Osteitis Pubis

Where is Osteitis Pubis painful? (Body Chart)

Osteitis Pubis

What are the classical features of Osteitis Pubis?

Best characterised as a bone stress injury 

Age: All ages, more frequent in the younger population as higher activity levels, 20-50 years old 

Gender: 3 to 5 times more common in males compared to females. 

Activity: Running, rapid change of direction, acceleration, deceleration 

Sport: long-distance runners, soccer, ice hockey, tennis, AFL, netball, basketball

Where is Osteitis Pubis painful?

– Pain on the pubic bone especially close to the pubic symphysis 

– May radiate to surrounding structures but will stay localised to the lower abdomen and proximal/medial thigh 

– Most commonly unilateral however can be bilateral // depends on how far progressed the pathology is and where it is on the pubic bone

Characteristics of symptoms for Osteitis Pubis

– Pain during, and after loading 

– Pain increases with loading // no warm-up effect 

– During the activity: sharp pain, can be described as pulling or catching  

– After the activity: dull ache, deep inside 

– Intermittent symptoms depend on the activity 

– Report loss of function

– Reduced power production 

Typical activity capability/restriction for clients with Osteitis Pubis

– Will become increasingly restrictive with loading

– Likely start with mild symptoms that do no inhibit function and can progress to the point of inability to participate in activity 

– Report loss of power (ie reduced kicking distance)

– Reduced agility (unable to cut and push off of the affected side)

– Pain on activities that increase intraabdominal pressure (cough, sneeze) 

Behaviour of symptoms for Osteitis Pubis


– Running, change of direction, kicking, jumping, agility, variable surface, stairs, plyometric exercises, shear forces, abduction 


– Stable surface, rest, NSAIDs, increased cadence, reduced speed

24-hour pattern:

– Mechanically related so will be activity dependant 

– If aggravated may ache at night or the next morning

Typical history of a client with Osteitis Pubis

– Highly active individuals 

– Typically a recent increase in loading // review training diary if available 

– Unlikely to have a traumatic incident 

– Start with dull ache and soreness after aggravation, will progress with increases to loading

– As the pathology progresses it will start to inhibit function (starts with high-level activities like power and sprinting) and will affect lower-force activities (ie running and stairs)

– If not managed will become more disabling

Pathobiological mechanisms behind Osteitis Pubis

– Nociceptive dominant 

– May have a tendency to become nociplastic as the population may be hesitant to give the relative rest required for optimal healing to occur 

– Also nociplastic potential as symptoms typically prolonged for 6/12 months 

– Recurrence of injury is common and past experiences should be explored to identify psychosocial factors

Proposed pathology underlying Osteitis Pubis

– Best described as a bone stress injury 

– Repeated trauma on the pubic bone from its muscular attachments

– Loading causes repeated damage of the bone and leads to tissue pathological changes 

– The higher the contractile demand of these muscle groups the increased forces being placed on the bone 

– Can cause inflammatory process and also muscle restriction

– Endpoint is sclerosis of the pubic symphysis 

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Tenderness on the pubic symphysis 

– Tenderness on rectus abdominis insertion 

– Tenderness on the pubic body and ramus

– Tenderness at the adductor insertion 

– Pain on a contraction of abdominals and adductors 

– Reduced internal rotation at the hip 

– Reduced abduction at the hip 

– Reduced hip flexor length 

– Reduced strength into adduction // increased if combined with rectus abdominis activation


– Reduced balance/proprioception of the lower quarter 

– Reduced lumbopelvic control 

– Reduced abductor strength 


– Running technique (reduced stability or adductor activation)

– Kicking technique (adductor load biased)

Typical contributing factors to Osteitis Pubis

– History of back dysfunction 

– History of SIJ dysfunction 

– Hip anterioversion 

– Coxa vara 

– Hip hypomobility 

– Participation in high load activities 

– Leg length discrepancy 

– Irregular loading patterns (sporadic)

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability

– Serious pathology needs to be excluded due to the overlapping nature of symptoms

– If unsure send for imaging prior to local treatment 

– Care with stretching and shear forces at the pubic symphysis as likely cause irritation 

Relevant diagnostic imaging for Osteitis Pubis

– Shortly after onset imaging may be negative, isotope scintigraphy will demonstrate intensive uptake at this stage of the lession 

– Changes start to occur over time including becoming sclerotic and “motheaten” in appearance  

– Changes on imaging typically will persist even after the symptoms have resolved 

– X-ray will identify bone changes if present for a period of time // minimum 2 weeks 

– CT will have better detail however provides a similar value as an x-ray

– MRI is the gold standard for detail and diagnosis. Provides evidence of edema which the other options will not display 

Typical prognosis for Osteitis Pubis

– Good prognosis if the patient is unloaded aggressively 

– 6-8 weeks of pain-free activity minimum prior to returning to activity 

– Estimated to take between 6-12 months for full symptoms resolution

– Can resume activity prior to that point however requires monitoring 

– No correlation between imaging and return to sport, should be function/criteria dependant

Management/treatment selection for Osteitis Pubis

Unloading (high-level evidence)

– Need to have a period of relative rest just like with other boney injuries

– Minimum of 6-8 weeks of pain-free activity 

– Limit shearing and stretching forces during this time 


– Abdominal and hip joint stretches (low-level evidence) 

– Reconditioning adductors (high-level evidence) 

– Pacing to progressively reintroduce load in the affected area (high-level evidence) 


– Lumbopelvic control with aggravating activities 

– Optimise mechanics // abductor conditioning and ratio to adductors


Hyperbaric chamber (low-level evidence) 


– Gait analysis // biomechanical review to minimise adductor strain 

– Orthotics for leg length 

– Pacing with a return to activity (high-level evidence)


– Refer to doctor for NSAID’s if required 

– Will assist with pain in the early stages of rehabilitation 


– Can assist in the early stages to maintain CV fitness

– No frog kicking to minimise stress on the affected area 

Shock wave therapy

– High-level evidence for reduced pain however no difference in function 


– Send for referral if failed conservative

Differential Diagnosis for Osteitis Pubis

– SIJ // palpation, symptoms differentiation 

– FAI // hip assessment, 

– Adductor enthesopathy // palpation, imaging

– Rectus abdominis enthesopathy // palpation, imaging

– Inguinal hernia // palpation with cough 

– Inguinal impingement // neuro symptoms, palpation 

– Lower back referral // lumbar range and PAMS

– Somatic referral 

– Osteomyelitis // constitutional symptoms 

– Labral pathology // labral tests

– Fracture // imaging

– Visceral // palpation, B&B dysfunction 

– Prostatitis // constitutional symptoms, B&B dysfunction


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