Osteitis Pubis - ptpainite

Introduction

Osteitis pubis is defined as idiopathic inflammation of the pubic symphysis and surrounding structures, but is most likely related to overuse or trauma [1]. Osteitis pubis was first described in patients who underwent suprapubic surgery and it remains a well-known complication Invasive surgery on the pelvis. It may also occur as an inflammatory process in athletes [2].

Image 1: anterior view pelvis.

Quick Facts

Osteitis pubis is a rare cause of groin pain but is more common in athletic patients, especially football players, runners, and rugby players.
Patients often experience groin pain that is worse with activity.
Plain x-rays and MRI may help in the diagnosis.
This condition is usually treated with activity restriction with NSAIDs and physical therapy.
In rare cases, surgical intervention may be required [3].

Clinical presentation

The presentation is typical, with varying degrees of pelvic and/or perineal pain during hip adduction. [4]

Epidemiology

To date, no epidemiological studies have been conducted to determine the true incidence of osteitis pubis. Athletes have been reported in 0.5% to 8% of cases, with higher rates in distance runners and soccer kickers, especially male soccer players (10% to 18%) Injuries per year[3]

Etiology

Figure 2: Anterior view of the pelvis with red pubis.

Although the cause is sometimes unknown, the most common causes are:

pregnancy/childbirth
High level of physical activity: see Exercise-induced pubic pain
urological or gynaecological surgery
trauma
psoriatic arthritis
ankylosing spondylitis[4]

Pathophysiology

The pubic symphysis is a non-synovial two-joint joint with a fibrocartilaginous disk separating the hyaline cartilage. The joint usually has minimal motion due to the static ligament complex. The pubic symphysis is the insertion point of the rectus abdominis and the origin of the rectus abdominis Adductor complex. The antagonistic nature of the rectus abdominis elevating the pubic symphysis while the adductors depress the joint is the focal point for the development of osteitis pubis—repetitive use of the anterior pelvic musculature leading to chronic tendonitis. this Chronic muscle imbalances lead to abnormal stress on the pubic symphysis, leading to instability of the pubic symphysis, stress response of the pubic bone, and ultimately degeneration of the hyaline cartilage. Another emerging theory is that the development of osteitis pubis is secondary to increased compensatory movement The joint is restricted in motion due to motion elsewhere in the kinetic chain, such as femoroacetabular impingement. [3]

Diagnosis

X-rays and MRI are both helpful in diagnosing osteitis pubis. In the early stages, plain films may appear normal.

In chronic osteitis pubis, the pubic symphysis exhibits lytic changes, sclerosis, and enlargement.
Instability of the pubic symphysis can be seen on the flamingo view (obtained by bilateral bilateral and single-leg support on a pelvic anterior-posterior radiograph). A subluxation greater than 2 mm is considered a positive finding for symphyseal instability.
MRI has become the imaging modality of choice. MRI has high sensitivity for differentiating between chronic and acute cases.[4]

Treatment

The treatment of osteitis pubis includes conservative treatment and surgical treatment.

The first option remains conservative treatment.

Conservative interventions include: rest NSAIDs; progressive physical healing (see pubalgia). There is no dogmatic treatment strategy that produces a variety of outcomes. Conservative treatment of osteitis pubis can be prolonged. It may take some athletes six months or more to return to pre-injury levels but usually most return by 3 months.
Although long-term conservative treatment remains the mainstay of treatment. Only about 5% to 10% of athletes require surgical treatment.

Steroid injections have been shown to be a useful adjunct therapy

If conservative treatment does fail, surgical intervention may be required. The time frame for when conservative treatment is considered failure has not been established. Usually at least six months of conservative treatment before surgical options are chosen Discussion [3].