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Osteitis Pubis

Osteitis pubis is characterized by inflammation of the pubic symphysis and the adjacent bones. This inflammation leads to bony changes of the pubis symphysis, causing both acute and chronic groin pain. The condition is one of the most common causes of chronic groin pain in athletes, but it may affect nonathletes as well. Osteitis pubis is a self-limited condition that resolves with time, but a variety of treatment modalities may be used to treat the symptoms.

Anatomy

The pelvis is a bony structure that connects the lower spine and trunk to each of the lower extremities. The pelvis is composed of two bony structures known as the os coxae (hipbone). There is a left and a right os coxa. Each os coxa consists of three bones (the ilium, ischium, and pubis) that are fused together. The muscles of the abdomen, groin, and thigh attach to the bones of the pelvis. The two hipbones are joined anteriorly (in the front) at the pubic symphysis and posteriorly (in the back) to the base of the spinal column. The pubic symphysis is the midline cartilaginous joint uniting the left and right pubic bones. It includes a cartilaginous disk that is approximately 3 to 5 millimeters (mm) wide.

Causes

Osteitis pubis is an inflammatory lesion of the pubic symphysis. It is commonly seen in athletes, but it may also be seen during or after pregnancy and after prostate or bladder surgery. Although its exact cause is undetermined, in athletes it is associated with mechanical strain from trauma and repetitive twisting and cutting movement. These actions cause the abdominal and groin muscles to exercise a pulling or traction force on the pubic bone, which in some cases can result in excessive stress and inflammation. Osteitis pubis most commonly affects long-distance runners, weight lifters, ice hockey players, swimmers, fencers, soccer players, football players, and Australian-rules football players.

X-ray of a normal pelvis, including the two pubic bones (white arrows) and the pubic symphysis (gray arrow)

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Source: Adam J. Farber, M.D.

Symptoms

Increased stresses across the pubic symphysis lead to inflammation and groin pain. Patients report a gradual onset of groin pain, which may be felt on one or both hips. The pain may radiate into the inner aspect of the thigh, groin area, scrotum, or testicles or into the abdomen. This pain worsens with kicking, running, jumping, abdominal straining (e.g., coughing or doing sit-ups), or pivoting on one leg. In addition to pain, osteitis pubis may also be associated with instability of the pubic symphysis and/or loss of hip range of motion.

Diagnosis

The diagnosis of osteitis pubis is made by correlating the patient's history of symptoms with characteristic physical examination and radiographic findings.

Physical Examination

Tenderness along the upper border of the pubic bone and pubic symphysis directly beneath the skin are the characteristic findings on physical examination; lack of tenderness in this area rules out the diagnosis of osteitis pubis. Pain is often present when the examiner outwardly moves the patient's leg away from the body (hip abduction). In addition, having the patient attempt to bring the leg back toward the body (hip adduction) while the examiner resists this motion will also typically elicit pain. Limitations in hip rotation also may be seen on physical examination.

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