two patients competed in touch
rugby and 1 in field hockey.
Patients were graded into 4 categories based on their
functional ability before surgical intervention. Grade 4
patients could play all sports with no pain, grade 3 patients
could run but could not participate fully in sports, grade 2
patients could not run, and grade 1 patients had symptoms
with walking. In addition, patients were given a 10-point
visual analog score to grade their pain, ranging from no pain
(0) to the worst pain ever experienced by the patient (10).
The type and duration of previous treatments under-
taken by the patients were recorded. Patients were seen by
general practitioners, sports physicians, and physical thera-
pists and were commenced on a range of various therapies.
These included resting, stretching exercises as described
previously designed to improve core stability and improve
range of movement, injection into the symphysis pubis, and
regular use of oral NSAIDs. As many different treatment
modalities were undertaken by the patients, and for dif-
fering lengths of time before the surgical referral, quan-
tifying these details was not attempted. In all cases
described here, patients failed to respond to these meth-
ods with inadequate relief of symptoms or recurrence of
the problem.
Patients were investigated with the use of various imag-
ing techniques, including MRI, bone scan, and radiography,
and the findings of these investigations were noted.
Corticosteroid plus local anesthetic injection into the pubic
symphysis under imaging guidance was used both as an
investigative tool and for symptomatic control. Patients
were classified as having complete resolution of symptoms
within 24 hours after injection, partial improvement, or nil
improvement. Injection of the symphysis that gave resolu-
tion of symptoms was considered to be a good indicator of an
isolated lesion in the pubic symphysis, whereas only partial
or very limited relief was felt to indicate additional injuries.
Patients then underwent curettage of the pubic symphysis.
Patients were positioned supine and square draped so that
the umbilicus was on view, which helps to isolate the sym-
physis pubis. A transverse incision 3 cm in length centered
over the symphysis pubis was performed with routine
exposure of the superoanterior aspect of the left and right
pubic body and pubic symphysis. A 19-gauge needle was
used to isolate the pubic symphysis, and a 1.5-cm incision
124 Radic and Annear The American Journal of Sports Medicine
was placed over the symphysis pubis, again in the trans-
verse orientation. Curettage was performed of the fibrocar-
tilage disc and hyaline endplates of both pubic bodies until
healthy marrow bone was removed from both pubic bodies.
The curettes were 0.5 to 1 cm in size and enabled safe curet-
tage of the joint without penetrating outside the joint. A
2-mm drill was used to perform 3 passes into each pubic
body, advancing peripherally and staying well within the
confines of the bone. The wound was closed in layers with
1-0 Vicryl for joint and deep fascia and fat sutures and sta-
ples for skin. In 15 patients, samples of the curetted mate-
rial were sent for histopathologic evaluation. Corticosteroid
was not injected into the pubic symphysis at the time of sur-
gery for fear of postoperative infections in the joint.
Patients were managed postoperatively with overnight
hospitalization and bed rest. They were given crutches to
use for 5 to 10 days postoperatively, as dictated by the
patient, with first review undertaken 2 weeks after sur-
gery, primarily for a wound check. Rehabilitation centered
on physical therapy, focusing on core stability exercises,
with resumption of training at 3 months and return to
sport guided by the patient and clinical signs thereafter.
Patients were then reviewed at a mean of 24.31 months
(range, 12.5-59.6 months) postoperatively for follow-up
and progress monitoring. Patients commented on any pres-
ence of symptoms at review, any recurrence of their symp-
toms in the period postoperatively, and at what time in
their postoperative period these recurrences occurred.
Their progress after surgery was noted, with time to pain-
free running, return to training, and return to full activity
recorded. Patients were also given an activity grading
relating to their functional ability. The same activity
grades were used as those preoperatively, and the 2 were
compared. All patients were again asked to complete the
10-point visual analog score for their pain at final review.
Matched-pair comparison analysis was used to compare
pain scores preoperatively and postoperatively using a sig-
nificance level of .05. Twelve of the 23 patients also under-
went a postoperative MRI scan at a mean of 19.10 months
(range, 8.84-41.72 months), and any findings of residual
osteitis pubis were noted. Patient satisfaction was graded
as worse, same, better, or much better. Patients were also
asked whether they thought surgery was worthwhile, not
worthwhile, or unsure of the usefulness of the procedure.
RESULTS
Athletes reported the typical history of a subacute onset of
pain in the region of the pubic symphysis. The discomfort
had been present for a mean of 13.2 months (range, 2-36
months) before presentation, and deep palpation of the
pubic symphysis reproduced these symptoms. Several
patients also had some referred pain into the hip, thigh,
abdomen, and scrotal areas. Patients reported that pain
increased in severity during activities such as abdominal
strengthening exercises, kicking activities, running, cough-
ing, and sneezing. Pain was improved with rest and anal-
gesia but did not completely resolve. Results of the visual
analog score before surgery showed a mean pain score of
6.9 (range, 3-9). Examination of the patients was consid-
ered positive for osteitis pubis in all 23 patients. All phys-
ical examination was carried out by Mr Peter Annear, who
was also the operating surgeon in all cases.
Overall, 35% of patients (n =8) fell into the most severe
activity grade 1, in which their symptoms of osteitis pubis
were present on walking; 39% of patients (n =9) who
underwent curettage of their pubic symphysis were
classed as activity grade 2; and only 6 patients (26%) had
less severe symptoms where they were able to run but
unable to compete in physical activity at their desired
level, classed as activity grade 3 (see Table 1).
All of the 23 patients interviewed had been seen by a
range of physical therapists, general practitioners, and
sports physicians before surgery. As a requisite for surgery,
all patients had failed nonoperative approaches outlined
previously, including stretching, rest, core stability exer-
cises, and steroid injections.
