Management of Osteitis Pubis in Athletes: Rehabilitation and Return to Training (PDF)

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Open Access Journal of Sports Medicine Dovepress open access to scientific and medical research Open Access Full Text Article Review Management of osteitis pubis in athletes: rehabilitation and return to training – a review of the most recent literature This article was published in the following Dove Press journal: Open Access Journal of Sports Medicine Alessio Giai Via 1 Abstract: Osteitis pubis is a common cause of chronic groin pain, especially in athletes. Antonio Frizziero 2 Although a precise etiology is not defined, it seems to be related to muscular imbalance and Paolo Finotti 2 pelvic instability. Diagnosis is based on detailed history, clinical evaluation, and imaging, Francesco Oliva 3 which are crucial for a correct diagnosis and proper management. Many different therapeutic approaches have been proposed for osteitis pubis; conservative treatment represents the first-line Filippo Randelli 1 approach and provides good results in most patients, especially if based on an individualized Nicola Maffulli 4,5 multimodal rehabilitative management. Different surgical options have been also described, 1 Department of Orthopaedic Surgery but they should be reserved to recalcitrant cases. In this review, a critical analysis of the and Traumatology, Hip Surgery Center, IRCCS Policlinico San Donato, Milano, literature about athletic osteitis pubis is performed, especially focusing on its diagnostic and Italy; 2Department of Physical and therapeutic management. Rehabilitation Medicine, University Keywords: osteitis pubis, pubalgia, groin pain, rehabilitation, review of Padova, Padova, Italy; 3Department of Orthopaedics and Traumatology, Tor Vergata Hospital, University of Rome “Tor Vergata”, Rome, Italy; Introduction 4 Department of Musculoskeletal Osteitis pubis is a painful chronic overuse condition affecting the pubic symphysis and Disorders, School of Medicine and Surgery, University of Salerno, Salerno, surrounding soft tissues. It is characterized by pelvic pain and local tenderness over Italy; 5Centre for Sport and Exercise the pubic symphysis. It commonly affects athletes, especially those who participate Medicine, Queen Mary University of London, Barts and the London School in sports that involve kicking, turning, twisting, cutting, pivoting, sprinting, rapid of Medicine and Dentistry, Centre for acceleration and deceleration or sudden directional changes.1 Osteitis pubis has been Sports and Exercise Medicine, Mile End Hospital, London, England described in athletes who play sports such as soccer, rugby, ice hockey, Australian Rules football and distance running.2 The diagnosis is difficult because of the anatomical complexity of the groin area, the biomechanics of the pubic symphysis region and the large number of potential sources of groin pain. Also, nomenclature is often confusing, resulting in different terms that describe similar clinical conditions.3 We present a review of literature to examine the current knowledge of osteitis pubis, with particular interest in the management of athletes suffering from this condition. Materials and methods This work represents a descriptive non-systematic review on the management of Correspondence: Francesco Oliva, M.D., osteitis pubis in athletes. A search of two databases (PubMed and Cochrane Library) Ph.D. Department of Orthopaedics and Traumatology, Tor Vergata Hospital, was performed using the terms “osteitis pubis” or “pubalgia” in the title of articles University of Rome “Tor Vergata”, combined with the terms “athlete,” “athletic,” “sport,” “training,” “rehabilitation” Rome, Italy Tel +39 338 567 0924 and “rehabilitative” as keywords. Search results were limited to articles written in Email [email protected] English and published between January 1, 2012 and August 31, 2018. The deci- submit your manuscript | www.dovepress.com Open Access Journal of Sports Medicine 2019:10 1–10 1 Dovepress © 2019 Giai Via et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. http://dx.doi.org/10.2147/OAJSM.S155077 php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Giai Via et al Dovepress sion to limit the bibliographic research to the most recent consensus. Eventually, 19 articles met the inclusion criteria literature is due to the fact that the purpose of this article and 37 articles were excluded (Figure 1). Only one of the was to perform a descriptive and not a systematic review of selected articles is a prospective double-blinded controlled literature. This is certainly a limitation, but it must be also study (level I), while most of the studies are retrospective considered that all recent literature is strongly influenced case series, case reports or reviews of literature (Table 1). by the previous one. The search with the aforementioned