The main complaint of individuals with osteitis pubis is chronic pain in the pelvic region that can appear in various regions and can range from mild to severe[10]. Based upon clinical findings in patients with this condition, four stages have been identified [8] [9]:

• Stage I - Pain is localized to the kicking leg, unilaterally, and is aggravated after practice.
• Stage II - Pain extends bilaterally into inguinal regions, but is still aggravated only after exercise.
• Stage III - In addition to bilateral inguinal regions, lower abdominal muscle pain is noted. Exacerbation of pain is noted during kicking, fast running, change in direction and changes in stance.
• Stage IV - The inguinal, lower abdominal and lower back regions are reported to be painful, while pain is reported to occur when defecating, sneezing, or even walking.

Pain might be quite debilitating for patients, especially athletes, which is why a prompt evaluation and confirmation of the underlying cause is necessary.

• Pain

  Inability to return to sport See Also Internal Hip Anatomy (Main) Physical Exam Hip Hip Pain (Main) External Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/ References ↑ Ekstrand J, Hilding J. [wikism.org]

  Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. [dovepress.com]

  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. [functionalanatomyblog.com]

  Pain with walking can be in one or several of many distributions: perineal, testicular, suprapubic, inguinal, and in the scrotum and perineum. pubis symphysis Osteitis Pubis Symptoms The pain or discomfort can be located in the pubic area, one or both [orthofixar.com]

  Common complaints include the following: Pain localized over the symphysis and radiating outward Adductor pain or lower abdominal pain that then localizes to the pubic area (often unilaterally) Pain exacerbated by activities such as running, pivoting [emedicine.medscape.com]

• Inflammation

  Overuse is the most likely etiology of the inflammation, and the process is usually self-limiting. [orthofixar.com]

  Osteitis Pubis is the inflammation of the pubic symphysis due to non-infection. The pubic symphysis is the joint where two the two iliac bones of the pelvis connect in the front. [rebalancept.com]

  Repeated stress placed on the pubic symphysis can lead to inflammation and irritation. [4lifephysiotherapy.com.au]

  When aggravating motions occur at the joint, microtrauma causes inflammation and muscle spasms can result. [pamelamorrisonpt.com]

  By the time the inflammation has gone this far, it's going to take some medication to reverse. Cortisone is not the answer because it will further soften the bone. PRP works perfectly to decrease the inflammation and strengthen the bone again. [nydailynews.com]

• Weakness

  CONCLUSION: Osteitis pubis group displayed concentric weakness of back muscle and eccentric weakness of abdominal muscles that lead to disturbance of the normal concentric abdominal/back ratio. [ncbi.nlm.nih.gov]

  Ultrasound Development and progression of a specialised home exercise program aimed at improving core stability, strengthening weak muscles (particularly hip adductors and gluteals) and stretching tight muscles. [4lifephysiotherapy.com.au]

  Osteitis Pubis Associated Injuries / Differential Diagnosis Coccydynia Adductor strain Hamstring strain Osteitis Pubis Complications Continued pain Pelvic instability Weakness Osteitis Pubis Follow-up Care Athletes generally should refrain from sports [eorif.com]

  Ultrasound or electrotherapy Development and progression of a specialised home exercise program aimed at improving core stability, strengthening weak muscles (particularly hip adductors and gluteals) and stretching tight muscles. [pivotalmotion.physio]

  It is an overuse injury in which characteristic symptoms include: a localized ache or weakness feeling in the pubic symphysis/ lower abdominal and/or adductor region. [prohealthcare.com.au]

• Surgical Procedure

  Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. [ncbi.nlm.nih.gov]

  Complications and revision surgical procedures were reported, and preoperative and postoperative radiographs were assessed. [benjamindombmd.com]

  Curettage, arthrodesis, wedge resection, and wide resection of the pubis are surgical procedures. [boneandspine.com]

• Inguinal Hernia

  A 55-year-old man underwent herniorrhaphy for a direct inguinal hernia, followed in 48 hours by herniorrhaphy for a femoral hernia. [ncbi.nlm.nih.gov]

  Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: A systematic review. Hernia. 2005 ;9: 109 – 114. Google Scholar | Crossref | Medline 12. [doi.org]

  hernia Athletic pubalgia/Sport Hernia/Inguinal Related Groin pain Pelvic stress fracture (pubic rami, femoral neck) Investigations Xray (AP pelvis): findings typically occur after condition has been present for a while and include: – widening of the [sportmedschool.com]

  […] symphysis degenerative changes within the joint can be seen MRI bone marrow edema found early Bone scan increased activity in area of pubic symphysis Differential Athletic pubalgia Stress fracture of the pubic rami Stress fracture of the femoral neck Inguinal [orthobullets.com]

  Osteitis pubis is caused either by trauma, pelvic operations, repair of inguinal hernia, childbirth or overuse through, for example, running. [netdoctor.co.uk]

• Sneezing

  Symptoms are described as "groin burning," with discomfort while climbing stairs, coughing, or sneezing. A greater understanding and awareness of osteitis pubis will reduce patient and physician frustration while improving overall outcomes. [ncbi.nlm.nih.gov]

  Symptoms of osteitis pubis have been described as “groin burning” with discomfort while climbing stairs, coughing, or sneezing. [orthofixar.com]

  Sneezing or coughing, transferring from sitting to standing positions, and lying on one side can also exacerbate the pain. Clicking or popping may also occur at the joint upon walking or strenuous movements. [pamelamorrisonpt.com]

• Overeating

  A soft tissue mass with calcification, and an audible or palpable click over the symphysis might be detected during daily activities. Correct examination of this region involves examining the position of the pelvic girdle. [orthofixar.com]

  Cryomassage 10 minutes over painful area. [physiotherapy-treatment.com]

  The patient was treated with indomethacin and showed clinical and radiologic improvement over the next 6 months. [ncbi.nlm.nih.gov]

• Abdominal Pain

  Symptoms of Osteitis Pubis: *Groin pain or lower abdominal pain *Sacroiliac Joint Dysfunction *Lower back pain and hip pain *Pain localized over the Pubic symphysis Osteitis Pubis Treatment At Rebalance in Philadelphia and Narberth Main Line, we take [rebalancept.com]

  Demographics Common in participants in exertional sports or distance running Signs and Symptoms Lower abdominal pain or anterior pelvic pain with exertion, responds to rest Lower abdominal pain or anterior pelvic pain with sit-ups, kicking, running, sprinting [accessphysiotherapy.mhmedical.com]

  The medical literature was searched using the following key words: "abdominal pain," "pelvic pain," "inflammation," "symphysis pubis," and "enthesopathy." [ncbi.nlm.nih.gov]

  Osteitis pubis: an important pain generator in women with lower pelvic or abdominal pain: a case report and literature review. [gpnotebook.com]

  Design: Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. [doi.org]

• Hip Pain

  Inability to return to sport See Also Internal Hip Anatomy (Main) Physical Exam Hip Hip Pain (Main) External Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/ References ↑ Ekstrand J, Hilding J. [wikism.org]

  Chronic cases of hip bursitis involving hip pain which continues for more than a few weeks may require a corticosteroid injection into the hip. [ossurwebshop.co.uk]

  Pain Groin Pain Hip Joint Pain Hip Arthritis - Osteoarthritis Hip Labral Tear Hip Pointer Femoroacetabular Impingement - FAI Perthes Disease Slipped Femoral Capital Epiphysis Stress Fracture Avascular Necrosis of the Femoral Head Lateral Hip Pain Gluteal [physioworks.com.au]

  The most frequent symptoms were pubic pain and adductor pain. Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. [ncbi.nlm.nih.gov]

  Symptoms of Osteitis Pubis: *Groin pain or lower abdominal pain *Sacroiliac Joint Dysfunction *Lower back pain and hip pain *Pain localized over the Pubic symphysis Osteitis Pubis Treatment At Rebalance in Philadelphia and Narberth Main Line, we take [rebalancept.com]

