Osteitis Pubis: Symptoms, Types, Causes and Treatment

Osteitis pubis is an under-recognized but significant source of pain for athletes and non-athletes alike. It involves inflammation of the pubic symphysis—the joint at the front of the pelvis—and can cause persistent discomfort that disrupts daily life and athletic performance. This article will explore the symptoms, types, causes, and treatment options for osteitis pubis, drawing on up-to-date research and clinical experience to offer a comprehensive overview of this complex condition.

Symptoms of Osteitis Pubis

Osteitis pubis often presents as a confusing array of symptoms, making it a challenging diagnosis. The pain can range from mild discomfort to severe, activity-limiting agony, and its location and character may vary from person to person. Recognizing the hallmark symptoms is the first step toward effective management and recovery.

Symptom	Location	Aggravating Factors	Sources
Pubic pain	Pubic symphysis	Exercise, movement	1 2 3 4 5
Groin pain	Anterior/medial	Running, pivoting, kicking	2 3 4 5
Adductor pain	Inner thigh	Hip adduction, flexion	1 2 4
Lower abdominal pain	Lower abs	Coughing, sneezing, stairs	1 3 4
Perineal/scrotal pain	Pelvic/perineum	Movement, activity	1 2 3 4

Table 1: Key Symptoms

Common Presenting Symptoms

Most patients with osteitis pubis report pain centered around the pubic symphysis—the joint at the front of the pelvis. This pain is often described as aching, burning, or sharp and may radiate to the groin, lower abdomen, inner thigh (adductor region), or even the perineal and scrotal areas in men 1 2 3 4. For women, hip pain can also be prominent 1.

Aggravating and Relieving Factors

Symptoms are often made worse by activities that load or stress the pelvis:

• Running, cutting, or kicking (common in soccer, hockey, rugby, and running)
• Hip adduction and flexion against resistance
• Rapid changes of direction
• Climbing stairs, coughing, or sneezing

Pain typically improves with rest, but can persist during daily activities if the condition becomes chronic 2 3 4.

Associated Physical Signs

Clinical examination may reveal:

• Tenderness over the pubic symphysis and adductor muscle origins
• Decreased hip rotation
• Pelvic malalignment or sacroiliac joint dysfunction 1

In some cases, patients may walk with a "waddling" gait to reduce pain 13.

Types of Osteitis Pubis

Osteitis pubis is not a one-size-fits-all diagnosis. Several types and classifications exist, reflecting the varied causes and presentations in different populations.

Type	Common Population	Key Features	Sources
Mechanical	Athletes	Overuse, microtrauma	1 2 4 5
Obstetric	Postpartum women	Related to childbirth	1 3 8
Inflammatory	Any	Autoimmune/inflammatory	1 3 8
Infectious	Post-surgery, device	Bacterial infection	7 8 9

Table 2: Types of Osteitis Pubis

Mechanical (Sport-Related) Osteitis Pubis

The most prevalent form, especially among athletes, is mechanical osteitis pubis. This type results from repetitive stress and microtrauma at the pubic symphysis, often due to high-impact sports such as soccer, rugby, and distance running 1 2 4 5. It is sometimes also called "athletic osteitis pubis" or "pubic overload syndrome."

Obstetric Osteitis Pubis

This type occurs in women, typically postpartum, due to the stress and stretching of the pelvis during childbirth. It may also follow pelvic surgeries or trauma related to pregnancy and delivery 1 3 8.

Inflammatory and Autoimmune-Associated

Some patients develop osteitis pubis due to underlying inflammatory or rheumatic disorders, though this is less common. It may occur in association with systemic inflammatory diseases or as a reaction to trauma or surgery 1 3 8.

Infectious Osteitis Pubis

While classic osteitis pubis is non-infectious, a small subset of cases are caused by infection (osteomyelitis pubis). These typically occur after pelvic or urological surgery, or following the implantation of medical devices. Infectious osteitis pubis presents similarly but requires very different management 7 8 9.

Causes of Osteitis Pubis

Understanding the root causes of osteitis pubis is crucial for both prevention and tailored treatment. The condition is multifactorial, with several recognized triggers.

Cause	Risk Group	Mechanism	Sources
Overuse/microtrauma	Athletes	Repetitive muscle strain	1 2 4 5
Surgery/trauma	Post-op patients	Disruption/inflammation	3 8 7
Childbirth	Postpartum women	Pelvic ligament stress	1 3 8
Infection	Device/surgery cases	Bacterial invasion	7 8 9
Inflammatory diseases	All	Autoimmune response	3 8

Table 3: Causes of Osteitis Pubis

Overuse and Microtrauma

The most common cause, particularly in athletes, is repetitive overuse. Activities that involve rapid acceleration, deceleration, twisting, or kicking put tremendous stress on the pubic symphysis. Microtrauma accumulates, leading to inflammation and pain 1 2 4 5.

