Pregnancy Related Pelvic Girdle Pain: Management & Solutions
PR-PGP is pain that is felt between the top of your pelvis and the bottom of your buttocks. Other names you may see if you searched the term pelvic girdle pain are:
Pubic Symphasis dysfunction / Symphasis Pubis Dysfunction (SPD)
Sacroiliac Joint pain
PGP is either categorized as “specific” or “non-specific” PGP. “Specific” PGP occurs when there is a specific event or medical cause, such as a fall, fracture, inflammatory arthritis. “Non-specific” PGP, which is more common, often arises during or shortly after pregnancy. So the saying “it will get better” after birth isn’t always accurate. PGP is often misdiagnosed, misunderstood, and poorly managed.
PR-PGP affects approximately 50% of pregnant women and resolves in most women within 12 months of giving birth. It typically starts at the end of your first trimester and then peaks between weeks 24 – 36. Fortunately, many cases resolve within a year of having their baby, however, up to 8-10% of women can continue to have pain for 1-2 years postpartum.
The key is there are solutions to the problem with good assessment and management you can reduce pain and improve your daily activities again.
What causes PGP?
There are many changes that happen to your body during pregnancy that affect how your body works.
- The stretching of your abdomen and stomach muscles as your belly is growing.
- Your baby sitting on and stretching your pelvic floor muscles.
- The shift in your center of gravity moving forward placing more stress on your back and challenging your balance.
- During pregnancy progesterone, relaxin, and estrogen increase making your joints more “loosey goosey”.
The reason for this is to make the ligaments around your pelvis more loose to prepare for birth. When your muscles aren’t strong enough to support this extra movement, pain and inflammation can occur. If the muscles are strong and working together correctly, you will be less likely to experience pain. PR-PGP refers to pain felt either at the back of the pelvis, on one or both sides, and/or pain over the pubic bone (SPD).
The pain is generally located between the top of the pelvis and the bottom of the buttocks. You may also have pain that is referred into the buttock, and/or down the leg, so is often confused with sciatica. Pain involving the pubic symphysis joint can also refer pain into the groin, inner thigh, abdomen, and vaginal area.
Conditions potentially causing pelvic girdle pain
Pain is typically felt with unilateral, or one sided activities, however you may also note it with the following activities:
- Prolonged Walking
- Standing on one leg
- Rolling over in bed
- Getting into or out of your car
- Standing or sitting for long periods
- Going up or down stairs
- Getting up from a chair
- Putting on your pants
- Carrying a toddler on your hip
- Pushing a shopping cart or stroller
- Intimacy or intercourse
This can be extremely frustrating and overwhelming for women as it can limit your everyday activities, affecting your quality of life. The good news is that there is a lot that can be done to significantly reduce or even resolve your pain.
What Structures make up the pelvic girdle
Your pelvis is composed of three bones that are fused together: ilium, ischium, and pubis. Your sacrum sits between them in the back.
The three joints within your pelvis are 2 sacroiliac joints (SIJs) in the back, and the pubic symphysis in the front. When we aren’t pregnant, there is very minimal movement that occurs at these joints because the ligaments that support them are very tight. These joints help us to transfer loads and forces from our lower body to our upper body.
What is the Core made up of?
- Transverse abdominis
- Pelvic Floor
What are the roles of the core?
- Core (Multifidus, TrA, Diaphragm, and PF) stabilizes back, hips, pelvis
- Pelvic floor acts as a sling to hold in our pelvic organs against gravity and increases in abdominal pressure (pregnancy, cough/sneeze/laugh, aging)
- Controls stop and start of urine and feces
- Improves sexual function
Management of PGP during pregnancy
Treating the Symptoms
Symptoms experienced with PR-PGP are due to inflammation around the pelvic joints. If you have experienced an injury or flare up, you will want to manage the symptoms the same way as if you had sprained your ankle. For the first 48 hours or so you’ll want to rest and ice, and manage it as though you have sprained your ankle. You’ll want to rest it in comfortable positions, such as laying with a pillow between your knees and ankles to maintain good positioning of your pelvis. Your physiotherapist can also help you with gentle joint mobilizations, soft tissue mobilization, stretches, and simple exercises, which all help to reduce pain.
Ice: Icing your injured area helps to reduce swelling and inflammation, therefore reducing pain. You should aim to ice for 20 minutes every 2 hours or 5 times a day. Make sure you cover your ice pack with a cloth or pillowcase to avoid ice burn.
Rest: Rest your joints initially by getting your body weight off your low back as much as possible. This means whatever is most comfortable for you. After your initial period of rest, you’ll want to begin exercising, with specific exercises prescribed by your physiotherapist, to ensure the muscles you need to help control your back and pelvis are working optimally. This is important because if you rest all the time without specific exercises, the muscles you need to help will get progressively weaker, and you will continue to get sore with less and less activity.
