What is pregnancy related pelvic girdle pain?
During pregnancy the body rapidly adapts for the growing baby (gestation), delivery, and breastfeeding. During these changes, some women will develop pregnancy related pelvic girdle pain, meaning pain within or around the pelvic area. Sometimes this will persist into the time well after birth (postpartum period). Pregnancy related pelvic girdle pain is pain around the pelvic ring – the pelvis is formed by 3 bones, the left and right halves of the pelvis and the sacrum (the tail bone) in between at the back. Pelvic girdle pain can include some of the following diagnoses:
- symphysis pubis dysfunction – issues linked to where the two pelvic bones meet at the front
- sacroiliac pain – issues linked to where the left and right halves of the pelvis meet with the sacrum at the back, forming the left and right sacroiliac joints respectively
- low back pain
- perineal pain – pain in the saddle area.
Pregnancy related low back and pelvic girdle pain affects on average, 45.3% of pregnant women (Wu). Unfortunately, patients find it hard to pinpoint exactly where their pain is, with symptoms often vague and variable. Historically, this has made understanding the causes and the diagnosis of the pregnancy related pelvic girdle pain difficult and delayed development of effective treatments.
What causes pregnancy related pelvic girdle pain?
Pregnancy related pelvic girdle pain has long been attributed to
- changes that happen to the body and its postural alignment to accommodate a growing fetus in the abdominal cavity
- hormonal changes that relax the body, including the ligaments of the pelvis or pelvic girdle, to prepare for delivery.
While changes in posture and hormones could contribute to pregnancy related pelvic girdle pain there is not a causal relationship (meaning that there is not clear that one causes the other). (Franklin, Marnach, Bjorklund, Aldabe) For example, some people with postural changes may experience severe pelvic girdle pain during pregnancy, while others may have no pain with similar changes in posture.
The known risk factors for pregnancy related pelvic girdle pain include:
- previous low back pain,
- back or pelvic trauma (such as a previous fall),
- a high level of stress, and
- low job satisfaction (Albert).
Pregnancy related pelvic girdle pain is more complicated than just posture and hormones and requires consideration of the physical, emotional, and social changes of the pregnant person.
The pregnant body demonstrates wide variation in posture (alignment) and muscle activation (the way muscles work) in response to changes in body position and the hormone-driven body relaxation (Moore, Biviá-Roig).
Normally the upper body including the rib cage sits above the pelvis. However, in pregnancy, often the abdomen and pelvis will shift forward. This can change how muscles around the abdomen, back and pelvis work together as they try to accommodate for the increasing abdominal mass, that is, the weight of the baby/babies.
The relaxation occurring through the body allows for increased movement of the joints. Increased joint mobility can in turn influence how muscles to help stabilize the back of the pelvis (sacroiliac joint), front of the pelvis (pubic symphysis), bottom of the pelvis (perineum) and side of the hip.
For most pregnant women, the muscles and fascia surrounding the pelvis sufficiently support the relaxed ligaments of the pelvic and pubic joints, maintaining stability during functional tasks such as sitting, standing, walking, rolling in bed etc. The pelvis does not become a wobbly ring of bones in pregnancy and pain is not directly related to strains occurring within the pelvis. This is because all pain is an output of the brain, it is a collection of danger signals from multiple systems of the body. Signals from pelvic muscles and ligaments are sent to the brain for processing, but other information will also influence pain processing. For example, mental stress, lack of sleep, poor general health or a low immune system can all impact on processing of information and whether the brain sees the overall situation as potentially dangerous and therefore painful. (You can read more about pain and the brain here) It is important that all of these components are considered in the evaluation of pregnancy related pelvic girdle pain.
What helps pregnancy related pelvic girdle pain?
Understanding how to help yourself is a key part of overcoming pregnancy related pelvic girdle pain. The Pelvic Obstetric and Gynecological Physiotherapist group offers a free booklet for patient education with practical information augmenting this blog post.
While general and group exercises improve low back pain, these non-specific forms of exercise do not show the same benefit with pregnancy related pelvic girdle pain (Shiri, Liddle). However, individualized exercises that specifically aim to improve muscle support around the abdomen and pelvis have been shown to improve pain (Bogaert J, Vermani).
Rather than a generalized approach, it is important that exercise should be supervised and tailored to the individual person to promote In other words, exercises tailored for each individual woman’s circumstance and reviewed regularly offer a better outcome.
Exercises that may help pregnancy related pelvic pain include:
- Aquatic exercises. These exercises may help by promoting movement, decreasing fear and apprehension, and strengthening muscles that support the abdomen and pelvis without increased stress from gravity. Aquatic exercises have also been shown to reduce pain (Vermani).
- Land based exercises that target the pelvic floor, lower abdominal muscles (transverse abdominis), diaphragm, and back muscles (multifidus) may help by increasing support, decreasing postural strain, improving coordination, and alleviating stress on painful areas. pain (saddle area pain at the bottom of the pelvis) can be caused by overactivity or underactivity of the pelvic floor muscles Pelvic floor exercises for perineal pain should be prescribed by a trained professional to prevent exacerbating possibly overactive pelvic floor muscles.
