Athletic osteitis pubis

Athletic osteitis pubis is a painful and chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. Athletes with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centred directly over the pubic symphysis. Pain may also be felt in the adductor region, lower abdominal muscles, perineal region, inguinal region or scrotum. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis. The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction. The differential diagnosis for osteitis pubis is extensive and includes many other syndromes resulting in groin pain. Imaging, particularly in the form of MRI, may be helpful in making the diagnosis. Treatment is variable, but typically begins with conservative measures and may include injections and/or surgical procedures. Prolotherapy injections of dextrose, anti-inflammatory corticosteroids and a variety of surgical procedures have been reported in the literature with varying efficacies. Future studies of athletic osteitis pubis should attempt to define specific and reliable criteria to make the diagnosis of athletic osteitis pubis, empirically define standards of care and reduce the variability of proposed treatment regimens.     

Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain

OBJECTIVES: To examine the relation between the clinical features of groin pain and groin magnetic resonance imaging (MRI) appearances in a group largely comprising elite Australian Rules football players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The relation between a past history of groin pain and these other MRI findings was also examined. METHOD: In a prospective study, 116 male subjects (89 footballers, 17 umpires, 10 sedentary men) were examined before history taking and groin MRI. The clinical history was not known to the examiner (GMV) and radiologists (JPS, GTF). Clinical evidence of groin pain and examination findings were correlated with the presence of increased signal intensity within the pubic bone marrow. A past history of groin pain was correlated with the presence of other MRI findings such as cyst formation, fluid signal within the pubic symphysis disc, and irregularity of the pubic symphysis. RESULTS: Fifty two athletes (47 footballers, five umpires) had clinical features of groin pain with pubic symphysis and/or superior pubic ramus tenderness. A high incidence of increased signal intensity (77%) within the pubic bone marrow was identified in this group. There was an association between this group of athletes and the MRI finding of increased signal intensity (p<0.01). There was also an association between a past history of groin pain and the presence of other MRI findings (p<0.01). CONCLUSIONS: Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow oedema. An association exists between the clinical features of osteitis pubis and the MRI finding of pubic bone marrow oedema. A high incidence of pubic bone marrow oedema was also noted. Degenerative features visualised by MRI, such as subchondral cyst formation, were associated with a past history of groin pain. A stress injury to the pubic bone is the most likely explanation for these MRI findings and may be the cause of the clinical entity osteitis pubis.     

Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury

BACKGROUND: Little data exist on the results of treatment for sports-related chronic groin injury. HYPOTHESIS: Sports-related chronic groin injury treated with a conservative (rest) program results in a satisfactory outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Professional Australian male football players, at the end of the playing season, had their groin injury diagnosed using specific clinical and magnetic resonance imaging (MRI) criteria. Those assessed as having a non-hip-related cause for their chronic groin injury were treated principally by 12 weeks of complete rest from active weightbearing activities. Response to treatment was assessed at different stages of rehabilitation by recording the number of athletes who had returned to playing football and the number of athletes without symptoms. RESULTS: Twenty-seven athletes were considered to have chronic groin injury. Clinical and MRI (pubic bone marrow edema N = 26 [96%]), hyperintense line N = 25 [93%]) criteria suggested a pubic bone stress injury as diagnosis for the chronic groin injury. Eighty-nine percent of athletes returned to sport in the subsequent playing season, with 100% having returned by the second playing season after diagnosis. Forty-one percent of the athletes were without symptoms at the commencement of the following playing season, rising to 67% by the end of that playing season. CONCLUSIONS: Conservative management of athletic chronic groin injury resulted in an excellent outcome when assessed by the return to sport criterion. However, the results were only satisfactory if the criterion of ongoing symptoms after treatment was used. More research is needed to compare the efficacy of all treatments that are used in this troublesome condition.     

Osteitis pubis in athletes. Infection, inflammation or injury?