For each article, the level of evidence is defined on the basis criteria provided a total of 56 articles. As a fundamental of the classification shown in Table 2.4 criterion for inclusion in the review, the studies had to deal with recent concepts in the diagnosis and therapy of osteitis Epidemiology and pathogenesis pubis in athletes. Articles that did not specifically concern Osteitis pubis is a common source of groin pain in athletes. osteitis pubis, but dealt generically with groin injuries The incidence in athletes has been reported as 0.5%–8%, without distinguishing osteitis pubis from the frequently with a higher incidence in distance runners and athletes associated pathologies, were excluded. Articles concerning participating in kicking sports, in particular in male soccer osteitis pubis in non-athletes were also excluded. To avoid players, who account for 10%–18% of injuries per year.5,6 selection bias, all the authors analyzed the search results The etiology is not completely clear and is still being and disagreement over article inclusion was resolved by debated. Muscle imbalance between the abdominal and hip Articles identified by Articles identified by PubMed search Cochrane library search n=111 n=8 Articles after exclusion of duplicates n=56 Articles evaluated for Excluded eligibility articles n=56 n=37 Articles included in the review n=19 Figure 1 Flow chart for search and selection of articles. 2 submit your manuscript | www.dovepress.com Open Access Journal of Sports Medicine 2019:10 Dovepress Dovepress Review: management of osteitis pubis in athletes Table 1 Characteristics of selected studies Author and year Study design Main conclusions Levels of evidence Angoules, 20152 Review OP is usually self-limiting and responds well to conservative IV treatment; in chronic recalcitrant cases surgical approach is needed Hegedus et al, 201314 Review Following a precise paradigm should lead to a more successful IV diagnosis and treatment of athletic pubalgia Beatty, 201222 Review Treatment includes non-operative measures of rest, rehabilitation, IV pharmacotherapy and may also include injections or surgery Jardí et al, 201526 Case series The protocol presented ensures a safe return for elite athletes, IV with full recovery longer in football players and increasing with age Cheatham et al, 201530 Review There is grade D evidence that a non-operative program is effective III in helping athletes return to their pre-injury levels Schöberl et al, 201731 Prospective Non-surgical therapy is successful in treating athletic osteitis pubis. I double-blinded Shock wave therapy reduced pain, thus enabling return to football controlled within 3 months of trauma McAleer et al, 201732 Case series A non-operative rehabilitative protocol is successful in athletes with IV osteitis pubis, enabling return to sport within 11 weeks Elattar et al, 201634 Review A variety of surgical options have been reported for athletic IV pubalgia, with successful outcomes and high rates of return to sport Gupta et al, 201542 Case series Endoscopic pubic symphysectomy is a safe, minimally invasive IV treatment for recalcitrant osteitis pubis Matsuda et al, 201543 Case series Endoscopic pubic symphysectomy is a minimally invasive procedure IV that may be useful in treating recalcitrant osteitis pubis Larson, 201446 Review An association between FAI and athletic pubalgia has been IV recognized, with better outcomes reported when both are managed concurrently or in a staged manner Ross et al, 201547 Review There is a subset of athletes that presents both athletic pubalgia and IV intra-articular hip disorders such as FAI Kajetanek et al, 201848 Retrospective In patients with athletic pubalgia, a la carte surgery confined to the IV non-controlled injured structure(s) produces excellent return to play outcomes Masala et al, 201749 Prospective Pulse-dose radio frequency is an effective and safe technique in the IV non-randomized management of chronic pubalgia in athletes non-controlled Scholten et al, 201550 Case report Ultrasound-guided needle tenotomy and PRP injection can be a safe IV and effective option in refractory cases of athletic pubalgia Henning, 201457 Review Overuse injuries can usually be managed non-operatively through IV rest and control of regional muscle imbalances McAleer et al, 201558 Case report A nine-point conservative strategy has been successful in an elite IV football player Rossidis et al, 201559 Retrospective Laparoscopic hernia repair accompanied by an ipsilateral adductor IV review longus tenotomy is a useful surgical technique for athletic pubalgia Ellsworth et al, 201460 Review A precise distinction between athletic pubalgia and inguinal IV disruption allows for an efficient rehabilitative plan of care Abbreviations: FAI, femoroacetabular impingement; OP, osteitis pubis; PRP, platelet rich plasma. Table 2 Classification