Why a Diagnosis of Osteitis Pubis is Not Enough

 In Lower Limb

Osteitis Pubis: What is it?

Osteitis Pubis (OP) is a very common term used to describe pain in the groin. It can happen after pubic region surgeries but most often it is used to describe groin pain in athletes. It is a very common condition especially in field athletes during pre-season and early season. It is often the source of much frustration for athletes as it is usually a long and difficult injury to overcome with treatment options usually vague and of varying levels of effectiveness.

Fortunately, much research is being done in the area and Physiotherapists are gaining a more accurate understanding of this age old reoccurring issue. In a literal sense, Osteitis Pubis translates to ‘inflammation of the pubic symphysis and surrounding tissues”. The Pubic Symphysis is where the right and left sides of the pelvis join at the front of your hips, in between the two pieces of bone there is a wedge of cartilage which helps to accommodate some natural twisting movements of the hips.

Previously, Osteitis Pubis (OP) was always thought to be the result of pelvic instability during activity, which would cause twisting of the Pubic Symphysis joint, excess movement and therefore a build up inflammation and resultant pain. To build a picture in your mind, each time you step forward there is a normal amount of pelvis twist. An image I like to think of is a rubix cube. Now hold the rubix cube with both hands and twist slightly back and forward as if someone is walking. Although it is different between men and women that have given birth,  Garras, Carothers and Olson (2008) believe that up to 5mm of movement is available in people that have no pubic pain.

Previously, treatment for OP used to involve a period of rest from running and kicking and a core strengthening program specifically designed at using the deep core muscle which wraps around our lower spine (transverse abdominus).

Enter the 21st Century: what we now know

After years of field sport competitors being sidelined by the infamous OP, we now have a much better explanation of what is happening at the pubic symphysis which can cause so much pain. Firstly, the old explanation of too much movement at the pubic symphysis can still be true. However, that is most likely to be true only for older athletes or for females and almost never the cause of pain in 16-28 year old male athletes (the most common groin pain group). We know this because it easy to diagnose pelvic instability, we can simply take an Xray of your pelvis standing on one leg (we call it flamingo), it will show if your pelvis has too much movement, it’s that simple (Garras, Carothers and Olson, 2008)

If instability isn’t the main cause of Osteitis Pubis, what is?

The main cause of OP is actually a build up of stress on the pubic bone #performbetter @pogophysio Click To Tweet

The main cause of OP (especially in male athletes) is actually a build up of stress on the pubic bone. Adductors (Groin Muscles) and Abdominals (Abs) attach onto the pubic bones right next to the pubic Symphysis, when we run, change direction and kick the muscles pull on this patch of bone (McAleer et al., 2017) . Over time, this pulling can cause inflammation to build up on the thin top layer of the bone resulting in pain (Angoules, 2015). It is a bone stress injury and is in the same category as Shin Splints.

Therefore, a much more accurate name for this type of groin pain is……… Pubic Bone Stress Syndrome!

There are also other sources of OP pain. There can be an issue with the tendon or attachment of either a groin or hip flexor muscle. There can also be a less common issue with the joining of the cartilage of the joint and the bone.

If you physiotherapist is educated enough to offer you a diagnosis that goes one step further than Osteitis Pubis, than they should know how to tell the difference between these sorts of injuries, however, if they are unsure, an MRI can usually pinpoint the problem (Gaudino et al., 2018).

In Summary:

Osteitis Pubis is an outdated term for a grouping of different problems which can occur in the pubic region causing groin pain (Weir et al., 2015). These Problems are:

  1. Pubic Bone Stress Syndrome- A bone stress response caused by too much of a particular activity which uses the abdominals and groin muscles strenuously
  2. Adductor Tendinopathy or Enthesopathy: Pain arising from either the tendon of an adductor muscle or it’s attachment onto the pubic bone
  3. Abdominal Tendinopathy or Enthesopathy: Pain arising from either the tendon of an abdominal muscle or it’s attachment onto the pubic bone
  4. Pubic Symphysis Irritation or Instability: Pain arising from the pubic symphysis due to excess movement between left and right sides of pelvis
  5. Pubic Apophysitis: A stress reaction of the growth plate inside the pubic bone of an adolescent
  6. Anterior Pubic Aponeurotic Lesion: A tear of the layer of connective tissue which joins the groin muscles to the abdominal muscles over the top of the pubic bones

Why does it matter if your therapist clarifies the source of your groin pain?

An accurate diagnosis is absolutely key in managing injuries. If your therapist is able to pinpoint which of these issues are causing your pain (there can be more than one at a time), then they should be able to guide you through the recovery much quicker.

For example, a pubic symphysis irritation should only require 1-2 weeks rest and some midline and pelvic strengthening, as opposed to pubic bone stress syndrome which would need on average 6 weeks rest and strengthening of adductor and hip extensor muscles with a slower return to full training.

I look forward to outlining treatment options further in my next Blog, but for now remember;

  • Osteitis Pubis is a grouping of different conditions
  • Not all pubic pain is caused by instability
  • An accurate diagnosis will dictate the treatment and return to sport timeline (you might be able to get back quicker than you think!)
  • If your therapist tells you that you have Osteitis Pubis I suggest that you ask them to clarify.

Michael Harders
Master Physiotherapist

Featured in the Top 50 Physical Therapy Blog


Angoules, A. (2015). Osteitis pubis in elite athletes: Diagnostic and therapeutic approach. World Journal of Orthopedics, 6(9), p.672.

Garras, D., Carothers, J. and Olson, S. (2008). Single-Leg-Stance (Flamingo) Radiographs to Assess Pelvic Instability: How Much Motion Is Normal?. The Journal of Bone and Joint Surgery-American Volume, 90(10), pp.2114-2118.

Gaudino, F., Spira, D., Bangert, Y., Ott, H., Beomonte Zobel, B., Kauczor, H. and Weber, M. (2018). Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome.

McAleer, S., Lippie, E., Norman, D. and Riepenhof, H. (2017). Nonoperative Management, Rehabilitation, and Functional and Clinical Progression of Osteitis Pubis/Pubic Bone Stress in Professional Soccer Players: A Case Series. Journal of Orthopaedic & Sports Physical Therapy, 47(9), pp.683-690.

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K., Lovell, G., Meyers, W., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A., Schilders, E., Serner, A., Silvers, H., Thorborg, K., Tyler, T., Verrall, G., de Vos, R., Vuckovic, Z. and Hölmich, P. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 49(12), pp.768-774.

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