Osteitis pubis
Illustration of the symphysis pubis between the pubic bones

Definition

Osteitis pubis, simply named inflammation of the symphysis pubis, is an inflammatory condition of the joint between the two pubic bones also involving the insertion of the surrounding muscles.

Left, rectus abdomini and Right, adductor longus are two of the muscles inserting at the pubis, which may lead osteitis pubis when overused

Pathology

The symphysis pubis is a cartilaginous joint that holds together the pubic bones. The inflammation of the pubic symphysis is mostly the result of repetitive trauma. It is common amongst individuals involved in competitive soccer, hockey, football and running where a strong load is posed on the pubis when kicking or in recurring adduction and abduction of the hips. It is also caused by excessive contraction of the abdominal muscles. This pathology is also called athletic pubalgia. Osteitis pubis can also arise during pregnancy when the symphysis becomes lax in preparation of childbirth or following pelvic surgery.

The pubic bones are covered with cartilage tissue and are kept together by a fibrocartilage disk firmly tightened by ligaments. Several muscles insert at this point including adductors (magnus, brevis, longus), rectus, pectineus and gracilis. Strong ligaments keep these muscles in place and limit the movement of the symphysis. However, continuous strain caused by pulling forces onto the pubic joint may trigger inflammation of the region followed by tissue destruction.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Kicking the ball strains the pubic symphysis leading to osteitis pubis

Causes

There are several identified causes leading to osteitis pubis, however in some cases its aetiology remains unknown. Below a few frequent causes:

Sport (athletics, soccer, hockey, football, marathon run)

Pregnancy/childbirth

Gynaecologic surgery

Urologic surgery

Trauma in different severities

Unknown

Intensive training is a risk factor for osteitis pubis

Risk factors

Common risk factors for the development of osteitis pubis include:

Competitive/extreme sports

Training on hard surfaces

Training with poor footwear

Pregnancy

Previous pelvic surgery

Incorrect anatomy and posture

Getting out of the car puts pressure on the pubic symphysis causing pain in patients with the condition especially pregnant women

Symptoms

The most frequent symptoms of osteitis pubis are:

Pain to the groin region

Pain in the lower abdomen/frontal hips

Tenderness when pressing the pubis

Pain when squeezing the thighs together

Pain when abducting the legs

Pain when getting out of the car

Pain aggravated during sport

Limp due to pain

Loss of joint flexibility

Separation of the symphysis pubis in a X-ray image

Diagnosis

For the diagnosis of osteitis pubis the clinical examination is usually sufficient. With medical history the examiner acquires information on predisposing factors, injuries and surgeries that may have led to the pathology. To obtain a clear view of the anatomy of the pubis and to exclude the presence of stress fractures (pubic rami and femoral head), bone erosion, diastasis (separation) of the symphysis and tissue degeneration or inguinal hernia, the examiner will request imaging via X-rays and MRI and ultrasound.

Treatment

Antiinflammatory treatment is the first resource for conservative treatment of osteitis pubis

Nonoperative treatment

Most cases of osteitis pubis are treated conservatively following a simple regime based on antiinflammatory therapy with oral NSADs, rest from intensive sport practice and by adopting changes in physical activities that may have caused the condition. Only seldom a local steroid injection is recommended. In pregnancy osteitis pubis is usually transitory and improves after birth.

Example of symphisis fixation in a fractured pelvis

Surgical treatment

Surgery is indicated if osteitis pubis refractory to conservative treatment but only in rare cases (5-10%). Open or endoscopic surgery involves the resection of the wedges of the pubic symphysis with or without fixation of the symphysis with metal implants. The success of this procedure is limited with the possibility of pelvic complications. The resulting instability of the pelvis may become a serious functional problem causing significant pain.

Exercises are useful to strengthen the core muscles and buttocks

Rehabilitation

Physiotherapy is the optimal approach for the treatment of osteitis pubis. In severe cases it begins with partial weight bearing achieved with the use of crutches. Additional therapeutic measures comprise:

Rest

Manipulation

Joint mobilisation

Soft tissue massage

Stretching

Anti-inflammatory therapy (NSAIDs)

Exercise to strengthen abdominal, adductor and abductor muscles

Advice on activity modification

Use of proper footwear

Clinical Pilates

Adopting a correct posture during physical activities can prevent injuries

Prevention

The incidence of osteitis pubis can be prevented by following the rules below:

Reduce sport intensity

Maintain strength of pelvic, abdominal and gluteal muscles

Ergonomic advice of proper posture during physical activity

Keep muscle and joint flexibility (hip, knee and lower spine)

Wear suitable footwear during sport

Modify sport habits

Introduce stretching and warm-up prior to sport

Avoid hard surface when running