of levels of evidence Levels of Criteria for analysis and inclusion evidence I Meta-analysis and systematic reviews of randomized, controlled trials (RCTs) of high quality, or RCTs with minimum or low risk of bias. Systematic reviews of high quality relative to cohort studies or case–controls. II Cohort studies or randomized case–controls of high quality with minimal risk of confounding or bias and with high or discrete probability of causation. III Case–control studies and retrospective comparison of well-conducted studies with reasonable probability of causation. IV Non-analytic studies as case series or individual cases. Open Access Journal of Sports Medicine 2019:10 submit your manuscript | www.dovepress.com 3 Dovepress Giai Via et al Dovepress adductor muscles is currently considered the most important tion is not standardized and includes various tests, such pathogenetic factor in the development of osteitis pubis.7 as lateral compression and pubic symphysis gap test with Abdominal muscles act synergistically with the posterior isometric adductor contraction.8 Verrall et al13 proposed paravertebral muscles to stabilize the pelvis. They allow a three provocation tests (i.e., Single Adductor, Squeeze and single-leg stance while maintaining balance and contribut- Bilateral Adductor tests) for the assessment of chronic groin ing to the power and precision of the kicking leg. Stabiliza- pain in athletes, with bilateral adductor test exhibiting the best tion during the single-leg stance also results from gluteus metrics.14 Restricted range of hip motion, positive FABER and adductor muscle activity. The adductors are antagonists test, sacroiliac joint dysfunction and weakness of abductor to the abdominal muscles. Imbalances between abdominal or adductor muscles can be associated with clinical findings.6 and adductor muscle groups disrupt the equilibrium of In addition, some authors suggest that local corticoid and/or forces around the symphysis pubis, predisposing the athlete anesthetic injections in the pubic symphysis may be helpful to a subacute periostitis caused by chronic microtrauma.8 diagnostic tools.15,16 Reduced internal rotation of the hip and instability of the Rodriguez et al8 classified athletes with osteitis pubis into sacroiliac joint could represent other possible predispos- four stages, based on clinical examination and diagnostic ing factors as they lead to increased shearing stress in the features (Table 3). However, it is not a validated classification pelvis.9 and only empiric in nature since the authors included only a Whatever the cause, the biomechanical overload leads to small number of patients. a bony stress response in the parasymphyseal bone and/or Diagnosis is challenging because of the anatomical degenerative changes in the cartilage of the pubic symphysis, complexity of the groin area, the biomechanics of the usually in the absence of inflammatory findings.10 pubic symphysis region and the large number of potential sources of groin pain (Table 4).6,17 A differential diagnosis Diagnosis is mandatory. Even though osteitis pubis is considered a self-limiting condi- Imaging is not pathognomonic, but radiographs, triple- tion, players with groin pain frequently have to stop sporting phase scintigraphy and MRI can assist physical examination activities for many months and long absence from sports is and confirm diagnosis and/or exclude other pathologies and not feasible for high level athletes. For this reason, an early possible sources of groin pain.18 diagnosis and a multimodal therapeutic approach are man- Plain radiographs may demonstrate symphyseal bony datory. The diagnosis of osteitis pubis starts with recording sclerosis, erosions and widening or narrowing of the joint, the history and clinical evaluation. Athletes suffering from especially in the chronic phase, while radiographic changes osteitis pubis typically present anterior and medial groin pain. may be absent in the early or mild forms of the condition.19 Pain may also affect pubic symphysis, adductor musculature, A “flamingo view” (an anterior–posterior view of the pel- lower abdominal muscles, perineal region, inguinal region vis with the patient standing on one leg) can give evidence of or scrotum.11 Pain may be unilateral or bilateral, and it is pelvic instability (Figure 2), as a vertical subluxation greater exacerbated by running, kicking, hip adduction or flexion, than 2 mm or a widening of the symphysis greater than 7 mm and eccentric loads to the rectus abdominis.12 are considered pathognomonic.20 At clinical evaluation, tenderness on palpation of the Bone scintigraphy may reveal increased tracer uptake in symphyseal region is common. However, clinical examina- the pubic symphysis region and parasymphyseal bone, even Table 3 Stages of osteitis pubis Stages Side of pain Site of pain Characteristics of pain 1 