Chiropractic can treat the disorder, which has symptoms including localized pain in the pubic symphysis region

Osteitis pubis is a disorder affecting the pubic symphysis, whereby inflammation about the articulation results in localized symptoms and signs.

The pubic symphysis articulation is a hyaline joint containing a fibrocartilage disc. Ligamentous attachments surround the articulation anteriorly, posteriorly, and inferiorly. In addition, the cruciate ligament provides a contribution from the inguinal ligament anteriorly and the arcuate ligament inferiorly. Muscle groups insert around the anterosuperior aspect of the articulation, including that of gracilis, adductor longus and brevis, and a portion of the rectus femoris.

Etiology
Although various explanations as to the etiology exist, a commonly accepted theory relates to a reduction in the venous flow locally, resulting in intraosseous venous engorgement, in turn leading to a localized form of osteopenia. However, this is one of several possible explanations that have been proposed. It may develop due to direct trauma or be more clinically frequent due to trauma-related situations such as pregnancy, multiparity, repetitive strain, or ligamentous stretching. The condition may also occur due to an underlying inflammatory arthropathy, including rheumatoid arthritis or the HLA-B27-related spondyloarthropathies, or due to infection. The development of infection may relate to recent pelvic surgery—for example, to the prostate or bladder. Some authors consider the diagnosis of osteomyelitis pubis separate from that of osteitis pubis.¹ The organisms frequently detected if aspiration is performed include Staphylococcus Aureus, Eshcherichia coli, or Pseudomonas aeruginosa.

Examination
The symptoms of osteitis pubis include localized pain in the pubic symphysis region, pain in the lower abdominal area, and discomfort in the region of the adductor muscle group. The pain may be described as “groin burning.” Occasionally, an audible “click” will be described by the patient. Examination of the region reveals exquisite pain over the pubic symphysis, tenderness about the adductor longus muscle, and a reduction in the range of external rotation and abduction of the hip.

Imaging
Imaging of osteitis pubis—including conventional/digital radiography, scintigraphy, and magnetic resonance imaging (MRI)—may be performed to determine the diagnosis of the disorder. Radiography demonstrates a bilateral involvement of the pubic bone and articulation with loss of the articular margin, irregularity, and increased density in the subarticular region and regions of erosions demonstrable (Figure 1). Laxity of the articulation may develop detectable either on static imaging with a pubic symphysis distance of more than 7 mm or when, during the stress views for the articulation (flamingo views), the superior margins of the articulation are misaligned more than 2 mm. During the evolution of the process, the radiograph may demonstrate the development of osteophytes, as well as a reduction in the pubic symphysis distance. Eventually, the articulation may remodel and bear no hallmarks of the disorder, or in some cases may develop an ankylosis.² Scintigraphy is rarely performed but demonstrates a focal uptake at or about the articulation on delayed scans. MRI is a useful imaging modality to study the evolution of osteitis pubis, since it permits the detection of the degree of inflammation as para-articular marrow edema and it is able to determine the effect on the articular margin of the pubic bone and the development of extrusion of the intra-articular disc.

Figure 1: A 34-year-old male came to a chiropractor with generalized lower abdominal and groin pain. On the closeup image of the pubic symphysis, the articular margin is not visible. In addition, erosions and subchondral sclerosis are evident on both sides of the joint in
this patient with osteitis pubis.

Differential Diagnosis
The differential diagnosis for osteitis pubis includes articular-based disorders, as well as more unusual pathologies. The articular-based disorders that may be considered include those that may include inflammation of the cartilaginous joints and enthuses. Such inflammatory arthropathies include Ankylosing spondylitis and Reiters syndrome.³ In addition, other pathologies that lead to changes similar to osteitis pubis include hyperparathyroidism, both in the primary and secondary form, osteomalacia, and in rare cases, radiation therapy where the region of the pubis has been included in the region exposed to the radiation.

Management Options
The treatment options available vary relating to the diversity of explanations surrounding the development of the disorder. In some patients, no pain is detectable, and the finding is determined on imaging performed for a separate reason. Conventional medical options include providing oral analgesic medication, injecting the articulation directly with a steroid and local analgesic, and, occasionally, surgical fusion if pain and instability do not respond to other therapeutic options.⁴ In addition, a broad spectrum of treatments have been used with varying effect, including immobilization, radiation, and the addition of antibiotics.

Chiropractic treatment options include a local approach toward the articular and muscular component of the disorder, as well as assessing the patient for pelvic dysfunction. Although the physiotheraphy literature discusses the management of osteitis pubis, very little current literature exists on the chiropractic management of this condition. Muscular regions that have been approached used isolated muscle function, including the iliopsoas, quadriceps, and gluteus medius, and then the addition of higher-level trunk stability, allowing the patient to perform activities that were previously painful.⁵ CP

Michelle Wessely, BSc (Chiropractic), DC, DACBR, is head of radiology and head of clinical research at Institut Franco-Europeen de Chiropratique, Ivry-Sur-Seine, France. She can be reached at michelle_wessely@yahoo.com.  

References
1. Pauli S, Willemsen P, Declerck K, Chappel R, Vanderveken M. Osteomyelitis pubis versus osteitis pubis: a case representation and review of the literature, Br J of Sports Med, 2002;36(1):71-73.
2. Yochum T, Rowe L. Chapter 10: Arthritic Disorders. In: Essentials of Skeletal Radiology. 3rd ed. Lippincott Williams & Wilkins. 2004:1078–1080.
3. Resnick D. Osteitis pubis. Chapter 53. Disorders of other Endocrine glands and of pregnancy, In: Diagnosis of Bone and Joint Disorders. 2130-2131.
4. O’Connell M, Powell T, McCaffrey N, O’Connell D, Eustace, S. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. Am J Roentgenology. 2002;179:955–959.
5. McCarthy A, Vicenzino B. Treatment of osteitis pubis via the pelvic muscles. Manual Therapy. 2003;8(4),257–260.