If you’re a runner with tightness in the groin or lower tummy, you might have osteitis pubis, or pubic overload. It’s also common in change-of-direction sports such as football, rugby, netball, and hockey. So what is osteitis pubis, and how can we treat it more effectively?
What is osteitis pubis?
Osteitis pubis is an overuse injury that overloads the pubic bones and the pubic symphysis (the joint at the front of the pelvis). The adductor and abdominal muscles are closely involved. Running places significant shearing forces through the symphysis, which these muscles balance — and when training increases too quickly, excessive muscle tension on the pubic bones leads to swelling and pain around the groin. Other conditions, such as hip impingement, can increase the risk.
How is osteitis pubis diagnosed?
We usually diagnose osteitis pubis based on the history and examination, sometimes adding an MRI to confirm the findings and rule out other causes.
It typically develops gradually after an increase in mileage or intensity, often starting on one side first. Early on, the pain “warms up” and eases during a run. If training isn’t reduced, it can spread to both sides, become more constant, and produce more diffuse pain in the tummy and lower back.
It’s essential to rule out other causes of groin pain — hip stress fractures, hip impingement, sports hernia, and urological or gynaecological conditions — so see a professional to confirm the diagnosis. (For the wider differential, see groin pain in runners.)
How long does pubic bone pain take to settle?
Most people improve, but it can take up to 12 months — and getting help early speeds recovery. Some clinicians stage the severity on a 4-point scale; higher stages take longer to return to sport.
| 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 |
Managing osteitis pubis means balancing rest from aggravating activity with strengthening the adductors and other pelvic muscles. Physiotherapy is the first approach and works for most people; shockwave therapy alongside rehab can shorten the return to sport. Injections help in severe or stubborn cases, and surgery — unpredictable — is generally avoided.
Is there evidence for these treatments?
Yes. One study in footballers found that a staged rehabilitation programme returned players to football in four months, compared with eight months in the comparison group, with no recurrence at one year.
Osteitis pubis exercises: the principles
Reduce the load and control the pain
First, get the pain under control — generally aiming to keep it at 2/10 or below. That may mean reducing or pausing running. If mild pain (1–2/10) after a 60-minute run settles by the next day, you may be able to keep running at a lower level — perhaps 30 minutes every other day, pain-free. If pain comes on after 15 minutes and lingers for days, you’ll likely need to stop running for weeks or months.
Maintain fitness
While running is reduced, keep your general conditioning up with non-impact training — swimming, static bike, or elliptical.
Targeted strengthening
Good running needs adequate hip movement and muscular control. Your physiotherapist should assess for restricted movement (such as hip impingement), muscle tightness (hip flexors), or weakness, then build a targeted programme. Exercises are selected and progressed carefully so they don’t flare symptoms — often a step-ladder approach, starting with isometric core and hip work and progressing to dynamic, gym-based strengthening through the pelvis and legs.
Monitor pain to guide your return to running
Careful symptom monitoring guides when to reintroduce or increase running. A key tool is the adductor squeeze test — a ball or blood pressure cuff is squeezed between the knees for 5 seconds, usually after each run. If your squeeze pain rises from under 2/10 to 5/10 after increasing your running, you’ve done too much. If it’s the same or lower, you’re at the right level and may be ready to progress. Strength-based milestones — a minimum squeeze force, and holding an adductor side-bridge for 30 seconds without increased pain — also help guide progression.
Frequently asked questions about osteitis pubis
Can osteitis pubis cause bladder problems?
Possibly. The bladder sits just behind the pubic symphysis, so inflammation there can irritate it and cause symptoms such as increased urinary frequency. Still, bladder symptoms should be evaluated to rule out infection or other causes.
Can osteitis pubis cause testicular pain?
Yes — inflammation of the pubic symphysis commonly refers pain into the groin and testicle. See a doctor to rule out a testicular problem or another groin condition, such as a sports hernia.
What type of doctor treats osteitis pubis?
A sports medicine doctor who can confirm the diagnosis and rule out other causes of groin pain, working alongside a physiotherapist for rehab.
How long does osteitis pubis take to heal?
Usually, even with good rehab and a graded return to running, symptoms take 6–12 months to settle.
Should I have an injection for osteitis pubis?
Only if pain persists despite 3–6 months of good rehab, injections don’t cure osteitis pubis — they create a window to rehab. See osteitis pubis injections for the options.
Final word about osteitis pubis
Osteitis pubis (pubic overload) can be treated successfully in most runners, but it takes months to resolve. See an expert to get the diagnosis right, then apply the basics: reduced running, targeted rehab, and a graded return. Only consider injections if the pain continues.
Scott Newton is a musculoskeletal physiotherapist based in central London, specialising in pelvic and lower-limb injuries in runners. Contact him via www.londonrunningphysio.com.
For a medical assessment, MRI, or injection where rehab hasn’t been enough, Dr Masci can see you in London — contact the team here or call +44 (0) 203 488 0350.
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