Injection of the pubic symphysis of corticosteroid under
imaging guidance was carried out in all patients. Complete
resolution of symptoms was achieved with this injection in
19 patients (83%), whereas 3 patients (13%) had partial
resolution of symptoms. However, in all cases, any
improvement in symptoms was temporary, with return of
symptoms with resumption of activities. One patient had
an inconclusive result from injection into the pubic sym-
physis as the result of a vaso-vagal attack, and therefore
the procedure was abandoned. Complete resolution of
symptoms was considered to be a good indication that
symptoms arose from pathologic changes confined to the
pubic symphysis. Imaging investigations were also under-
taken to confirm the diagnosis of osteitis pubis. Fifteen
patients had an MRI scan preoperatively, with 13 of those
(87%) showing signs of osteitis pubis. The MRI findings
consistent with osteitis pubis included marrow edema and
the presence of a symphysial effusion. Other pelvic lesions
were also noted on MRI scans: 4 patients had concurrent
partial tears of an adductor tendon unilaterally. Six
patients were investigated with a bone scan of the pelvis;
5 of these patients demonstrated definite increased uptake
in the pubic symphysis region, whereas 1 patient’s scan
returned an inconclusive result. Plain radiographs were
also used in 6 patients to aid with diagnosis, with all 6
showing features of osteitis pubis, including sclerosis, ero-
sion, resorption, or instability of the pubic symphysis.
There were no significant complications perioperatively
or postoperatively. Fifteen of 23 patients operated on had
TABLE 1
Distribution of Patient Activity Grades
Activity
No. of Patients
Grade Description Preoperative Postoperative
1 Pain with walking 8 0
2 Pain with running 9 3
3 Pain with full activity 6 6
4 No pain with full activity 0 14
Vol. 36, No. 1, 2008 Treatment-Resistant Osteitis Pubis in Athletes 125
histologic reporting on the samples taken from the pubic
symphysis. However, as previous studies of this area have
demonstrated, none of those samples showed any signifi-
cant inflammatory infiltrate. Primarily, changes of degen-
erative cartilage were observed in those samples sent for
histopathologic evaluation.
At follow-up, patients were again asked to complete a
visual analog score regarding any osteitis pubis symptoms
from which they now suffered. This returned with a mean
of 2.83 (range, 0-7). Compared with preoperative visual
analog scale scores, postoperative pain scores were found
not to be statistically significant (P=.36). Fourteen
patients (61%) had improved their activity grades to a
level 4, indicating the ability to participate in all sports at
their desired levels. Six patients (26%) reported an activity
grading of 3, indicating some restriction in sporting activ-
ity, with only 3 patients with an activity grade of 2. No
patients reported an activity grade of 1 at their follow-up,
equivalent to symptoms present during walking.
The patients’ recovery course was monitored by calcu-
lating the time taken for each patient to return to pain-free
running, training in the chosen sports, and return to full
activity. It should be noted here that 2 patients (9%) in the
group did not reach pain-free running in their recovery
course. An additional 4 patients (6 of total group, 26%)
were unable to return to full training at the time of follow-
up, and 1 further patient (7 of total group, 30%) had not
regained participation in full physical activity to which
they could before the onset of their symptoms of osteitis
pubis. However, 1 of those patients who did not return to
full activity had effectively retired from his chosen sport
before the surgery. Those patients who were able to partic-
ipate in resumption of the various levels of physical activ-
ity were then used to calculate mean times to pain-free
running, full training, and full activity (Table 2).
A postoperative MRI was conducted in 12 patients. Nine
of these patients had also been investigated with MRI pre-
operatively, which enabled us to compare preoperative and
postoperative scans. Seven of those 9 patients (78%)
showed improvement in features associated with osteitis
pubis (marrow edema, symphysial effusion), whereas 22%
(2/9) showed persistent MRI signs of osteitis pubis. Three
other patients had MRIs conducted postoperatively but
had no preoperative MRIs for comparison. Two patients
showed very low or mild residual edema in the pubic rami
unilaterally, both with nil effusions. One patient’s MRI
demonstrated moderately severe osteitis pubis with the
presence of a symphysial effusion, but no presence of pubic
rami edema. Table 3 shows the relationship between MRI
results and the patient’s return to sporting activity.
Patients were asked about any episodes of recurrence of
symptoms of osteitis pubis during the follow-up period.
Nine patients (39%) reported no problems or recurrence of
symptoms during the postoperative period. A further 6
patients (26%) did experience the return of symptoms
previously attributed to osteitis pubis at 8, 10, 10, 12, 13,
and 18 months postoperatively, but these resolved with
further rest and have not troubled them since.
Seven patients (30%) stated that they have not been able
to resume their previous levels of physical activity. Of these,
1 patient had been able to play a minimal number of com-
petitive sporting games but was continually troubled by groin
symptoms. Six of these patients had not been able to reach
full training. One was troubled by quadriceps and hamstring
injuries, considered separate from his osteitis pubis, whereas
another was injured at work when undertaking heavy lifting.
Two patients were unable to reach pain-free running. One of
these patients underwent a postoperative MRI demonstrat-
ing resolution of the previously evident changes of osteitis
pubis. In both cases, further surgical treatment was not rec-
ommended by the operating surgeon.
The 1 woman in the study reported a very good postopera-
tive recovery procedure with return to full activity at 3
months after her procedure. However, she did experience a
recurrence of symptoms at 11 months after the procedure,
after which she opted for a fusion procedure of the pubic sym-
physis. Of significance in this case is her obstetric history,
which included 1 standard vaginal delivery (4 years previous
to onset) and 1 breach delivery (2.5 years previous to onset).
Patient level of satisfaction with the procedure was high,
with 39% of patients (n =9) reporting feeling much better
and a further 39% patients (n =9) reporting feeling better
than before surgery. Of the remainder, 3 patients (13%)
thought their symptoms were the same as before surgery,
and 2 patients (9%) thought their symptoms had increased in
severity since their curettage. When subjects were asked if
they felt the procedure was worthwhile, 16 of the 23 inter-
viewed (70%) thought it was, 6 patients (26%) thought it was
not worthwhile, and 1 patient (4%) was unsure.
