There are many causes of groin pain in athletes. One of the more common causes of groin pain is osteitis pubis, also known as pubic symphysitis. This condition occurs when there is significant inflammation and overload of the pubic symphysis. So, what is osteitis pubis, and can an osteitis pubis steroid or cortisone injection help?
What is the pubic symphysis?
The pubic symphysis is a thin joint containing cartilage in the middle. It joins the two parts of the pelvic bones together. It sits in front of the bladder; attached from above is the rectus abdominis, and below is the adductor longus.
Causes
Inflammation of the pubic symphysis occurs due to various causes:
- Sport is the most common cause.
- Trauma or a fall can cause an inflamed joint
- Pregnancy can overload the pubic symphysis, causing pain
Some people are prone to this condition, ranging from extreme sports to reduced movement of the hips to muscular imbalances between the abdominal and adductor muscles.
Osteitis pubis Diagnosis
Symptoms of osteitis pubis develop gradually over time. Pain is usually in the center, although it can move from one side to another. Typically, symptoms are worse after running and a change of direction activity. There is associated limping and weakness of the pelvic muscles.
Overall, it is essential to make sure other causes of groin pain are ruled out, such as sports hernia, hip impingement and hip stress fracture.
Osteitis pubis radiology
Sometimes, imaging is needed, mainly if the pain has not settled with simple treatments.
Generally, in osteitis, an MRI scan of the pelvis shows swelling of the pubic bone on either side of the joint or thickening of the adductor tendon. However, we must carefully interpret these imaging changes, as many occur in active sportspeople without pain.
A recent study found that these MRI findings were more common in athletes with groin pain:
- Swelling in the pubic bone close to the joint (subchondral bone marrow oedema)
- Rupture of the capsule of the pubic symphysis, also called ‘cleft’ sign
Overall, we suggest an MRI for groin pain to exclude other causes, including severe pathology.
Osteitis pubis recovery
Overall, we know that pubic overload takes many months to get better. Indeed, taking shortcuts such as a cortisone injection or surgery will not get you back to sports faster. Also, the sooner you start treatment, the quicker the improvement and return to sports will be.
Your therapist should test your strength in your hip abductors and adductors to see if you have a strength weakness that needs correcting.
Osteitis pubis rehabilitation: an example of a structured rehab program
Initially, we treat the inflammation to reduce pain in the pubic bone. These simple treatments include rest from aggravating sports, anti-inflammatory tablets such as ibuprofen, compression shorts, and soft tissue massage.
Next, we suggest you see an experienced therapist to guide your rehab. Overall, the focus of recovery should be on improving the mobility and flexibility of your hips and strengthening the muscles surrounding the pelvis. The rehab exercises are staged in this order:
- Isometric adductor exercise (especially if the person has high pain levels)
- Standing single-leg crab walks and adductor machine exercises
- Copenhagen adductor strengthening exercise – using short and long levers
Generally, we recommend three sessions per week to strengthen the pubic bone pain. You should also work the other muscles in the pelvis, including the hip flexors and glutes. Overall, you can work through low-level pain, also known as stable pain. Also, therapists often check progress by using the isometric squeeze test to see if you are coping with rehab – any reduction in strength of a squeeze test is an early warning sign that you’re progressing exercises too quickly and your pubic bone pain worsens.
Finally, as your pubic bone pain settles, your therapist will guide the progression of your activity from straight-line running to changing direction running to the sport.
For complex cases, we use injections to help with exercise. Generally, we only recommend injections if you continue to struggle with pain despite 3-6 months of rehab.
In almost all cases, surgery is not recommended as surgery results are unpredictable.
More about osteitis pubis steroid injection
Overall, there are several options for an osteitis pubis cortisone injection.
- Cortisone Injection for Pubic Symphysis: For cases primarily involving the pubic symphysis, we suggest an osteitis pubis cortisone injection. This injection is usually done with a longer needle just above the joint. These injections are typically performed with ultrasound guidance to improve accuracy and effectiveness. They provide pain relief for a few months and sometimes longer. Like any injection, they are not risk-free with possible adverse effects, including infection (1:10000) and ineffective injection.
- Tendon injections: For cases with predominantly tendon pathology, such as adductor tendonitis, we inject the tendon with cortisone or PRP. These injections are performed with ultrasound to relieve tendon-associated pubic overload pain.
- Groin nerve blocks: We use these injections for people with pain in the adductor, inguinal, lower abdominal, perineal, or pelvic area. Generally, we use a numbing solution with a small dose of cortisone. Injecting around a nerve can reduce pain from the area supplied by the nerve—this is usually immediate and has an effect of up to one month. The nerves injected include the obturator nerve for adductor pain, the ilioinguinal nerve for inguinal pain and the pudendal nerve for perineal pain. Generally, nerve blocks are less invasive than joint injections.
Generally, for cases of pubic overlap, we use a combination of joint, tendon and nerve injections, with the choice of the injection dependent on the specific presentation. Overall, it is essential to understand that these injections do not cure the problem but help with the rehab.
Other frequently asked questions about Osteitis pubis
Can Osteitis Pubis cause bladder problems?
Maybe. The bladder sits just behind the pubic symphysis. Inflammation of the pubic symphysis joint can irritate the bladder, leading to bladder issues such as an increase in urinary frequency. However, bladder symptoms should be investigated further to exclude problems like infection.
Can Osteitis pubis cause testicular pain?
Yes. It is common for inflammation of the pubic symphysis to cause pain in the groin radiating into the testicle. However, you should see a doctor to exclude problems in the testicle or other groin conditions, such as a sports hernia.
What type of doctor treats osteitis pubis?
Generally, you should see a sports medicine doctor who can assess you to confirm the diagnosis and exclude other causes of groin pain.
How long does osteitis pubis take to heal?
Generally, it takes many months for the symptoms to settle. Despite a good rehab programme and graduated return to running, symptoms can take 6-12 months to settle.
Final word from Sportdoctorlondon about osteitis pubis steroid injection
Osteitis pubis, or pubic overload or pain in the pubic bone, is common in runners and change-of-direction sports—generally, the earlier the diagnosis, the faster the return to sport. Rehab is the main form of treatment, but osteitis pubis steroid injection can be used carefully in complex cases. Overall, we need to remember that there are no quick fixes for this condition and that an osteitis pubis cortisone injection or surgery can delay progress or be harmful.
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