Osteitis Pubis (Pubic Symphysis Stress)

Osteitis pubis is a chronic overuse inflammatory condition of the pubic symphysis. It is seen in athletes who kick, sprint and pivot (soccer/football, Australian football, distance running), and it also occurs post-partum and after pelvic or urological surgery.

Mechanism. Repetitive shear and traction cross the symphysis from two opposing pulls: the adductors, arising below, and the rectus abdominis, inserting above. The rectus abdominis and adductor longus share a common aponeurosis at the anterior symphysis, so their opposing forces generate cyclical shear across the joint and load it directly. That is the mechanical basis of the disease.

The joint. The pubic symphysis is a secondary cartilaginous joint (amphiarthrosis). The two pubic bones are joined by a fibrocartilaginous interpubic disc and reinforced by the superior pubic and arcuate (inferior) pubic ligaments, which allow only small movement.

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"Osteitis pubis" and "athletic pubalgia" are the older vocabulary, and both were the reason the Doha agreement on terminology for groin pain in athletes was written. The same patient was being given a different diagnosis in every clinic, which made research and communication almost impossible. The agreed system sorts athletic groin pain into three groups.

What was formerly called osteitis pubis is now PUBIC-RELATED groin pain: local tenderness of the symphysis and the immediately adjacent bone, without another entity better explaining the picture.

Part of a spectrum. It is best understood as part of the athletic pubalgia or chronic groin-pain spectrum rather than as an isolated diagnosis. It overlaps with adductor-related groin pain, rectus abdominis injury, "sports hernia" or inguinal disruption (core muscle injury) and even femoroacetabular impingement, where constrained hip motion can transfer stress to the symphysis. Two consequences follow, and both are examinable.

First, the entities coexist rather than compete. Adductor-related pain is the commonest single entity in athletic groin pain. A symphysis loaded by an adductor problem, or by a hip that cannot rotate, is a symphysis that keeps hurting after the symphysis itself has been treated, and a groin examination that stops at the first positive finding will miss the one driving the others.

Second, the diagnosis is clinical. Doha deliberately defines the entities by palpation and resisted testing, not by MRI, because imaging in this region is abnormal in athletes who have no pain at all.

Symptoms. Central groin, suprapubic or symphyseal pain, often radiating into the adductors or the lower abdomen. It is worse with kicking, sprinting, pivoting or change of direction and sit-ups, and sometimes with coughing or sneezing.

Examination. The findings are tenderness directly over the pubic symphysis and pain on resisted adduction, sometimes with a positive squeeze test. Because the condition overlaps with the rest of the groin-pain spectrum (below), the assessment is a structured groin-pain examination that seeks concurrent pathology.

The adductor squeeze test. Done properly, it is both a diagnostic sign and a monitoring tool. With the patient supine, the examiner's fist or a sphygmomanometer cuff is placed between the knees and the patient squeezes maximally, at three positions:

• Hips and knees at 0 degrees (legs straight)
• 45 degrees of hip flexion
• 90 degrees

The position that reproduces pain helps localise the problem. A cuff gives a pressure in millimetres of mercury that can be recorded and compared at each review, which converts "getting better" into a measurement, and that measurement is what a criteria-based return to sport needs (see Management). The adductor-specific interpretation and the Copenhagen protocol are in Adductor and Groin Strain.

Symphyseal sclerosis and erosion are the appearance of a bone under stress, and several very different processes stress it. The "inflammatory symphyseal changes" on imaging are therefore not specific: the differential includes septic arthritis of the pubic symphysis and inflammatory arthropathy, and, in the older or systemically unwell patient, malignancy. The broader classification of athletic groin pain sits in Athletic Groin Pain and Athletic Pubalgia.

Raised markers. The table gives normal or near-normal markers for overuse osteitis pubis, yet the Broos report in the evidence section describes an athlete with osteitis pubis whose inflammatory markers were raised, in whom imaging excluded malignancy and lymphoma. Raised markers are a reason to investigate before labelling overuse, and that case shows the investigation can still end at osteitis pubis.

Management is predominantly conservative and prolonged. Once infection and malignancy are excluded, osteitis pubis is managed as the overuse condition it is, and recovery and return to sport are slow.

Conservative care. Relative rest and activity modification, NSAIDs or analgesia, and a graduated rehabilitation programme that restores adductor and core (rectus/abdominal) strength and balance and corrects the underlying load.

Treat the whole groin. Identify and address concurrent adductor-related pain, rectus pathology, sports hernia or inguinal disruption and FAI, for the reasons given under the Doha classification.

Refractory cases. A corticosteroid (or other) symphyseal injection can help selected recalcitrant cases.

Surgery is last-line, for the few who fail prolonged non-operative care: symphyseal curettage or arthrodesis, for example, or treatment of the associated pubalgia or adductor pathology.

Return to sport is slow and criteria-based (pain-free, restored strength) to limit recurrence. The squeeze test gives the criterion a number: a squeeze pressure that has returned towards the athlete's baseline and is pain-free, rather than an impression.