DISCUSSION
Many treatment regimens have been applied to osteitis pubis
including rest, activity, NSAIDs, oral and injected steroids,
physical therapy, heat, bracing, anticoagulation therapy,
antibiotics, and radiation.6-8,10,13,14,17 Nowadays, the most com-
mon practice in dealing with osteitis pubis is modification of
activity patterns and physical therapy.6-8,14,21 Recommended
rehabilitation consists of improving hip range of motion; devel-
oping strength and power of the hip rotators, flexors, and
adductors; and improving strength of the lumbar stabilizers
and upper and lower abdominal muscles.6-8,14,16,21,23 Drug
therapy has traditionally been directed at providing anti-
inflammatory and analgesic effect with the use of NSAIDs
or cyclooxygenase-2 inhibitors.6-8 However, there is still no
evidence to conclusively support any treatment modality.
Recovery with nonoperative management can take an
extended period of time, which is often unsatisfactory for
TABLE 2
Time Course of Recovery
Range, mo
Activity Mean, Level Not
Attained mo Minimum Maximum Attained
Pain-free jogging 3.14 1.5 6 2 patients
Training 4.44 2.5 7 6 patients
Full activity 5.63 2.5 12 7 patients
126 Radic and Annear The American Journal of Sports Medicine
professional athletes—time spent away from the game can
result in poor team performances, low morale for the ath-
lete, and loss of wages.
Conflicting opinions exist as to the role of corticosteroid
injections in the treatment of osteitis pubis. Fricker et al8
stated that corticosteroid injections have little effect on the
course of osteitis pubis but did not present data to validate
this. Holt et al13 presented a series of 12 athletes treated
with an injection of a mix of 4 mg dexamethasone and
1 mL each of 1% lidocaine and 0.25% bupivacaine into the
symphysis pubis of various protocols. Batt et al2presented
2 case reports of collegiate football players with osteitis
pubis who were treated with betamethasone injections. In
both instances, injection gave symptomatic relief for a
period of time. Batt et al concluded that with persistent
symptoms, the use of corticosteroid injections can be useful
in treating athletes with osteitis pubis, for whom time away
from activity is particularly undesirable. Batt et al and Holt
et al provided figures that suggest steroid injection into the
pubic symphysis can be used for symptomatic relief of osteitis
TABLE 3
Comparison of Preoperative and Postoperative MRI Findings
MRI Clinical Outcome, mo
Patient Preoperative Postoperative Running Training Full Activity
1 2-cm marrow edema on right, Persistent edematous tissue; 6 Not any Not any
slightly less on left; partial partial-thickness tearing of
adductor longus tear adductor origins slightly more
than previous
2 Low-grade cortical irregularity; Nil effusion; reduction 4 7 8
no significant symphysial in marrow edema
marrow edema; nil effusion
3 Prominent marrow edema within the Complete resolution of 3 Not any Not any
pubic bones; partial tear involving extensive marrow edema;
adductor longus and brevis origin nil effusion; residual partial-
from anteroinferior margin of right thickness adductor origin tear
pubic body
4 No MRI evidence of active osteitis Increased prominence 2 5 6
pubis; small partial tear of partial-tear left
of left adductor tendon adductor tendon;
nil effusion; nil edema
5 Marrow edema 3 cm left, Small symphysial effusion; 2 2.5 2.5
2 cm right marrow edema remained within
body of pubic bones 2 cm
6 3- to 3.5-cm marrow edema Nil effusion; previously Not any Not any Not any
each side of pubic symphysis; evident marrow edema
moderately prominent filling body of pubic rami
osteitis pubis completely resolved
7 5-mm pubic body edema; No current MR evidence 3 4 4.5
spurring; subchondral of marrow edema
sclerosis
8 Moderate to severe osteitis pubis; Marrow edema within body 3 4 4.5
small fluid in symphysis; of left pubic bone diminished
moderate reactive marrow significantly; a small band of
edema, left greater than R fluid-type signal intensity
remains within symphysis
inferiorly
9 Focal marrow edema within Very mild marrow edema 3.5 Not any Not any
the body of the left pubic bone within the body of the pubic
bones, diminished postoperatively
10 Not done Nil effusion; very low marrow edema 4 5 6
in body of right pubic bone;
nil marrow edema left
11 Not done Mild residual edema inferior 2 5 6
aspect left pubic bone;
nil effusion; previous evidence
of right adductor tear/lengthening
12 Not done Symphysial effusion; superior 4 6 7
bony spurring; nil groin pathology;
moderate to severe osteitis pubis
Vol. 36, No. 1, 2008 Treatment-Resistant Osteitis Pubis in Athletes 127
pubis. Similar outcomes have been found in other studies,2,6,13
although with small numbers of patients. How ever, follow-up
in each study was limited, providing insufficient information
on recurrence of symptoms. Repeated injections into the
joint are often required, with no fixed regimen as to how
these patients are to be managed.
Although generally regarded as a self-limiting problem,
osteitis pubis refractory to nonoperative treatment has been
reported.5,9-11,18,19,23 Schnute19 was the first to describe a
wedge resection of the symphysis pubis to provide relief of
symptoms. However, Moore et al17 reported on 2 cases in
which patients developed debilitating posterior instability of
the pelvis and necessitated operative stabilization 12 and 18
years after wedge resection of the symphysis pubis for treat-
ment of osteitis pubis. Both patients required bilateral
arthrodesis of the symphysis pubis and the sacroiliac joints
to relieve symptoms. Moore et al concluded that there is a
risk of late posterior instability of the pelvis after resection of
the symphysis pubis and that arthrodesis of the symphysis
pubis to improve stability of the pelvic ring is a more suitable
option for the patient with refractory osteitis pubis.17 Grace
et al10 and Coventry and Mitchell5have reported on similar
symphysis pubis resections, with initial success in reducing,
or eliminating, symptoms. However, longer follow-up of
patients revealed a high risk of the return of symptoms, pos-
sibly because of the progressive posterior instability related
to the disruption of the anterior part of the pelvic ring.17
Williams et al23 presented a series of 7 professional male
rugby players suffering from osteitis pubis who were
treated with arthrodesis of the pubis symphysis by bone
grafting supplemented by a compression plate. In this
series, all patients received a minimum of 13 months
(range, 13-48 months) of supervised nonoperative treat-
ment consisting of courses of rest, physical therapy, and
NSAIDs. Outcomes of the study reported that all patients
were free of symptoms, and none were taking analgesic
medications. Patients had resumed light training at 3.7
months (range, 3-6 months), and full match fitness was
achieved at 6.6 months (range, 5-9 months). Although out-
come was successful, postoperative recovery is lengthy
when adopting arthrodesis as a surgical method of treating
osteitis pubis refractory to nonoperative therapy.