Sports commonly implicated include:

• Soccer
• Rugby
• Hockey
• Long-distance running
• Tennis 1 4 5

Biomechanical factors such as limited hip rotation and pelvic malalignment can further increase risk 1 6.

Surgery, Trauma, and Childbirth

Osteitis pubis was first described in patients after pelvic or urological surgeries (e.g., prostatectomy, bladder or gynecologic operations) 3 8. Childbirth is another classic trigger, as the pelvis widens and ligaments stretch, sometimes excessively 1 3 8.

Infection

Though rare, direct infection of the pubic symphysis can occur, especially in association with surgical procedures and implanted devices. This form is called osteomyelitis pubis and requires prompt identification and antibiotic treatment 7 8 9.

Inflammatory and Systemic Diseases

Less commonly, systemic inflammatory disorders can trigger osteitis pubis, either alone or in combination with trauma or surgery 3 8.

Treatment of Osteitis Pubis

Managing osteitis pubis requires a nuanced, stepwise approach. Most patients respond well to conservative treatment, but persistent cases may need more advanced interventions.

Treatment	Approach	Indication	Sources
Rest & NSAIDs	Conservative	First-line, mild cases	3 5 10 11 12
Physical therapy	Conservative	Return to function	5 11
Injections	Minimally invasive	Moderate/severe, refractory	2 5 11 12
Surgery	Invasive	Chronic, severe cases	5 13 14 15
Antibiotics	Infectious cases	Confirmed infection	7 8 9 11

Table 4: Treatment Options

Conservative Management

Most cases of osteitis pubis can be managed without surgery:

• Rest: Essential for reducing inflammation. Activity modification is critical, especially avoiding sports that caused the symptoms.
• NSAIDs: Non-steroidal anti-inflammatory drugs provide pain relief and reduce inflammation 3 5 10 11 12.
• Physical Therapy: Targeted rehabilitation focuses on restoring hip mobility, pelvic stability, and core strength. Stretching and strengthening of the adductor and abdominal muscles are key components 5 11.
• Gradual Return: Athletes are guided back to activity only when pain-free and functional capacity has returned 5.

Injection Therapies

For patients who do not improve with conservative measures, local injections may be considered:

• Corticosteroid Injections: Direct injection of steroids into the pubic symphysis can speed pain relief and return to sport. Some studies report good outcomes, with many athletes resuming full activity within weeks 2 12.
• Prolotherapy: Injections of dextrose solution have been explored, though results are variable 2 11.

Surgical Interventions

Surgery is reserved for chronic, severe, or treatment-resistant cases:

• Pubic Symphysis Curettage: Removal of diseased tissue while preserving ligaments can be effective, with many athletes returning to full activity within months 14 15.
• Wedge Resection or Fusion: More invasive procedures may be considered for refractory or structurally unstable cases, though risk of pelvic instability increases 13 15.
• Ligament-Preserving Techniques: Recent advances favor less disruptive approaches to avoid long-term complications 15.

Treatment of Infectious Osteitis Pubis

Confirmed cases of infection require targeted antibiotics, sometimes guided by bone biopsy or aspiration. Surgery may be necessary if there is abscess or bone destruction 7 8 9 11.

Prognosis and Follow-Up

• Most patients recover fully with appropriate treatment, though recovery can take several months 1 3 12.
• Recurrence is possible, particularly in athletes resuming high-risk activities too soon 1.
• Early recognition and tailored management are key to optimal outcomes.

Conclusion

Osteitis pubis, though often overlooked, is a significant cause of pelvic and groin pain, especially among athletes. With its multifaceted symptoms and causes, a thorough understanding is vital for effective management and recovery.

Key Takeaways:

• Symptoms: Persistent pubic, groin, and adductor pain, especially exacerbated by activity 1 2 3 4 5.
• Types: Mechanical (athletic), obstetric, inflammatory, and infectious forms exist 1 3 7 8.
• Causes: Overuse, surgery, childbirth, and occasionally infection or systemic inflammation 1 3 5 7 8.
• Treatment: Most cases resolve with rest, NSAIDs, and physical therapy. Injections and surgery are reserved for resistant cases. Infection requires antibiotics 2 5 10 11 12 13 14 15.

A multidisciplinary approach and early intervention can help most patients return to full function, whether on the playing field or in daily life.