Osteitis pubis? Steroid injection?

[Matt Garman]

Hi Rip & others,

Has osteitis pubis (OP, also known as pubic symphysitis) ever come up with any of your trainees? My wife has been suffering from this for about four months now. It's to the point where even normal daily activities are severely limited (she's effectively on bed rest).

While most cases of OP are due to overuse (running, soccer), in her case, we believe it was caused by over-production of the relaxin hormone during her last pregnancy (four years ago). She had pain during the last trimester of that pregnancy, and lots of pain immediately following delivery, but with physical therapy it went away after about a month, and no issues to speak of until late last year.

It took me two years to convince her to do strength training, but last year she was doing the novice SS program 2x/week, and using the Concept 2 rower 3x/week for cardio. She started to have pelvic pain late last year, so took almost three months off any kind of exercise/training. In early January, we tried to do a very simple workout: three light minutes on the Concept 2 to warmup; a few sets of body weight squats, and a couple sets of five with just the bar; and three sets of empty bar presses. The workout was in the morning, with no immediate pain, but by late morning there was noticeable pelvic pain that continued to worsen throughout the day.

The pain continued to get worse as the days went by. After trip to the GP and an X-Ray, we had a formal OP diagnosis, with a prescription for physical therapy. PT didn't seem to help and the pain continued to worsen, so we saw an osteo and had an MRI. The MRI didn't show any abnormalities, and the osteo basically said rest, ice and NSAIDs.

It was around mid-February before we realized "rest" really meant bedrest, i.e. virtually zero movement. She experienced very gradual improvement as weeks went on: first shedding the constant stream of NSAIDs she was taking, and then not constantly having an ice pack on her crotch all day. Last week she was starting to return to most of her normal activities; but still no "real" training, just the most rudimentary PT she was shown to do when this all started.

However, this weekend, the pain has come back with a vengeance, and she's back on NSAIDs and the ice pack. I'd say we're back to where we were 1.5 to 2 months ago.

We have an appointment with a second osteo next week for a second opinion. But already on the table, per the first osteo's suggestion, is a direct steroid injection (most likely methylprednisolone). To be clear, the doc isn't pushing it, just saying it's an option. Thus far, we've been adverse to the steroid injection, but this recent major setback has us reconsidering.

I couldn't find any posts talking about OP. I found a number of posts talking about steroid injections, and I get the feeling you and the community are generally not hot on them. But, just wondering if you've seen any cases where steroid injections can be helpful?

That ended up being much longer than expected, so, to summarize:

• Have you dealt with any cases of OP? If so, what have you found to work?
• Is it worth considering the steroid injection?

Lastly, if Rip or anyone else out there knows of any particularly good OP resources in the greater Chicago area, we'd be grateful to hear.

Thanks!

[Mark Rippetoe]

Has anyone suggested the possibility of an infection? Has she tried an antibiotic cycle?

[Matt Garman]

Has anyone suggested the possibility of an infection? Has she tried an antibiotic cycle?

She has not tried an antibiotic cycle.

Both the ortho and our own research mentioned the possibility of an infection (i.e. sometimes an infection is mis-diagnosed as OP). However, I cannot remember all the specifics, but we did rule out infection pretty early on... she was showing improvement (until this most recent week). She's never had a fever. She did just have a routine OBGYN exam, which included a physical; they didn't test for infection specifically, but her white blood count is normal. Also, her MRI was normal; IIRC, an infection should cause some kind of degradation of the pelvic tissue that would be visible on the MRI. I'm not 100% sure of that last statement. I remember a conversation where we were pretty confident it was not an infection, but now I can't remember the details of that conversation.

At a minimum, we will revisit this idea when we see the next doc for the second opinion.

Thanks again!

[Mark Rippetoe]

Here's how you diagnose an infection: She takes a cycle of an appropriate antibiotic. If it goes away, it was an infection.

