Symphyseal cleft injection

Dr Henry Knipe et al.

Symphyseal cleft injections (symphysography) are performed as both diagnostic and therapeutic measures for patients with (suspected) osteitis pubis, usually under CT or fluoroscopy. 

  • suspected or confirmed osteitis pubis
  • factors to be considered as per any musculoskeletal injection, e.g. anticoagulation, local skin infection

Most patients with athletic pubalgia will have undergone imaging, usually MRI, to identify signs of osteitis pubis. 

  • can be performed under fluoroscopy or CT, or less commonly ultrasound
  • the patient lies supine on the table
  • sterile wash and drapes, sterile gloves
  • 5 mL syringe; 25G hypodermic needle; short-acting local anesthetic (e.g. lidocaine)
  • 3 mL syringe x 2, 22G spinal needle
  • iodinated contrast
  • steroid (e.g. methylprednisolone, triamcinolone); long-acting local anesthetic (e.g. bupivacaine)
  • dressing

A commonly used technique is 1-3:

  • skin markers placed over the pubic symphysis
  • preprocedure planning image acquisition
  • needle track plan, aiming for the midpart of the pubic symphysis between upper and lower margins
  • mark skin entry point
  • sterile prep and drape
  • 2-3 mL short-acting local anesthetic to skin and subcutaneous tissue
  • advance 22G spinal needle to the fibrous capsule of pubic symphysis then advanced a further 1 cm into the symphyseal cleft
  • injection 0.5-1 mL iodinated contrast to outline symphyseal cleft (also allows to asses contrast extending into primary/secondary clefts as well as rectus abdominis insertional injuries)
  • note whether iodinated contrast injection provokes usual symptoms
  • injection steroid (e.g. 20 mg methylprednisolone) and 1 mL long-acting local anesthetic
  • withdraw needle and apply dressing

Evidence of effectiveness is limited to small case series, which have reported short-term symptom relief and successful return to play but a substantial percentage of non-responders with ongoing symptoms 4.

Article information

rID: 71970
Synonyms or Alternate Spellings:
  • Symphysography
  • Symphysis pubis injection
  • Pubic symphysis injection

ADVERTISEMENT: Supporters see fewer/no ads

Cases and figures

  • Case 1: for athletic pubalgia
    Drag here to reorder.
  • Updating… Please wait.

     Unable to process the form. Check for errors and try again.

     Thank you for updating your details.