What is the management of osteitis pubis?

Management of Osteitis Pubis

Osteitis pubis should be managed initially with conservative treatment including rest, NSAIDs at maximum tolerated doses, and physical therapy, with most non-athletic patients responding well to this approach within 2-4 weeks. 1, 2

Initial Assessment and Disease Activity Determination

Before initiating treatment, assess disease activity based on:

• Clinical symptoms: Bone pain localized to the pubic symphysis, groin, or lower abdomen 3
• Radiological measures: Bone marrow edema on MRI or increased tracer uptake on bone scan at the pubic symphysis 3
• Focal inflammatory signs: Local tenderness, swelling if present 3
• Inflammation markers: Elevated CRP or ESR if applicable 3

Active disease requires both clinical symptoms AND radiological activity—initiate treatment in these cases. 3 If symptoms exist without radiological findings, investigate alternative pain sources (myalgia, neuropathic pain, mechanical issues) before treating as osteitis pubis. 3

Treatment Goals

Establish these specific objectives with patients before starting therapy 3:

• Relieve bone pain caused by osteitis 3
• Maintain/regain functional capacity: Range of motion, reduction in fatigue, return to activities 3
• Reduce inflammation: Decrease bone marrow edema on imaging and normalize inflammatory markers 3
• Prevent structural damage: Monitor for secondary changes like sclerosis or erosions 3

First-Line Treatment (Conservative Management)

NSAIDs/COX-2 inhibitors at maximum tolerated and approved dosage for 2-4 weeks 3, 1:

• This represents the cornerstone of initial therapy for osteitis pubis 1, 2
• In non-athletic female patients, 87.5% (7 of 8) improved significantly with NSAIDs and physical therapy alone 1
• Athletes with stage I disease (early, mild symptoms) recovered in mean 26.7 days with conservative treatment 2

Adjunctive conservative measures 1, 2, 4:

• Complete rest from aggravating activities, particularly kicking sports 2, 4
• Physical therapy: Progressive rehabilitation program focusing on core stability and adductor/abdominal muscle balance 2
• Modalities: Electrical stimulation, ultrasound, cryotherapy 2
• Consider short courses of oral prednisolone as bridging therapy 3

Response evaluation at 2-4 weeks based primarily on pain reduction and functional improvement 3. If sufficient response, consider tapering to on-demand treatment. 3

Second-Line Treatment (Refractory Cases)

If insufficient response to NSAIDs after 2-4 weeks, escalate therapy 3:

Intravenous Bisphosphonates (First Choice)

Add or replace NSAIDs with IV pamidronate 3, 5:

• Administer 3-6 monthly courses 5
• In refractory cases, all three patients achieved clinical remission with IV pamidronate when conservative measures failed 5
• Remission confirmed on isotope bone scan with no recurrence at follow-up 5

Local Corticosteroid Injections

Corticosteroid injection into the pubic symphysis with or without local anesthetic 3, 4:

• Four case series support this approach for refractory symptoms 4
• Use as bridging management option 3

TNF-α Inhibitors (Alternative Second-Line)

Consider TNF inhibitors if bisphosphonates fail or are contraindicated 3:

• Particularly relevant if features of spondyloarthropathy coexist 3, 5
• Response evaluation at 3-6 months 3

Third-Line Treatment (Surgical Options)

Refer to expert center for surgical intervention if medical management fails 3:

Surgical options include 4:

• Pubic symphysis curettage 4
• Pubic bone stabilization 4
• Arthrodesis (fusion): Reserved for severe refractory cases 1

Important caveat: Surgery is rarely required in non-athletic patients (only 1 of 8 patients in one series), whereas athletes may benefit from earlier surgical intervention for faster return to sport. 1, 4

Special Considerations

Exclude Osteomyelitis Pubis

Critical pitfall: Osteomyelitis can occur concurrently with osteitis pubis 6:

• Suspect if fever, significantly elevated inflammatory markers, or failure of conservative treatment 6
• Obtain biopsy and culture of pubic symphysis to confirm diagnosis 6
• Treat confirmed osteomyelitis with prolonged antibiotic therapy (10 case reports support this) 6, 4

Patient-Specific Factors

• Athletes: May require more aggressive treatment for faster return to sport; midfielders most affected (42.8%) 2
• Non-athletic patients: Conservative management is highly effective; surgery rarely needed 1
• Post-surgical/gynecological procedures: Consider as etiologic factor 5, 6

Monitoring and Follow-Up

Reassess treatment response at predetermined intervals 3:

• 2-4 weeks for first-line treatment 3
• 3-6 months for second-line treatment 3
• Base assessment on clinical improvement primarily, integrate radiological findings if clinical response is unclear 3
• Routine follow-up imaging not required if evident clinical improvement occurs 3

Taper therapy with sustained sufficient response at 6-12 months of combined treatments 3

Common Pitfalls to Avoid

• Do not continue ineffective conservative treatment indefinitely—failure after 2-4 weeks should prompt escalation 3, 1
• Do not miss concurrent osteomyelitis—obtain cultures if conservative treatment fails 6
• Do not rush to surgery in non-athletes—87.5% respond to conservative measures 1
• Do not ignore biomechanical factors—address antagonistic forces between abdominal and adductor muscles, especially in kicking sports 2