Working Diagnosis:
Osteitis Pubis

Treatment:
After his lumbar MRI, he received two epidural steroid injections by Pain Management. After his hip MRI, he received a fluoroscopy-guided injection of his right hip. Finally, after the bone scan, he received an in-office steroid injection to the symphysis pubis.

Outcome:
He started a rehabilitation program with physical therapy. He had no relief after the lumbar epidural and intra-articular hip injections. After the steroid injection to his symphysis pubis he reported 100% relief of pain at one week. He completed PT and continued with a home exercise program. He had continued pain relief at three- and six-month follow-up visits. He was able to return to cycling without further pain at 4 weeks post injection. He returned to his usual cycling routine and distances at 2-3 months post injection.

Author's Comments:
Osteitis Pubis is one of the most common causes of groin pain in athletes (soccer, hockey, rugby, running, football). It is seen most commonly in men ages 20 to 50 years. An imbalance of the hip adductors and the rectus abdominis, as well as repetitive microtrauma during activity, have been shown to cause the pubic symphysis to become unstable leading to inflammation(3,4). Case Photo #3 Case Photo #4 Case Photo #5 This generally results in pain in the pubic symphysis that may radiate to the groin, thigh, or abdomen. Photo 6. In this case, although uncommon, pain may also radiate to the lower back or hip. This unusual presentation may delay diagnosis and treatment thus preventing athletes out of their desired sport longer than necessary. Treatment includes rest followed by a progressive rehabilitation program, oral anti-inflammatory medications, steroid injections, or possibly surgery if there is no improvement with conservative treatment options.

Editor's Comments:
Osteitis pubis is a common cause of groin pain in athletes. Concomittant pathology with the hip and lumbar spine is not unusual. However, this case illustrates an atypical pain referral pattern of osteitis pubis to the lumbar spine region. In this case a bone scan identified the diagnosis but most osteitis pubis diagnoses would be confirmed by MRI. X-rays can also be helpful and photo 5 shows mild subchondral erosive changes with joint irregularities and sclerosis of the symphysis pubis. With the growing use of MSK ultrasound in sports medicine, some would advocate that a diagnostic ultrasound scan could be done in office to help confirm the diagnosis. As part of the treatment, a period of rest and then progressive rehabilitation would be instituted to work on flexibility and strengthening. An injection can serve both as diagnostic confirmation and treatment.

References:
1. Weber M, Rehnitz C, Streich N. (2013). “Groin Pain in Athletes.” RoFo. 2013; 185(12): 1139-1148.
2. Kavroudakis E, Karampinas P, Evangelopoulos D, Vlamis J. (2011). “Treatment of Osteitis Pubis in Non-Athlete Female Patients.” Open Orthopaedics Journal.(5):331-334.
3. Osteitis Pubis. Medscape. http://emedicine.medscape.com/article/87420-overview. Accessed October 27th, 2014.
4. Groin Injuries in the Sportsperson. http://raycrowe.com/pages/view/GroinInjuries. Published 2009. Accessed November 1st, 2014.
5. Beatty, T. (2012). "Osteitis pubis in athletes." Curr Sports Med Rep 11(2): 96-98.
6. Hiti, C., et al. (2011). "Athletic Osteitis Pubis." Sports Medicine 41(5): 361-376.

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