Osteitis Pubis Description

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Osteitis pubis is a painful, inflammatory, noninfectious condition of the bone, periosteum, cartilage, and ligamentous structures around the pubic symph-ysis.1-5 It is considered the most common inflammatory condition of the pubic symphysis.5 It is not a rare condition, as proven by the large number of patient series published since its first description in 1923.6 The first description within the English literature was by Beer in 1924.7 Most of the early literature on this subject emerged from the field of urology. The first descriptions of osteitis pubis revealed its close association with urologic, gynecologic, and obstetric procedures and complications related to pelvic surgery.1,8 It is a diagnosis seen in almost every patient population, permitting most medical specialists some familiarity with the diagnosis; nonetheless, it remains poorly understood. Various clinical forms of osteitis pubis are believed to exist.2,8,9 No single etiologic factor has been identified as the cause for osteitis pubis. Athletic osteitis pubis is probably associated with overstress or microtrauma of the pubic symphysis and its surrounding structures.10,11 Pelvic instability and muscular imbalance may also play an important eti-ologic role.4,12-14 In the athlete, Spinelli15 in 1932 was the first to describe athletic osteitis pubis in fencers. Osteitis pubis has also been reported in ice hockey, wrestling, Olympic walking, rugby, tennis, running, football, diving, and basketball. Athletic osteitis pubis may evolve into a chronic, painful, disabling condition causing significant amounts of lost playing time. The symptoms may manifest acutely, such as after a forceful kick or an injurious fall, or may present slowly and insidiously.16 With adherence to non-

operative therapeutic measures, it is, the majority of times, a self-limiting condition.l However, surgical measures are thought to improve the small number of cases that become unresponsive to conservative means.4,8 Since osteitis pubis was described 79 years ago, confusion exists regarding its precise pathogene-sis, and the optimal treatments often elude us.

Etiology

A review of the pertinent anatomy and biomechanics is important in understanding this vague entity called osteitis pubis. Joints are classified into three basic types: synarthrosis, which are fibrous and rigid; di-arthrosis, which are synovial and freely movable; and amphiarthroses, which are slightly movable.3 The pubic symphysis is located between the two pubic bones. Articular hyaline cartilage lines the two joint surfaces, which are separated by a thick intrapubic fibrocarti-laginous disk. The disk has a transverse anterior width of 5 to 6 mm, anteroposterior width of l0 to l5 mm, and a central raphe^7 The joint lacks a well-developed synovial lining, making it less susceptible to pathologic inflammatory changes such as those seen with ankylosing spondylitis and Reiter's syndrome.3 The pelvic architecture is essentially a continuous bony ring with three interspersed semirigid joints, two sacroiliac joints and one pubic symphysis, designed to dissipate undue forces. The thick inferior arcuate pubic ligament rigidly bridges both the inferior pubic rami and provides the symphysis pubis joint with the majority of its stability. Together with the anterior pubic ligament, posterior pubic ligament, and the supra-pubic ligament, motion within the pubic symphysis is limited to less than 2 mm in healthy subjects.13,18 The muscles attaching at or near the pubic symphysis include the pyramidalis and rectus abdominis superiorly, the adductor and gracilis anteroinferiorly, and the obturator and levator ani posteriorly. Sensory nerve innervation comes via the branches from the puden-dal and genitofemoral nerves.

Published case reports and retrospective record reviews have been used to postulate an infectious, inflammatory, or traumatic cause of this condi-tion.3-5,9,10,14,19-21 One may think in terms of four primary clinical types: (a) noninfectious osteitis pubis associated with urologic procedures, gynecologic procedures, and pregnancy; (b) infectious osteitis pubis associated with local or distant infection; (c) sports-related or athletic osteitis pubis; and (d) degenerative/ rheumatologic osteitis pubis. Because of the various clinical forms, the clinical history, incidence, sexual predisposition, and the age of onset in the literature varies considerably.