Medical records of 59 patients (9 females and 50 males), who presented to sports medicine clinics at the Australian Institute of Sport and the University of British Columbia between 1985 and 1990 and who were diagnosed as suffering osteitis pubis, were reviewed and comparison of data obtained was made with the literature. Women average 35.5 years of age (30 to 59 years) and men 30.3 years (13 to 61 years). Sports most frequently involved were running, soccer, ice hockey and tennis. Clinical presentations of osteitis pubis fell into 4 main groups. 'Mechanical' (sport-related) was the largest group (n = 48), followed by 'obstetric' (n = 5), 'inflammatory' (n = 4) and 'other' (n = 2). Period of follow-up averaged 10.3 months (1 to 20 months) in women and 17.5 months (2 to 96 months) in men. Full recovery, when documented, averaged 9.5 months in men and 7.0 months in women. Osteitis pubis recurred in 25% of these men and none of these women at follow-up. The most frequent symptoms were pubic pain and adductor pain. Men also presented with lower abdominal, hip and perineal or scrotal pain; women with hip pain. Most common signs were tenderness of the pubic symphysis and tenderness of adductor longus muscle origin. Men also revealed tenderness of one or both the superior pubic rami and evidence of decreased hip rotation (unilateral or bilateral). Evidence of pelvic malalignment and/or sacroiliac dysfunction was frequently seen in both men and women. There was poor correlation between radiographic and isotope bone scan findings and the site and duration of symptoms and signs. Femoral head ratios were estimated on 30 hips in the series and 2 were judged to be at the upper limit of normal, perhaps indicating a form of epiphysiolysis producing tilt deformity of the head of the femur. It is clear that osteitis pubis in athletes is not uncommon and that factors such as loss of rotation of hips and previous obstetric history are important in the aetiology and management of this condition. Pelvic infection, which was believed to be the primary factor of osteitis pubis in the literature up until the 1970s, plays a very small role in this condition in athletes.     

Osteitis Pubis in the Active Patient

For more than 3 months, a young male soccer player had groin pain diagnosed as stemming from a “tight groin.” His discomfort, however, was characteristic of the overuse injury osteitis pubis: gradually worsening pain with significant tenderness on palpation of the symphysis pubis. X-ray and bone scan verified the diagnosis. Conservative treatment for osteitis pubis is often successful; our patient responded to a typical regimen of rest; flexibility and strength exercises for the low back, hip, and thigh; and a gradual return to running and full soccer activity.     

Successful treatment of osteitis pubis by using totally extraperitoneal endoscopic technique

Osteitis pubis is characterized by pain, inflammation, and sclerosis in the pubic symphysis. It is often a self-limiting disease in athletes, but persistent pain may occasionally need surgery. Video-assisted placement of extraperitoneal retropubic synthetic mesh to support the damaged area may hasten the healing of this injury. During 1997 - 2002 five elite level male athletes with chronic groin pain associated with osteitis pubis were operated. The diagnosis was based on clinical findings, x-ray, magnetic resonance imaging (MRI), and isotope bone scanning. A 10 x 15 cm polypropylene mesh was placed into preperitoneal retropubic space using video-assisted technique. The pain and return to sport were asked at 1, 6, and 12 months after surgery. Preoperative technetium bone scan revealed an enhanced isotope uptake of pubic bone in each patient. T2-weighted MRI (n = 3) indicated bone marrow edema, which was decreased postoperatively on repeated MRI scans. Periosteal edema and irritation were also seen at operation. No complications were associated with the insertion of mesh. All 5 athletes returned to their sport activities between one to two months after surgery. After one year, no tenderness or pain was observed in the pubic bone. When conservative treatment fails, the placement of retropubic mesh is safe and a mini-invasive method to hasten the rehabilitation of osteitis pubis in selected cases. The postoperative recovery was uneventful, and the patients returned rapidly to their sporting activities.     

Magnetic resonance findings of osteitis pubis

PURPOSE: To determine the correlation of MR findings with clinical features of osteitis pubis and to look for associating injuries complicating chronic cases. MATERIALS AND METHODS: Pelvic MR images of the 22 elite athletes with groin pain were taken. Correlation analysis between the MR findings and clinical properties was carried out. RESULTS: Six of the MR findings had strong correlation with duration of symptoms. Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema had significant correlation with acuity of the case. On the contrary, subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes correlated with the chronicity of the case. Associated tendon injuries correlated with the duration of symptoms; i.e., all tendon injuries were in chronic cases. CONCLUSION: Subchondral bone marrow edema, fluid in symphysis pubis joint, and periarticular edema are the most reliable MRI findings of osteitis pubis that has a history of less than six months. Subchondral sclerosis, subchondral resorption and bony margin irregularities, and osteophytes (or pubic beaking) are the most reliable MRI findings of the chronic disease that has been present for more than six months. Associated pathologies, especially adductor or other tendon injuries, underlie more than half of the chronic cases of osteitis pubis.     

Osteitis pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad.