Women’s Health Physiotherapy
Once you’ve taken the initial rest period, you’ll want to begin moving again. We recommend this be under the guidance of your physiotherapist. This is an effective way of improving your spinal and pelvic positioning, relieving tight and spasmed muscles, and to improve stability and control of your pelvis managing muscle stiffness and spasm.
Muscles that typically get tight are the gluteal muscles (buttocks), hamstrings, adductors (groin muscles), and hip flexors (muscles at the front of your hip/groin). Your physiotherapist will release and stretch these muscles, as well as show you how to perform these stretches and releases at home. However, if the cause of these muscles getting tight and sore (poor movement control) is not addressed, it will continue to be a problem. Your physiotherapist will help to improve the quality of your movement through structured rehabilitative exercises.
Why is it important to manage the inflammation?
Pain and inflammation changes how the body uses muscles in that area. Sometimes it forgets how to switch on muscles, and other times it turns them on, but much later than they need to come on for good movement control. The body may switch on all the big muscles in the area to splint the joint, commonly known as a muscle spasm, creating new pain, and preventing good movement control. As you can see, for efficient control of your joints, pain and inflammation must be kept at bay!
Bracing or Taping
Depending on your symptoms, you may benefit from wearing a pregnancy support belt, an SIJ (Sacroiliac joint) belt, such as a Serola Belt, or SRC pregnancy shorts or pants. These belts or pants are worn over your clothes to support your pelvic joints during and/or after your pregnancy to provide relief and help you to move around easier. Your physical therapist may also apply sports tape around your belly or pelvis for additional stability and support to help relieve pain.
Treating the cause of your pain
As we’ve discussed, the reason the pelvic joints become sore in pregnancy, is usually due to poor movement control secondary to the effects that pregnancy has on the biomechanics of your body. Your body is never more biomechanically challenged than when you are pregnant!
In order for your joints to be well controlled, it is vital that you have good awareness and control of your core muscles. These core muscles, as described above, are the foundation to your movement patterns. When these muscles are not working properly or together, your joints are no longer well controlled, which leads to soreness or pain.
To really treat the cause of your pain, your physical therapist will take a multifactorial approach. This means you will be working on not only your body, but your lifestyle, as well. Below lists what you can expect while working with your women’s health physical therapist.
Learning to breathe with your diaphragm instead of breathing with your shoulders or neck, will help to coordinate the muscles of your core. This is one of the first steps on your journey to pain-free living.
Pelvic Floor Muscle Training
Your pelvic floor muscles are the muscles at the base of your pelvis. They attach from the pubic bone at the front to the tailbone at the back and from side to side. These are the muscles that help maintain continence and support your pelvic organs.
To activate your pelvic floor muscles, squeeze and draw in as if stopping the flow of urine. You should feel closure around the anus and urethra. Women will feel this in the vagina also. It takes time to alter the pelvic floor muscles and improve their function.
Your women’s health physiotherapist will give you advice on lifestyle changes you can make to help manage your pain. The discussion may include information about general exercise (what is helpful versus unhelpful), education on activity modification, reducing your body weight or encouragement to see your Primary Care Physician if required.
Exercise During Pregnancy
Exercise is beneficial for pregnant women to lower the incidence of Gestational Diabetes Mellitus, excessive weight gain, hypertension, preterm birth, and caesarean birth.
After your period of rest to settle your pain, it is important to maintain your general fitness. This will help improve overall muscle tone in your body. The main types of exercise that are important to address are specific stabilization (movement control) exercises and cardio exercises such as walking, swimming, and cycling are all good ways to exercises.
General guidelines for exercise during pregnancy are 150 minutes per week or 5 days of 30 minutes moderate intensity aerobic exercise. Your physiotherapist will work with you to find the appropriate activities for you.
Attending Pre Natal Pilates classes is an excellent option during pregnancy, as well as postpartum to strengthen from the inside out, with exercises designed specifically for you. In addition to seeing your physiotherapist and/or doing your home program, these classes will help you to build a strong core foundation and progress you to be strong enough to participate in the activities you enjoy, look after your child, and prepare you for future pregnancies
Specific Stabilization Exercise
When you’re assessed by your physiotherpist, they will determine which muscles need to be particularly focused on to improve the movement of your low back and pelvic joints. From this, they will develop an exercise program to train these muscles to function better.
This is a skill your body needs to master. We must master these skills so our body remembers exactly what to do to reproduce that skill each time and with the right intensity as it is required. This is what is required for optimal movement control.
