A suspected case of Osteitis Pubis with discussion of symptoms, assessment, and treatment

This question was sent to me by a DC recently:

“I was just wondering what you found was the best imaging, confirmatory physical tests and treatment for Osteitis Pubis?  Just doing a lit search now about it and I would love your thoughts.

I have a 24 yr old pro soccer player that points to the pubic symphysis for location of sharp pain and says he sometimes gets pain in the perineum, which started 2 months ago and thinks it’s due to his weight training such as weighted (85lb) per hand lunges. Aggravating factors include doing a crunch or sit up, resisted adduction of the hips supine especially with quick release by my hands increases it, weighted dips, and any lifting also increases pain in pubic symphysis. Relieving factors include rest. I was thinking of getting an AP pelvis x-ray; however not sure if it would add any value as it may not show up on the film. The athlete was afraid it was a STD or infection as he said he urinating more frequently; however could be due to more intake of water. He saw his MD before me and the MD got blood and urine chemistry done and still waiting results. He said he saw his MD due to the fact the pain is off and on, that is sometimes when he trains he does not feel the pain and other times he trains he feels it, hence thought it was something more than mechanical. Just for completion I took his vitals all unremarkable (also no RED FLAGS) and performed a kidney punch and the athlete found it painful bilat and wasn’t sure as it felt different compared to a punch in the mid upper t-spine for comparison.

Anyways your thoughts & suggestions on this would be much appreciated.”

I cringe every time I have an athlete come in with groin pain as the number of differentials seems endless and all of the symptom patterns seem to overlap….here are a few of the more common causes of groin pain in athletes:

–       Conjoint tendon lesion

–       Adductor strain

–       Ilioinguinal or Iliohypogastric neuropathy

–       Inferior pubic ramus stress fracture

–       Obturator nerve frictional irritation

–       PAMA (Primary Abdominal Musculofascial Abnormality)

–       Iliolumbar or Sacroiliac referral

–       Spinal disc pathology with radiculopathy

–       Internal hip derangement (Slipped femoral capital epiphysis, synovitis, labral or chondral lesions)

–       Osteomyelitis of the symphysis

–       Femoral head AVN (Perthes)

–       Urinary tract or pelvic disorders, STD, etc.

First off, you are right to look for non-msk causes of the pain like pelvic & lower urinary tract disorders, obstetric or gynecological, rheumatologic conditions, and infection.  These definitely have to be ruled out in cases like these.  Assuming these are ruled out….pain that emanates from the area of the pubic symphysis (either unilaterally or bilaterally) into the lower abdomen, upper adductors, and scrotum is suggestive of osteitis pubis; the pathology of which condition is still uncertain.  Palpatory tenderness at the site, painful resisted adduction of the hip (the quick release pain is a common finding not discussed in the literature), and loss of internal rotation are considered the ‘hallmark’ signs, although I have also seen it present with palpatory pain as far proximal as the external oblique’s just inferior to the rib cage.  A symptom less commonly seen, but sometimes described is a painful ‘click’ at the symphysis

Figure 1 - Bone scan showing increased uptake in the symphysis pubis

with certain movements which may indicate instability (which can be seen using the ‘Flamingo’ view plain film – Patient stands on each leg in turn with the central ray at the symphysis pubis.  Movement of >2mm is considered significant).

Bone scan will usually demonstrate increased isotope uptake on the margins of the symphysis (figure 1).  Plain films (AP pelvis – as the one suggested by the practitioner above) can demonstrate erosive changes at one or both margins, and/or widening of the cleft; these findings (if present….as they don’t have to be) will be noted at

Figure 2 - plain film demonstrating signs of osteitis pubis

the lower end of the joint initially (figure 2).  Some recent literature regarding MR for this condition notes that ‘stress signs’ including bone-marrow edema may be present suggesting that the condition may in fact result from stress injury to the bone (figure 3).

The condition is generally expected to heal with time.  Personally, I

Figure 3 - MR scans demonstrating bone stress in the symphysis

approach the condition as I do with any bone stress type injury.  As it is unknown if activity should cease following diagnosis, I often recommend active rest so as not to allow for detraining of the athlete…..pool running is a great activity to recommend.  During this time, I tend to treat/balance the pelvis in terms of releasing abnormal tension and strengthening where necessary.  In terms of release, look to separate epimysial bundles in the groin and pelvis (figure 4).  I have been utilizing Progressive Angular Isometric

Figure 4 - Functional Range Release™ in the medial thigh region

Loading™ (P.A.I.L.’s) strategies for the adductor and hip flexor groups with some success recently noting a quick recovery of pain free range of motion.  This is then followed by Functional Range Conditioning™ for improving flexibility and outer range strength.

I also begin transverse abdominal training (along with kegal contractions and multifidii activation) as an EMG study that I read suggested its onset is delayed in patients with chronic groin issues (Cowan 2004).  Along the same lines, I often prescribe wearing compression shorts in order to relieve pain symptoms.

I hope this helps.  Good luck with this difficult condition.

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