If you are a runner who has tightness in the groin and/or tummy, you might have osteitis pubis or pubic overload. This condition is also common in sports involving a change of direction, such as football, rugby, netball, or hockey. So what is osteitis pubis, and how do we get it better?
What is Osteitis pubis?
Osteitis pubis is an overuse injury that causes an overload of the pubic bones and pubic symphysis. According to certain researchers, muscles such as the adductors and abdominal muscles are involved.
Generally, running places significant shearing forces through the symphysis pubis balanced by the abdominal and adductor muscles. When you increase running too rapidly for your body to cope, excessive muscle tension on the pubic bones can lead to swelling around the groin. Sometimes, other conditions such as hip impingement increase the risk of developing osteitis pubis.
Osteitis pubis diagnosis
Generally, we make an osteitis pubis diagnosis based on history and examination. Sometimes, we perform imaging such as MRI to confirm the changes and rule out other causes.
In general, osteitis pubis develops gradually after increasing mileage and/or intensity of running. Often, symptoms will develop on one side only. Initially, the pain will ‘warm up’ and improve during a run so that running is not so painful. Unfortunately, if training is not reduced, symptoms can worsen to both sides of the groin and become more intense and constant. This can result in more diffuse pain moving to the tummy and sometimes the low back.
Also, we need to rule out other conditions like hip stress fractures, hip impingement, hernias, and urological and gynaecological disorders. For this reason, we suggest you see a professional to make sure the diagnosis is correct.
How long does pubic bone pain take to get better?
Generally, pubic bone pain gets better in most people, but it can take 12 months. However, if you get help early, recovery can be a lot quicker.
Some practitioners classify the severity of pubic bone pain on a 4-point scale shown below. Overall, studies generally show that those with higher stages take longer to return to sport and running.
| Stages | Side of pain | Site of pain | Characteristics of pain |
|---|---|---|---|
| 1 | unilateral dominant | inguinal with radiation to adductors | pain warms up and worse after training |
| 2 | bilateral | inguinal and adductors | pain worse after training |
| 3 | bilateral | groin, adductor, suprapubic and abdominal | pain during training, kicking, sprinting |
| 4 | bilateral | all over groin, abdominal and into low back | pain at rest and at night, cannot train or run |
In general, management of this injury requires a careful balance of rest from activities such as running, combined with exercise to improve the strength of the adductor muscles and other muscles around the pelvis.
Overall, simple treatments such as physiotherapy should be your first approach as this provides good results for most patients. In addition, shockwave therapy with rehab reduces the time to return to sport. Sometimes, injections can help if the pain is severe or fails to settle. Generally, surgery is unpredictable and should be avoided.
Is there any evidence for the treatment of osteitis pubis?
Yes, several studies show effectiveness. In particular, one study with football players showed that those who received a staged rehabilitation program returned to football within four months, compared to 8 months in the other group. Additionally, those players who received staged rehabilitation had no recurrence of symptoms on a one-year follow-up.
Osteitis pubis exercises: what are the principles?
Pain reduction by reducing training load and modifying activity
First and foremost, it is vital to get the pain under control. Generally, we suggest keeping pain levels <2/10. This will mean that you will need to reduce or stop your running and other sports activity.
For example, if your symptoms are mild (1-2/10 on a pain scale) after a 60-minute run and settle by the next day, it may be possible to continue running at a lower level, aiming to get your pain as low as possible. This may mean that you can run for 30 minutes every other day without pain.
If symptoms are provoked after 15 minutes of running and last for three days with pain during simple activities, then it is likely that you’ll need to stop running for weeks or months.
Maintaining fitness for osteitis pubis
While high-impact activity such as running is avoided or reduced, it is essential to keep up general conditioning for a speedier return to running. Some examples of non-impact training include swimming, static bike, or elliptical trainer.
Osteitis pubis exercises
Generally, a good runner requires adequate hip movement and muscular control of movement in all joints. Therefore, your physiotherapist should assess for any restricted range of movement due to joint problems (e.g., hip impingement), muscle tightness (hip flexor tightness), or muscle weakness. As a result, this allows for a targeted rehabilitation program.
Overall, it is important that exercises are carefully selected and progressed so that they do not cause symptoms to worsen. Often, we use a step-ladder approach to help with exercise selection. Firstly, we might use isometric exercises targeting core and hip muscles lying on the floor. Then, as symptoms improve, the exercises gradually progress to more dynamic exercises with your physiotherapist. Gym-based strength training to optimise strength and stability through the pelvis and your lower legs is also likely to be beneficial.
Pain monitoring to return to running
Generally, careful monitoring of your symptoms in response to training is vital. These measures can be helpful to guide an appropriate stage to reintroduce running or increase the intensity of running.
For example, an important monitoring tool is a pain rating on an adductor squeeze test. In this test, a ball or blood pressure cuff is placed between the knees and squeezed as hard as possible for 5 seconds. Usually, this test is done after each running session. If, after increasing your running, your adductor squeeze pain score goes from <2/10 to 5/10, this would suggest that you have done too much and need to reduce. On the other hand, if your pain score is the same level or lower, you are training at the ‘right level’ and may be ready to increase your running.
There are also some valid strength-based criteria, such as a minimum force produced on squeeze test and the ability to hold an adductor side bridge for 30 seconds without an increase in pain. Overall, a physiotherapist can guide you through appropriate milestones to help you make proper changes to your rehab and running program.
Final word about osteitis pubis
Osteitis pubis or pubic overload can be successfully treated for most runners, but it can take months to resolve. Generally, we recommend you see an expert who can get the correct diagnosis. Overall treatment should apply basic principles of reduced running, rehab, and graded return to running. Finally, only consider injections if your pain continues.
Scott Newton is a musculoskeletal physiotherapist based in central London. He is an expert in managing pelvic and lower limb injuries in runners. Contact him directly through his website www.londonrunningphysio.com
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