- Posterior chain exercises. These exercises coordinating the large muscles of the buttock and back, the gluteus maximus and latissimus dorsi, may be beneficial for pregnancy related pelvic girdle pain in the back of the pelvic ring, as they result in additional support for relatively relaxed ligaments of the sacroiliac joints at the back of the pelvis.
- Anterior chain exercises. These exercises coordinating the abdominal and inner thigh muscles, the oblique and adductor muscles, may be beneficial for decreasing pregnancy related pelvic girdle pain in the front of the pelvic ring, by producing additional support for relatively relaxed ligaments at the pubic symphysis.
The use of an elasticised pelvic belt has been shown to help alleviate pain (Liddle).
The use of a supportive pillow placed under the abdomen when sleeping can reduce pelvic pain in late pregnancy. (Young) Pillows to support the position of the pelvis and hips can also relieve pain. This can be as simple as a pillow between the knees while lying on the side or others find the use of a body pillow can support the legs and arm at the same time.
Acupuncture adds to pain reduction when combined with specific abdominal and pelvic exercises and education (Liddle). One study showed acupuncture decreased pregnancy related pelvic girdle pain more than pelvic belts (Elden).
Multimodal and Manual Therapy (hands-on) Treatments
Manual therapy (hands on treatment) can reduce pain, and multimodal therapy, that is, a combination of treatment components (manual therapy, exercise, and patient education) has been shown to decrease pregnancy related pelvic girdle pain and the associated disability more than individual components of treatment (Liddle).
Need Help? How Can A Hip Pain Professional Help?
Your Hip Pain Professional can help by:
- Identifying primary movement, lifestyle, and structural causes of your pain.
- Teach appropriate postural and movement modifications to decrease pain in everyday activities.
- Utilize manual therapy and teach self-treatments to decrease pain.
- Advance specific exercises and confirm correct technique.
- Suggest supportive modalities including pelvic belts, pillows, taping, and other health care practitioners such as acupuncturist, and mental health practitioners.
- Clarify misconceptions regarding pregnancy related pelvic girdle pain and use brain-based techniques to decrease fear and apprehension driven responses.
This article was written as a guest blog by one of our Hip Pain Professionals Joanna Hess, PT, DPT, PRC, WCS. Joanna is based in New York, USA.
Check out more about Joanna and how you can contact her here.
- Wu WH, Meijer OG, Uegaki K, Mens JM, Van Dieen JH, Wuisman PI, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal. 2004 Nov;13(7):575-89.
- Franklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. Journal of Orthopaedic & Sports Physical Therapy. 1998 Sep;28(3):133-8.
- Marnach ML, Ramin KD, Ramsey PS, Song SW, Stensland JJ, An KN. Characterization of the relationship between joint laxity and maternal hormones in pregnancy. Obstet Gynecol 2003;101:331-5
- Bjorklund K, Bergstrom S, Nordstrom ML, Ulmsten U. Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 2000;79:269-75.
- Aldabe D, Ribeiro DC, Milosavljevic S, Bussey MD. Pregnancy-related pelvic girdle pain and its relationship with relaxin levels during pregnancy: a systematic review. European Spine Journal. 2012 Sep;21(9):1769-76.
- Albert HB, Godskesen M, Korsholm L, Westergaard JG. Risk factors in developing pregnancy‐related pelvic girdle pain. Acta obstetricia et gynecologica Scandinavica. 2006 May;85(5):539-44.
- Moore K, Dumas GA, Reid JG. Postural changes associated with pregnancy and their relationship with low-back pain. Clinical Biomechanics. 1990 Aug 1;5(3):169-74.
- Biviá-Roig G, Lisón JF, Sánchez-Zuriaga D. Changes in trunk posture and muscle responses in standing during pregnancy and postpartum. Plos one. 2018 Mar 27;13(3):e0194853.
- Shiri R, Coggon D, Falah‐Hassani K. Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta‐analysis of randomized controlled trials. European Journal of Pain. 2018 Jan;22(1):19-27.
- Liddle SD, Pennick V. Interventions for preventing and treating low‐back and pelvic pain during pregnancy. Cochrane Database of Systematic Reviews. 2015(9).
- Bogaert J, Stack M, Partinton S, Marceca J, Tremback-Ball A. The effects of stabilization exercise on low back pain and pelvic girdle pain in pregnant women. Annals of PRM. 2018;61, 157-158.
- Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Practice. 2010; 10(1), 60-71.
- Stuge B. Evidence of stabilizing exercises for low back-and pelvic girdle pain–a critical review. Brazilian journal of physical therapy. 2019 Mar 1;23(2):181-6.
- Young G, Jewell D. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2002;(1):CD001139.
- Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ 2005;330:761.
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