Osteitis Pubis (OP): A Comprehensive Overview

OP is a bone stress injury resulting in pain around the pubic symphysis, groin, and lower abdomen.

This blog aims to cover the following area of interest:

1) Etiology

2) Epidemeology

3) Investigations

4) Prognosis

5) Differential Diagnoses

6) Physiotherapy Management

The following information on OP’s etiology, epidemiology, investigations, and prognosis is summarised from the paper by Dirkx and Vitale (2022).

1)Etiology:

OP can be caused by several factors:

• Muscle imbalances that attach to the pubic symphysis
• Poor exercise load management
• Poor hip mobility, potentially due to existing hip pathology such as femoral acetabular impingement (FAI)

OP often presents with other pathologies, such as lower back/SIJ issues or hip joint pathology. Therefore, physical examinations should consider these pathlogies as well.

2)Epidemiology:

OP is most common in distance runners and sports that require kicking and changing direction, such as soccer.

3)Investigations:

• Both X-rays and MRI aid in the diagnosis of OP. In the early stages, X-rays might appear normal. In chronic OP, the pubic symphysis demonstrates lytic changes, sclerosis, and widening. Dynamic instability of the pubic symphysis can be observed on the flamingo view, obtained by double- and single-legged stance positions bilaterally on a pelvic anterior-posterior radiograph. Subluxation greater than 2 mm is considered a positive finding for symphyseal instability.
• MRI has become the imaging modality of choice. In the acute setting, MRI demonstrates subchondral bone edema, typically with bilateral involvement. However, pubic symphyseal bone marrow edema can commonly be found in asymptomatic patients, so matching clinical findings with MRI results is crucial to confirm the diagnosis. In chronic cases, MRI findings are similar to X-ray, demonstrating periosteal reaction, bone resorption, irregular contour of the articular surface, osteophytes, and subchondral cyst formation. MRI has high sensitivity for distinguishing between chronic and acute cases.
• MRI findings also correlate with clinical outcomes in OP patients. Those with edema in both the pubic bone and surrounding musculature had a much lower percentage of complete recovery, whereas those with edema confined to just the bone had a much higher chance of complete recovery at 18 months. Patients with FAI treated with hip arthroscopy who also had symphyseal changes, such as bone marrow edema, on MRI had inferior surgical outcomes compared to those without such changes.

4)Prognosis:

The prognosis for those with OP is very good. Those treated conservatively typically return to sports in approximately 3 months with a low chance of recurrence. Only 5% to 10% of patients with OP require surgery, which also has favorable outcomes, with most returning to sports in approximately 3 to 4 months.

The following information on physiotherapy management is summarized from a Masterclass given by Mosler (2024) on Physio Network.

5)Differential Diagnoses for Hip and Groin Pain:

According to the DOHA agreement (Weir et al., 2015), groin-related injuries can be classified into five groups:

• Hip joint-related pathology
• Iliopsoas-related pathology
• Adductor-related pathology
• Inguinal-hernia related pathology
• Pubic-related pathology

Other potential causes include:

• Referred pain from the lumbar spine or SIJ
• Red flags: Perthes disease, apophysitis/avulsion fracture, SUFE, avascular necrosis, reactive or infectious disease
• Medical concerns: testicular/ovarian/bone/prostate/urinary/digestive cancer, inguinal lymphadenopathy, intra-abdominal abnormality, prostatitis, UTI, kidney stones, appendicitis, diverticulitis, gynecological issues

6.1)Physiotherapy Subjective Interview:

A comprehensive subjective interview should include:

• Sports type, level of play, and timeframe for return to play
• Occupation, especially if physically demanding
• Previous injuries
• Loading history: high-level participation in sports with frequent directional changes during early to mid-teenage years (3-4x/week) can be associated with a higher incidence of FAI
• Family history of hip osteoarthritis or related issues
• Specific movements that reproduce pain (running, changing direction, kicking, squatting)
• Load-related parameters: pain at the end of the week or session, specific sessions that increase pain
• Changes in sports or gym-related training load before the onset of pain
• Questions to determine the severity and irritability of the injury: pain over a 24-hour period, night pain

6.2)Physical Examination:

The physical examination starts with palpation and orthopeadic tests to rule in or out different pathologies that could produce pain around the pubic area. It is useful to rule out potential differential diagnoses first, followed by confirming the most probable diagnosis. In diagnosing OP, tenderness on palpation of the pubic symphysis bone itself (not the attached tissues) raises suspicion. Diagnosing OP is tricky, as it may present with other pathologies like FAI or be confused with soft tissue issues like adductor or lower abdominal problems. Ruling out other pathologies helps to paint a clear clinical picture.

The clinical examinations for the pathologies mentioned in the DOHA agreement are beyond the scope of this blog. For more information, refer to Weir and colleagues’ paper (2015).

Once OP is confirmed, the physical examination assesses potential contributing factors such as:

• Hip range of motion: flexion, internal/external rotation, extension, adduction/abduction, and bent knee fall out
• Strength and endurance of the hip and trunk, with a focus on eccentric hip strength especially with long-standing hip and groin injury
• Functional testing: single-leg sit-to-stand, static and dynamic balance (star excursion), single-leg hop, triple hop, and triple crossover hop tests
• Neurodynamic tests
• Examination of other joints like the lumbar spine and SIJ
• Subjective outcome measures: HAGOS

6.3)Physiotherapy Treatment:

1. Compression shorts and manual therapy for tight adductor muscles can help manage groin pain.
2. Exercise and rehabilitation should be prescribed based on the contributing factors identified during the physical assessments and be specific to the individual’s sport. This includes not only hip and groin rehabilitation but also trunk stability, quadriceps, hamstring, and calf strengthening exercises, balance, and cardiovascular fitness.
3. During the mid to late stages of return to sports rehabilitation, sports-specific skills and team training should be included. For example, in soccer, drills like retraining kicking, dribbling, and changing direction skills should be incorporated. For detailed progression of return to kicking in soccer, refer to Arundale and colleagues’ paper (2015).
4. In the late stages of return to sports rehabilitation, the individual’s level of sports, type of load/movements, position of play, volume of physical activities, and intensity should be progressively increased to the pre-injury level or the required level of demand in the sport.

“Are you suffering from a long-standing hip or groin injury and have not seen much progress with your current treatment? Book a complementaty “Discovery Call” today to get a second opinion from our experienced Sports Physiotherapist.”

Arundale, A., Silvers, H., Logerstedt, D., Rojas, J., & Snyder-Mackler, L. (2015). An interval kicking progression for return to soccer following lower extremity injury. International Journal of Sports Physical Therapy, 10(1), 114–127. https://tcomn.com/wp-content/uploads/2021/06/ijspt-01-114-interval-kicking-program.pdf

Dirkx, M. & Vitale, Christopher. (2022). Osteitis Pubis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556168/

Mosler, A. (2024). Groin pain in athletes: Unravelling the mystery. Physio Network. https://www.physio-network.com/masterclass/groin-pain-in-athletes/

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K. M., Lovell, G., Meyers, W. C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A. G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., … Hölmich, P. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 49(12), 768–774. https://doi.org/10.1136/bjsports-2015-094869