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Osteitis Pubis

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Osteitis Pubis

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Osteitis pubis, an inflammation of the pubis symphysis and subsequent stress reaction of the surrounding bone, is caused by rotational, tension, or shear forces placed on the symphysis. Osteitis pubis usually appears during the third and fourth decades of life, occurring more commonly in men.

See Also: Athletic Pubalgia (Sports Hernia)

Osteitis Pubis Causes

Many theories have been put forward concerning the etiology and progression of this disease, but the cause of osteitis pubis remains unclear.

Osteitis pubis is seen in athletes who participate in activities that create continual shearing forces at the pubic symphysis, as with unilateral leg support or acceleration–deceleration forces required during multidirectional activities. These include activities such as running, racewalking, gymnastics, soccer, basketball, rugby, and tennis. Overuse is the most likely etiology of the inflammation, and the process is usually self-limiting.

Osteitis pubis has been likened to gracilis syndrome, an avulsion fatigue fracture involving the bony origin of the gracilis muscle at the pubic symphysis and occurring in relation to the directional pull of the gracilis. However, osteitis pubis does not necessarily involve a fracture. The process could be the result of stress reaction, which might be associated with several biomechanical abnormalities.

Pain with walking can be in one or several of many distributions: perineal, testicular, suprapubic, inguinal, and in the scrotum and perineum.

pubis symphysis
pubis symphysis
Osteitis Pubis

Osteitis Pubis Symptoms

The pain or discomfort can be located in the pubic area, one or both groins, and the lower rectus abdominis muscle. Symptoms of osteitis pubis have been described as “groin burning” with discomfort while climbing stairs, coughing, or sneezing.

During the physical examination, pain can be elicited by having the patient squeeze a fist between the knees with resisted long and flexed adductor contraction. Range of motion in one or both hips may be decreased. An adductor muscle spasm might occur with limited abduction and a positive FABER test.

A soft tissue mass with calcification, and an audible or palpable click over the symphysis might be detected during daily activities. Correct examination of this region involves examining the position of the pelvic girdle. The normal position for the pelvic bowl is 45 degrees in the sagittal plane and 45 degrees in the coronal plane. Pubic motion is assessed by locating the pubic crest and then gently testing the mobility of each available direction.

Dysfunction of this articulation may be primary or secondary and, when present, is always treated first, because a loss of function or integrity of this joint disrupts the mechanics of the entire pelvic complex.

The impairment pattern is determined by palpating the position of the pubic tubercles and correlating the findings with the side of the positive kinetic test, with the restricted side indicating the side of the impairment. An altered positional relationship within the pelvic girdle is significant only if a mobility restriction of the SIJ or pubic symphysis, or both, is found.

The inguinal ligament is usually very tender to palpation on the side of the impairment. It is common to find the pubic symphysis held in one of the four following positions:

  1. Anteroinferior.
  2. Posterosuperior.
  3. Anterosuperior.
  4. Posteroinferior

MRI is used to identify the condition.

See Also: Patrick Test | FABER test
Osteitis Pubis xray
Osteitis Pubis x-ray
Osteitis Pubis MRI
Osteitis Pubis seen on MRI

Osteitis Pubis Treatment

Osteitis Pubis Treatment for the inflammatory type is conservative and most athletes return to their respective sports within a few days to weeks. The treatment includes:

  1. Plenty of rest from weight-bearing activities,
  2. A course of nonsteroidal anti-inflammatory medicine,
  3. Physical therapy to gently mobilize, stretch, and strengthen the muscles about the groin.
  4. Patients should be able to swim for exercise.

Osteitis Pubis Exercises Protocol

Phase I:

  1. Static adduction against a soccer ball placed between feet when lying supine. Each adduction is held for 30 seconds and is repeated 10 times.
  2. Abdominal sit-ups performed both in straight direction and in oblique direction. Patient performs five sets to fatigue.
  3. Combined abdominal sit-up and hip flexion (crunch). Patient starts from supine position and with a soccer/ basketball placed between knees. Patient performs five sets to fatigue.
  4. Balance training on wobble board for 5 minutes.
  5. One-foot exercises on sliding board, with parallel feet as well as with a 90-degree angle between feet.

Five sets of 1-minute continuous work are performed with each leg, and in both positions.

Phase II (from third week)

  1. Leg abduction and adduction exercises in side lying position on side. Patient performs five series of 10 repetitions of each exercise.
  2. Low-back extension exercises while in prone position over end of treatment table. Patient performs five series of 10 repetitions.
  3. One-leg weight-pulling abduction–adduction, standing. Patient performs five series of 10 repetitions for each leg.
  4. Abdominal sit-ups both in straightforward direction and in oblique direction. Patient performs five sets to fatigue.
  5. One-leg coordination exercise flexing and extending knee and swinging arms in same rhythm (crosscountry skiing on one leg). Patient performs five sets of 10 repetitions for each leg.
  6. Skating movements on sliding board. This is performed five times for 1-minute continuous work.
osteitis pubis exercises
Osteitis Pubis Exercises
osteitis pubis exercises
Osteitis Pubis Exercises


  1. Middleton RG, Carlile RG. The spectrum of osteitis pubis. Compr Ther. 1993;19(3):99-102. PMID: 8222595.
  2. Wiley JJ: Traumatic osteitis pubis: the gracilis syndrome. Am J Sports Med 11:360–363, 1983.
  3. Fricker PA, Tauton JE, Ammann W: Osteitis pubis in athletes. Infection, inflammation, or injury? Sports Med 12:266–279, 1991.
  4. Barry NN, McGuire JL: Overuse syndromes in adult athletes. Rheum Dis Clin North Am 22:515–530, 1996.
  5. Grace JN, Sim FH, Shives TC, et al.: Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg 71A:358–364, 1989.
  6. Andrews SK, Carek PJ: Osteitis pubis: a diagnosis for the family physician. J Am Board Fam Pract 11:291–295, 1998.
  7. Holt MA, Keene JS, Graf BK, et al.: Treatment of osteitis pubis in athletes. Am J Sports Med 23:601–606, 1995.
  8. Hiti, CJ, et al: Athletic osteitis pubis. Sports Med, 41:361, 2011.
  9. Morelli, V, and Smith, V: Groin injuries in athletes. Am Fam Physician, 64:283, 2001.
  10. LeBlanc, KE, and LeBlanc, KA: Groin pain in athletes. Hernia, 7:68, 2003.
  11. Mehin R, et al: Surgery for osteitis pubis. Can J Surg, 49:170, 2006.
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