Osteitis Pubis (Pubic Symphysis Stress)

Osteitis pubis is a chronic overuse inflammatory condition of the pubic symphysis, and in a footballer with chronic central groin pain worse with kicking it is high on my differential. It is caused by repetitive shear and traction across the symphysis from the opposing pulls of the adductors below and the rectus abdominis above, which share a common aponeurosis at the pubis, and it is seen in athletes who kick, sprint and pivot. The pain is central, suprapubic or symphyseal, often radiating to the adductors or lower abdomen, and worse with kicking, sprinting, pivoting and sit-ups; on examination there is tenderness directly over the symphysis and pain on resisted adduction. Crucially, I would assess it as part of the athletic pubalgia or groin-pain spectrum rather than in isolation, because it overlaps with adductor-related pain, rectus abdominis injury, sports hernia or inguinal disruption, and femoroacetabular impingement, where constrained hip motion transfers stress to the symphysis. For imaging, radiographs may show symphyseal sclerosis, erosion and widening, with a flamingo view for instability, and MRI is the most sensitive, showing subchondral bone-marrow oedema on either side of the symphysis. Importantly, I would exclude infection - septic arthritis of the symphysis - and, in the right patient, inflammatory arthropathy or malignancy, particularly if there are systemic features.

Management is predominantly conservative and, importantly, prolonged, because recovery is slow. I would start with relative rest and activity modification, NSAIDs and analgesia, and a graduated rehabilitation programme that restores adductor and core - rectus and abdominal - strength and balance and corrects the underlying load and biomechanics. Because osteitis pubis sits within the athletic pubalgia or groin-pain spectrum, I would identify and treat any concurrent pathology, such as adductor-related groin pain, rectus abdominis injury, a sports hernia or inguinal disruption, or femoroacetabular impingement, since an untreated associated problem will perpetuate symptoms. For refractory cases, a corticosteroid or other symphyseal injection can help, and surgery is reserved for the few who fail prolonged non-operative care - options include symphyseal curettage or arthrodesis, or treatment of the associated pubalgia or adductor pathology. Return to sport should be slow and criteria-based, when the athlete is pain-free with restored strength, to limit recurrence. Throughout, I would have ensured at the outset that infection and, where relevant, inflammatory arthropathy or malignancy were excluded.