• Muscle Weakness

  Other risk factors for this injury include: decreased hip range of motion, muscle tightness, weak adductor strength and previous injuries. The presenting symptoms of osteitis pubis can be almost any complaint about the groin or lower abdomen. [sportsmedtoday.com]

  This build up of stress can be caused by: - Poor lumbo-pelvic control/muscle weakness - Abdominal muscle overactivity - Lack of hip range of motion - Significant increase in exercise/activity (particularly dynamic and agility work) It is more common in [lifecare.com.au]

  He or she will conduct a careful physical examination, checking for muscle weakness and areas of pain and tenderness. Imaging tests, such as an x-ray or bone scan, may be ordered to confirm your diagnosis and rule out other causes of your symptoms. [upswinghealth.com]

• Muscle Strain

  As the etiology of groin pain can be complex, assessment by a physiotherapist is important as pain in this area may also be related to muscle strains, sportman’s hernias, stress fractures, infections, referral from the spine or hip joint injuries. [physica.com.au]

  Thigh Muscle Strain Thigh Muscle Strain When a tear occurs in a quadriceps muscle it can be classified as first, second or third degree thigh muscle strain, depending on its severity. [ossurwebshop.co.uk]

  The differential diagnosis of pain in the pubic symphysis includes muscle strain, prostatitis, orchitis, arthritis, fracture and osteitis pubis. Other causes include ankylosing spondylitis, Reiter syndrome, urolithiasis and hyperparathyroidism. [aafp.org]

  Pubic-related Groin Pain Osteitis Pubis Inguinal-related Groin Pain Inguinal hernia Sportsman's hernia Iliopsoas-related Groin Pain Hip Flexor Strain Other Muscle-related Pain Piriformis Syndrome Muscle Pain - Muscle Strain Poor Hip Core DOMS - Delayed [physioworks.com.au]

  Take time to rest and recover In order to increase the performance of your muscles, it is essential that you give yourself some time to recover from the strain of exercise. [supacore.com]

• Low Back Pain

  Due to the instability in the region it is not uncommon for the athlete to have experienced a previous history of groin strains, a "sportsman's" hernia or low back pain. [physioworks.com.au]

  […] and abdominal pain during training, kicking, sprinting 4 bilateral all over groin, abdominal and into low back pain at rest and at night, cannot train or run In general, management of this injury requires a careful balance of rest from activities such [sportdoctorlondon.com]

  Causes of groin pain in athletes include musculotendinous strains, sports hernias, stress fractures, intra-articular hip pathology, referred low-back pain, genitourinary pathology, and osteitis pubis. [arthroscopytechniques.org]

• Pelvic Pain

  These cases illustrate that pubic osteomyelitis can mimic the principal features of osteitis pubis including characteristic pelvic pain and gait disturbance, symmetrical bony destruction of the symphysis pubis, absence of fever, a long interval between [ncbi.nlm.nih.gov]

  Demographics Common in participants in exertional sports or distance running Signs and Symptoms Lower abdominal pain or anterior pelvic pain with exertion, responds to rest Lower abdominal pain or anterior pelvic pain with sit-ups, kicking, running, sprinting [accessphysiotherapy.mhmedical.com]

  Osteitis Pubis can cause abdominal pain, pelvic pain and, in our experience, sacroiliac joint dysfunction as well. Many people mistake it for a groin pull. It is common in athletes. [rebalancept.com]

The diagnostic workup of patients with suspected osteitis pubis should be thorough and a high dose of clinical suspicion is needed [7]. Because numerous conditions may cause similar symptoms, both laboratory and imaging studies should be used to confirm osteitis pubis and exclude other pathologies. Laboratory studies should include a complete blood count, CRP, ESR and fibrinogen to exclude osteomyelitis, which invariably shows the presence of active inflammation and elevations of these parameters [5]. Sometimes, an aspiration biopsy and subsequent culturing of the obtained material is needed for its exclusion in patients with inconclusive results. However, the initial differentiation can be made by the presence of fever, as infectious etiologies tend to manifest with increased body temperature [3]. Physical examination or ultrasound techniques may reveal muscle tears or sports hernia, while plain radiography may reveal stress fractures or soft-tissue tumors.