Athletic osteitis pubis is associated with activities requiring repetitive kicking or hip abduction/adduction motions, such as soccer, hockey, and Australian rules football.9,22 The true patho-genesis of this disorder remains obscure. A number of theories have been proposed, including trauma to the pubis symphysis periosteum, abnormal pelvic biomechanics,4,23 low-grade indolent infections,24 inflammatory causes,l reflex sympathetic dystrophy, avascular necrosis of the interpubic disk of fi-brocartilage,25 and venous thrombosis of the pubic veins.5,26 The two strongest arguments against an infectious etiology are the fact that osteitis pubis is a self-limiting condition and surgical specimens have failed to grow organisms.2,8,23 Additionally, histologic analysis of material obtained from surgical specimens has been consistent with nonspecific chronic inflammatory tissue.23

In athletes, the etiology is thought to be associated with muscle imbalance between the abdominal and adductor muscles, pelvis instability, and chronic overuse stress injury.4,5,l0,l4,20 Coventry et al.8 emphasized that external trauma did not play a significant role in their review of 45 cases of osteitis pubis. Muscle imbalance between the abdominal wall musculature and hip adductor muscles has been suggested as a major etiologic factor in athletes.l4,20 The muscles implicated include the rectus abdominis, gracilis, and adductors longus.5^0 An imbalance between abdominal and adductor muscle groups disrupts the balance of forces around the symphysis pubis, which acts as the central pivot point, leading to chronic micro-trauma.20 As a consequence of the repetitive trauma, blood supply to the injured muscle attachments may be impaired, intensifying the injury and exceeding the capacity of tissue to heal and remodel.20,27

Abnormal biomechanics of the pubic symphysis and the sacroiliac joints is the second possible etio-logic factor in athletes.4,22,23 Abnormal vertical motion of the pubic symphysis has been documented in patients with osteitis pubis. In one radiographic review, all patients with osteitis pubis had greater than 2 mm of mobility at the pubic symphysis^8 Williams et al.23 postulated that repeated vertical shear stresses and microtrauma resulted in a clinical syndrome consisting of osteitis pubis and coexisting vertical pubic instability greater than 2 mm in a group of competitive rugby football players. All their subjects with recalcitrant osteitis pubis and pelvis instability returned to sports after undergoing arthrodesis of the pubic symphysis joint.

Abnormal motion at the pubic symphysis may be brought about by abnormalities in the sacroiliac or the hip joints. Large increases in rotational and transla-tional motion within the pubic symphysis have been experimentally created in a cadaveric study by fusing the sacroiliac joints.28 Major and Helmsl0 demonstrated clinically and radiographically the coexistence of sacroiliac joint abnormalities in a subgroup of athletes with osteitis pubis. Harris and Murray4 also found chronic stress lesions in the sacroiliac joint in more than 50% of their subjects. The role of such abnormalities is not clearly understood. Whether the sacroiliac joint plays an etiologic role or is a manifestation of osteitis pubis remains to be determined.

Last, radiographic studies of athletes with osteitis pubis have demonstrated that the underlying patho-physiology may be a chronic stress injury to the pubic bone.l0,ll A prospective, blinded magnetic resonance imaging (MRI) study by Verrall et al.11 found a high incidence (77%) of increased signal intensity in symptomatic Australian rules football players. The increased signal intensity in the pubic symphysis was characteristic for bone marrow edema caused by a stress injury to the bone. They went on to list other etiologies capable of producing such bone marrow changes including osteomyelitis, infiltrating neoplasm, and direct trauma. These authors proposed that a tension stress injury from chronic stresses across the pubic symphysis was the most likely explanation for their observations. The idea that osteitis pubis is caused by a stress injury, akin to a stress fracture, is a reasonable one as the pubic symphysis is exposed to large amounts of shear stresses during sports activities. This possibility requires further research.