Mulhall et al18 presented a case report of 2 professional
soccer players, ages 25 and 26, with 1- and 1.5-year histo-
ries of groin pain, respectively, related to osteitis pubis that
were refractory to nonoperative management. During that
time, both patients had undergone nonoperative therapy,
including analgesia, NSAIDs, physical therapy, and at
least 2 local steroid injections with no benefit. The surgical
procedure was similar to that described here, although an
injection of methylprednisolone (40 mg) and 0.5% bupiva-
caine infiltration under direct vision was added. Patients
commenced a program of nonspecific hip stretching exer-
cises on the first postoperative day. Both cases reported
no complications of wound problems or infections, and
patients returned to full, professional sporting activity
within 6 months. Mulhall et al concluded pubic symphysis
curettage in resistant osteitis pubis was an acceptable
method of treatment but still required further study with
randomized analysis to further evaluate its usefulness.
Studies have recorded various time frames for recovery,
ranging from 3 to 12 months.1,2,6,8,16,21 The largest study,
conducted by Fricker et al,8reviewed the records of 59
patients (50 men and 9 women) seen at the sports medi-
cine clinics at the Australian Institute of Sports and the
University of British Columbia suffering from osteitis
pubis; 44 men and 4 women were considered to have
sports-related osteitis pubis. Full recovery was classed as
pain-free function and participation in all desired activi-
ties. Treatment protocols for the patients varied but con-
sisted of anti-inflammatory medications, electrotherapy
modalities, stretching and flexibility exercises, strengthen-
ing of muscle groups, and modification of activities. Fricker
et al reported recovery times of a mean of 9.6 months for
male patients (range, 3 weeks to 48 months) and 7 months
for female patients until return to physical activity. How -
ever, these times refer to a group of 20 men and 2 women,
and it is unsure from the study what the outcome was for
the remainder of subjects. Recurrence was also calculated
for sports in which there was more than 1 participant rep-
resented in the study, with an overall figure of 9 of 37 for
men (24.3%) and 0 of 2 for women (0%). Our results of the
patients studied in this series suggest that a full return to
activity may be reached, on average, in 5.63 months (95%
confidence interval, 4.47—6.78 months). We compare this
with the results of the research of Fricker et al, the largest
series reported in the literature to date, which indicated a
recovery time of 9.6 months for men and 7 months for
women.8The study samples are appropriately similar in
terms of age of patient, duration of onset, and types of
sports activities undertaken by patients.
Of the 23 patients reported here, 7 (30%) had been unable
to reach full participation in physical activity at the time of
follow-up. As a result, the mean times for full recovery to be
reached by the study group were taken from the remaining
16 patients. In comparison, the original study base of
Fricker et al was 59 patients. The quoted times for full recov-
ery are based on 20 patients for whom full recovery was doc-
umented.8It is unclear from the literature as to what the
outcome was for the remainder of the patients. On average,
patients returned to pain-free running by 3.14 months (91%
of patients; range, 1.5-6 months), training by 4.44 months
(74% of patients; range, 2.5-7 months), and full activity by
5.63 months (70% of patients; range, 2.5-12 months).
Of interest in this research is the use of postoperative
MRI to assess the degree of marrow edema or symphysial
effusion. This is the first research that we are aware of
that has been able to conduct postoperative MRIs on
patients treated for osteitis pubis. Research has already
shown that MRI is the best imaging tool in comparing sever-
ity of osteitis pubis clinically with MRI features.6,20,21 As
only 9 patients were assessed with preoperative and postop-
erative MRI scans, we were unable to objectively assess any
changes in the MRI findings of osteitis pubis postopera-
tively. But subjectively, as shown by our results earlier, one
can see a general improvement in marrow edema and a
reduction of any symphysial effusion. In addition, persist-
ence of edema or effusions was generally related to a less
satisfactory outcome with regards to ability to perform at a
desired level of physical activity. These results support the
128 Radic and Annear The American Journal of Sports Medicine
theory that curettage of the pubic symphysis can allow for
healing of osteitis pubis in treatment-resistant cases.
From the research presented here, we were also able to
gain insight into the patient’s perception of the surgery at
the follow-up interview. As follow-up was a mean of 24.31
months, it can be assumed that this is an adequate length of
time for patients to assess the successfulness of the surgical
procedure on a personal basis. The pain score for subjects
improved from a mean of 6.9 to 2.8 (P=.36). Our research
indicated that 39% (n =9) thought their symptoms were
much better than before surgery, and 39% (n =9) were at
least better than previously. Only 9% (n =2) thought their
symptoms had increased in severity since their surgical pro-
cedure. These figures correlate well with those obtained
when patients were asked about their surgical outcomes,
with 16 of 23 patients (69%) agreeing the procedure was
worthwhile. As such, it would appear that patients generally
found the procedure successful to some degree, and it is
worth noting here that these patients were only considered
for surgery when their symptoms had been resistant to
more traditional forms of therapy for osteitis pubis.
