Management of osteitis pubis in athletes: rehabilitation and return to training – a review of the most recent literature

Figures & data

Figure 1 Flow chart for search and selection of articles.

Table 1 Characteristics of selected studies

Author and year	Study design	Main conclusions	Levels of evidence
Angoules, 2015^Citation2	Review	OP is usually self-limiting and responds well to conservative treatment; in chronic recalcitrant cases surgical approach is needed	IV
Hegedus et al, 2013^Citation14	Review	Following a precise paradigm should lead to a more successful diagnosis and treatment of athletic pubalgia	IV
Beatty, 2012^Citation22	Review	Treatment includes non-operative measures of rest, rehabilitation, pharmacotherapy and may also include injections or surgery	IV
Jardí et al, 2015^Citation26	Case series	The protocol presented ensures a safe return for elite athletes, with full recovery longer in football players and increasing with age	IV
Cheatham et al, 2015^Citation30	Review	There is grade D evidence that a non-operative program is effective in helping athletes return to their pre-injury levels	III
Schöberl et al, 2017^Citation31	Prospective double-blinded controlled	Non-surgical therapy is successful in treating athletic osteitis pubis. Shock wave therapy reduced pain, thus enabling return to football within 3 months of trauma	I
McAleer et al, 2017^Citation32	Case series	A non-operative rehabilitative protocol is successful in athletes with osteitis pubis, enabling return to sport within 11 weeks	IV
Elattar et al, 2016^Citation34	Review	A variety of surgical options have been reported for athletic pubalgia, with successful outcomes and high rates of return to sport	IV
Gupta et al, 2015^Citation42	Case series	Endoscopic pubic symphysectomy is a safe, minimally invasive treatment for recalcitrant osteitis pubis	IV
Matsuda et al, 2015^Citation43	Case series	Endoscopic pubic symphysectomy is a minimally invasive procedure that may be useful in treating recalcitrant osteitis pubis	IV
Larson, 2014^Citation46	Review	An association between FAI and athletic pubalgia has been recognized, with better outcomes reported when both are managed concurrently or in a staged manner	IV
Ross et al, 2015^Citation47	Review	There is a subset of athletes that presents both athletic pubalgia and intra-articular hip disorders such as FAI	IV
Kajetanek et al, 2018^Citation48	Retrospective non-controlled	In patients with athletic pubalgia, a la carte surgery confined to the injured structure(s) produces excellent return to play outcomes	IV
Masala et al, 2017^Citation49	Prospective non-randomized non-controlled	Pulse-dose radio frequency is an effective and safe technique in the management of chronic pubalgia in athletes	IV
Scholten et al, 2015^Citation50	Case report	Ultrasound-guided needle tenotomy and PRP injection can be a safe and effective option in refractory cases of athletic pubalgia	IV
Henning, 2014^Citation57	Review	Overuse injuries can usually be managed non-operatively through rest and control of regional muscle imbalances	IV
McAleer et al, 2015^Citation58	Case report	A nine-point conservative strategy has been successful in an elite football player	IV
Rossidis et al, 2015^Citation59	Retrospective review	Laparoscopic hernia repair accompanied by an ipsilateral adductor longus tenotomy is a useful surgical technique for athletic pubalgia	IV
Ellsworth et al, 2014^Citation60	Review	A precise distinction between athletic pubalgia and inguinal disruption allows for an efficient rehabilitative plan of care	IV

Abbreviations: FAI, femoroacetabular impingement; OP, osteitis pubis; PRP, platelet rich plasma.

Table 2 Classification of levels of evidence

Levels of evidence	Criteria for analysis and inclusion
I	Meta-analysis and systematic reviews of randomized, controlled trials (RCTs) of high quality, or RCTs with minimum or low risk of bias. Systematic reviews of high quality relative to cohort studies or case–controls.
II	Cohort studies or randomized case–controls of high quality with minimal risk of confounding or bias and with high or discrete probability of causation.
III	Case–control studies and retrospective comparison of well-conducted studies with reasonable probability of causation.
IV	Non-analytic studies as case series or individual cases.

Table 3 Stages of osteitis pubis

Stages	Side of pain	Site of pain	Characteristics of pain
1	Unilateral, dominant	Inguinal, with radiation to adductors	Pain alleviation after warm-up, pain exacerbation after training
2	Bilateral	Inguinal and adductors	Pain exacerbation after training
3	Bilateral	Groin, adductor region, suprapubic, abdominal	During training, kicking, sprinting, turning. Cannot achieve training goals, forced to withdraw
4	Generalized	Generalized, radiation to lumbar region	Walking, getting up, straining at stool, simple activities of daily living

Table 4 Differential diagnosis of groin pain

Intra-articular pathologies	Extra-articular pathologies	Non-musculoskeletal disorders
Femoroacetabular Impingement Syndrome (FAI)	Insertional adductors and rectus abdominis tendinopathy	Genitourinary
Acetabular labral tears	Groin pain disruption	Adnexa torsion
Chondral lesions	Osteitis pubis	Nephrolithiasis
Femoral neck stress fractures	Adductor muscles injuries	Orchitis
Osteoarthrosis	Lumbar radiculopathy	Ovarian cystis
Transitory synovitis	Pubic ramus stress fracture	Pelvic inflammatory disease
Osteonecrosis of the femoral head	Apophyseal avulsion fractures	Urinary tract infections
Osteochondritis dissecans	Internal snapping hip syndrome	Endometriosis
Legg–Calvè–Perthes disease	Greater trochanter pain syndrome	Prostatitis
Epiphysiolysis of the femoral head	Sacroiliac joint disorders	Testicular cancer
Septic arthritis	Nerve entrapment	Testicular torsion
Oncologic process		Intra-abdominal pathologies
		Sports hernia
		Inguinal hernia
		Appendicitis
		Diverticulitis/Diverticulosis
		Lymphadenitis
		Inflammatory bowel disease

Note: Data from Maffulli et al.⁶

Figure 2 “Flamingo view” radiograph (obtained with the patient bearing weight alternately on each leg) that shows vertical pubic subluxation greater than 2 mm and underlying degenerative changes.

Note: A caudal osteolysis is visible on the right side (arrow).

Figure 3 Coronal T2 fat suppression MRI image showing marked bilateral diffuse symphyseal bone marrow edema and parasymphyseal edema (arrows).

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