Osteitis Pubis

Lower Limb

Overview

Osteitis pubis is an inflammatory condition of the pubic symphysis and surrounding bone, commonly occurring in athletes involved in activities requiring repetitive kicking, twisting, or rapid acceleration/deceleration. The condition results from biomechanical stress and microtrauma to the pubic joint and associated musculature, presenting with chronic groin pain that significantly impacts athletic performance.

Pathophysiology

Osteitis pubis develops through cumulative microtrauma to the pubic symphysis caused by repetitive stress from adductor muscle pull, rectus abdominis tension, and dynamic hip instability. This leads to inflammatory changes in the symphyseal joint, surrounding bone, and associated soft tissues.

Patient Education

Osteitis pubis requires a comprehensive approach addressing both local inflammation and the underlying biomechanical dysfunction causing repetitive stress; early intervention focusing on load management and muscle balance is essential to prevent chronic pain patterns.

Typical Presentation

Site

Pubic symphysis and medial groin region, often bilateral; pain may radiate into lower abdomen or medial thigh

Quality

Dull, aching pain with inflammatory characteristics; may describe as sharp with certain movements

Intensity

Moderate to severe (6-8/10); typically worsens with activity and improves with rest, though morning stiffness is common

Aggravating

Adduction against resistance, kicking, running, twisting and turning, rapid acceleration/deceleration, sit-ups, climbing stairs, prolonged standing on one leg

Relieving

Rest, ice application, anti-inflammatory medication, gentle stretching of adductors, core stabilization work, activity modification

Associated

Hip adductor tightness and tenderness, lower abdominal pain, hip flexor tightness, reduced hip internal rotation, core muscle weakness, altered pelvic biomechanics, pain with provocative tests (adduction squeeze test)

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Adductor Squeeze Test (Adductor Longus Provocation)

Procedure

Patient supine, hips bent to 45° and knees to 90°. Place your fist or a ball between the knees and ask the patient to squeeze as hard as they can for a few seconds.

Positive Finding

Pain at the pubic symphysis or groin.

Interpretation

Loads the pubic symphysis through the adductors. A positive test fits pubic-related or adductor-related groin pain but does not separate them. Squeeze strength is useful to track progress. No study confirming this figure for osteitis pubis was found, so no figure is shown. One study of Australian football players (Verrall 2005) compared squeeze and adductor pain tests with pubic bone marrow oedema on MRI and found them only moderately sensitive; its full text has not been read.

Sources

No accuracy study

Palpation of the Pubic Symphysis

Procedure

Patient supine. Palpate the pubic symphysis and the pubic bone on each side, then the adductor tendons just below and the lower rectus abdominis just above, comparing sides.

Positive Finding

Tenderness over the pubic symphysis or pubic bone that reproduces the patient's pain.

Interpretation

Pubic bone tenderness supports pubic-related groin pain (osteitis pubis, pubic bone stress). Tenderness mainly over the adductor tendon points to the adductors; over the inguinal canal to inguinal-related groin pain. In practice these often overlap.

Sources

No accuracy study

Single-Leg Stance and Hop (Pubic Loading)

Procedure

Ask the patient to stand on one leg, then hop gently if standing is comfortable. Repeat on the other leg.

Positive Finding

Pain at the pubic symphysis with single-leg loading.

Interpretation

Single-leg loading shears the pubic symphysis. Pain supports pubic-related groin pain; sharp focal bone pain with hopping should raise concern for a pubic ramus or femoral neck stress fracture and needs imaging.

Further reading

No accuracy study

Resisted Hip Adduction (Standing or Supine)

Procedure

Patient supine with the legs straight. Ask the patient to push the leg inwards against your hand on the inside of the knee, then repeat from an abducted position.

Positive Finding

Pain at the pubic symphysis or adductor origin.

Interpretation

Loads the adductors and the pubic bone where they attach. A positive test fits pubic-related or adductor-related groin pain.

Sources

No accuracy study

Resisted Sit-Up

Procedure

Patient supine with the knees bent. Ask the patient to do a straight sit-up, then an oblique sit-up, against light resistance on the chest or shoulder.

Positive Finding

Pain at the pubic bone, lower abdomen or inguinal region.

Interpretation

Loads the rectus abdominis where it attaches to the pubic bone. Pain at the pubic bone fits pubic-related groin pain; pain over the inguinal canal suggests inguinal-related groin pain.

Sources

No accuracy study

Pelvic Distraction Test

Procedure

Patient supine. Place your hands on the front of both iliac crests (ASIS) and push down and outwards, gently spreading the front of the pelvis.

Positive Finding

Pain at the pubic symphysis or at the sacroiliac joints.

Interpretation

Mainly a sacroiliac joint pain provocation test. Pain at the front of the pelvis may reflect pubic symphysis irritation but this has not been studied. Not a validated test for osteitis pubis.

