Pubic Rami Stress Fractures

Stress fractures to the pelvis are rare in the general sporting population, but a real risk in distance runners and triathletes. Stress fractures occur over a period of time when bone can no longer withstand submaximal repetitive forces. In an athlete these stress related injuries can occur due to abnormal stress placed on normal bone, or normal stress put on bone with decreased bone density (osteopenic or osteoporotic bone).

Inferior pubic rami stress fractures usually occur in the inferior pubic rami adjacent to the pubic symphysis, and commonly occur at the insertion of the adductors and/ or external rotators of the hip

The athlete will complain of pain in the hip, buttock, adductor or inguinal area that increases with activity and then eases with rest. The athlete will often report they cannot run due to pain, and in later stages of the injury, they may report pain on walking, or pain on single leg stance or hopping. Physiotherapy assessment will often find pain on certain tests and tenderness on palpation of the inferior pubic rami. Bone scan, CT and MRI may be used to identify stress fractures and bony oedema.

Inferior pubic stress fractures need 6-12 weeks rest, with the latter 6 weeks involving a gradual return to loading/running program. Progression of treatment will be guided by pain. It is important to address risk factors including careful examination of training history (volume, speed and training surface); assess running form, stride frequency and running shoes; plus address hormonal and nutritional balance if necessary.