[Will Morris]

Kenalog, Marcaine, and Lidocaine injected into the pubic symphysis. Works like a charm. With CBC being okay, and no evidence of infection on imaging, I'd recommend the K+M+L injection.....or, seeing a chiro with good hands.

[Mark Rippetoe]

Yes, it may be a chronic dislocation. It doesn't need a methylpredisone injection.

[Will Morris]

Injecting solu-medrol is a bit overkill, especially when the diagnosis is sketchy.

[Matt Garman]

Here's how you diagnose an infection: She takes a cycle of an appropriate antibiotic. If it goes away, it was an infection.

We were told that if it was an infection, then this particular type of infection calls for a week or two of IV antibiotics, followed by months of oral antibiotics. If it was the standard 10 days of amoxicillin, sure, why not? But since this particular cycle is months-long, she'd necessarily be resting during that time; if she gets better, how do you know if it's from the antibiotics or the rest?

Yes, it may be a chronic dislocation. It doesn't need a methylpredisone injection.

Would chronic dislocation show up in the imaging? How does one distinguish between OP and chronic dislocation? Or maybe you are suggesting the dislocation is the underlying cause of the OP?

Injecting solu-medrol is a bit overkill, especially when the diagnosis is sketchy.

I guess I'm surprised at the suggestion of a sketchy diagnosis. While neither my wife nor I am medically trained, we have done a lot of online research on OP (keep in mind she's on bed rest, so she's not hurting for time). We haven't come across any inconsistencies between her symptoms, our layperson knowledge of OP, and what we've been told by the docs. However, she does appear to have a quite severe case of it. Maybe the fact that we're getting a second opinion suggests we're not confident of the diagnosis? The second opinion is mostly just for re-assurance, and also to see if there's anything more we can be doing to get her back on her feet more quickly. Basically, same motivation as this post.

Everything we've learned says it's just a matter of rest, ice, PT and time. And that's probably just it. But, since "time" is on the order of many months, we're trying to determine if we've missed anything, and if a steroid shot might be worthwhile shortcut.

Kenalog, Marcaine, and Lidocaine injected into the pubic symphysis. Works like a charm. With CBC being okay, and no evidence of infection on imaging, I'd recommend the K+M+L injection.....or, seeing a chiro with good hands.

Thoughts on Kenalog versus Solu-Medrol?

(For my reference: methylprednisolone is aka solu-medrol is aka depo-medrol. Kenalog is aka triamcinolone.)

In my original post, I forgot to mention: while reading bedtime stories to our kids, my wife took an accidental knee to her crotch from our six year old. (Yeah, I know, vital information, flame away!) This is our best guess as to what triggered her recent relapse into pain. It's just weird that day 1 after the knee incident was only a hint of very mild soreness, i.e. nothing too remarkable in the grand scheme of things. But in the days since, it has gotten worse. I would think an explicit injury like that would have an immediate, rather than gradual effect.

[Mark Rippetoe]

How old is your wife, and how long has she been resting in bed?

[Will Morris]

I don't know what you want me to say man. Osteitis Pubis typically refers to inflammation of the pubic symphysis, but it shows up on MRI with evidence of bone marrow edema or subchondral sclerosis. Also, infection is readily identified on MRI, and osteomyelitis would almost certainly show up on routine labs with an elevated White Blood Cell count and she would feel like death. Bed rest is virtually never indicated for orthopedic conditions. I'm curious as to how the decision was made that bed rest was the treatment of choice here.

In your case, the diagnosis would be "pubic symphysis pain" and it would make sense to seek the services of a good manual therapist, since that is the treatment that is the cheapest and carries virtually no risk other than the risk of losing $35. Kenalog is a better option, as it does not have as severe side effects as Solu-Medrol. Then again, I come to that suggestion because I work hand-in-hand with a very skilled orthopedic surgeon, and he never injects solu-medrol for joint injections. Kenalog + Marcaine + Lidocaine is our go to, and I can't think of a time where it wasn't effective.