The research presented here does have limitations. First,
there were a significant number of patients lost to follow-up
and who therefore were unable to be interviewed. We would
have preferred to be able to follow all patients after surgery,
in that it would give a more accurate idea of outcome for the
study sample and increase the size of the study. All research
published to date regarding surgical intervention of osteitis
pubis has been troubled by small patient numbers. Moreover,
as reported in previous research, complications of alternative
surgical procedures developed 18 to 20 years after the origi-
nal corrective procedure and long-term follow-up may be
needed to fully define any complications. However, we feel
that more significant is the difficulty in obtaining random-
ized controlled data comparing this surgical procedure with
more conservative therapy. First, all patients considered for
surgery in these cases had already failed nonoperative ther-
apy. Ideally, to compare surgical treatment versus nonopera-
tive therapy, patients would need to be randomized to either
treatment modality. Such a study, however, poses numerous
logistical problems, and it is unlikely that it is possible to do
such research.
CONCLUSION
Published data on the results of curettage of the symphysis
pubis for treatment of osteitis pubis are very limited. Our
research depicts the outcomes of 23 patients (22 male and
1 female), representing 58% follow-up, who underwent
curettage of the pubic symphysis for osteitis pubis that had
been resistant to more conservative methods. In general,
our results suggest that this relatively simple procedure
can be of significant benefit to those athletes wishing to
return to their previous levels of physical activity, with
70% of patients returning to full physical activity at a
mean of 5.63 months after surgery. In addition, 61% stated
they were pain free at the time of review. As osteitis pubis
is generally a condition affecting athletes participating at
a high level of physical activity, it is often unacceptable for
them to be away from their chosen sports for extended
periods of time. At present, it appears that there is no def-
inite solution to resolve this issue, although we believe
that this procedure can provide a significant benefit to
such athletes, with a shorter recovery time than that of
more conservative methods. When considering the ideal
method of treatment of osteitis pubis, it is clear from the
current published data that further research needs to be
conducted in this area. Specifically, larger, randomized
studies need to be designed such that treatment methods
can be compared accurately.
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... Osteitis pubis (OP) in athletes is an idiopathic inflammatory condition that affects the pubic symphysis and the surrounding soft tissues and is caused by overuse or trauma [1][2][3][4][5][6][7]. It was first documented as a complication after suprapubic surgery by Beer in 1924, but it was later renamed athletic OP by Spinelly in 1932 [5]. ...
... It was first documented as a complication after suprapubic surgery by Beer in 1924, but it was later renamed athletic OP by Spinelly in 1932 [5]. OP is more common in high-level athletes, who train intensively, such as soccer, rugby, Australian Rules football, distance running, and ice hockey players [6,7]. It is characterized by pain in the pubic symphysis that worsens with physical activity. ...
... The prevalence of athletic OP has recently been observed to range from 0.5% to 8%. However, in kicking sports, mainly male soccer players sustain significantly more injuries, at a frequency ranging from 10% to 18% per year [2,4,6,7]. OP is a self-limiting disease that improves with activity modification and individualized conservative treatment, while surgical treatment is required for about 5% to 10% of patients. However, not all athletes are eligible for conservative treatment due to difficulties in pain management and the long or unpredictable time frame of conservative treatment [6,7]. ...
Article
Full-text available
Osteitis pubis (OP) is a self-limiting, noninfectious inflammatory disease of the pubic symphysis and the surrounding soft tissues that usually improves with activity modification and targeted conservative treatment. Surgical treatment is required for a limited number of patients. This study aims to investigate the current literature on the surgical treatment of OP in athletes. A systematic review was conducted on two databases (MEDLINE/PubMed and Google Scholar) from 2000 to 2021. The inclusion criteria were adult patients with athletic OP who underwent surgical treatment and studies published in English. The exclusion criteria included pregnancy, infection OP, or postoperative complications related to other surgical interventions, such as urological or gynecological complications. Fifty-one surgically treated cases have been reported in eight studies, which included short-term, mid-term, and long-term studies ranging from one patient to 23 patients. The surgical treatment methods were as follows: (a) pubic symphysis arthrodesis, (b) open or endoscopic pubic symphysectomy, (c) wedge resection of the pubic symphysis, and (d) polypropylene mesh placed into the preperitoneal retropubic space endoscopically. The main indication for surgical intervention was failure of conservative measures and long-lasting pain, disability, and inability to participate in athletic activities. Wedge resection of the pubic symphysis has been the less preferred surgical treatment in the recently published literature. The most common surgical method of treatment of OP in athletes, which entailed the existence of posterior stability of the sacroiliac joint, in the current literature is open pubic symphysis curettage. Recently, there has been a tendency for pubic symphysis curettage to be performed endoscopically.
... Pain can be unilateral or bilateral, and it is typically [11,25]. Clinically, pressure pain over the os pubis, either as a result of deep palpation or even pain at rest, is the primary clinical sign [26,27]. Due to the effect on the proximal origin of the adductor muscles, the adductor squeeze test at 0-, 45-and 90-degree hip flexion is frequently also positive [28]. ...
... Long-standing pubic-related groin pain is typically described as a self-limiting condition that responds well to conservative therapy [11,13,26,56]. The primary therapeutic goal in youth soccer is a rapid but sustainable return to play without recurrent problems and no further negative influence of the injury on the athlete's career. ...
Article
Full-text available
Background Despite being a common overuse entity in youth soccer, scientific data on risk factors, rehabilitation and return to play for long-standing pubic-related groin pain is still rare. The current prospective cohort study aims to evaluate potential risk-factors, propose a criteria-based conservative rehabilitation protocol and assess return-to-play outcomes among professional youth soccer players suffering from long-standing pubic-related groin pain. Methods Male soccer players with long-standing (> 6 weeks) pubic-related groin pain from a professional soccer club’s youth academy were analyzed for possible risk factors such as age, team (U12 - U23), younger/older age group within the team, position and preinjury Functional movement score. All injured players received a conservative, standardized, supervised, criteria-based, 6-level rehabilitation program. Outcome measures included time to return to play, recurrent groin pain in the follow-up period and clinical results at final follow-up two years after their return to play. Results A total of 14 out of 189 players developed long-standing pubic-related groin pain in the 2017/2018 season (incidence 7.4%). The average age of the players at the time of the injury was 16.1 ± 1.9 years. Risk factor analysis revealed a significant influence of the age group within the team (p = .007). Only players in the younger age group were affected by long-standing pubic-related groin pain, mainly in the first part of the season. Injured players successfully returned to play after an average period of 135.3 ± 83.9 days. Only one player experienced a recurrence of nonspecific symptoms (7.1%) within the follow-up period. The outcome at the 24-month follow-up was excellent for all 14 players. Conclusions Long-standing pubic-related groin pain is an overuse entity with a markedly high prevalence in youth soccer players, resulting in a relevant loss of time in training and match play. In particular, the youngest players in each team are at an elevated risk. Applying a criteria-based rehabilitation protocol resulted in an excellent return-to-play rate, with a very low probability of recurrence. Trial registration The trial was retrospectively registered under DRKS00016510 in the German Clinical Trials Register on 19.04.2021.
