Pelvic Girdle Pain
 

Pelvic Instability Network Support (PINS)
 
Pelvic Girdle Pain (PGP) back
Pregnancy begins the physiological changes through a pattern of hormonal secretion and signal transduction thus initiating the remodelling of soft tissues, cartilage and ligaments. Over time, the ligaments could be stretched either by injury or excess strain and in turn may cause pelvic girdle instability.
 
Pelvic girdle pain can begin the early weeks (wk 14-22) and then remains fairly constant until the increasing of the size and weight of the fetus. Towards the end of the 2nd trimester and in the third the symptoms of PGP can increase varying from mild, moderate to severe with accompanying degrees of pain and disability. A combination of postural changes, the growing baby, unstable pelvic joints under the influence of pregnancy hormones and changes in the centre of gravity can all add to the degree of pain or discomfort. In some cases it can come on suddenly following a fall or a sudden abduction of the thighs (opening to wide too quickly!).
 
PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system (1a) , altered laxity/stiffness of muscles (2) , laxity to injury of tendinous/ligamentous structures to ‘mal-adaptive’ body mechanics(1b).
 
For most women PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weight bearing activities. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PGP(3a). During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients . After pregnancy, problems are serious in about 7%(4). There are geographical differences or  socio-economy of the countries that determine a higher incidence of PGP(5). After delivery instability/pelvic pain can take from 11 weeks, 6 months or even to 2 years postpartum to subside. (3b)
 
If a woman experiences PGP during one pregnancy she is more likely to experience it in subsequent pregnancies; but the severity cannot be determined(6). Healthcare professionals advise letting the symptoms from one pregnancy settle before trying for another baby.
 
Causes of Pelvic Girdle Pain back
Sometimes there is no oblivious explanation for the cause of Pelvic Girdle Pain. Usually there is a combination of factors causing this condition but the levels of the hormone relaxin are not a predictor of pelvic
instability (7) (8) (9) (10) (11).
Factors such as:
  • Hypermobility, genetical ability to hyper flex and over extend joints. (About 1 in 4 women with laxity in their joints have pelvic girdle pain.
  • The position of the baby altering the loading stresses on the pelvic ligaments and joints.
  • An event during the pregnancy or birth that caused injury or strain to the pelvic joints or rupture of the symphysis pubis.
  • A change in the activity of the pelvic muscles and/or hip, abdominal, back and pelvic floor.
  • Previous pelvic girdle pain during pregnancy.
  • Higher age at first pregnancy.
  • The pelvic joints moving unevenly.
  • A history of pelvic trauma.
    • (17)
  • Strenuous work, previous low back pain.(12)
  • Twin pregnancy.  
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    Definition of a Concept;  Pelvic Girdle Pain  back  
    Pelvic type 1: The pelvic ligaments support the pelvis sufficiently. Even when the muscles are used incorrectly, no complaints will occur when performing everyday activities. This is the most common situation in persons who have never been pregnant, who have never been in an accident, and who are not hyperactive.
     
    Pelvic type 2: The ligaments alone do not support the joint sufficiently. A coordinated use of muscles around the joint will compensate for ligament weakness. In case the muscles around the joint do not function, the patient will experience pain and weakness when performing everyday activities. This kind of pelvic often occurs after giving birth to a child weighing 3000 grams or more, in case of hyperactivity, and sometimes after an accident involving the pelvis. Type 2 is the most common form of pelvic instability. Treatment is based on learning how to use the muscles around the pelvis more efficiently.
     
    Pelvic type 3: The ligaments do not support the joint sufficiently. This is a serious situation whereby the muscles around the joint are unable to compensate for ligament weakness. This type of pelvic instability usually only occurs after an accident, or occasionally after a (small) accident in combination with giving birth. Sometimes a small accident occurring long before giving birth is forgotten so that the pelvic instability is attributed only to the childbirth. Although the difference between Type 2 and 3 is often difficult to establish, in case of doubt an exercise program may help the patient. However, if pelvic type 3 has been diagnosed then invasive treatment is the only option: in this case parts of the pelvic are screwed together.
    (Extract: About pelvic girdle instability….by Jan M.A. Mens, physician for Orthopaedic Medicine.)
    Symptoms back
    Pain is usually felt low down over the symphyseal joint, this area may be extremely tender to the touch. Pain may also be felt in the hips, groin and lower abdomen and can radiate down the inner thighs. You may waddle or shuffle, and may be aware of an audible clicking sound coming form the pelvis. Pelvic pain can develop slowly during pregnancy, gradually gaining in severity as the pregnancy progresses.
     
    During pregnancy and after, the symphyseal can gap can be felt moving and/or straining when walking, climbing stairs and turning over in bed. These activities can be difficult or even impossible. Pain may remain static, i.e. in one place such as the front of the pelvis producing the feeling of having been kicked, in other cases it may start in one area and move to other areas, you may experience a combination of symptoms. Any weight bearing activity has the potential of aggravating an already unstable pelvis, and daily activities such as turning over in bed, getting in and out of a car or bath and climbing the stairs can all prove to be problematic.
     
