It started as a niggle somewhere around round five. You warmed up, it eased off, so you kept playing. Now it hurts when you kick, when you sprint off the mark, when you twist to get out of the car, and the three weeks off over the mid-season break didn't fix it. If that's roughly your story, this is most likely osteitis pubis, and the reason rest alone hasn't worked is that rest was never the treatment for it.
The pubic symphysis is the small joint at the front of your pelvis where the left and right halves meet. It's a busy piece of anatomy: your adductors (the inner thigh muscles) pull down and inwards on it from below, while your lower abdominals pull up from above. Kicking, sprinting and changing direction load both at once, in opposite directions, thousands of times across a season.
When that repeated load outpaces what the joint and the bone either side of it can adapt to, the area becomes irritated and painful. It's an overload problem, which is why it creeps up gradually rather than arriving in one bad moment. Reported rates in athletes sit between 0.5% and 8%, higher in distance runners and kicking sports, and in male soccer players it accounts for roughly 10 to 18% of injuries a year 1.
A note on what your physio will call it. In 2014, twenty-four groin pain experts from fourteen countries (including the Australian Institute of Sport, La Trobe and the University of Sydney) agreed on a shared way to classify groin pain in athletes. Under it, what you'd search as "osteitis pubis" is pubic-related groin pain, defined by local tenderness at the pubic symphysis and the bone next to it 2, and the older term is no longer recommended 4. The change is practical: the newer system points at which tissue is tender, and that's what changes the plan.
Groin pain in athletes isn't one condition, and that consensus exists because it kept being treated as though it were. The alternatives worth separating out 2:
Osteitis pubis is the one where the tenderness sits centrally, on the pubic symphysis itself.
Two complications. More than one of these is often present at once: hip impingement especially, which showed up on imaging in 86% of one group of athletes treated for this kind of groin pain 1. And groin pain has causes outside muscles and joints entirely, including the lumbar spine, nerve entrapments and abdominal or genitourinary conditions 1. Which is why a long-running groin problem deserves an assessment rather than a guess.
Diagnosis starts with your history and a hands-on examination 1. The finding that defines it is simple: it's tender when the clinician presses on the pubic symphysis and the bone right beside it, and the pain is one you recognise as your own 2. Most will add a squeeze test, where you press your legs together against resistance. The examination isn't standardised, though 1, and the consensus group found no single resistance test that specifically brings on this pain 2.
An X-ray can show changes at the joint, mostly once the problem has been around a while 1. Scan findings are also common in athletes with no symptoms at all, which makes imaging on its own a difficult way to diagnose groin pain 2. It backs up the examination.
Conservative, physiotherapy-led care is first-line here, and the literature describes early diagnosis and a multimodal plan as mandatory 1. In practice:
Pushing structure over rest isn't a preference. In a randomised trial of 68 athletes with long-standing groin pain (a median of 40 weeks of it), 23 of the 34 given an active strengthening and coordination program returned to sport with no groin pain, against 4 of the 34 who had hands-on physiotherapy without it 3. In a controlled trial in amateur footballers with osteitis pubis specifically, 42 of 44 players across two rehabilitation groups were back playing within four months, versus roughly eight months in a rest-only group 1.
One limit on that: the strongest of those trials studied adductor-related groin pain, not osteitis pubis. And a 2023 review pooling five trials found exercise therapy produced better short-term pain scores than passive treatment added to exercise, but rated its own certainty very low, because the trials were small and none blinded their participants, therapists or assessors 4. The direction of the evidence is consistent; the quality of it isn't. You're better off knowing that.
These come up often. They're a medical procedure, not something Well Motion physiotherapists prescribe or administer (outside our scope), but if your doctor raises one, the published picture is mixed. The review of this condition describes the evidence as low, reports a high rate of non-responders, notes that many patients kept having pain or needed repeat injections, and concludes there isn't enough evidence on short- or long-term effectiveness 1.
Also sometimes suggested, also outside physiotherapy scope. Both its effectiveness and how it's meant to work remain controversial in the literature 1.
Reserved for roughly 5 to 10% of cases that don't settle with conservative care, and only after at least three months of well-conducted rehabilitation 1. The same review is blunt about it: little evidence supports one surgical method over another, or indeed the need for surgery at all 1.
Rehabilitation for osteitis pubis follows The Well Motion Recovery Path™. The joint sets the pace: you go up a phase when it copes with the load of the one you are in, whatever the fixture list says.
How long it usually takes. Athletes who rehabilitate it are generally back at their pre-injury level in about 4 to 14 weeks 1. That range comes from a single review, so treat it as a guide. If three months of well-run rehabilitation has not settled it, a specialist opinion is considered 1.
No trial has tested prevention of osteitis pubis on its own. Groin problems in footballers have been trialled, and that's the best guide available:
Most cases settle with the approach above, given time and a program that actually progresses. Stop playing on and get it assessed if:
None of that is cause for alarm. It just means what's driving the pain hasn't been identified yet, and the sooner it is, the shorter the road back tends to be.
We start by listening: how it began, what makes it worse, and what it's stopping you from doing. Then we examine the area, explain what we find in plain English, and agree a plan with you. Your first visit is 40 minutes at Engadine and 30 minutes at our other clinics.
We see patients at Engadine, Mount Annan, Narellan and Appin, and at home through our mobile physiotherapy service. If you have private health cover, here's how health fund rebates work for physiotherapy.
Pain at the front and inside of the groin, centred on the pubic symphysis, sometimes extending into the adductors, lower abdominals, inguinal region, perineum or scrotum. One-sided or both. It's typically worse with running, kicking, bringing the leg across the body and loading the lower abdominals, and the area is usually tender to press on 1.
Months, not weeks. Most athletes who rehabilitate it return to pre-injury level within about three months, reported range 4 to 14 weeks. A rest-only group in a controlled study took around eight months, and often had the pain return within the first year 1.
Less an avoid-list, more a running order. Early-stage programs use gentle prolonged stretching but deliberately leave out the adductors and the muscles running from the pelvis to the thigh, and use a stationary bike instead of running. Running and changes of direction come later, and kicking is reintroduced last, in the sport-specific stage 1.
Start with a physiotherapist: non-surgical, physiotherapy-led care is first-line, and early diagnosis with a multimodal plan is what the literature recommends 1,4. Ahmed's background is on his profile page, and our sports physiotherapy page covers how we structure return-to-sport work.
Usually not. Diagnosis starts with your history and a clinical examination. MRI is the best imaging test available, but the same bone marrow swelling it looks for also shows up in athletes with no symptoms at all, so a scan has to be read alongside the examination, not instead of it 1. X-rays can look normal in early or mild cases.
Often, yes. Restricted hip range of motion, weakness through the adductors and abductors, and pelvic dysfunction commonly show up alongside it, and reduced hip internal rotation is itself a predisposing factor 1,4. That's a reason to have the hip assessed too, instead of treating the groin in isolation.
Pregnancy-related pelvic joint pain, caused by increased ligament laxity and load through the pelvis.
Read moreA strain of the adductor muscles that pull the leg inward, common in sports with sudden changes of direction.
Read moreA strain of the inner-thigh muscles, closely related to a groin strain but specific to the adductor group.
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