... attempts to normalize forces across the pubic symphysis, address the superficial nerve structures in the inguinal area generating pain, and/or mitigate the secondary osseous abnormalities in the pubic bone. 8,30,47,60,84 Previous systematic reviews have assessed the effectiveness of surgical treatment for CGP in athletes. 11,31,33,54,69,76 Those reviews, however, present significant limitations: inclusion of studies with short postoperative follow-up (<6 months), 11,31,33,54,69,76 exclusion of open surgical treatment, 54 failure to include techniques to treat adductor-or pubic-related CGP, 54 lack of categorization for the surgical techniques according to the anatomic area addressed, 11,76 main outcomes not presented as return to preinjury level of activity, 33,76 and failure to include studies published in the past 5 to 10 years. ...
... 5 b 0 Gill (2020) 24 Koutserimpas (2020) 37 0 1 Gerhardt (2020) 23 4 4 2 Van Meirhaeghe (2019) 79 3 3 Piozzi (2019) 57 1.5 Zoland (2018) 85 Emblom (2018) 19 1 2 2 1 9 c 0 Kajetanek (2018) 32 Roos (2018) 63 Matikainen (2017) 45 Pokorny (2017) 58 7 0 Kopelman (2016) 36 0 Santilli (2016) 67 Rossidis (2015) 65 2 Boukhris (2014) 6 5 de Queiroz (2014) 14 17 13 d Schilders (2013) 68 7 Messaoudi (2012) 46 3 Dojčinović (2012) 16 Maffulli (2012) 40 0 0 5 2 3 e Dellon (2011) 13 0 0 0 0 0 Robertson (2011) 62 1.8 0 1.8 Atkinson (2010) 2 1.5 1.5 1.5 34 Radic (2008) 60 26 Ziprin (2008) 83 Paajanen (2008) 53 12. 17 2 Kumar (2002) 38 11 Srinivasan (2002) 73 0 Irshad (2001) 30 4.5 9 4.5 Williams (2000) 82 14 f Meyers (2000) 47 1.2 0.6 Brannigan (2000) 7 Ziprin (1999) 84 Hackney (1993) 26 Malycha (1992) 41 Akermark (1992) 1 Polglase (1991) 59 1.5 a Values are presented as percentages. Blank cells indicate not reported. ...
Article
Full-text available
Background Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes. Purpose To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed. Study Design Systematic review; Level of evidence, 4. Methods The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed. Results Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin. Conclusion Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.
... Of those patients, 72% were able to return to sport at an average of 5.6 months [4]. Radic et al. examined the role of pubic symphysis curettage in 23 patients who had failed conservative therapy [67]. While pain scores did not statistically differ pre-and postoperatively, 61% of patients were able to return to full sporting activity. ...
Chapter
Pelvic instability and osteitis pubis can be challenging for physicians to diagnose and treat. While initial management is conservative (including physical therapy, injections, anti-inflammatories, etc.), a subset of patients benefit from surgical intervention guided by the clinical presentation and imaging. Good functional outcomes can be achieved with several surgical techniques, including anterior and posterior pelvic ring fixation and fusion.
... So wurde berichtet, dass eine Instabilität der Symphyse zu vermehrten Rotationsbewegungen im Bereich des ISG mit konsekutiver Hypermobilität und arthrotischen Veränderungen führt [24]. Eine offene Kürettage der Symphyse über einen Pfannenstielzugang hat sich als sicheres Verfahren und weniger invasiv als eine vollständige Resektion oder Keilresektion gezeigt [25]. Zuletzt wurden als Weiterentwicklung sowohl die reine endoskopische als auch eine arthroskopisch assistierte Mini-open-Symphysioplastik eingeführt [10,20]. ...
Operationsziel: Therapie des schambeinbedingten Leistenschmerzes über eine minimal-invasive Symphysioplastik. Indikationen: Therapierefraktärer schambeinbedingter Leistenschmerz auf Basis einer Osteitis pubis. Kontraindikationen: Leistenschmerz anderer Genese. Operationstechnik: Nach minimal-invasivem Zugang erfolgt die Eröffnung der anterioren Kapsel unter Schonung der dorsalen Kapselanteile und des Ligamentum arcuatum pubis. Die Symphysenendplatten werden mittels Kugelfräse arthroskopisch assistiert remodelliert. Die neu geschaffene Schambeinfuge wird mit autogenem Fibrin gefüllt, um die Bildung eines Neodiskus zu unterstützen. Abschließend erfolgt der schichtweise Wundverschluss. Weiterbehandlung: Teilbelastung mit 20 kg an Unterarmgehstützen für 4 Wochen, danach langsames Aufbelasten. In den ersten 4 Wochen sollte die Flexion auf 60° und die Innenrotation auf 10° eingeschränkt werden. Ergebnisse: Seit 2010 bis 2018 wurden 10 Sportler (7 männlich, 3 weiblich; Durchschnittsalter 34,1 ± 7,8 [23–47] Jahre) mittels arthroskopisch assistierter, minimal-invasiver Symphysioplastik und operativer Therapie des femoroazetabulären Impingementsyndroms behandelt. Die durchschnittliche Nachuntersuchungszeit betrug 5,1 (2–9) Jahre. Alle Patienten konnten zu ihrem Sportniveau zurückkehren. Der Non-Arthritic Hip Score (NAHS) zeigt zum Follow–up-Zeitpunkt einen signifikanten Anstieg von 64,4 ± 15,1 (32,1–86,5) auf 91,4 ± 9,8 (62,4–98,75) Punkte (p< 0,0001). Die durchschnittliche Patientenzufriedenheit (Skala 0 bis 10; 10 höchste Zufriedenheit) lag bei 9,8 ± 0,4 (9–10).