Clinical Presentation

Osteitis pubis is not only a diagnostic problem but also a therapeutic dilemma often requiring a multi-disciplinary approach. Making the diagnosis of osteitis pubis is not particularly difficult when the radiographs corroborate the diagnosis. However, the physician is faced with a difficult diagnostic challenge when an athlete presents with groin pain and nondiagnostic radiographs, especially if the symptoms are chronic. In this particular clinical setting, a referral to a general surgeon to rule out an inguinal hernia, spermatic cord problems, abdominal wall defects, and other urologic conditions is warranted. And, in the female athlete, a gynecologist referral to evaluate for conditions such as ovarian cysts, endometriosis, and pelvic inflammatory disease is appropriate.

Fricker et al.9 reviewed the records of 59 patients with osteitis pubis who presented in their sports clinic. Women averaged 35.5 years of age and men 30.3 years. The sports most frequently involved in this large series were running, soccer, ice hockey, and tennis. The most frequent symptom was pubic and adductor pain. Men also presented with lower abdominal, hip, perineal, or scrotal pain. The pain varies in intensity and duration. The onset may be either acute or insidious. Frequently, the injured athlete is unable to recall an inciting traumatic event. Osteitis pubis can prove difficult to diagnose because the pain symptoms may be ambiguous and generalized around the hip, thigh, and abdomen. This ambiguous constellation of symptoms can probably be explained by the richly innervated pubic symphysis and its complex pain referral patterns.17

The athlete's symptom is aggravated by activities that require sudden hip flexion or abduction/adduction such as running, kicking, single-leg pivoting, and jumping. Symptoms may be aggravated with abdominal stress including coughing, sneezing, and defecat-ing.5 Physical examination findings are localized to the pubic symphysis and surrounding area. Invariably, there is exquisite tenderness to deep palpation of the pubic symphysis and over the adductor muscle ori-gins.4,8,9 Patients may have decreased hip rotation unilaterally or bilaterally, which may be a result of restricted abduction of the thighs and adductor spasms.9,17 In severe cases patients may exhibit a waddling gait due to pain and tightness of the adductor muscles.2 A provocative test is reproducing symptoms with resistive adduction with the hips and knees flexed 90 degrees.14 Coventry and William2 described two provocative maneuvers: (a) the rocking cross-leg test in which the examiner bears down on the crossed knee while holding down the opposite iliac crest; and (b) the lateral pelvis compression test, done with the patient on his or her side and the examiner pressing the presenting wing.

Laboratory analysis adds little diagnostic value except for ruling out the presence of other pathologic processes such as infection and malignancies. Radiographic changes lag behind clinical symptoms by 2 or 3 weeks, so that early on in the disease process, plain radiographs will be of no diagnostic value.1,29 The reported radiographic incidence in soccer players is 14% to 28%.30 Radiographs do not correlate with the clinical severity of the disease.4,9,17,31 Harris and Murray4 have defined radiographic changes associated with osteitis pubis in athletes. These findings include marginal irregularity, symmetric bone resorption, widening of the symphysis, reactive sclerosis along the rami, and sacroiliac joint irregularities2 (Figure 5.1). Cortical avulsions at the site of the adductor tendon insertion may also be seen.10,16 In patients with pelvis instability, clicking of the symphysis4 and radiographic abnormalities of the sacroiliac joints may also be pres-ent.9,10 To assess for pubic symphysis instability, flamingo views (single-leg standing anteroposterior radiographs taken while standing on each lower extremity) can be used. Abnormal flamingo views indicating instability demonstrate pubic vertical motion greater than 2 mm.13,18

The diagnosis of osteitis pubis can be assisted with further studies such as a technetium-99m isotope bone scan.29 Positive findings for osteitis pubis show increased uptake at the pubic symphysis on the delayed views, indicating increased bone turnover. MR plays an important role in the evaluation of groin pain in the athlete. MRI is useful for evaluating the surrounding soft tissue structures and bone marrow edema and is especially good for ruling out occult her chapter 5: extraarticular sources of hip pain

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