There are many causes of groin pain in athletes. One of the more common causes of groin pain is osteitis pubis also known as pubic overload. This condition occurs when there is significant inflammation and overload of the pubic symphysis. So, what is osteitis pubis, and can an osteitis pubis injection help?

What is the pubic symphysis?


The pubic symphysis is a thin joint containing cartilage in the middle. The joint joins the two parts of the pelvic bones together. It sits in front of the bladder. attached to the joint from above is the six-pack muscle – rectus abdominis- and below the adductor longus.


Inflammation of the pubic symphysis occurs due to various causes:

  • sport is the most common cause.
  • trauma or fall can cause an inflamed joint
  • pregnancy can overload the pubis symphysis causing pain

The reasons why some people are prone to this condition ranges from excessive sport to reduced movement of the hips to muscular imbalances between the abdominal and adductor muscles.


groin examination

Generally, symptoms develop gradually over time. Pain is usually in the center although can move from one side to another. Generally, symptoms are worse after running and change of direction activity. There is associated limping and weakness of the muscles in the pelvis.

Overall, it is important to make sure other causes of groin pain are ruled out.

Osteitis pubis radiology

Sometimes, imaging is needed especially if the pain has not settled with simple treatments.

Generally, an MRI scan of the pelvis shows swelling of the pubic bone on either side of the joint or thickening of the adductor tendon. However, we need to be careful about the interpretation of these imaging changes, as many of these changes occur in active sportspeople without pain.

Overall, we order MRI in. groin pain to exclude other causes including serious pathology.

Treatment of pubic overload

Overall, we know that pubic overload takes many months to get better. Certainly, taking shortcuts such as a cortisone injection or surgery will not get you back to sport faster. Also, the sooner you start treatment, the faster is the improvement and return to sport.

Your therapist should test your strength in your hip abductor and adductors to see if you have strength weakness that needs correcting.

Osteitis pubis rehabilitation: an example of a structured rehab program

women doing adductor strengthening
copenhagen adductor strengthening by young male

Initially, we treat the inflammation to reduce pain. These simple treatments include rest from aggravating sport, anti-inflammatory tablets such as ibuprofen, compression shorts, and soft tissue massage.

Next, we suggest you see an experienced therapist to guide your rehab. Overall, the focus of rehab should be on improving the mobility and flexibility of your hips and strengthening the muscles surrounding the pelvis. The rehab exercises are staged in this order:

  • isometric adductor exercise (especially if the person has high pain levels)
  • standing single leg crab walks and adductor machine exercises
  • Copenhagen adductor strengthening exercise – using short and long levers

Generally, we recommend 3 sessions per week of strengthening. You should also work the other muscles in the pelvis including hip flexor and glutes. Overall, you can work through low-level pain, also known as stable pain. Also, therapists often check progress by using the isometric squeeze test to see if you are coping with rehab – any reduction in strength of a squeeze test is an early warning sign that you’re progressing exercises too quickly.

Finally, as your pain settles, your therapist will guide the progression of your activity from straight-line running to change of direction running to sport.

For difficult cases, we use injections to help with exercise. Generally, we only recommend injections if you continue to struggle with pain despite 3-6 months of rehab.

In almost all cases, surgery is not recommended as the results of surgery are unpredictable

More about osteitis pubis injection 

Overall, there are a number of options for an osteitis pubis injection.

Firstly, for cases that involve primarily the pubic symphysis, we suggest a cortisone injection into the joint. This injection is usually done with a longer needle coming from just above the joint.

Secondly, for people with pain in the adductor, perineal or pelvic area (near the lower abdomen), we may consider a nerve block. Generally, we use a numbing solution with a small dose of cortisone. Injecting around a nerve can reduce pain coming from the area supplied by the nerve – this is usually immediate but also has a longer-lasting effect of up to 1 month.

Overall, it is important to understand that these injections are not to cure the problem but to help the rehab.

Final word from Sportdoctorlondon

Osteitis pubis also known as pubic overload is common in runners and change of direction sports. Generally, the earlier the diagnosis, the faster the return to sport. Rehab is the main form of treatment, but injections can be used carefully in difficult cases. Overall, we need to remember that there are no quick fixes for this condition and that an osteitis pubis injection or surgery can delay progress or be harmful.

Related conditions:

Dr. Masci is a specialist sport doctor in London. 

He specialises in muscle, tendon and joint injuries.

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