Unilateral, Inguinal, with radiation Pain alleviation after warm-up, pain exacerbation dominant to adductors after training 2 Bilateral Inguinal and adductors Pain exacerbation after training 3 Bilateral Groin, adductor region, During training, kicking, sprinting, turning. Cannot suprapubic, abdominal achieve training goals, forced to withdraw 4 Generalized Generalized, radiation to Walking, getting up, straining at stool, simple lumbar region activities of daily living 4 submit your manuscript | www.dovepress.com Open Access Journal of Sports Medicine 2019:10 Dovepress Dovepress Review: management of osteitis pubis in athletes Table 4 Differential diagnosis of groin pain Intra-articular pathologies Extra-articular pathologies Non-musculoskeletal disorders Femoroacetabular Impingement Insertional adductors and rectus Genitourinary Syndrome (FAI) abdominis tendinopathy Acetabular labral tears Groin pain disruption Adnexa torsion Chondral lesions Osteitis pubis Nephrolithiasis Femoral neck stress fractures Adductor muscles injuries Orchitis Osteoarthrosis Lumbar radiculopathy Ovarian cystis Transitory synovitis Pubic ramus stress fracture Pelvic inflammatory disease Osteonecrosis of the femoral head Apophyseal avulsion fractures Urinary tract infections Osteochondritis dissecans Internal snapping hip syndrome Endometriosis Legg–Calvè–Perthes disease Greater trochanter pain syndrome Prostatitis Epiphysiolysis of the femoral head Sacroiliac joint disorders Testicular cancer Septic arthritis Nerve entrapment Testicular torsion Oncologic process Intra-abdominal pathologies Sports hernia Inguinal hernia Appendicitis Diverticulitis/Diverticulosis Lymphadenitis Inflammatory bowel disease Note: Data from Maffulli et al.6 Figure 3 Coronal T2 fat suppression MRI image showing marked bilateral diffuse symphyseal bone marrow edema and parasymphyseal edema (arrows). Figure 2 “Flamingo view” radiograph (obtained with the patient bearing weight alternately on each leg) that shows vertical pubic subluxation greater than 2 mm and underlying degenerative changes. Note: A caudal osteolysis is visible on the right side (arrow). seal region (Figure 3); on the other hand, subchondral sclerosis, subchondral resorption with bony irregularity though the degree of uptake is poorly correlated with dura- and osteophytosis or pubic beaking are characteristic of tion and severity of symptoms.21 chronic phases.7 As a gold standard, MRI provides a more detailed view Nevertheless, some studies report similar marrow edema of the symphysis pubis and surrounding soft tissues as in asymptomatic athletes also; so a correlation between MRI well as the bony pelvis and hips. The most common find- and clinical examination is mandatory.22,23 ing in athletic osteitis pubis of less than 6-month duration Recently, some authors proposed dynamic ultraso- is the presence of a hyper-intense signal on T2-weighted nography as a non-invasive diagnostic tool for evaluating images within the symphysis and adjacent parasymphy- osteitis pubis, but its high operator-dependency and lack of Open Access Journal of Sports Medicine 2019:10 submit your manuscript | www.dovepress.com 5 Dovepress Giai Via et al Dovepress precise methodological criteria seem to determine a poor the field, performing exercises mimicking their sport. Kicking reproducibility.24 is allowed only at the end of this stage. Eccentric abdominal wall strengthening exercises are started. Good results have Treatment and return to sport been reported with this progressive rehabilitation program, Osteitis pubis is typically described as a self-limiting condi- despite some differences between protocols.26 Most of the tion that improves with rest. However, management of groin athletes return to pre-injury levels within 3 months (from 4 pain is sometime difficult and patients can undergo extended to 14 weeks). Moreover, a successful long-term follow-up periods of rest, which is not feasible for athletes. Different was reported between 6 and 48 months for all patients.30 treatments have been proposed, ranging from conservative In one of these studies, Jardì et al26 described a specific management to surgical procedures. Unfortunately, few level conservative protocol for the treatment of six elite athletes one studies have been published in the most recent literature in three different sports (two football, two basketball, two and most of the scientific articles are retrospective case series rugby players) who were diagnosed with osteitis pubis or case reports, making it difficult to draw conclusions about stage III and IV according to Rodriguez classification.8 The this topic (Table 1). average time to start squad training was 2 months, while an average of 3 months was required to return to competition. Conservative treatment Basketball players had the shortest recovery, followed by Conservative management includes rest, limited