... Osteitis pubis is an overuse syndrome characterized by pain and tenderness from the groin to the pubic symphysis caused by exercise [1]. Repeated traction forces caused by the rectus abdominis and adductor muscles attached to the pubic bone cause loading and instability of the pubic symphysis [2][3][4][5]. ...
Article
Full-text available
Femoroacetabular impingement syndrome (FAIS) has been associated with osteitis pubis; however, it is still unclear whether hip dysplasia is associated with osteitis pubis. This study aimed to investigate (i) the incidence of pubic bone marrow edema (BME) on magnetic resonance imaging in symptomatic patients with FAIS, borderline developmental dysplasia of the hip (BDDH) and developmental dysplasia of the hip (DDH) undergoing hip arthroscopic surgery with labral preservation and (ii) the demographic and radiographic factors associated with pubic BME. A total of 259 symptomatic patients undergoing hip arthroscopic surgery between July 2016 and April 2019 were retrospectively reviewed and divided into three groups: FAIS (180 patients), BDDH (29 patients) and DDH (50 patients). Diffuse changes in the pubic bone adjacent to the pubic symphysis were labeled pubic BME, and the prevalence of their occurrence was examined. Multivariate logistic regression analysis was performed to identify factors involved in pubic BME, and odds ratios (ORs) for relevant factors were calculated. There was no significant difference in the prevalence of pubic BME among the three groups (20 [11.1%] of 180 FAIS patients, 6 [20.6%] of 29 BDDH patients and 7 [14%] of 50 DDH patients, P = 0.325). Multivariate logistic regression analysis showed that acetabular coverage was not associated with pubic BME, whereas younger age and greater alpha angle were still independent associated factors [age ≤26 years (OR, 65.7) and alpha angle ≥73.5° (OR, 4.79)]. Determining the possible association of osteitis pubis with cam impingement in dysplastic hips may provide insights toward a more accurate understanding of its pathophysiology.
Chapter
Osteitis pubis refers to lower abdominal or groin pain arising from hypermobility of the pubic symphysis, degenerative change to the symphyseal cartilaginous disk, and stress reaction in the peri-symphyseal bone. It is initially treated conservatively, but if symptoms persist after 12 weeks, surgical intervention is an option. A number of procedures have been described, but they all involve either resecting the symphyseal cartilaginous disk or fusing the joint. Both types of procedures have reasonable return to play rates.
Chapter
Pubic symphysis instability is an uncommon cause of hip or groin pain. This situation is observed mostly in patients with history of rheumatologic, obstetric, or urologic conditions and athletes with history of repetitive overuse hip, groin, pelvis, core, or spine injury. Traumatic separation of the joint can happen in females due to stretch or rupture of ligamentous structures during birth. Individuals with hypermobility syndromes (such as Ehlers-Danlos Syndrome) are at elevated risk of symphysis instability. Athletes may be at higher risk of developing symptomatic symphysis instability in the setting of core muscle injury. Osteitis pubis is a more common condition which can cause similar symptoms. Even without known risk factors, many patients may present with symptomatic pubic symphysis instability. Symptoms are usually nonspecific and can mimic other pathologies in this area. Thus, diagnosis relies on assimilating the patient’s subjective complaints, objective physical examination, and relevant imaging. Pain during sports activity and weight-bearing along with tenderness over the symphysis and adductor origin are the most common clinical findings. Weight-bearing plain radiographs, especially single-leg stance “flamingo” views, are usually diagnostic. Nonoperative treatment includes oral nonsteroidal anti-inflammatory medications, rest, activity modification, and physical therapy. Diagnostic and therapeutic injections may be utilized in the evaluation and treatment of patients with symptomatic symphysis instability before considering surgical reconstruction. Surgical intervention may be indicated if nonoperative treatment fails. Limited literature exists on specific techniques and post-operative outcomes. As with most hip preservation surgery, optimal patient selection, expectation management, and safe open, laparoscopic, or endoscopic techniques are critical to obtain optimal outcomes. Consultation with general surgery and/or urology is valuable to assist in the decision to surgically manage the condition.
Article
Full-text available
Osteitis pubis is a painful condition that affects the pubic symphysis and surrounding tendinous attachments. One common cause stems from unusual biomechanical stress to the pelvis. Patients typically have a variety of vague and nonspecific symptoms, which makes accurate diagnosis of this condition difficult, particularly for clinicians not familiar with the disorder. A systematic approach to evaluating these patients is essential because the differential can be quite large and includes isolated muscle tears, lumbar radiculopathy, and stress fractures. Fortunately, once the diagnosis is confirmed, conservative treatment such as rest and nonsteroidal anti-inflammatory drugs usually leads to a favorable outcome.
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Osteitis pubis is a potential cause for unexplained pubic pain in athletes. It may be confused initially with adductor muscle strain, hernia, or prostatitis. The persistence of pain and tenderness of the pubic tubercles, ischial rami, rectus abdominis insertion, and adductor origin are consistent findings. The diagnosis is confirmed by characteristic x-ray changes in the pubic symphysis. Symptomatic relief may be obtained with rest, non-steroidal anti-inflammatory agent, and gradual resumption of sports activity.
