What is the recommended approach for rehabilitation of osteitis pubis?

Rehabilitation of Osteitis Pubis

Initial Management: Conservative Treatment is the Foundation

For osteitis pubis rehabilitation, start with NSAIDs at maximum tolerated dosage combined with complete rest and structured physical therapy, as this conservative approach successfully resolves symptoms in the vast majority of non-surgical cases. 1

First-Line Treatment Protocol

• Begin NSAIDs/COX-2 inhibitors at maximum approved dosage for 2-4 weeks as the cornerstone of initial therapy 1
• Implement complete rest from aggravating activities, particularly running, kicking, pivoting, and stair climbing 2, 3
• Initiate physical therapy incorporating electrical stimulation, therapeutic ultrasound, laser therapy, and cryotherapy/cryomassage 1, 3

Structured Rehabilitation Program Components

Physical therapy should follow a progressive, staged approach:

• Start with "small amounts often" (pacing principle) rather than intensive sessions 4
• Begin with isometric strengthening exercises for both legs, targeting quadriceps and proximal hip girdle muscles, even when pain is unilateral 4
• Progress to range of movement and stretching exercises as tolerated 4
• Advance to aerobic activity only after pain subsides with basic exercises 4
• Link exercise regimens to daily activities (e.g., before morning shower) so they become habitual rather than additional burdens 4

Response Evaluation Timeline

• Assess treatment response at 2-4 weeks based primarily on pain reduction and functional improvement 1
• If sufficient response occurs, continue treatment and re-evaluate at 12 weeks 4
• With sustained improvement, consider tapering to on-demand treatment 4

When Conservative Treatment Fails

Second-Line Options for Refractory Cases

If inadequate response after 2-4 weeks of maximal conservative therapy:

• Consider intravenous bisphosphonates (pamidronate) as first choice for refractory cases 1
• Local corticosteroid injections into the pubic symphysis can serve as bridging management 1
• TNF-α inhibitors may be considered if bisphosphonates fail or are contraindicated 1

Surgical Intervention

Surgery is rarely required for non-athletic patients and should be reserved for cases with complete failure of conservative management after 6-12 months 5. In one case series of eight non-athletic women, only one patient (12.5%) required surgical arthrodesis after conservative treatment failure 5.

Treatment Goals and Monitoring

Establish clear treatment objectives with patients before starting therapy: 4

• Relieve bone pain localized to the pubic symphysis, groin, or lower abdomen 1
• Maintain or regain functional capacity including range of motion and quality of life 4
• Reduce inflammation as measured by focal tenderness, elevated CRP/ESR, and radiological findings 1
• Prevent structural damage to the pubic symphysis 4

Ongoing Assessment

• Monitor disease activity based on clinical symptoms (bone pain at pubic symphysis) and radiological measures (bone marrow edema on MRI or increased tracer uptake) 1
• Include focal inflammatory signs (local tenderness, swelling) and inflammation markers (CRP, ESR) in assessment 1
• Reassess at predetermined intervals: 2-4 weeks for first-line treatment, 3-6 months for second-line treatment 1

Adjunctive Supportive Measures

Throughout rehabilitation, implement these general recommendations: 4

• Provide patient education about the nature of osteitis pubis as a self-limiting inflammatory condition 2
• Consider short courses of oral prednisolone as bridging therapy while awaiting effect of other agents, but avoid long-term glucocorticoid use 4
• Address lifestyle modifications including activity modification and avoidance of pain-provoking movements 2

Common Pitfalls to Avoid

• Do not rush return to sport or activity - osteitis pubis can run a prolonged course if mismanaged 3
• Do not overlook the possibility of concurrent osteomyelitis pubis if conservative treatment fails, as this requires antibiotic therapy 6, 7
• Do not assume surgery is necessary - in non-athletic populations, conservative treatment with NSAIDs and physical modalities represents a fair option with success rates approaching 87.5% 5

Expected Recovery Timeline

For athletes with stage I disease (earliest presentation), mean recovery time is approximately 27 days with conservative management 3. However, recovery can be significantly longer in more advanced cases or when diagnosis is delayed 2, 3.