Osteitis pubis can be used to describe pain emanating from the pubic symphysis, which is the joint where the two halves of the pelvis come together at the front of the pelvis. The pelvic bones form a ring with the pubic symphysis at the front and are joined at the back of the pelvis at joints on each side of the sacrum (the sacro-iliac joints). The pubic symphysis is a thin joint which under normal circumstances has very minimal motion. In osteitis pubis, or with other types of groin pain, the pubic symphysis can be out of line, with one side higher or lower, or further forward or back than the other. It can also move more than it should during movement and walking, and it is this malalignment and excess movement that can result in inflammation and pain.
Osteitis pubis is thought to result from inflammation of the pubis symphysis, and the ligaments that attach to it and is characterised by pain, and sclerosis and bony changes of the pubis symphysis, which can be seen on X-ray and MRI scan. It can be very debilitating for sportsmen and women and for women post childbirth. In addition to being very painful, it can cause muscle inhibition, and feelings of weakness and loss of power. It can also result in a loss of technique and performance.
Causes of Osteitis Pubis
Osteitis Pubis can have a number of different causes and it is this that can make it a difficult problem to get rid of. We have found that the more complex and resistant cases of osteitis pubis have many of the causative factors, and that unless the physiotherapist is able to address most or all of them, the result is likely to be less good, especially in the sporting population.
The pubic symphysis can be an area that becomes notoriously difficult to heal once it has become chronic. Causes of osteitis pubis can include the following, which are also factors that can prevent or slow down the healing process, causing ongoing pain:
- Sports activities (football and rugby are most common)
- Surgical procedures (gynaecological or abdominal, hernia repairs)
- Pregnancy and childbirth
- Spinal malalignment
- Pelvic malalignment (the pubic symphysis itself may be out of line)
- Poor posture
- Leg length difference
- Foot biomechanics
- Technique- walking and /or running
- Poor flexibility
- Poor muscle strength and recruitment – although muscles can also become overactive and therefore short and tight
- Breathing issues
- Reduced core strength and control of the spine and pelvis during activity
- Poor glut strength and overuse of adductors
- Visceral organs (organs in the abdominal or pelvic cavity) may become affected, which can refer pain, or cause pelvis malalignment
- Hip problems
- Poor balance
Symptoms of Osteitis Pubis
The most common symptom of osteitis pubis is pain over the front of the pelvis. The pain is often central, although can be worse on one side than the other. It can also radiate down into one thigh or into the groin. It is possible to have similar pain in the groin without having full osteitis pubis and it would still be treated in a similar way
Other symptoms can include:
- Limping gait
- Pain during sport
- Change of technique through inhibition of muscles
- A feeling of generally being “crooked”
- Pain in the groin
- Pain in the lower abdomen
X-rays of patients with osteitis pubis typically show an irregular pubic symphysis with sclerotic (thick) bone edges and evidence of chronic inflammation. An MRI test is usually not needed, but will show inflammation of the joint and the surrounding bone.
Getting Rid of Osteitis Pubis
Generally when a client presents with osteitis pubis or chronic groin strain, there is usually a mitigating factor that is preventing it from healing. This may be that the joint itself is out of line for some reason, or that the muscles that function around the pelvis are too tight, too weak or overactive. This can cause changes in the way you move or stand. Invariably it is this that is not allowing the area to heal and the resultant pain in the pubic symphysis then causes further dysfunction in the body, as it tries to compensate. It is only by re-aligning the spine and pelvis and stretching and/or strengthening the muscles around the trunk, pelvis and lower limb, and re-training how we use those muscles, and the way we walk or run, that we can start to allow the painful area to heal. This is sometimes why cortisone injections may not work in the area (although they can be effective if the area is aligned and the issues above have been addressed). In our experience, it is better to have a cortisone injection once all causative factors have been addressed, as the result will be more likely to be successful.
It is always important to find out why the osteitis pubis came on initially. We have seen some cases where the groin pain has arisen because of issues with the shoulder or neck for example.
Treatment of Osteitis Pubis
The physiotherapist will take a thorough case history and will assess all of the areas described above.