activity, ice rugby and football players. No recurrences were reported and anti-inflammatory drugs, followed by a rehabilitation at a follow-up of at least two seasons. However, the results program. Conservative management aims to correct muscular of this study are limited by the small cohort of included imbalance around the pubic symphysis, and it usually con- patients. sists of a progressive exercise program, involving stretching In a recent prospective double-blinded controlled level and pelvic musculature strengthening.25 Physical therapy is I study, Schöberl et al31 analyzed amateur football players usually prescribed and a progressive sport-specific program with osteitis pubis and divided them into three groups. is indicated before a return to sporting activities.25 However, Patients in groups 1 and 2 received an intensive 3-phase there is a lack of standard rehabilitative protocols, resulting rehabilitation program. Group 1 additionally received three in extremely different rehabilitative programs, with variable weekly sessions of shock wave therapy directly on the pubis, outcomes and time to recovery. while group 2 was treated with sham shock wave therapy. Recent studies underline the importance of an individual- The control group was treated with rest and stopping of ized progressive multimodal rehabilitation program.26–29 In participation in all sporting activities; they did not receive this program, patients are moved through the protocol stages shock wave therapy. Forty-two of the 44 players of groups after they are able to perform exercises without pain and have 1 and 2 returned to football within 4 months, but return-to- achieved adequate levels of motion and core stability grad- sport was significantly earlier in group 1. No recurrences ing.27,29 The first stage is to focus on pain control and improve were reported in both groups at 1-year follow-up. On the lumbo-pelvic stability. Gentle prolonged stretching, except other hand, time to return-to-play was significantly longer for the adductors and ischiopubic muscles, is started. Cycling (8 months) in the control group, and players frequently on an exercise bike is introduced as cardiovascular training. experienced recurrent groin pain during the first year. Phys- In the second stage, Swiss balls and other aids are indicated iotherapy seems to have been successful for treatment of for performing resistance and strengthening exercises of osteitis pubis in the athletes, and local shock wave therapy the pelvis, abdominal and gluteal muscles. Abdominal core significantly reduced pain, thus enabling return-to-play isometrics targeting the transversus abdominis, abdomi- within 3 months of injury.31 McAleer et al32 described a nal crunches, gluteal bridges with and without resistance non-operative rehabilitation program for professional and bands, Swiss ball exercises for abdominal core, manual hip aspiring professional football players with osteitis pubis. strengthening and resistance hip strengthening with band are Their rehabilitative protocol was based on a specific nine- indicated. The third and fourth stages included eccentric hip point program that included pain control, tone reduction of exercises, side stepping with bands, lunge and squat exercises over-active structures, improved range of motion at hips, and progressive sport-specific training. Running is gradually pelvis and thorax, adductor strength, functional movement increased, and changes of pace and direction are introduced. assessment, core stability, lumbo-pelvic control, gym-based To reproduce the sport requirements, athletes start training on strengthening and field-based conditioning/rehabilitation. 6 submit your manuscript | www.dovepress.com Open Access Journal of Sports Medicine 2019:10 Dovepress Dovepress Review: management of osteitis pubis in athletes All players returned to training, without symptoms, within complication of surgery, they reported only transient post- 60 days and, to play, within 72 days. The authors also rec- operative edema of the scrotum in men and of the labia in ommended to patients a daily prophylactic program to be women, which resolved within 24 hours in all cases. Similar followed after recovery and this may have contributed to the results have been reported by Matsuda et al.43 absence of symptom recurrence in all players at a follow-up Recently, some authors demonstrated the association period ranging from 16 to 33 months. between osteitis pubis/athletic pubalgia and femoroacetabular impingement (FAI).44,45 In these patients, better results have Local injections been reported after treatment of both intra and extra-articular If symptoms fail to improve with conservative measures, pathologies, with a high rate of return to previous level of local injections can be used. Injections of corticosteroids activity/sport.46,47 in the symphyseal region and surrounding