Article
Medical records of 59 patients (9 females and 50 males), who presented to sports medicine clinics at the Australian Institute of Sport and the University of British Columbia between 1985 and 1990 and who were diagnosed as suffering osteitis pubis, were reviewed and comparison of data obtained was made with the literature. Women average 35.5 years of age (30 to 59 years) and men 30.3 years (13 to 61 years). Sports most frequently involved were running, soccer, ice hockey and tennis. Clinical presentations of osteitis pubis fell into 4 main groups. ‘Mechanical’ (sport-related) was the largest group (n = 48), followed by ‘obstetric’ (n = 5), ‘inflammatory’ (n = 4) and ‘other’ (n = 2). Period of follow-up averaged 10.3 months (1 to 20 months) in women and 17.5 months (2 to 96 months) in men. Full recovery, when documented, averaged 9.5 months in men and 7.0 months in women. Osteitis pubis recurred in 25% of these men and none of these women at follow-up. The most frequent symptoms were pubic pain and adductor pain. Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin. Men also revealed tenderness of one or both the superior pubic rami and evidence of decreased hip rotation (unilateral or bilateral). Evidence of pelvic malalignment and/or sacroiliac dysfunction was frequently seen in both men and women. There was poor correlation between radiographic and isotope bone scan findings and the site and duration of symptoms and signs. Femoral head ratios were estimated on 30 hips in the series and 2 were judged to be at the upper limit of normal, perhaps indicating a form of epiphysiolysis producing tilt deformity of the head of the femur. It is clear that osteitis pubis in athletes is not uncommon and that factors such as loss of rotation of hips and previous obstetric history are important in the aetiology and management of this condition. Pelvic infection, which was believed to be the primary factor of osteitis pubis in the literature up until the 1970s, plays a very small role in this condition in athletes.
Article
The authors report experiences of their own and of their colleagues at the Mayo Clinic in 45 cases of osteitis pubis, in the hope of removing this condition from the narrow vision of the specialist who sees but an occasional case and correlating it with the broader aspects of the problem. They emphasize that it concerns not only the urologist and other specialists—orthopedist, radiologist, gynecologic surgeon, and internist—but also the general practitioner. Since cultures of material obtained from the bone at operation or by biopsy in 5 cases were sterile, they believe that the underlying difficulty is venous congestion secondary to inflammation in the adjacent urinary tract. Treatment was aimed at clearing up the urinary infection and relieving symptoms by local measures. In 5 cases symptoms were relieved by surgery.
Article
Osteitis pubis is a condition that often affects athletes involved in running and kicking sports. Men are more often affected than women, and the onset is usually in the third or fourth decade of life. The condition is usually self-limiting, although recovery typically takes many months. There are many factors that contribute to this condition, including muscle action on the pelvis, limitation of rotation of the hip, pelvic biomechanics (for example, sacroiliac dysfunction), neurogenic factors, and overuse. Symptoms and signs relate to pubic pain and tenderness. Management includes modified activity during recovery; physical therapy to correct improper function of muscles and faulty biomechanics of the back, pelvis, and lower limbs: judicious use of medications and attention to underlying or associated conditions, perhaps rheumatologic disease or obstetric factors. Pubic (symphysial) instability is recognized as a sequel to osteitis pubis and usually becomes asymptomatic. Clinical investigations, including x-ray and isotope scanning are useful in diagnosis but not in providing a prognosis. (C) Lippincott-Raven Publishers.
Article
Three cases of osteitis pubis detected by bone scanning with Tc-99m MDP in professional ice hockey players are presented. This entity is related to mechanical stress and aggravated by forceful contraction of the adductor and rectus abdominis muscles. The signs, symptoms, and laboratory data are relatively nonspecific, as are radiographic findings in the early stage (pubic symphysitis). The use of bone scanning in the appropriate clinical setting aids in diagnosis.
Article
Medical records of 59 patients (9 females and 50 males), who presented to sports medicine clinics at the Australian Institute of Sport and the University of British Columbia between 1985 and 1990 and who were diagnosed as suffering osteitis pubis, were reviewed and comparison of data obtained was made with the literature. Women average 35.5 years of age (30 to 59 years) and men 30.3 years (13 to 61 years). Sports most frequently involved were running, soccer, ice hockey and tennis. Clinical presentations of osteitis pubis fell into 4 main groups. 'Mechanical' (sport-related) was the largest group (n = 48), followed by 'obstetric' (n = 5), 'inflammatory' (n = 4) and 'other' (n = 2). Period of follow-up averaged 10.3 months (1 to 20 months) in women and 17.5 months (2 to 96 months) in men. Full recovery, when documented, averaged 9.5 months in men and 7.0 months in women. Osteitis pubis recurred in 25% of these men and none of these women at follow-up. The most frequent symptoms were pubic pain and adductor pain. Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin. Men also revealed tenderness of one or both the superior pubic rami and evidence of decreased hip rotation (unilateral or bilateral). Evidence of pelvic malalignment and/or sacroiliac dysfunction was frequently seen in both men and women. There was poor correlation between radiographic and isotope bone scan findings and the site and duration of symptoms and signs. Femoral head ratios were estimated on 30 hips in the series and 2 were judged to be at the upper limit of normal, perhaps indicating a form of epiphysiolysis producing tilt deformity of the head of the femur. It is clear that osteitis pubis in athletes is not uncommon and that factors such as loss of rotation of hips and previous obstetric history are important in the aetiology and management of this condition. Pelvic infection, which was believed to be the primary factor of osteitis pubis in the literature up until the 1970s, plays a very small role in this condition in athletes.
Article
Ten patients had a wedge resection of the symphysis pubis for the treatment of symptoms of osteitis pubis that had been recalcitrant to non-operative treatment for at least six months. Preoperatively, the average duration of symptoms was thirty-two months. The symptoms included a waddling gait and crepitus, pain, and tenderness over the symphysis pubis. The early radiographic signs of the disease were rarefaction of the adjacent pubic bones and widening of the symphysis pubis. Later signs included sclerosis and narrowing of the symphyseal joint space. Pathological examination of the resected joint revealed chronic inflammatory reaction in all patients. At an average of fourteen months postoperatively, all of the patients had marked improvement and were fully active. However, at an average of ninety-two months postoperatively, three of the ten patients were not satisfied with the result. One patient needed bilateral sacro-iliac arthrodesis for pain that was caused by instability.