Sources

⚠ Red Flags

  • •Systemic symptoms suggesting infection (fever, malaise, night sweats)
  • •Severe unrelenting pain unresponsive to conservative treatment over 3-6 months
  • •Neurological symptoms (numbness, tingling in lower abdomen or genitalia)
  • •History of trauma with acute severe pain and inability to weight bear
  • •Constitutional symptoms or weight loss
  • •Imaging evidence of significant erosive changes or osteomyelitis

⚡ Yellow Flags

  • •High sports performance pressure or fear-avoidance behaviors
  • •Catastrophizing about pain impact on athletic career
  • •Psychosocial stress coinciding with symptom onset or exacerbation
  • •Low mood or depression secondary to activity restrictions
  • •Poor body awareness or proprioception
  • •Perfectionist or obsessive training patterns without adequate recovery

Osteopathic Techniques

Conservative care (rest, anti-inflammatories and a progressive physiotherapy programme) is the mainstay. Most athletes return in about 3 months, some take 6 months or more, and only 5–10% need surgery. No trials of osteopathic techniques for osteitis pubis were found.

Safety: Osteitis pubis is not an infection, but pubic osteomyelitis is in the differential, along with athletic pubalgia and adductor or rectus abdominis strain. X-rays and MRI help confirm the diagnosis.

Region

Adductors near the pubic symphysis

Technique

Soft tissue, hip and thighNo trials found

Rationale

Hands-on work to the hip and thigh muscles to ease tension and pain, given alongside exercise.

How it's done & evidence

How it's done

Hands-on kneading, stretching and sustained pressure to the muscles around the hip and thigh: the hip flexors, adductors and hamstrings, and tensor fasciae latae with the iliotibial band.

Evidence in Osteitis Pubis

Searched 24 Oct 2026: no trials of adductor soft tissue technique in osteitis pubis.

Sources

Region

Adductors

Technique

Muscle energy, hip and thigh musclesNo trials found

Rationale

Low-force, patient-powered stretch for tight hip and thigh muscles.

How it's done, cautions & evidence

How it's done

The muscle (for example the hamstrings, adductors or rectus femoris) is taken to its barrier. The patient pushes gently, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Osteitis Pubis

Searched 24 Oct 2026: no trials of adductor MET in osteitis pubis.

Region

Pubic symphysis

Technique

Muscle energy, pelvis (innominate and pubis)No trials found

Rationale

Gentle patient-powered contractions to restore pelvic (innominate or pubic) movement.

How it's done, cautions & evidence

How it's done

The innominate (or pubis) is taken to its restricted barrier. The patient makes a short, gentle contraction against equal resistance (a few seconds), relaxes, and the new barrier is taken up. Repeat, then re-check pelvic landmarks. Check for pubic dysfunction first, with consent.

Cautions

Do not use if the contraction causes severe pain, with a fracture or unstable joint in the area, or after recent surgery.

Evidence in Osteitis Pubis

Searched 24 Oct 2026: no trials of pubic MET in osteitis pubis.

Sources

Region

Lumbosacral and pelvic regions

Technique

Articulation, lumbarNo trials found

Rationale

Gentle, rhythmic mobilisation of the lower back and pelvis to ease stiffness.

How it's done, cautions & evidence

How it's done

Rhythmic, low-velocity movement of restricted lumbar segments within their passive range, with no thrust, usually side-lying or prone. The amplitude can vary.

Cautions

Side effects reported in trials were mild and short-lived: soreness, tiredness or a flare of existing symptoms.

Evidence in Osteitis Pubis

Searched 24 Oct 2026: no trials of lumbar or pelvic mobilisation in osteitis pubis.

Sources

Rehabilitation Exercises

Supine Adductor Stretch (Long Lever)

StretchingBeginner

Standing Hip Flexor Stretch (Modified Lunge Position)

StretchingBeginner

Transverse Abdominis Activation (Supine Hollowing)

StrengtheningBeginner

Side-Lying Hip Abduction

StrengtheningBeginner

Quadruped Alternating Arm/Leg Reach (Bird Dog)

PosturalIntermediate

Glute Bridge with Pelvic Stability

StrengtheningIntermediate

Single Leg Standing with Hip Stability (Clamshells Incorporated)

BalanceIntermediate

Copenhagen Adduction Exercise (Supine with Ball)

StrengtheningIntermediate

Hip Internal/External Rotation Mobilization (Supine Figure-4)

Range of MotionBeginner

Standing Hip Abduction with Resistance Band

StrengtheningIntermediate

Planks with Progressive Leg Lifts (Anti-Rotation)

PosturalAdvanced

Aquatic Running (Pool Running with Belt)

CardiovascularIntermediate

Referral Criteria

  • •Persistent symptoms beyond 3-6 months despite comprehensive conservative treatment
  • •Imaging evidence (MRI/CT) showing significant bone erosion, cystic changes, or osteomyelitis
  • •Inability to participate in functional activities despite structured rehabilitation
  • •Signs of systemic infection or inflammatory arthropathy
  • •Need for advanced imaging or specialist evaluation (sports medicine physician, orthopaedic surgeon)
  • •Consideration of interventional procedures (steroid injection, radiofrequency ablation) if conservative measures plateau
  • •Suspicion of underlying systemic conditions (ankylosing spondylitis, inflammatory bowel disease-associated arthritis)