Osteitis pubis (pubic bone stress injury): symptoms, causes, treatment and recovery

The pubic symphysis is the joint at the front of the pelvis where the left and right pubic bones meet. Several muscle groups, including the lower abdominal muscles and the muscles of the inner thigh, attach in this area, so it takes a lot of load in running, kicking and changing direction.

Osteitis pubis is the traditional name for pain arising from this region. A UK sports injury information site explains that it was long thought to be an inflammation of the joint, but that investigations have shown no inflammation to be present, which is why many clinicians now prefer the term pubic bone stress injury. You may see either name on a letter or report.

The site also cautions that osteitis pubis is not a common condition and is sometimes used as an umbrella term for longstanding groin pain. This is one reason why a careful assessment is worthwhile before assuming that groin pain is osteitis pubis.

The sports injury site describes pain in the groin or pelvic area when running, doing sit-ups or squatting, which may develop gradually and is often mistaken for a muscle strain or groin strain. The pain can radiate around the groin but is significant at a point in the middle of the groin at the front. In severe cases the athlete may begin to walk with a waddling gait.

The sources used here link the pain with exercise such as running, sit-ups and squatting. If you have persistent pain in the same spot, a clinician should examine it.

• Pain at the front of the pelvis or in the groin, often central.

• Pain with running, sit-ups, squats or kicking.

• Pain that develops gradually rather than from a single injury.

• In severe cases, a waddling walk.

The sports injury site says rest is the main form of treatment: in most cases only a few days are needed, but bad ones may require up to 3 months of complete rest from aggravating activity. A doctor may prescribe anti-inflammatory medication, advise on a rest period depending on severity and prescribe a rehabilitation programme, and in some cases may give a corticosteroid injection. It stresses always consulting a doctor before taking any medication.

Rehabilitation proceeds in stages. The site describes early rest and cold therapy, then adductor stretching when it is not painful, then gradually adding exercises for the abdominals, hip abductors, adductors and hip flexors, and finally sport-specific training. It says that if in doubt you should get advice from a sports injury specialist or medical professional, as osteitis pubis can sometimes take months to recover.

According to the sports injury site, osteitis pubis is caused mainly by overuse, or can result from direct impact. It is most frequent in sports such as football and hockey as well as during pregnancy. Repeated stress on the pubic bones from running, kicking and twisting, particularly with a sudden increase in training load, appears to be the common thread.

The Doha agreement is a useful reminder that groin pain in athletes has several sources. It classifies groin pain into adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain, plus hip-related groin pain and other causes. Because several structures can contribute, a rehabilitation plan usually looks at the whole hip and pelvis.

Diagnosis is based on history and examination. The sports injury site says an X-ray may show an irregular pubic symphysis, with signs of bone thickening and inflammation. The Doha agreement notes that definitions are based on history and physical examination, making them simple and suitable for both clinical practice and research.

A clinician will want to rule out a true hernia, hip problems and other causes of pelvic pain. The sports injury site specifically advises confirming the diagnosis and ruling out a hernia. NHS guidance on pelvic pain lists many possible causes, including infections and bowel, bladder and reproductive conditions, so new, severe or unexplained pelvic pain should be assessed rather than assumed to be a sports injury.

Increasing activity too quickly is a common reason for setbacks. Increase running and sport-specific work gradually, keep to pain-free progression and allow rest days. A physiotherapist can set clear criteria for each stage and look at the strength and mobility of the hips, core and trunk.

If you are pregnant or postnatal and have pain at the front of the pelvis, mention it to your midwife, GP or a women's health physiotherapist, because pelvic girdle pain is common in pregnancy and has its own management.

On the NHS, a GP or a self-referral to a musculoskeletal physiotherapy service is the usual starting point, with imaging or a sports medicine or orthopaedic opinion if the diagnosis is unclear or progress stalls. Waiting times vary by area.

Private sports physiotherapists and sports medicine doctors often see athletes quickly and can arrange scans. Check that any practitioner has experience of groin and pelvic injuries and will explain the rehabilitation plan, how progress will be measured and what the next step is if you do not improve.