Introduction 

Osteitis pubis is the inflammation of pubic symphysis along with the adjacent muscle attachments. Primarily, it is considered to be a possible complication of pelvic surgeries initially diagnosed in patients who have undergone suprapubic surgery. Besides this, it is also possible to develop this condition as an inflammatory disorder of an overuse aspect in sports. 

The actual incidence of Osteitis pubis is unknown since no large epidemiological studies exist. Rates amongst athletes are between 0.5 and 8% with a greater occurrence in distance athletes and kicking sports especially male soccer players of which 10-18 % of all annual injuries are due to it. One study that involved 189 athletes with groin pain found that 14% had osteitis pubis. Isolated osteitis pubis was found in 9.3%, and combined cases with adductor microtears in 42.3 % in an MRI study of 97 athletes, although this difference is getting smaller with women becoming more active participants in sports. 

The pubic symphysis is a non-synovial joint containing a fibrocartilaginous disc between layers of hyaline cartilage and having restricted movement due to the ligamentous support. It is where the rectus abdominis and adductor complex attach and their actions are opposite each other, thereby generating stress, which may result in osteitis pubis. Repeated loading can lead to tendinosis, muscle imbalance, abnormal transmission of forces, joint instability, bone stress and degeneration of cartilage. An alternate theory proposes the condition results of compensatory movement because of limited mobility in other areas, like in femoroacetabular impingement (FAI); cadaveric analysis has demonstrated that there is a greater rotation of the pubic symphysis in cam-type FAI. Other causes are irritation of the urologic procedures on the inguinal ligament such as the Marshall-Marchetti-Krantz (MMK) procedure or direct trauma to the joint. 

The exact cause of osteitis pubis is not fully understood, though it is often linked to repetitive stress affecting the pubic symphysis. This joint acts as a pivot which connects opposing muscle groups of the anterior pelvis such as the rectus abdominis and the adductor complex. The constant tension on these structures may cause microtrauma and induce muscle imbalance and consequently the distribution of forces over the pubic symphysis may be disturbed and the normal biomechanics of the structure can be altered. Such changes exert extra stress to the pubic bone and can result in the destruction of the cartilage. Also, but with less demonstrative evidence, abnormal hip mechanics such as those related to femoroacetabular impingement (FAI) have been implicated. Rare causes reported in literature are rheumatologic in nature, previous pelvic or urologic surgeries and pregnancy. 

The osteitis pubis has an excellent prognosis. The majority of the patients heal under conservative therapy and can back in the sports within three months, and the recurrence rates are not high. Only 5-10 % of cases require surgery, and the outcome is usually good, recovery to play is usually within 3-4 months.

Age group

Most common in young to middle-aged athletes, especially men in their 20s–40s. 

Findings include localized tenderness over the pubic symphysis, pain with resisted adduction or sit-ups, reduced hip mobility, and occasionally an antalgic gait. 

Frequently linked to high-impact or repetitive activities such as distance running, soccer, hockey, and sports involving frequent kicking or twisting. Can also follow pelvic surgeries, pregnancy, or rheumatologic conditions. 

Onset may be gradual with chronic groin pain that worsens with activity, though some patients present acutely after an inciting event. 

The treatment of osteitis pubis largely depends on the conservative approach which includes rest, NSAIDs, and gradual physical therapy. The time taken to recuperate is generally 3 months, but this may take 6 months or more. Prolotherapy and steroid injections have demonstrated some potential benefits although their efficacy is not clear. Surgery is required in only 5-10% of cases and usually following more than half a year of unsuccessful non-operative treatment. This can be surgically treated by symphyseal curettage, fusion, wedge resection, or muscle repair, and most athletes are able to resume sport in approximately 6 months. The results are mostly positive irrespective of the process. Symptoms of osteitis pubis in concomitant patients with femoralacetabular impairment (FAI) can be frequently relieved by treating FAI only. 

Internal Medicine

Reduce or temporarily stop aggravating activities such as running, kicking, or sudden directional changes. 

Adjust training load with gradual return-to-play programs. 

Incorporate cross-training (e.g., swimming, cycling) to maintain fitness without stressing the pubic symphysis. 

Emphasize proper warm-up, stretching, and core stabilization exercises. 

Address biomechanical contributors such as poor footwear, uneven playing surfaces, or training errors. 

Internal Medicine

Ketoprofen 
Ketoprofen is a potent NSAID, which has a powerful anti-inflammatory and analgesic action. It is usually first-line choice because of the ease of daily administration, which improves compliance. Lower doses are recommended for elderly patients, those with small body size, or individuals with renal or liver impairment. The dosages that exceed 75 mg are not likely to cause any additional advantage. Excess doses are to be administered with a lot of care and patient observation. 

Indomethacin (Indocin) 
Indomethacin is highly effective in the treatment painful conditions such as ankylosing spondylitis, but there is little strong scientific evidence that supports its effectiveness. It acts by blocking the COX enzymes, which cause the production of prostaglandins and inflammation. Gastric side effects may be more intense than other NSAID and thus, tolerance is to be observed. 

Internal Medicine

If conservative treatment fails, surgery may be considered, typically after at least six months of nonoperative management. Surgical procedures may include: symphyseal curettage, fusion, wedge resection and procedures that strengthen or repair abdominal or pelvic floor muscles. Case reports and series, such as arthrodesis with plate and bone graft report favorable outcomes of returning to sport and resolving symptoms. Success has also been achieved using endoscopic techniques. There are no major differences in surgical indications, and the prognosis is usually the same in all types of surgery, and most athletes are able to resume full activity approximately six months after surgery. 

Internal Medicine

Treatment of osteitis pubis is usually progressive. During the acute stage, the emphasis is on pain management and rest, activity modification to prevent running, kicking or twisting, and NSAIDs and supportive care methods, such as ice. A gradual rehabilitation is also initiated in the subacute phase with physical therapy aimed at core stabilization, pelvic floor and hip strengthening, and adductor, hip flexor and abdominal muscle stretching. Cross-training which involves cycling or swimming, can be done without straining the pubic symphysis and therefore is considered as being of low impact. Sport-specific exercises, and progressive loading are introduced in the advanced stage, where gradual recovery to complete functioning is achieved once the strength and the flexibility and biomechanics are regained. In patients with unremitting symptoms, adjunctive treatments including corticosteroid injections or prolotherapy should be considered, and surgical treatment including symphyseal curettage, fusion, or muscle repair should be used in cases of refraction.