OBJECTIVES: To assess bone marrow edema at the pubic symphysis with magnetic resonance imaging (MRI), and its relation to training and osteitis pubis in an elite group of junior soccer players. SETTING: Soccer players on scholarship at the Australian Institute of Sport (AIS). PATIENTS: Nineteen players from an elite junior men's soccer squad. INTERVENTION/ASSESSMENT: Serial MRI examinations of the pubic symphysis over a 4-month training and playing period, training session questionnaire, and review of clinical diagnosis, investigations, and records on presentation of athletes with groin pain at the Department of Sports Medicine. MAIN OUTCOME MEASURES: Assessment of bone marrow edema (4-point scale) on MRI scans, review of athlete questionnaires, and review of clinical records. RESULTS: Initial MRI scans showed moderate to severe bone marrow edema at the pubic symphysis in 11 of the 18 asymptomatic players. There was a greatly decreased risk of developing groin pain (osteitis pubis) with more training prior to entry of the AIS soccer program (odds ratio per 4 sessions of training, 0.003). The correlation between initial bone marrow edema grading and pre-AIS training was small. The increase in bone marrow edema grading from baseline over the scans was 0.5 (90% CL, 0.4). CONCLUSIONS: Substantial amounts of bone marrow edema at the pubic symphysis can occur in asymptomatic elite junior soccer players, but it is only weakly related to the development of osteitis pubis. Progressing training loads more slowly in athletes presenting with low current training loads may be a useful strategy for the prevention of osteitis pubis in junior soccer players.     

Hip joint range of motion restriction precedes athletic chronic groin injury

Although a restricted hip range of motion has been previously associated with chronic groin injury the temporal course of this association remains unclear. Accordingly the purpose of this prospective cohort study was to report preliminary findings examining whether hip joint range of motion restriction is associated with subsequent onset of athletic chronic groin injury. End-range internal and external hip joint range of motion was determined in 29 elite Australian football players, without previous history of groin injury. The players were followed for two subsequent playing seasons for the development of chronic groin injury. Four athletes developed chronic groin injury defined as at least 6 weeks of groin pain and missing match playing time. In athletes that developed chronic groin injury a lower body weight (p = 0.02) and reduced total hip joint range of motion (p = 0.03) were found to be associated. This study suggests that hip stiffness is associated with later development of chronic groin injury and as such may be a risk factor for this condition. This work should be viewed as preliminary and caution is advised in applying the conclusion to clinical practice as the numbers in this study were small.     

Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail

Seven rugby players with osteitis pubis and vertical instability at the pubic symphysis were treated operatively after nonoperative treatment had failed to improve their symptoms. The vertical instability was diagnosed based on flamingo view radiographs showing greater than 2 mm of vertical displacement. The players had undergone at least 13 months of nonoperative therapy before surgery was considered. Operative treatment consisted of arthrodesis of the pubic symphysis by bone grafting supplemented by a compression plate. At a mean follow-up of 52.4 months, all patients were free of symptoms and flamingo views confirmed successful arthrodesis with no residual instability of the pubic symphysis. Based on our results with this procedure, we believe that arthrodesis of the pubic symphysis has a role in the treatment of osteitis pubis that is recalcitrant to nonoperative treatment. The combination of osteitis pubis and vertical pubis symphyseal instability may be the cause of failure of nonoperative treatment.     

Osteitis pubis

Osteitis pubis is a painful condition, usually caused by abnormal muscle forces acting on the symphysis pubis. The symptoms of osteitis pubis mimic many other injuries that affect the athlete’s groin. To correctly diagnose this condition, the clinician must maintain a high index of suspicion. Reports suggest this condition is more common in men than women. Confirmatory radiographs, bone scans, and magnetic resonance imaging aid the diagnosis. Once diagnosed, the prognosis for full recovery is good, although lengthy. Typical treatments include physical therapy, involving strengthening the abdominal and hip muscles, and improving range of motion of the hip, particularly the muscles of internal rotation. Corticosteroid injections, wedge resection of the symphysis, curettage, and arthrodesis have all been used with variable success.     

