Osteitis pubis is regarded as an inflammatory condition of the pubic symphysis which can cause chronic pain, particularly in athletes whose activity involves intensive running. Unfortunately, the condition is not fully understood as far as its pathophysiology and aetiology are concerned. It is thought that the pubic symphysis is subjected to strain from the forces of the rectus abdominis and the adductors, which produce a dysfunction of the pelvic ring resulting in its instability. The pathological and anatomical finding on imaging consists of degenerative lesions. Theories have been put forward according to which the instability of the pelvic ring may be likened to that caused by fractures of the pelvis, and this explains the long period of recovery from this condition, which may extend to between 18 and 24 months. The movements associated with such syndromes appear to be those involving rapid changes of direction, vigorous side-to-side movements and also turns accompanied by poor movement of the legs. The typical movement is when the athlete moves from side to side during play, as a midfielder does in football, combined with a stretching movement in order to reach the ball or while defending. Such stretching movements produce external rotation of the hip that reaches the end of its range of movement. As the hip cannot contribute any further abduction of the limb, the abduction forces place a greater load on the weak link of the ring, that is to say the pubic symphysis. Patients with a restricted range of hip movement are thought to be more prone to such injuries. It is very important for the clinician making the diagnosis to note that the pain reported by the patient may not be confined to the region of the pubic symphysis but may also be referred to the anal region or even the rectum. The athlete may often report an atypical, deep-seated ache in the general region of the hip. Plain radiographs may show lytic or sclerotic areas at the pubic symphysis, and a single-leg standing radiograph will often demonstrate a widening of the pubic symphysis of more than two millimetres. A bone scan may occasionally be diagnostic, while magnetic resonance imaging can very often show bone oedema in the pubic bone, sometimes a fine fracture line and, more rarely, disruption of the pubic capsule and anteroposterior displacement of the pubic symphysis.
Treatment
Many treatment options have been proposed, among them injection with a local anaesthetic and a steroid, rest for 12 to 18 months, the injection of sclerosing agents in order to strengthen the sacroiliac joints and the pelvic ring, injection of pamidronate to reduce the bone oedema and the pain and, more rarely, surgical stabilisation of the pubic symphysis with fixation implants. It is important that the orthopaedic surgeon informs the patient that this condition is fairly persistent and could last for up to two years from its initial onset.
More recently, femoroacetabular impingement has been recognised as a cause of osteitis pubis. By restricting the range of movement of the hip, it produces abnormal micro-motion of the pubic symphysis and in the long term osteitis pubis develops. This is treated by the surgical elimination of the femoroacetabular impingement by means of hip arthroscopy. In this way the normal anatomy is restored, creating proper congruence of the articular surfaces and more harmonious movement. Recent studies have documented the effectiveness of arthroscopic treatment of femoroacetabular impingement in cases of osteitis pubis in professional athletes.