tissues have In a retrospective level IV study, Kajetanek et al48 included been used in various studies. However, the evidence is low. 27 patients who had failed at least 3 months of appropriate Some of these articles report resolution of pain at short-term conservative therapy and then underwent surgery for athletic follow-up with corticosteroids injections but a high rate of pubalgia with injury to the abdominal wall and/or adductor non-responders.33 Moreover, despite successful return to sport attachment. Each patient received a la carte surgery, which participation, a large percentage of these patients continued was confined to the injured structure(s) only on the affected to report pain and/or required multiple injections.30 There side (abdominal wall, adductor tendon or both), without is not enough evidence regarding the short- and long-term routine contralateral procedure, with the aim of limiting efficacy of corticosteroid injections.33–35 morbidity and reducing recovery time. The results showed One study reported on prolotherapy (dextrose injections) that 25 (92.6%) patients were able to return to their previous for the treatment of recalcitrant pubalgia.36 Nevertheless, the sport activity within a mean of 3–4 months and experienced literature is very limited and the efficacy and mechanism of no recurrence during 1-year follow-up. Time to return to play action of prolotherapy remain controversial. was significantly shorter in the group with abdominal wall injury only as compared to patients with adductor tendon Surgical treatment injury only or combined injuries. Surgery is usually performed when conservative treatments fail. It may be indicated after at least 3 months of well- Novel approaches conduced rehabilitation protocol.37 Surgical intervention is Recently, other treatments have been proposed. Masala et required for 5%–10% of patients recalcitrant to conservative al49 in 2015 reported on pulse-dose radio frequency on 32 approaches.6 patients with chronic pubic pain refractory to conservative Many different open or minimally invasive surgical pro- therapies. The goals of this percutaneous treatment were cedures have been proposed, including open or endoscopic to denervate the genital branches of the genitor-femoral, curettage of the symphysis pubis, arthrodesis of the sym- ilioinguinal and iliohypogastric nerves and the obturator physis with or without bone graft and wedge resection.38 All nerve. These nerves provide motor and sensory innervation procedures can be associated with the release of the adductor of the groin region, and they can be involved in entrapment tendons or with adductor enthesis repair.2,39–41 These surgi- or irritation syndromes that cause pubic pain. Twenty-four cal treatments vary widely in their invasiveness, impact on patients referred a significant pain reduction at final follow- pelvic biomechanics and recovery time. Even if most authors up (9 months) after one treatment. Six of 7 patients who were reported favorable outcomes after surgical procedures, most treated twice referred significant pain reduction only after the articles are retrospective case series, and studies are available second procedure, while only one patient had no pain relief up today.6 Given the lack of adequate clinical trials, little evi- after two treatments. All patients tolerated the procedure dence exists to support one surgical method over another, or well, with some minimal post-operative discomfort during indeed the need of surgery itself. Moreover, clinicians should the first few days, but without complications during the evaluate cost-effectiveness and consider possible side effects early or late period of follow-up. However, further studies of each procedure. are required. Gupta et al42 described an endoscopic technique for Scholten et al50 reported a case of distal rectus abdominis pubic symphysectomy, proposing it as a safe and feasible, ultrasound-guided needle tenotomy and platelet-rich plasma minimally invasive procedure for recalcitrant cases. As a injection, followed by a progressive rehabilitation. The patient Open Access Journal of Sports Medicine 2019:10 submit your manuscript | www.dovepress.com 7 Dovepress Giai Via et al Dovepress was pain free and went back competition 8 weeks after the consecutive series of 38 professional athletes who had been procedure. treated for symptomatic FAI. Twelve patients (32%) had undergone previous surgery for athletic pubalgia or osteitis Discussion pubis. All these patients returned to play after treatment of Groin pain is well-known among both athletes and physicians. FAI. Furthermore, 39% of patients were diagnosed with oste- Osteitis pubis is a painful degenerative condition of the pubic itis pubis/athletic pubalgia and FAI, and they had complete symphysis, surrounding soft tissues and tendons. It was first resolution of pain and returned to play