We see many patients with osteitis pubis every year, but very few have been offered effective osteitis pubis treatment. So what is this diagnosis? What causes it? How can it be easily treated? Let’s dig in.
What Is Osteitis Pubis?
Before we can get into osteitis pubis treatment, we need to understand more about the diagnosis itself. Your pelvis is a ring with two joints in the back called the sacroiliac (SI) joints and one in the front known as the symphysis pubis. That front joint can get inflamed and when that happens the medical term is osteitis pubis. This is also called athletic pubalgia or just pubalgia.
The symphysis pubis is a disc-like fibrous joint that’s meant as a shock absorber (1). It lives in the middle of your groin, just above your genitals, so it can cause pain in the middle of the groin area. That pain can also be referred into the lower abdomen or even into one side or the other in the groin and slightly downward.
To better understand what this diagnosis is and why this all happens, you need to comprehend a bit more about this structure.
Notice that the “Ra” here is the rectus abdominus, which is the middle-lower abdominal muscle that attaches to the front of the pelvis. This pulls up. The muscle opposing this force is the adductor, which pulls down (“Al” here). This is mirrored on the other side of the symphysis pubis, making a force couple of left-right muscles pulling up on the structure and left-right muscles pulling down.
What Causes Osteitis Pubis?
Now that you know how this area is built, it’s not hard to see how it might get inflamed and pissed off. First, the symphysis pubis joint itself can be unstable due to the ligaments that hold it together being lax or loose. This can happen due to direct trauma or even pregnancy as the baby’s head exits the birth canal.
This problem has also been described in kicking athletes, so overuse can also cause osteitis pubis. However, if that’s the cause, then stopping the kicking for a few days or weeks should heal it. If that doesn’t happen, then read on.
Also realize that as described above, the pelvis is a ring with three joints. Hence, if the sacroiliac (SI) joint ligaments in the back are loose, then the symphysis pubis will get too much wear and tear as well, causing inflammation upfront (see image here). Hence, a problem in the low back can cause a problem is the symphysis pubis.
In addition, as shown above, the abdominal muscles are pulling up on the symphysis pubis and the adductor muscles are pulling down. So asymmetry or weakness in either one can place too much stress on the symphysis pubis and lead to inflammation. In addition, tendinitis in any of these muscle tendons can also do the same thing.
How is Osteitis Pubis Treated?
Physical therapy is usually the first line of treatment (2). Another option is the injection of steroids into the area. The downside there is that high dose steroids can harm tissues, despite being a potent anti-inflammatory. Other options include dextrose prolotherapy and platelet-rich plasma (2,4). Radiofrequency treatment of the nerves has also been reported as well as shock wave therapy (5,6).
Surgery for this disorder is uncommon (3). This usually involves bolting the joint together or removing the joint. Both of these can lead to more problems in the SI joint. If the joint is fused together, this overloads the SI joints and if you remove the joint this causes instability in the rest of the ring, which again hits the SI joints.
How Do We Treat this Problem?
Since there are few randomized controlled trials on any of these treatments, using the research to guide the osteitis pubis treatment isn’t really possible. We have seen great results in these patients by using platelet-rich plasma and dextrose prolotherapy to tighten loose ligaments. These are ultrasound-guided injections into the ligaments that support the symphysis pubis as well as areas of tendinopathy in the adductors or rectus abdominis.
However, just treating the symphysis pubis is often not enough. Remember, this problem can be caused by unstable SI joints that have loose ligaments as well. Hence, using ultrasound guidance to treat those ligaments is often needed. Meaning, treating the whole pelvic ring is usually a smart idea.
The upshot? Osteitis pubis treatment options are out there. In my experience, for patients that fail physical therapy, the way to fix this is to tighten the ligaments around the joint itself and other joints of the pelvic ring (SI joints).
(1) Lentz SS. Osteitis pubis: a review. Obstet Gynecol Surv. 1995 Apr;50(4):310-5. https://www.ncbi.nlm.nih.gov/pubmed/7783998
(2) Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking-sport athletes with chronic groin pain. Arch Phys Med Rehabil. 2005 Apr;86(4):697-702. https://www.ncbi.nlm.nih.gov/pubmed/15827920
(3) Mehin R, Meek R, O’Brien P, Blachut P. Surgery for osteitis pubis. Can J Surg. 2006;49(3):170–176. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3207605/
(4) Kraeutler MJ, Garabekyan T, Mei-Dan O. The use of platelet-rich plasma to augment conservative and surgical treatment of hip and pelvic disorders. Muscles Ligaments Tendons J. 2016;6(3):410–419. Published 2016 Dec 21. doi: 10.11138/mltj/2016.6.3.410
(5) Schöberl M, Prantl L, Loose O, et al. Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study. Knee Surg Sports Traumatol Arthrosc. 2017;25(6):1958–1966. https://www.ncbi.nlm.nih.gov/pubmed/30613167
(6) Masala S, Fiori R, Raguso M, et al. Pulse-dose radiofrequency in athletic pubalgia: preliminary results. J Sport Rehabil. 2017;26(3):227–233. https://www.ncbi.nlm.nih.gov/pubmed/27632851