Discussion

The primary intent of this systematic review was to review the literature on the treatment of osteitis pubis in athletes. No level 1 studies were identified with our search strategy (table 1). All case reports/series described initial treatment of the condition with conservative measures, typically including rest, non-steroid anti-inflammatory drugs (NSAIDs), physical therapy and, in one case series, the use of compression shorts. It is thought that osteitis pubis is caused by repetitive twisting/cutting manoeuvres with stress at the pubic symphysis from restrictive hip movement.27 Imbalances between the hip adductor and abdominal muscles have been thought to contribute in the development of osteitis pubis.19 Also, it has been found that an active rehabilitation programme that improves the coordination and strength of muscles that act on the pelvis helps decrease pain in patients who experience chronic groin pain.18 Therefore, conservative therapy is typically the first step in the treatment of osteitis pubis.

The symptoms of osteitis pubis can range from self-limited to chronic, lingering for months to years.18 25 It does appear from one large case series examining the effects of conservative treatment that patients diagnosed earlier in their course experience fewer symptoms and return to play faster.18 This case series graded the severity of osteitis pubis based on symptom severity. Stage 1 was unilateral symptoms involving the dominant leg and inguinal pain in the adductor muscles. Stage 2 was bilateral symptoms with inguinal pain involving the adductor muscles. Stage 3 involved bilateral inguinal pain involving the adductor muscles and abdominal symptoms. Stage 4 involved pain in the adductor and abdominal muscles referred to the pelvic girdle and lumbar spine with defecation, sneezing and walking on uneven surfaces with an inability to perform activities of daily living. In this specific case series, return to play ranged from 4 to 10 weeks. The rehabilitation focused on core stability with an emphasis on adductor and gluteal strength and endurance. The stage 1 group (least severe) returned to play in 3.8 weeks, approximately half the time it took for the stage 2 group to return to play (6.7 weeks). Although a small case series, it demonstrated that a successful rehabilitation programme can expedite return to play in milder cases of osteitis pubis.

Another conservative approach incorporated compression shorts in limiting groin pain and improving athletic performance in individuals with osteitis pubis.5 Eleven athletes who were already receiving conservative treatment involving physical therapy and NSAIDs were fitted with compression shorts during specified agility drills. In all cases, there was no difference in performance of the drills as to whether the athletes did or did not wear the shorts. The participants did note a significant decrease in pain during exercise while wearing the shorts; however, the study did not comment on length of treatment required for return to play. Although this approach did not improve athletic ability, a reduction in pain during exercise is an important factor that can play a role in the symptom management of osteitis pubis.

The authors purposely did not include a study analysing active physical training as treatment for adductor related groin pain in athletes.3 The study took 68 athletes with adductor related groin pain (mean symptoms 40 weeks) and assigned them randomly to either a physiotherapy treatment without active therapy or an active training programme that aimed to stabilise the hip and pelvis with special attention to the adductor muscles. This study demonstrated that the active training programme was effective in the treatment of longstanding adductor related groin pain. However, because this study analysed athletes with groin pain without a specific diagnosis of osteitis pubis, and since this systematic review only looked at studies that involved treatment of osteitis pubis, the authors did not include the results in this paper.

Three case series employed corticosteroid injections with or without local anaesthetic into the pubic symphysis.4 9 20 Because no consistent type, strength or quantity of medication for injection was used between the three studies, it is difficult to draw any definitive conclusions on an ideal strategy. A mean of 1.24 injections (range of 1–3) was performed. Needle placement into the pubic symphysis was confirmed with fluoroscopic guidance in only one study.20 Overall success rates for return to sport following corticosteroid injections were moderate (58.6% with a mean of 8 weeks from the first injection). There was also a high number of athletes who did not respond to injection (20.7%) and were unable to return to sport at all. Timing of injection from the start of symptom onset may indeed play a role in the overall success rate. The results of one study suggest that injection of corticosteroid in athletes with chronic symptoms (>16 weeks) does not promote as rapid a recovery as injection in athletes with acute symptoms (<2 weeks).9 Seven of eight athletes in the chronic group were able to return to sport on average at 10 weeks and required a mean of 1.75 injections, while all three athletes in the acute group returned to sport within 2 weeks and only required one injection each. Corticosteroid injections for the treatment of osteitis pubis appear to demonstrate a high safety profile; there were no reports of postinjection complication such as haematoma or infection in the 29 athletes that received at least one injection. Further investigation is needed to determine whether pain reduction and faster return to play following injection are attributable to the corticosteroid alone, anaesthetic alone or a combination of the two, and could be answered through a properly designed RCT.

