FEMORAL ACETABULAR IMPINGEMENT
August 5, 2015
PRIMARY CARE FRACTURE MANAGEMENT
June 1, 2016

OSTEITIS PUBIS

Description:

– Inflammation of symphysis pubis and surrounding structures including attaching tendons and ligaments.

– The condition is more common in soccer, hockey, football and running sports

– The symphysis pubis is composed mostly of cartilage, along with 4 ligaments with provide stability to the joint

– Muscles/tendon attachments: adductor magnus/brevis/longus, gracilis, rectus abdominis, pectineus

Pathophysiology:

– etiology of symptoms not well known but the predominant theory suggests repetitive trauma and opposing shearing forces as the culprit

– imbalances between the adductors and abdominals may play a role

History:

– patients will typically complain of insidious onset of midline, bilateral or less commonly, unilateral pelvic area pain.

– aggravated with activities involving hip adduction/abduction

– pain may radiate to hip, testicle, perineum or lower abdominal area

Exam:

Tenderness on palpation over symphysis pubis or either side of it

Pain with resisted adduction or abdominal muscle contraction

Differential Diagnoses:

Adductor tendinopathy

Inguinal hernia

Athletic pubalgia/Sport Hernia/Inguinal Related Groin pain

Pelvic stress fracture (pubic rami, femoral neck)

 

Investigations

Xray (AP pelvis): findings typically occur after condition has been present for a while and include:

– widening of the symphysis

– bony resorption

– osteopenic changes at articular margins

* note: some of above changes may be present in asymptomatic individuals

– May consider MR or bone scan if the diagnosis in doubt after hx, px, and xray. Bone scan should ideally be reserved for cases where the diagnosis cannot be obtained otherwise due to increased radiation risk

– MRI findings: fluid in the joint, bone marrow edema, adductor insertional tears, subchondral sclerosis may be present in chronic cases

– Bone scan findings: increased uptake at symphysis may especially pick up subtle changes

 

Treatment (step wise approach suggested; no studies comparing effectiveness of tx modalities)

1)

– Rest, NSAIDs

– PT: strengthen pelvic stabilizes (core, adductor strengthening, balance and stability training)

2.

– Fluoroscopically guided cortisone injections (may consider oral prednisone if barriers to injection present: 60 mg for 5 days or a prednisone taper over 2 weeks (i.e 60mg x 4 days, then 40 mg x 4 days, then 20 mg x 4 days OR 60mg x 1d, then 50mg x 1d, then 40mg x 1d, then 30mg x 1d, then 20mg x 1d, then 10mg x 2)

3.

Surgery: mx approaches

– curettage: degenerative area around symphysis debrided

– wedge resection: trapezoid shaped area of symphysis is resected

– wide resection: as above but with wider areas of resection

– arthrodesis +/- bone grafting

* Risks: pelvic instability may occur after wedge resection

Dr. Kevin Asem (Aug 5, 2015 PRND) 

References:

1) Johnson. R. Osteitis Pubis. Current Sports Medicine Reports; 2003 vol 2 pg 98-102

2) Uptodate article on Osteitis Pubis

3) Corey J. Hiti,1,2 Kathryn J. Stevens,3 Moira K. Jamati,1 Daniel Garza1 and Gordon O. Matheson.  Athletic Osteitis Pubis Sports Med 2011; 41 (5): 361-376

4)  Vincent,C. Osteitis pubis. J Am Board Fam Pract. 1993;6(5):492.