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.
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.
There are various classification systems for a shoulder impingement syndrome.
Stages of subacromial impingement in athletes - Jobe’s Classification
Pure impingement with no instability
Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement
Primary instability due to intrinsic ligament laxity with secondary impingement
Pure instability with no impingement.
Grading of impingement changes - Milgrom’s Ultrasound Classification:
Stage 1 Bursal thickness from 1.5 to 2.0 mm
Stage 2 Bursal thickness over 2.0 mm
Stage 3 Partial or full thickness tear of the rotator cuff.
Impingement lesions - Copeland Levy Classification:
This is based on the location of the impingement, either on the acromial or the bursal side.
A0 normal - smooth surface
A1 minor deterioration, haemorrhage or local inflammation
A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament
A3 exposed bone areas.
B0 normal - smooth surface
B1 minor deterioration, haemorrhage, inflammation
B2 major deterioration of the cuff, partial thickness tear
B3 full thickness tear of the rotator cuff
B4 massive cuff tear.
According to the Habermeyer Classification the fractures to the proximal humerus are divided into:
Type 0 one fractured part without dislocation
Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion
Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities
Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.
These are defined further as:
One-part fractures are non-displaced fractures or fractures with minimal displacement
Two-part fractures only involve a single segment
Three-part fractures involve two segments
Four-part fractures occur when all humeral segments are involved (see image in pathology section)
The injury severity is proportional to the increasing number of fractures.
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)
Trauma in different severities
Common risk factors for the development of osteitis pubis include:
Training on hard surfaces
Training with poor footwear
Previous pelvic surgery
Incorrect anatomy and posture
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
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.
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.
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.
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:
Soft tissue massage
Anti-inflammatory therapy (NSAIDs)
Exercise to strengthen abdominal, adductor and abductor muscles
Advice on activity modification
Use of proper footwear
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