Our review of the literature identified only one case series using prolotherapy (dextrose and lidocaine) to treat osteitis pubis.21 Numerous injection sites were targeted across the pubic rami and into the pubis symphysis rather than one single injection into the pubic symphysis. A mean of 2.8 treatments (range 2–6) were performed which is more than the reported number of corticosteroid injections. Similar to corticosteroid therapy, prolotherapy also appears to demonstrate a high safety profile with no reports of postinjection complication in the 24 athletes that received at least one treatment course. Interestingly, prolotherapy did produce high success rates for return to sport (91.7% with a mean of 9 weeks from the first injection series) in this study, suggesting that this treatment option should be investigated further.21 Ideally, an RCT would be conducted to critically assess the efficacy of this approach.

Six case series reported the use of surgical options to treat osteitis pubis in athletes.6 22,–,26 It should be noted that subjects suffered from prolonged osteitis pubis (mean 17 months of symptom duration prior to surgery) that was refractory to other treatment modalities including rest, rehabilitation exercises, NSAIDs and/or injection therapy. Two case series were identified for three different surgical techniques (curettage of the pubic symphysis, polypropylene mesh placement into the preperitoneal retropubic space and pubic symphysis stabilisation). No study compared multiple surgical techniques, and so it is impossible to make head-to-head comparisons as to the most effective surgical approach. Overall, 37 out of 46 athletes (80.4%) were able to return to sport following surgery with a mean return to play of 4.6 months. Given the severity and prolonged duration of symptoms in this treatment group, the results seem particularly satisfying. The success rates for return to sport for each individual surgical type were 72% for curettage of the pubic symphysis, 92% for polypropylene mesh placement into the preperitoneal retropubic space and 100% for pubic symphysis stabilisation (omitting one athlete where return to play was not commented on). Surgical treatment with polypropylene mesh placement into the preperitoneal retropubic space provided the quickest return to sport times, averaging 7.2 weeks. In light of the invasive nature of surgical treatment options, safety of the athlete is of particular concern. Of the 46 athletes who underwent surgery, there were only two postoperative complications reported (4.3%): one athlete noted 6 weeks of haemospermia, and a second athlete suffered from 6 months of intermittent scrotal swelling during exercise (both athletes underwent pubic symphysis stabilisation procedures).

The case reports of osteomyelitis pubis in athletes were all spontaneous and non-traumatic. The exact mechanism of how it occurs is unknown; however a bacterial infection of the symphysis pubis appears to play a role. It is thought that microtrauma of the symphysis pubis in athletic activity may predispose the pubis to bacterial seeding.4 Osteomyelitis pubis should be suspected in a patient with acute onset of pubic symphysis pain, fever and symptoms of systemic involvement. Nine out of the 10 cases that described osteomyelitis pubis had an organism (most commonly S aureus) identified. The standard treatment for all cases was hospital admission and intravenous antibiotics. In all cases, patients required a minimum of 6 weeks of treatment. Complete recovery was described in seven of the 10 cases, with mean recovery at 12.9 weeks. Return to activity was reported in only one case, in which the patient was running at 4 months' follow-up.

Of note, of the 171 athletes treated for osteitis pubis or osteomyelitis of the pubic symphysis, only nine were females (5.3%). Therefore, based on the results of this systematic review at least, osteitis pubis occurs more often in males. It is difficult to determine whether these data represent a true difference in predisposition for the condition between sexes, or it could be an under-representation of the female population in the reported literature.

In summary, the mean return to play for athletes diagnosed as having osteitis pubis was 9.55 weeks using conservative treatment (41/42 athletes), 8 weeks for corticosteroid injections (17/29 athletes), 9 weeks following prolotherapy (22/24 athletes), 22.4 weeks after pubic symphysis curettage (18/25 athletes), 7.2 weeks using preperitoneal retropubic mesh placement (12/13 athletes) and 26.4 weeks for pelvic stabilisation (7/8 athletes). Return to play was not specified in the cases of osteomyelitis pubis. Comparison of the return to play time frames provided by each of the various treatment options is limited based on several factors. Conservative therapy was the first-line treatment for both the injection and surgical case reports/series. In addition, the surgical case reports/series were populated with refractory cases of osteitis pubis that failed more conservative modalities, resulting in an overall prolonged disease state prior to treatment. Of the three surgical techniques examined, preperitoneal retropubic mesh placement appears to provide the fastest return to sport, although a head-to-head trial comparing all three techniques would provide more conclusive data.