Groin pain in athletes: role of magnetic resonance

INTRODUCTION: Aim of our work was to evaluate the diagnostic role and potentials of Magnetic Resonance Imaging (MRI) in the study of groin pain in athletes and in the differential diagnosis among the pathological conditions that cause this syndrome. MATERIAL AND METHODS: MRI examinations were performed with a 1.5 T superconductive magnet, and a 0.2 T permanent magnet. Spin-Echo (SE) T1-w, PD, SE T2-w, Gradient-Echo (GE) T2-w and fat saturation sequences were used, on axial, sagittal and coronal scan planes. We performed MRI on twenty-five athletes (22 men and 3 women; age range 17 to 32 years) with chronic groin pain of questionable origin who had been complaining of it for at least 6 months. In 22 cases, radiographs were available; Computed Tomography (CT) had been performed in 3 cases and Ultrasound (US) in 7 cases. Nine patients were submitted to MRI after the symptoms had disappeared. RESULTS: In all patients, MRI provided an accurate depiction of pubic bone alterations and of adjacent myotendinous structures. In 14 cases, osteitis pubis was diagnosed, which was bilateral in 2 cases only (muscular asymmetry of the rectus abdominis was found in 4 of these patients); 4 patients had myotendinous posttraumatic changes (1 hematoma of the psoas muscle and 3 injuries of the abductor muscles of the thigh); 4 patients presented isolated dysmetria of rectus abdominis muscles, with unilateral involvement of the sacroiliac joint in 1 patient; 3 patients had inguinal hernia, surgically confirmed in all cases. DISCUSSION: Osteitis pubis, intended as reactive intraspongiuos edema of the pubic bones, is the most frequent cause of groin pain in athletes. In the early diagnostic phases, both plain films and CT may be negative or not specific. On the other hand, MRI has always proved to be a valuable diagnostic technique in detecting the osteitic change as an area of low signal intensity on T1-w images and of high and homogeneous signal intensity on T2-w scans without fat suppression. Dysmetria of the straight muscles of the abdomen, which may be associated, is always well depicted by MRI on axial planes. Both posttraumatic and dysmetric changes of the muscular structures adjacent to the pubis are well documented by US and MRI. The latter, however, thanks to its multiplanar capabilities, allows better spatial assessment of the alteration, especially if located at peri-insertional level. Possible associated diseases such as the involvement of the sacroiliac joints are also well shown by MRI. Inguinal hernias are easily demonstrated by MRI, which allows the direct visualization of the hernial sac within the inguinal canal. CONCLUSIONS: In our experience, only MRI can permit an accurate and early diagnosis of the different sport-related pubic conditions. MRI is also a valuable tool in monitoring the alterations with reference to their response to treatment, which may also help bring the athletes back to their activities.     

Radiology

Hip and groin pain are a common complaint among athletes of all ages, and may result from an acute injury or from chronic, repetitive trauma. Hip injuries can be intraarticular, extraarticular, or both. Labral abnormalities may occur in asymptomatic patients as well as in those with incapacitating symptoms and signs. Athletic hip injury leading to disabling intraarticular hip pain most commonly involves labral tear. The extraarticular causes are usually the result of overuse activity, leading to inflammation, tendonitis, or bursitis. In clinical practice, the term athletic pubalgia is used to describe exertional pubic or groin pain.     

Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation

PURPOSE: To determine whether the secondary cleft sign demonstrated in the symphysis pubis at magnetic resonance (MR) imaging is a marker of injury in athletes presenting with groin pain. MATERIALS AND METHODS: Ethics review board approval was not required for studies involving retrospective image or case record review; informed consent for review was not required. Eighteen male athletes (mean age, 24 years; age range, 19-32 years) were included for study. All patients underwent radiography and MR imaging (coronal fast spin-echo T1-weighted, transverse fast spin-echo T2-weighted, and coronal turbo short inversion time inversion-recovery [STIR] imaging) of the pelvis. Subsequent image-guided nonionic contrast material injection was followed by a 0.5% bupivacaine hydrochloride (1 mL) and methyprednisolone acetate (20 mg) injection into the central cleft of the symphysis pubis. Comparison was made between imaging findings at symphyseal cleft injection and appearances at preprocedure MR imaging, with specific reference to the presence of a secondary cleft. The sensitivity and specificity of MR imaging in demonstrating the secondary cleft sign were compared with those of the reference standard, imaging at symphyseal cleft injection. MR images from a reference group of 70 asymptomatic athletes who underwent STIR imaging of the pelvis were analyzed for evidence of a secondary cleft. RESULTS: Osteitis pubis was diagnosed in six patients on the basis of radiography and/or MR imaging. A secondary cleft was identified in 12 of 18 patients at MR imaging, was best visualized at coronal STIR imaging, and was confirmed in each patient during contrast material injection into the central physiologic symphyseal cleft. In no patient was a secondary cleft identified at symphyseal cleft injection and not identified at MR imaging (sensitivity and specificity, 100%). In each patient, the side of the secondary cleft corresponded to the side of symptoms that responded to local anesthetic and steroid injection. Four of the six patients with osteitis pubis had evidence of a secondary cleft. In one patient, a secondary cleft was not identified at MR imaging or symphyseal cleft injection, but adductor avulsion was identified at MR imaging. No evidence of a secondary cleft sign at MR imaging was identified in the reference group. CONCLUSION: The secondary cleft sign demonstrated at MR imaging is a marker of groin injury in athletes presenting with groin pain.     

