What is the appropriate diagnosis and treatment approach for a patient with osteitis pubis, considering factors such as age, athletic status, and medical history?

Osteitis Pubis: Diagnosis and Treatment

Critical Distinction First

Osteitis pubis is a localized inflammatory condition of the pubic symphysis that differs fundamentally from chronic non-bacterial osteitis (CNO), which is a systemic autoinflammatory disease requiring more aggressive immunosuppressive therapy. 1, 2 This distinction is essential because CNO typically presents with multifocal bone involvement (anterior chest wall, spine, mandible) and associated features like palmoplantar pustulosis, psoriasis, or inflammatory arthritis, whereas osteitis pubis is confined to the pubic symphysis region. 3

Diagnostic Approach

Clinical Presentation

• Pain localization: Anterior and medial groin pain, pain directly over the pubic symphysis, or radiating to the adductor region, lower abdominal muscles, perineal region, or scrotum 2, 4
• Pain characteristics: Atraumatic bone pain persisting over 6 weeks with inflammatory properties (pain irrespective of motion or during the night), aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis 3, 5, 4
• Functional impairment: Difficulty with ambulation, characteristic "waddling gait," and inability to sustain athletic activity at high levels 4, 6

Laboratory Investigation

• Routine testing: Full blood count, inflammatory markers (CRP, ESR - may be mildly elevated), renal function, alkaline phosphatase, calcium, 25-hydroxy-vitamin D, parathyroid hormone, and phosphate 3, 2
• Note: Inflammatory markers lack specificity and may be elevated due to various factors, rendering them non-specific for diagnosis 3, 2

Imaging Evaluation

• First-line imaging: MRI is preferred for initial evaluation, showing bone marrow edema at the pubic symphysis as the earliest pathological feature 1, 2
• Alternative: CT combined with nuclear imaging (bone scan showing increased tracer uptake) if MRI is unavailable 3, 2
• Timing caveat: Radiographic findings (reactive sclerosis, rarefaction, osteolytic changes) lag behind symptoms by approximately 4 weeks 6
• Clinical examination limitations: Presence of purulent drainage and bone exposure have notably low sensitivity (22-33%) for diagnosis 3

Differential Diagnosis to Exclude

• Infectious osteomyelitis (the major differential - requires exclusion through clinical course and response to non-antibiotic therapy) 3, 6
• Malignant bone tumors 3
• Other rheumatic musculoskeletal diseases 3
• Metabolic bone diseases 3
• Athletic injuries in active patients 5, 4

Treatment Algorithm

First-Line: Conservative Management (2-4 Weeks)

Initiate NSAIDs/COX-2 inhibitors at maximum tolerated and approved dosage as the cornerstone of initial therapy. 1, 2 Specific options include:

• Indomethacin 1
• Ibuprofen 1
• Celecoxib 1
• Etoricoxib 1
• Meloxicam 1

Adjunctive measures (all initiated concurrently):

• Complete rest 1, 2
• Structured physical therapy using the "small amounts often" pacing principle rather than intensive sessions 1
• Isometric strengthening exercises for both legs (quadriceps and proximal hip girdle muscles), even when pain is unilateral 1
• Range of movement and stretching exercises progressed as tolerated 1
• Electrical stimulation, ultrasound, laser, and cryotherapy 2, 5
• Exercise regimens linked to daily activities to become habitual 1

Response evaluation at 2-4 weeks:

• If sufficient response (pain reduction and functional improvement): Continue treatment and re-evaluate at 12 weeks 1, 2
• If insufficient response: Consider NSAID rotation or escalate to second-line therapy 1, 2

Second-Line: Refractory Cases (After Failed Conservative Management)

For patients failing conservative management after 2-4 weeks, add intravenous bisphosphonates as the preferred second-line option, with pamidronate as the first choice. 1, 2

Alternative second-line options:

• TNF-α inhibitors (infliximab, adalimumab, or etanercept) if bisphosphonates fail or are contraindicated 1, 2
• Local corticosteroid injections into the pubic symphysis as bridging management 2
• Short courses of oral prednisolone as bridging therapy while awaiting effect of other agents (avoid long-term glucocorticoid use) 1

Reassessment timeline: 3-6 months for second-line treatment 1, 2

Surgical Intervention (Rare)

Surgery is rarely required for non-athletic patients and should be reserved for cases failing 6+ months of conservative management. 7, 8 When indicated:

• Ligament-sparing arthroscopic curettage technique preserving adjacent ligamentous structures 8
• Avoid complete resection or arthrodesis that may cause iatrogenic pelvic instability 8

Treatment Goals and Monitoring

Establish clear treatment objectives before starting therapy:

• Relieve bone pain localized to the pubic symphysis, groin, or lower abdomen 1, 2
• Maintain or regain functional capacity including range of motion and quality of life 1, 2
• Reduce inflammation (focal tenderness, elevated CRP/ESR, radiological findings) 1, 2
• Prevent structural damage to the pubic symphysis 1, 2

Disease activity monitoring parameters:

• Clinical symptoms (bone pain at pubic symphysis) 2
• Radiological measures (bone marrow edema on MRI or increased tracer uptake) 2
• Focal inflammatory signs (local tenderness, swelling) 2
• Inflammation markers (CRP, ESR) 2

Special Populations

Athletes

• Represent 3-5% of all injuries in professional soccer players 5
• Midfielders most affected (42.8%), defenders and forwards equally affected (25.7%) 5
• Mean recovery time for stage I disease: 26.7 days with conservative management 5
• May require surgical intervention earlier than non-athletes for faster return to competition 7, 8

Non-Athletic Female Patients

• Surgery rarely required (only 1 in 8 patients in one series) 7
• Conservative treatment with NSAIDs and physical modalities represents a fair option regarding pain and limitation of everyday activity 7

Critical Pitfalls to Avoid

• Do not confuse with CNO: If patient presents with multifocal bone involvement, anterior chest wall pain, or associated features like palmoplantar pustulosis or psoriasis, consider CNO and refer to rheumatology 3, 1
• Do not rely on inflammatory markers alone: CRP and ESR are non-specific and can be elevated due to various factors 3, 2
• Do not delay imaging: Radiographic findings lag 4 weeks behind symptoms; use MRI for early diagnosis 6
• Monitor bisphosphonate adverse effects: Atypical femoral fractures and osteonecrosis of the jaw; ensure good dental hygiene before treatment 1
• Avoid long-term glucocorticoids: Use only as short-term bridging therapy 1