Osteitis pubis
Illustration of the symphysis pubis between the pubic bones


Osteitis pubis, simply named inflammation of the symphysis pubis, is an inflammatory condition of the joint between the two pubic bones also involving the insertion of the surrounding muscles.

Left, rectus abdomini and Right, adductor longus are two of the muscles inserting at the pubis, which may lead osteitis pubis when overused


The symphysis pubis is a cartilaginous joint that holds together the pubic bones. The inflammation of the pubic symphysis is mostly the result of repetitive trauma. It is common amongst individuals involved in competitive soccer, hockey, football and running where a strong load is posed on the pubis when kicking or in recurring adduction and abduction of the hips. It is also caused by excessive contraction of the abdominal muscles. This pathology is also called athletic pubalgia. Osteitis pubis can also arise during pregnancy when the symphysis becomes lax in preparation of childbirth or following pelvic surgery.

The pubic bones are covered with cartilage tissue and are kept together by a fibrocartilage disk firmly tightened by ligaments. Several muscles insert at this point including adductors (magnus, brevis, longus), rectus, pectineus and gracilis. Strong ligaments keep these muscles in place and limit the movement of the symphysis. However, continuous strain caused by pulling forces onto the pubic joint may trigger inflammation of the region followed by tissue destruction.

Arm abduction is restricted by the inflamed bursa and tendons, reducing the joint space
Cross section of the shoulder depicting the compression of the bursa (red) above the rotator cuff (white) and below the deltoid muscle


There are various classification systems for a shoulder impingement syndrome.

Stages of subacromial impingement in athletes - Jobe’s Classification

Pure impingement with no instability

Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement

Primary instability due to intrinsic ligament laxity with secondary impingement

Pure instability with no impingement.

Grading of impingement changes - Milgrom’s Ultrasound Classification:

Stage 1 Bursal thickness from 1.5 to 2.0 mm

Stage 2 Bursal thickness over 2.0 mm

Stage 3 Partial or full thickness tear of the rotator cuff.

Impingement lesions - Copeland Levy Classification:

This is based on the location of the impingement, either on the acromial or the bursal side.

Acromial side

A0 normal - smooth surface

A1 minor deterioration, haemorrhage or local inflammation

A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament

A3 exposed bone areas.

Bursal side

B0 normal - smooth surface

B1 minor deterioration, haemorrhage, inflammation

B2 major deterioration of the cuff, partial thickness tear

B3 full thickness tear of the rotator cuff

B4 massive cuff tear.

Two-part proximal humerus fracture

According to the Habermeyer Classification the fractures to the proximal humerus are divided into:

Type 0 one fractured part without dislocation

Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion

Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities

Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.

These are defined further as:

One-part fractures are non-displaced fractures or fractures with minimal displacement

Two-part fractures only involve a single segment

Three-part fractures involve two segments

Four-part fractures occur when all humeral segments are involved (see image in pathology section)

The injury severity is proportional to the increasing number of fractures.

Three-part proximal humerus fractures

Kicking the ball strains the pubic symphysis leading to osteitis pubis


There are several identified causes leading to osteitis pubis, however in some cases its aetiology remains unknown. Below a few frequent causes:

Sport (athletics, soccer, hockey, football, marathon run)


Gynaecologic surgery

Urologic surgery

Trauma in different severities


Intensive training is a risk factor for osteitis pubis

Risk factors

Common risk factors for the development of osteitis pubis include:

Competitive/extreme sports

Training on hard surfaces

Training with poor footwear


Previous pelvic surgery

Incorrect anatomy and posture

Getting out of the car puts pressure on the pubic symphysis causing pain in patients with the condition especially pregnant women


The most frequent symptoms of osteitis pubis are:

Pain to the groin region

Pain in the lower abdomen/frontal hips

Tenderness when pressing the pubis

Pain when squeezing the thighs together

Pain when abducting the legs

Pain when getting out of the car

Pain aggravated during sport

Limp due to pain

Loss of joint flexibility

Separation of the symphysis pubis in a X-ray image


For the diagnosis of osteitis pubis the clinical examination is usually sufficient. With medical history the examiner acquires information on predisposing factors, injuries and surgeries that may have led to the pathology. To obtain a clear view of the anatomy of the pubis and to exclude the presence of stress fractures (pubic rami and femoral head), bone erosion, diastasis (separation) of the symphysis and tissue degeneration or inguinal hernia, the examiner will request imaging via X-rays and MRI and ultrasound.


Antiinflammatory treatment is the first resource for conservative treatment of osteitis pubis

Nonoperative treatment

Most cases of osteitis pubis are treated conservatively following a simple regime based on antiinflammatory therapy with oral NSADs, rest from intensive sport practice and by adopting changes in physical activities that may have caused the condition. Only seldom a local steroid injection is recommended. In pregnancy osteitis pubis is usually transitory and improves after birth.

Example of symphisis fixation in a fractured pelvis

Surgical treatment

Surgery is indicated if osteitis pubis refractory to conservative treatment but only in rare cases (5-10%). Open or endoscopic surgery involves the resection of the wedges of the pubic symphysis with or without fixation of the symphysis with metal implants. The success of this procedure is limited with the possibility of pelvic complications. The resulting instability of the pelvis may become a serious functional problem causing significant pain.

Exercises are useful to strengthen the core muscles and buttocks


Physiotherapy is the optimal approach for the treatment of osteitis pubis. In severe cases it begins with partial weight bearing achieved with the use of crutches. Additional therapeutic measures comprise:



Joint mobilisation

Soft tissue massage


Anti-inflammatory therapy (NSAIDs)

Exercise to strengthen abdominal, adductor and abductor muscles

Advice on activity modification

Use of proper footwear

Clinical Pilates

Adopting a correct posture during physical activities can prevent injuries


The incidence of osteitis pubis can be prevented by following the rules below:

Reduce sport intensity

Maintain strength of pelvic, abdominal and gluteal muscles

Ergonomic advice of proper posture during physical activity

Keep muscle and joint flexibility (hip, knee and lower spine)

Wear suitable footwear during sport

Modify sport habits

Introduce stretching and warm-up prior to sport

Avoid hard surface when running