To confirm the diagnosis of osteitis pubis, MRI studies are necessary. Bone marrow edema that spans across the entire symphysis or suchondral resportion are diagnostic hallmarks of this condition [4]. In some cases, widening of the pubic symphysis may be noted as well.

Treatment principles may significantly vary and depend on the severity of the condition [3], but a multimodal approach is found to be of most benefit [11]. However, conservative management is the initial strategy, consisting of bed rest, use of NSAIDs and appropriate physical therapy composed of exercises that are aimed to improve strength and range of motion of lumbar and pelvic muscle groups, in order to relieve the weight of the pubic bones and the symphysis [12]. In the majority of patients, an individualized approach is necessary to achieve optimal therapeutic outcomes [13]. Adjuvant use of various modalities, such as ultrasound, electrical stimulation, friction massage and laser has been mentioned in literature and may provide better results compared to exercise alone [9]. Studies have estimated that return to regular sports activities was achieved in approximately 9 weeks with conservative therapy only [3]. If conservative management is not sufficient, or if the clinical severity of the condition necessitates other forms of treatment, the use of corticosteroids and dextrose has been documented, but with variable results. Some reports indicate marked reduction of symptoms with repeated injections of corticosteroids such as betamethasone or methylprednisolone combined with an anesthetic such as lidocaine or buvipacaine. This treatment modality has shown a return to professional physical activity within several weeks in certain studies[12]. Injection of dextrose with lidocane has also shown to be effective in reducing pain [14], but their efficacy remains to be confirmed in larger studies. Surgical management is reserved for those in whom neither of the recommended regimens manage to reduce symptoms and allow return to previous activities, making about 5-10% of all patients [15]. Curettage of the pubic symphysis, insertion of a polypropylene mesh into the retropubic space and bone grafting are procedures that may be performed and show variable success rates [13].

Osteitis pubis is a self-limiting condition that does not pose any risk to the patient's overall condition, but various obstacles exist in its resolution. Firstly, making the diagnosis may last up to several months, because a plethora of other conditions present with almost identical symptoms, including osteomyelitis, stress fractures, pubic tendinopathy, sports hernia and various other, which have to be excluded in the diagnostic workup [1]. Secondly, the recovery depends on the severity of structural damage. Thirdly, the recovery process may be significantly prolonged in severe cases who require a multimodal approach to successfully treat this condition.

Various factors have been proposed to contribute in the pathogenesis of osteitis pubis since its initial clinical description almost 100 years ago [6]. Repetitive trauma and shear stress, however, seems to be the most likely candidate, while direct trauma, pelvic surgery and childbirth described as potential causes [5]. Regardless of the cause, the end-result is inflammation and damage of the pubic symphisis and the bony structures that are attached to this fibrocartilaginous structure.

The most significant risk factor for this condition is strenuous physical activity. Conversely, it is most frequently diagnosed in elite athletes of both gender. Some studies report a slight predilection toward male gender [7] [1], but large-scale epidemiological studies without bias have not been performed yet and epidemiology data solely rest on isolated studies. The incidence rate of osteitis pubis is established to range between 0.5-7% in the general athletic population [8], indicating that this condition is not commonly encountered in medical practice. Specific types of sports have shown to predispose athletes to this condition, such as those that put significant pressure on the hip and the pubic bones, including ice hockey, soccer, rugby, tennis, but also long-distance running [9].

The pathogenesis model of osteitis pubis remains incomplete, but it is thought that initial events include trauma that induces abnormal activity of osteoclasts and propagate inflammatory changes [2]. During physical activity such as running or kicking, great mechanical forces are exerted on the pelvis, but also on the muscle groups that are involved in these motions. These changes lead to osseous resorption and reduced stability of the pubic symphisis and the adjacent bony structures that should maintain adequate tendon attachment of hip adductors and abdominal muscles [2]. Consequently, the appearance of pain as a result of structural damage to either tendons or the bony structures is the hallmark of this condition.