Treatment will then begin to address these issues, aiming to help re-align the spine and pelvis, to reduce pain and normalise the way you move.
Treatment can include:
- Spinal and pelvic alignment work
- Muscle energy techniques
- Soft tissue work and stretching
- Myofascial release
- Lower limb and core muscle strengthening
- Referral to podiatry if necessary for leg length assessment and biomechanical analysis
- Visceral work if required- this can often hold the body out of alignment
- Postural analysis
- Retraining of walking and running technique
- Retraining of technical skills
- Balance retraining
- Home exercise program
- Breathing retraining
Treatment of osteitis pubis is most successful, particularly in the more chronic cases, if all of the above are addressed if required. We have had a large amount of success in treating osteitis pubis at CSPC by treating it in this way, and with the greatest chance of non-recurrence. With the high level sportsperson, we may also have to retrain running technique, and the way they move during their sport, for example around a football pitch.
We frequently see patients with osteitis pubis who have also developed issues with breathing, which further exacerbates symptoms and movement dysfunctions, which must also be retrained. This may happen due to the patients resorting to breath-holding and overusing the abdominal muscles to try to stabilise the pubic symphysis, and this must also then be retrained.
If osteitis pubis and groin pain are treated by addressing all of the causes and not just the symptoms, there is a greater chance that the injury will not return, or if it does, it will not be as bad as it was initially. Most of the resistant cases are caused by problems with technique, biomechanics, visceral issues, surgeries, accidents and breathing issues, and by being thorough and addressing as many of the issues as possible, the sportsperson should be able to return to high level sport, often performing at a higher level, as many of these issues have been present for years, causing other minor injuries, until they result in this major injury, which then needs to be fully addressed and rehabilitated.
Pregnancy and Osteitis Pubis
Osteitis Pubis is very common in pregnant women and women post pregnancy. During pregnancy, a hormone called relaxin is released immediately, which helps to prepare the ligaments in the pelvis for birth. Relaxin not only affects the ligaments around the pelvis, but also affects all other ligaments in the body, for example, those around the hips, shoulders and in the feet. Relaxin starts to affect ligaments at 6 weeks, and relaxin levels peak at 12 weeks, but continue throughout pregnancy. The pubic symphysis and SI joints particularly affected by relaxin. The other additional effect for pregnant women, is that by the ligaments around the pelvis, hips and feet becoming more lax, there will be more joint play in all the joints, further affecting the stability of the pubic symphysis, and causing pain. Lax ligaments in the hips and feet will also cause changes in biomechanics, which can affect the pelvis.
More specific advice for pelvic pain in pregnancy will be given on the pages on pregnancy on this website.
Advice for sufferers of Osteitis Pubis
Below are some stretches and exercises that we recommend to those suffering from osteitis pubis. Please note that these are no substitute for a full assessment, but may help to start addressing some of the symptoms.
Tight quads (the muscles down the front of the thigh) will have the effect of tipping the pelvis forwards (anteriorly tilting the pelvis). If one quads is tighter than the other, the pelvis will also have a torsion (twist) in it, which will stress the pubic symphysis. To run, walk and kick a football without stressing the pubic symphysis, it is necessary to have full range in the quads. We recommend the following stretches and foam rolling exercises.
Quadriceps stretch (front of thigh):
- Lying on side, bottom knee bent up level with hips
- Tighten abdominals, and flatten back
- Hold top ankle so that heel is touching buttock
- Pull top leg back behind you until good stretch is felt in front of thigh
- Keep knee lower than hip and back flat
- Hold 30 seconds x 3
Foam rolling the quadriceps:
Face-down with both thighs resting on top of the foam roller. Support yourself on your elbows and forearms, and keep your abdominal and back muscles tight to stabilize your spine. Roll slowly back and forth on the roller, from just above your knees to just below your hips, and pause at any spot that feels especially tender.
Short hamstrings will cause a posterior tilt of the pelvis due to their attachment onto the sitting bones. This will cause a flattening of the lumbar spine (lower back) and a loss of lordosis. If one hamstring is shorter than the other, it can also cause a torsion (twist) in the pelvis, putting stress on the pubic symphysis. A flattened lumbar spine will also inhibit the core muscles, leading to poor pelvic control. We recommend the following hamstring stretch.