Your physical therapist will explain which form of each exercise is appropriate for you. This is a highly individualized situation. Once your body has mastered these movements and improved the stability of your low back and pelvis this will help you to reduce your pain and likelihood of it returning in the future.
PR-PGP in Labor
By the time you have reached this time you will ideally be going into labor and delivery with your PGP well managed and under control. If you are experiencing pain at this time there are various positions you may consider: Kneeling, standing, on your hands and knees, sitting on an exercise ball, leaning over the bed or table, or laying on your side.
During labor you may want to try several positions to get comfortable. If one position is uncomfortable, such as sitting on a swiss ball, you may want to try going on your hands and knees. Even if a particular position is not causing you PGP, various positions will feel better than others as contractions intensify and the baby moves. Continue to move around and try new positions as you will eventually find a position that is most comfortable for you. Having a doula or support partner to help you into various positions, as well as to help you to relax and focus during this time will be extremely beneficial.
Management of PGP after Pregnancy
Many women are told their symptoms will go away after the baby is born, and for several women that is true. As mentioned earlier, 10% still have pain 1-2 years postpartum.
Thankfully there is a lot you can do during pregnancy and throughout postpartum to manage and resolve these symptoms. Being proactive prior to having symptoms or taking control of your pain during pregnancy, and staying active will help to resolve your pain either during your pregnancy or after your baby is born.
Once you’ve had your baby your body is continuing to produce hormones running through your body. Your baby is no longer putting pressure through your pelvis, however the laxity of your pelvic joints is still present for quite a while after your child is born. Typically this is one year after your child is born or even up to a year after you have stopped breastfeeding. During pregnancy, your muscles have been stretched, organs have been moved around, and your center of balance has changed. You will need to focus on strengthening the same muscles as we discussed earlier, particularly the abdominal and pelvic floor muscles, to get them working properly and to stabilize your core and pelvis.
No two women are alike. Everyone progresses at different rates, so you will need an individualized plan from your women’s health physiotherapist to provide you with optimal results. Discussing your final goals, such as what type of exercise, work, and physical function, is important in developing your long term program.
We recommend starting a proper rehabilitation program no later than 3-6 weeks after your baby is born, however it is up to you! You need to begin when you are ready. It is never too late to start a program, however the sooner you start the better to avoid developing poor use of your muscles, and bad habits that are hard to break.
This is a commitment, but worth the effort when you’re able to do the activities you enjoy without limitations or pain. The program prescribed is exercises done 3-4 times a week over a period of 20 weeks.
As discussed earlier, attending Post Natal Pilates classes is an excellent option during your postpartum period. The exercises are designed specifically for you and will help to continue to build a strong core foundation in addition to your home program. These classes will progress you to be strong enough to look after your child and return to the activities you love to do.
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Why did this happen to me?
○ There are many reasons why PR-PGP begins. Your body is drastically changing and there are stresses placed on your low back, abdomen, diaphragm and pelvis that your body doesn’t normally go through. Pregnancy may be the only reason why you are experiencing this. The good news is that this can be managed and even resolved!
When’s the best time to see a physiotherapist?
○ You should schedule your first appointment with your women’s health physical therapist as soon as you find out you are pregnant. They can put you on a plan to prevent issues from arising, prepare you for labor and delivery, and help you recover postpartum. If you are not seeing a physical therapist while pregnant, making an appointment if you notice pain or discomfort is your next best step. They will help you to manage your pain and treat the cause of your pain.
Why do I need to do Clinical Pilates?
○ Clinical Pilates is a method of exercising that targets your deep postural muscles, training them to work better to control your lumbar spine and pelvic joints. This is treating “the cause” rather than just treating the symptoms. Clinical Pilates is individually prescribed exercises, after a full assessment, by a physical therapist with Clinical Pilates training. It is not a generic Pilates class, where everyone does the same exercises.
How often do I need to do Clinical Pilates?
○ Once per week is the minimum you should do Clinical Pilates initially. Clinical Pilates is a “skill” more than “fitness”, just like learning a new tennis shot, or golf swing. If you have a lesson once per week, you will learn to play tennis. If you have a lesson twice a week, you will learn to play faster. When your body is learning something new, it is important to regularly attend your classes, or perform your exercises.
Is all exercise safe to do?
○ Not all exercises are treated equally. Your Women’s Health Physiotherapist will be able to guide you to find an exercise that is appropriate for you. Some exercises you may want to avoid with PR-PGP are single leg exercises such as the stair climber, running, biking, and breast stroke in swimming.
Will this happen again?
○ It is common for PR-PGP to return if you have had PGP in the past. However, if the joint control issues are addressed, then our experience is that our clients do well and have minimal recurrences of PGP. Doing the correct exercises and rehabilitation to address PGP will provide you with the support necessary to reduce your chances of recurrence.
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