Diagnostics in athletes with long-standing groin pain

Chronic adductor dysfunction, osteitis pubis and abdominal wall deficiency are mentioned as pathologies explaining long-standing groin pain (LGP) in athletes. The main objective of this study was to evaluate the validity of diagnostic tests used to identify these pathologies in athletic OKE. Additionally, starting points for intervention were searched for. A systematic literature search was performed to retrieve all relevant diagnostic studies and studies describing risk factors. The methodological quality of the identified studies was evaluated. Seventeen studies provided an insight into pathologies; eight provided relevant information for intervention. Adduction provocation tests are moderately valid for osteitis pubis. A pelvic belt might provide some insight into the role of the pubic symphysis during adduction provocation. Palpation can be used for provocation of adductors and symphysis. Roentgen, bone scan and herniography show poor validity. Bilateral abdominal abnormalities on ultrasound appear to be a valid marker for LGP. Magnetic resonance imaging (MRI) can visualize edema and other abnormalities, although the relation to groin pain is not unambiguous. The methodological quality of the studies ranged from poor to good. MRI and ultrasound should be the primary diagnostic tools after clinical examination.     

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.     

Osteitis pubis in athletes

Osteitis pubis is one of many etiologies of groin pain in athletes. It is a painful overuse injury of the pubic symphysis and the parasymphyseal bone that typically is found in athletes whose sports involve kicking, rapid accelerations, decelerations, and abrupt directional changes. Athletes most commonly present with a complaint of anterior and/or medial groin pain but also can present with lower abdominal, adductor, inguinal, perineal, and/or scrotal pain. Symptoms can be severe and can limit participation in sport until treatment is instituted. Imaging is useful for ruling out other etiologies of groin pain, identifying concomitant pathology, and confirming the diagnosis itself. Treatment is varied but usually includes nonoperative measures of rest, rehabilitation, and/or pharmacotherapy and also may include injections and/or surgical procedures. A high clinical suspicion should exist when evaluating soccer, rugby, or American football players and distance runners who present with complaints of groin pain.     

A Complete Approach to Groin Pain

IN BRIEF: Focused history questions and physical exam maneuvers are especially important with groin pain because symptoms can arise from any of numerous causes, sports related or not Questions for the patient should attempt to rule out systemic symptoms and clarify the pain pattern. Some of the most possible causes of groin pain include stress fracture of the femoral neck or pubic ramus, Legg-Calvé Perthes disease, slipped capital femoral epiphysis, acetabular labral tears, iliopectineal bursitis, avulsion fracture, osteitis pubis, strain of the thigh muscles or rectus abdominis, inguinal hernia, ilioinguinal neuralgia, and the ‘sports hernia.’ Depending on the diagnosis, conservative treatment is often effective.     

Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia

Athletic pubalgia (sportsman's hernia) is often repaired by surgery. The presence of pubic bone marrow edema (BME) in magnetic resonance imaging (MRI) may effect on the outcome of surgery. Surgical treatment of 30 patients with athletic pubalgia was performed by placement of totally extraperitoneal endoscopic mesh behind the painful groin area. The presence of pre‐operative BME was graded from 0 to 3 using MRI and correlated to post‐operative pain scores and recovery to sports activity 2 years after operation. The operated athletes participated in our previous prospective randomized study. The athletes with (n = 21) or without (n = 9) pubic BME had similar patients' characteristics and pain scores before surgery. Periostic and intraosseous edema at symphysis pubis was related to increase of post‐operative pain scores only at 3 months after surgery (P = 0.03) but not to long‐term recovery. Two years after surgery, three athletes in the BME group and three in the normal MRI group needed occasionally pain medication for chronic groin pain, and 87% were playing at the same level as before surgery. This study indicates that the presence of pubic BME had no remarkable long‐term effect on recovery from endoscopic surgical treatment of athletic pubalgia.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

Objective. To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. Design and patients. Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18–72 years, average 49 years; 11 women and 9 men). Results. All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. Conclusion. We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.