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Pubic rami bone stress injuries can be really tricky to catch but are another important BSI not to miss. Though considered moderate risk, they can take awhile to heal due to the attachment of so many muscles in the area and their involvement in trunk, spine and pelvic motion. 

When evaluating whether or not your or your patient's pain is related to a bone stress injury in any area, suspicion should be higher if there's a history of bone stress injury, any changes in training the past few weeks or months (increases in mileage or intensity, changes in surface, etc.), history of or current eating disorder, and/or history of or current amenorrhea or other menstrual cycle changes. Noting changes in hormones is especially important when suspecting BSI in the pelvis, as greater trabecular bone composition makes it more sensitive to estrogen deficiency. 

With bone stress injuries of the pelvis, pain is often much more vague than BSIs in other sites - it may move around and initially present as muscle tightness versus pain. 

When it comes to suspecting pubic ramus as the specific site of bone injury, here are some signs and symptoms to look out for: 

  • Unilateral, vague groin, hip and/or pelvic pain

  • Worse with loading or after loading e.g. running, single leg hop, single leg squat

  • Pain with active & resisted hip muscle testing - often painful with testing of both affected & unaffected sides

  • Tenderness to palpation over pubic ramus and/or symphysis

  • + hip impingement testing

Of note, sacral BSIs often coexist with pubic rami BSIs, so screening for low back pain is paramount.

Rehabilitation should begin with unloading to the point of no symptoms, then gradually reloading as tolerated. Maintaining musculoskeletal health with pain-free exercise during recovery is important for a smooth return to running, but this site is especially tough because avoiding stress to the site of injury can be challenging. The injured pubic ramus may be irritated by strong contractions of the muscles attaching nearby - including abdominals, hip adductors, hip abductors, hip extensors and hip flexors. This makes it challenging to create a rehab program that allows healing while still preserving some level of musculoskeletal loading. 


Each individual will be unique based on the grade and exact site of injury, but minimizing stress to the site of injury while staying as active as possible is key during the early stages of rehab. 

As rehab progresses, providing stress to the injured site to promote bone building will be important. Exercises that load the hip flexors, adductors, extensors and abductors in a progressive manner can be utilized to strengthen the previously injured area. 

Typically with this kind of BSI, return to running begins 6-12 weeks post-diagnosis with return to usual training taking 3-6 months, and sometimes longer. 

Struggling with a pubic ramus BSI or with recurrent bone injuries? Contact me below!

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