Osteitis Pubis in Athletes in the Era of Pubic-Related Groin Pain: Contemporary Concepts in Diagnosis, Rehabilitation, and Surgical Decision-Making

Background: Osteitis pubis (OP) is a recognized contributor of anterior pelvic and groin pain, particularly in athletic populations, and is currently included within the wider spectrum of pubic-related groin pain. Despite the growing body of literature, clinical management is still challenging and controversial. Significant conceptual confusion persists among related clinical entities; few reviews address the real-world clinical decision-making process; and a poorly defined “grey area” exists between conservative and surgical treatment strategies. Objectives: This extensive narrative review aimed to clarify key unresolved issues in the management of osteitis pubis by examining the available evidence to: (1) distinguish osteitis pubis from other causes of pubic-related groin pain; (2) evaluate the clinical criteria guiding progression through conservative treatment strategies; and (3) define the role and limitations of intermediate interventions between conservative and surgical management. Methods: An extensive narrative search of PubMed/MEDLINE for publications dated through 4 August 2026 was performed. Clinical studies, consensus statements, systematic and narrative reviews, randomized and nonrandomized trials, observational studies, and case series addressing epidemiology, pathophysiology, diagnosis, imaging, conservative treatment, intermediate interventions, surgery, and return to sport were considered. Reference lists of relevant articles were also screened to identify additional studies. Eligibility criteria, evidence directness, and design-specific methodological limitations were described. Results: The current literature shows considerable heterogeneity in terminology, diagnostic criteria, and imaging interpretation, with inconsistent clinico-radiological correlation. Pubic-related groin pain is a clinical regional classification, whereas OP is used here as an author-proposed clinico-radiological phenotype. Conservative management remains the first-line treatment; however, uniform criteria for defining treatment progression and failure are lacking, and much treatment evidence is indirect or derived from mixed groin-pain populations. Injection-based and other interventional therapies are widely used as diagnostic and therapeutic tools despite limited and heterogeneous evidence. Surgical treatment is reserved for selected refractory cases, although indications and techniques vary considerably across studies. Recent evidence further stresses the frequent coexistence of adductor, aponeurotic, inguinal, and hip-related abnormalities and the need to identify a clinically concordant pain generator before treatment escalation. Conclusions: This review offers a decision-oriented synthesis and proposes an evidence-informed clinical framework. Organizing the available evidence within a coherent diagnostic and therapeutic framework supports individualized clinical decision-making and identifies priorities for future high-quality studies.