Some preventive measures may include an immediate visit to the physician in order to prevent further aggravation of the condition. The most significant preventive measure, however, is maintaining adequate muscle strength and fitness in athletes who are susceptible to this type of injury. Through appropriate exercises and regular stretching, the risk of osteitis pubic can be greatly reduced.

Osteitis pubis is a self-limiting but potentially debilitating condition that is characterized by noninfectious inflammation of the symphysis pubis and the adjacent pubic bones. Repetitive trauma seems to be the causative event, which is supported by the fact that the vast majority of patients are athletes who are engaged in strenuous physical activity [1]. Various sports have shown to prone athletes to this condition - soccer, ice hockey, rugby and several other that are particularly demanding for the hip joint and involve kicking, twisting and pivoting motions as well as direct trauma to the pubic bones [1]. The symphysis pubis is composed of a fibrocartilaginous tissue and binds the pubic bones into a firm, stable joint. In its close proximity are the pubic rami, the sites for attachment of various muscles, the most important being the adductor muscles of the hip and abdominal muscles (rectus abdominis, as well as external and internal oblique) [2]. As the inflammatory changes in this disorder most commonly affect the site where adductor muscles attach, pain when attempting adduction that can be felt either anteriorly or medially in the groin is the most common symptom [3]. Based on severity of clinical findings, osteitis pubis is divided into four stages, but additional features are usually abdominal discomfort, aggravation of pain when attempting to perform physical activity that involves either adductor or abdominal muscles, while a physical examination may reveal tenderness in the area of the pubic symphysis [3]. To make the diagnosis, magnetic resonance imaging (MRI) is shown to be the imaging study of choice. Tendon injury and bone marrow edema are identified with very high sensitivity. MRI can greatly aid in distinguishing this condition from various other that may have similar symptoms, particularly osteomyelitis, due to its progressive nature and substantially different treatment strategy [4]. For these reasons, laboratory parameters such as C-reactive protein (CRP), sedimentation rate (ESR) and leukocyte count should be performed to make the distinction between the two clinical entities, as osteitis pubis does not cause elevations of inflammation markers [5]. Treatment principles encompass various approaches, including conservative management with non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy and appropriate exercising techniques to improve muscle strength. Surgery serves as a last resort for patients who are not recovering with non-invasive therapy.

Osteitis pubis is a condition that results from inflammation of the symphysis pubis, the anatomical structure that binds the pubic bones in front of the urinary bladder, and the surrounding bony structures. The cause of this condition is thought to be repeated and prolonged stress to this area as a result of strenuous exercise and trauma, which is why this condition is almost exclusively seen in athletes. Other causes include childbirth, trauma and surgery in the pelvic region. Various sports have shown to increase the risk of developing this type of injury, such as rugby, ice hockey, tennis and long-distance running, all of putting very high amounts of pressure on the hips and the muscles in the groin region. In fact, pain in the groin is the main clinical presentation of these patients and may range from mild to severely debilitating. Pain may last for weeks, months, or even years and depending on the severity of the condition, it may occur in the lower abdomen, or in severe cases, the lower back may be affected as well. In all patients, pain is aggravated during physical activity, while patients with serious injury may report pain during coughing or sneezing. Because these symptoms may significantly impair the quality of life of the patient, the diagnosis should be made as early as possible. However, this condition mimics numerous other, such as bacterial infection of the bone (osteomyelitis), fractures, or even malignant diseases. For these reasons, making the diagnosis can take up to a few months. To confirm osteitis pubis, the use of laboratory and imaging studies are necessary. Magnetic resonance imaging (MRI) is the gold standard in identifying changes specific for this condition, after which appropriate treatment strategies may be carried out. Initial management includes conservative measures, such as bed rest, avoiding movement that aggravates pain, use of non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy to improve muscle strength. Injections of corticosteroids and dextrose have shown good effects in certain studies and surgery, as the last resort, may be performed if all other modalities fail. Return to normal sports activities may be expected in several weeks, but the outcome depends on the severity of tissue injury.

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