- Sitting on chair
- Perfect posture, with good lumbar arch (lordosis)
- Slowly straighten one leg, maintaining perfect posture
- Full stretch is the point just before the back starts to lose its lordosis
- Hold 30 seconds x 5
Often overlooked as a contributing factor in Osteitis Pubis, calf strength is important, especially in the sports person. Adequate calf strength is required to push the foot off the ground, and helps to drive the legs through under the pelvis, especially when running. This helps to activate the muscles down the back of the body (i.e. hamstrings and gluts). When the calves are weak, the quads and hips flexors can over-activate to help lift the thigh through, in the absence of the drive from behind, which exacerbates the issues described above with tight quads. We recommend that all athletes should be able to do a minimum of 3 x 25 of each of the following exercises:
Soleus Raises (deep calf):
- Stand facing the wall, on one leg with the knee bent.
- Keep knee over second toe at all times.
- Without moving hips, lift heel off floor and go onto toes, then lower.
- Do not let knee fall in.
- Go through full range, aiming for smooth movement.
- Build up to 3 x 25
- Do daily after running
- Stand on edge of step on one leg with knee straight
- Fingers on wall for balance
- Go up and down with heel, keeping knee straight
- Go through full range with a smooth movement
- Build up to 3 X 25
- Do daily after running
(Once this becomes easy, you can make it more plyometric on alternate days by going for speed upwards)
Ability to flex the knee to hip height without hitching the hips
It is important to be able to bring the knee to hip height ( as you would when running or going up the stairs) without hitching the hip or deviating through the pelvis. Similarly it is important to be able to move the leg separately from the pelvis in a variety of other actions ( lunging, changing direction, kicking a ball etc). Inability to do this will stress the pubic symphysis and will inhibit stabilising muscles around the pelvis from working. This is a simple exercise that will start working on dissociating the hip from the pelvis.
Balance and dynamic balance
Poor balance and inability to stabilise the body when moving will result in stress on various joints and will mean that a variety of compensations will occur to try to keep the body from falling over. This can mean anything from breath-holding (see section on breathing pattern disorders), over activity in the abdominals, toe scrunching and a host of other issues.
The following exercises are useful in helping to retrain balance, although the exercise on the step should only be done if pain free, and if you have adequate balance to remain safe.
Good functional balance is important in all sports. A good test for assessing functional balance is to stand on one leg and turn the head from side to side, saying the days of the week out loud, making sure you aren’t screwing up your toes. By turning the head, speaking and breathing, you are training your balance reactions without using non-functional bracing strategies.
The exercises above are just a few that can be useful in starting to address issues with pubic symphysis pain. If the condition is long standing, or is very painful, it would be more useful to be fully assessed by one of our physiotherapists, to get personalised programme to get to the root causes of your pain and to help to address it as quickly as possible.
Do not do any of the exercises above if they cause pain at the time or increase pain after doing them. If this occurs, it is likely that you need some hands on and realignment work before starting on a rehabilitation programme.
Testimonial: David Falconer -Semi professional football player
I traveled to see Alison from Glasgow having suffered from osteitis pubis for around a year and after hearing good reports regarding her treatment of this condition.
After trying numerous physiotherapists, ART therapists, acupuncturists, chiropractors/ osteopaths, & surgeons in Scotland with no great results, I did have my doubts as to whether I would ever be able to play football pain free again and was contemplating hanging up my boots- luckily I heard about Alison, and I haven’t looked back.
The attention to detail and anatomy knowledge I experienced was unbelievable and the best I have ever received- every aspect of my body, posture, and breathing was analysed over a two day period that addressed every fundamental weakness/ issue I had.
Even though the aches, and pains that had plagued me for over a year felt better after these initial two days it was after a week+ of doing the exercises given to me that I seen a huge difference. I am now at the stage where I can play pain free and I can’t thank/ recommend Alison and the clinic highly enough.