Pubic rami bone stress injuries (BSIs) can be challenging to detect early and often present with vague symptoms. While these injuries fall into the moderate risk category, healing can be slow due to the numerous muscle attachments in the area and their significant role in pelvic and trunk movement.
At Volante PT and Performance, we regularly work with athletes across the Greater Phoenix Area, helping them understand and manage BSIs more effectively. If you’re a runner, an active individual, or a provider working with this population, it’s essential to be familiar with the patterns that indicate pubic ramus involvement.
Risk factors to consider
When evaluating symptoms, keep a high index of suspicion for BSI if any of the following are present:
- Previous bone stress injury
- Recent changes in training (e.g., increased volume, pace, surface)
- Low energy availability or eating disorder history
- Menstrual irregularities, including amenorrhea
In pelvic BSIs, hormonal health matters. The pubic ramus contains a high percentage of trabecular bone, making it more sensitive to hormonal changes, especially low estrogen.
Common symptoms of pubic ramus BSI
Pubic rami injuries don’t always follow a clear pattern. Symptoms may shift or be misinterpreted as soft tissue tightness. Watch for:
- Unilateral, vague pain in the groin, hip, or pelvis
- Discomfort during or after weight-bearing activities (e.g., running, hopping, single-leg squat)
- Pain with resisted hip muscle testing, even on the unaffected side
- Tenderness to palpation over the pubic ramus or pubic symphysis
- Positive response to hip impingement tests
Also, considering the possibility of coexisting injuries, sacral BSIs often occur alongside pubic rami injuries. Ask about any low back pain as part of a complete evaluation.
Rehabilitation strategy
Rehab should begin with a temporary reduction in load to allow symptoms to settle. The challenge with pubic ramus injuries is that nearby muscles, hip adductors, flexors, extensors, abductors, and core musculature are difficult to isolate from everyday movement.
Initial rehab focus:
- Reduce load until pain subsides
- Maintain musculoskeletal conditioning with pain-free movement
- Avoid exercises that stress the injury site directly
Progressive rehab approach:
- Gradually introduce controlled loading to the affected area
- Include strength work for hip flexors, adductors, extensors, and abductors
- Adjust volume and intensity based on symptoms
Return to running timeline
Healing timelines vary based on the location and severity of the injury. For pubic ramus BSIs, most runners begin a return-to-run program around 6 to 12 weeks after diagnosis. A full return to prior training levels typically takes 3 to 6 months, and in some cases, it may take longer.
For long-term success, attention to training load, nutrition, and bone health is non-negotiable. Working with a physical therapist who understands bone stress injuries and the specific demands of running can help improve outcomes and reduce the likelihood of recurrence.
If you’re dealing with a pubic rami bone stress injury or have had recurring BSIs, reach out to Dr. Stephanie Mundt at Volante PT. We help runners across the Greater Phoenix Area recover and return to training safely with individualized care and coaching.
Contact us to learn how we can help.