after surgical treat- described by Beer in 1924,51 and it is currently considered ment of FAI alone. Even though the pathogenesis is not fully as one of the most debilitating pain syndromes for athletes. understood, it is possible that the restricted range of motion Although the condition is considered self-limiting, it often of the hip related to FAI may lead to compensatory stresses requires stoppage of sporting activities for several months, on the lumbar spine, pubic symphysis, sacroiliac joint and representing a significant problem especially for elite ath- posterior acetabulum in high-performance athletes.55 Exces- letes. The etiology is still debated, but muscular imbalance sive biomechanical stress on the groin may lead to second- and pelvic instability have been identified as the most likely ary injury to the abdominal wall musculature, including the pathogenetic mechanism. However, groin anatomy is com- posterior inguinal wall, resulting in symptomatic osteitis plex and pain is often caused by the association of different pubis or groin pain disruption.55 pathologies. These may include not only intra-articular and Surgery should be reserved for a limited subgroup of extra-articular pathologies around the hip but also lumbar patients who fail conservative management, after at least spine conditions, nerve entrapments and intra-abdominal and 3 months of a well-conduced rehabilitative program. Many genitourinary pathologies. Therefore, accurate differential different surgical techniques have been described, but the diagnosis is mandatory. majority of published studies exhibit a low level of evidence Many different treatment protocols and strategies have with no randomized controlled trials. Recent works reported been proposed for osteitis pubis, including conservative better results and shorter time to return to sport, especially management and rehabilitation, injections and surgery. for patients with concurrent intra-articular pathologies such Conservative treatment is the first-line therapeutic approach, as FAI or sports hernia. Therefore, it is unclear whether the and it includes rest, limitation of sporting activities, ice and favorable outcomes are related to the treatment of concomi- anti-inflammatory drugs. A rehabilitative protocol aimed at tant pathologies or to the osteitis pubis itself. correcting muscular imbalances upon pubic symphysis is also indicated.52–54 Conclusion Despite a lack of standardized rehabilitative protocols, Evaluation and treatment of groin pain are challenging, and a recent literature underlines the importance of progressive correct diagnosis is mandatory for appropriate management. individualized rehabilitation, which usually consists of Conservative treatments are indicated to stabilize the pelvis four stages. However, the lack of level 1 studies makes and pubic symphysis. Core stability exercises and muscle it difficult to compare the outcomes and a gold standard stretching and strengthening exercises of the abdominal, treatment is still not exploitable. Shock wave therapy can adductor, flexor and extensor hip muscles are effective for be included in the conservative treatment protocol in addi- this purpose. Surgery is indicted for patients who do not tion to physical exercise. Few articles are published about respond to conservative management. injection therapy, with not enough evidence regarding the Despite these final considerations, it must be emphasized efficacy of steroid injections and prolotherapy. However, that this study presents some obvious limitations. First of all, promising results have been reported with the use of dex- the study population is limited. Second, this study is aimed trose injections. at focusing only on “osteitis pubis,” which, however, is a The relationship between athletic pubalgia and FAI is misnomer for a variety of different pathologies which are a growing topic. Although they are considered two distinct frequently associated with osteitis pubis. Third, this review pathologies, recent studies suggest that both conditions refers only to the latest literature from 2012 to 2018 and does frequently affect athletes with groin pain.46 Economopoulos not cover the complete literature about this topic. Therefore, et al55 reported that 86% of patients referring groin pain given the gross heterogeneity of the studies available and the and treated for osteitis pubis and/or sports hernia had a abovementioned limitations of this research, no meta-analysis radiographic evidence of FAI. Hammoud et al56 described a could be conducted. 8 submit your manuscript | www.dovepress.com Open Access Journal of Sports Medicine 2019:10 Dovepress Dovepress Review: management of osteitis pubis in athletes Nevertheless, this review could provide key directions for 20. Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. 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