Intended for healthcare professionals

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Practice Lesson of the Week

Osteoarticular infection of the symphysis pubis and sacroiliac joints in active young sportsmen

BMJ 2009; 339 doi: (Published 07 December 2009) Cite this as: BMJ 2009;339:b5019

Rapid Response:

Osteitis pubis needs strengthening/ rehab not rest

I read this article with interest. I felt drawn to comment on your
reference to the much more common condition of osteitis pubis,
particularly with reference to the frequency of positive imaging findings
and the treatment you suggested.

Many athletic patients are internet informed about their injuries,
particularly those who have presented to numerous practitioners who have
used buzz phrasology such as osteitis pubis or Gilmores groin. To me
osteitis pubis is very much an umbrella term that patients use for their
symptoms, rather than a distinct clinical entity - a bit like the term
"shin splints".

Most individuals are labelled as osteitis pubis clinically when they
have chronic groin pain that has progresed to bilateral or symphyseal
symptoms. But initially, on deeper questioning the symptoms will have
begun in one particular anatomical area, with a particular activity or be
of insidious onset after sport. This then means that the phenomenon of
"osteitis pubis" is actually a secondary one.
Dynamic lumbo-pelvic function is an incredibly complicated process and it
only takes one weak link in the chain to put greater stress on other
areas, which in turn begin to complain.

Thus if the bilateral pain and tenderness in chronic athletic
pubalgia is actually due to muscles, tendons and joints being unable to
cope with the additional load put upon them by compensating for the
primary abnormal/ injured structure. eg) degenerate hip joint, chronic
adductor tear, surely the answer is to train the various structures to be
strong enough to support their colleague until it heals or improves (if

The management is thus to rehabilitate lumbo-pelvic function through
core stability etc and to try to identify the primary failure and direct
treatment as indicated.
Rest and non-steroidals is not the answer. The complexity of managing
these individuals means that mean return to play is around nine months and
with a high relapse rate.

Some sports physicians suggest stepping away from the term osteitis
pubis altogether in favour of other slightly more descriptive ones like
pubic stress syndrome.

In the athletic population the majority of individuals who have
symphyseal changes on xray or marrow oedema on MR do not (yet) have
symptoms suggestive of osetitis pubis/ pubic stress syndrome. Indeed it
has been reported in asymptomatic Aussie Rules players that degenerate
symphyseal changes on xray are a common finding. So clinical correlation
is needed when reviewing positive imaging findings in such athletes.

Many thanks for this article which I enjoyed very much.

Competing interests:
None declared

Competing interests: No competing interests

13 February 2010
Jonathan R Hanson
ST6 Sport and Exercise Medicine
Belfast BT9