    Some women may find they need a referral to a physiotherapist in order to obtain crutches, a walking frame or in more severe cases a wheelchair to help them get about. For any woman who were physically active prior to pregnancy, to then suddenly become grounded by pelvic pain can be very frustrating and disabling. Anger, or resent towards the pregnancy or baby could occur. Other risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse. If this happens seek help, talk to your Health Provider about these feelings and if necessary gain referral to a counsellor to help you cope.
    Symptoms of Pelvic Girdle Pain
  • Symphysis Pubis pain, extremely tender to the touch.
  • Present swelling and/or inflammation over joint.
  • Difficulty lifting leg and pain pulling legs apart.
  • Unable to stand on one leg.
  • Unable to transfer weight through pelvis and legs.
  • Pain in hips and/or restriction of hip movement.
  • Transferred nerve pain down leg.  
  • Can be associated with bladder and/or bowel dysfunction.
  • A feeling of symphysis pubis giving way.
  • Standing with a stooped over back.
  • Malalignment of pelvic and/or back joints.
  • Struggle to sit or stand.
  • Pain may also radiate down the inner thighs.
  • You may waddle or shuffle and be aware of an audible ‘clicking’ sound coming form the pelvis.  
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    Self Help Management back
    Self help management techniques include
  • When getting into bed sit on the edge keeping knees close together, lie down on your side, lifting both legs at the same time. Reverse this to get up.
  • Try not to attempt to pull yourself up from lying on your back.
  • Keep knees together when rolling over in bed.
  • Sleep with a pillow between the legs; add more in other areas for support. When getting into a car: Sit down first and then swing legs keeping them together.
  • Avoid sofas and chairs that are too low or too soft.
  • Try to reduce the stress on the joint.
  • Avoid any movement with your knees apart.
  • Take smaller steps when walking.
  • Avoid stairs if possible.
  • Take breaks.
  • Move within the limits of pain. Avoid twisting, bending or squatting.

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    Conditions Associated with Pelvic Girdle Pain   back
    Pregnancy related Pelvic Girdle Pain (PGP) can be either specific (trauma or injury to pelvic joints or genetical i.e. connective tissue disease) and non-specific. Below are conditions that can be classified as specific and based on Dr Mens definition can be then classified into Pelvic Girdle Pain Type 1, 2 or 3.
     
    Diastasis Symphysis Pubis (DSP) back
    Diastasis Symphysis Pubis means an abnormally wide gap or separation between the two pubic bones at the symphysis pubis joint situated at the front of the pelvis.
     
    Symphysis Pubis Dysfunction (SPD) back
    The fibrocartilage holding the symphysis pubis together lengthens during pregnancy to prepare for the forces of childbirth. If the joint does not function sufficiently and causes pain and or instability this is symphysis pubis dysfunction.
     
    Pelvic Joint Syndrome (PJS) | Physiological Pelvic Girdle Relaxation (PPGR) | Symptom Giving Pelvic Girdle Relaxation (SGPGR)  back
     
    Relaxation that causes considerable pain and/or pelvic instability during pregnancy and/or postpartum; daily function is impaired. The symptoms appear in the first trimester. Pain in the symphysis pubis, sacroiliac joints and sometimes include the lower back. 
     
    Pelvic Arthropathy (PA) back
    Inflammatory and/or non inflammatory disease of the pelvic joints.
     
    Inferior Pubic Shear (IPS) | Superior Pubic Shear (SPS) | Symphyseal Shear (SS) back
    The action or force causing or tending to cause the two parts of the symphysis to slide relative to each other in a direction parallel to their plane of contact; it is usually found in an inferior/superior direction but is occasionally found to be in an anterior/posterior direction.
     
    Symphysiolysis  back
    Separation or slipping of symphyses, especially the symphysis pubis.
     
    Osteitis Pubis back
    Osteitis pubis, which means an inflammation of the pubic bone, it is a self limiting non-bacterial inflammatory process.  Go to Osteitis pubis for more information
     
    Sacroiliitis / One-sided Sacroiliac Syndrome / Double Sided Sacroiliac Syndrome back
    It is important to remember that the sacroiliac joints are equally affected by the hormones of pregnancy and become slightly looser. It is very common to find that although a woman might be complaining of groin and pubic pain, the main cause of the symptoms is actually at one or both of the sacroiliac joints and this puts extra stress on the symphysis. Any type of back or sacroiliac problem that causes excessive movement of the pelvis can result in excessive movement in the pubic symphysis and its ligaments. Sometimes an obvious limp is present due to one or both of the joints locking. There is a relation between asymmetric laxity of the sacroiliac joints and pregnancy related pelvic pain. This condition can begin either pre or post partum.
     
    Hypermobility back
    Hypermobility Syndrome is a inherited condition in which the protein, collagen which gives joints their intrinsic toughness is affected thus causing varying degrees of flexibility, with an increase in the range of motion beyond the normal range. The hyperlaxity in movements cannot be actively controlled.
    Joint hypermobility is also a feature of a rare, but more significant medical condition called Ehlers-Danlos syndrome that is characterized by weakness of the connective tissues of the body. This condition is inherited in specific genes passed on by parents to their children.  
     
    Pelvic Girdle Assessment Tools (13) back
    The level of severity in PGP can be adequately assessed by a combination of specific tests. Five of the most reliable assessment tools are:
  • Quebec Back Pain Disability Scale PDF
  • The active straight leg raise (view treatments)
  • Posterior pelvic pain provocation (view treatments)
  • Long dorsal sacroiliac ligament test
  • Hip abduction and adduction (view treatments)
    • Although not written in Medical Journals for assessing PGP, there is a questionnaire to assess yourself. go to
     
    Difference between Back Pain and Posterior Pelvic Pain(14) back
    Back pain  
  • A pain drawing  with markings drawn from the sacrum.
    • Back pain experienced when in forward flexion.
  • Decreased motion in the lumber spine.
  • Pain from palpation of the erector spina muscle.
    • Negative posterior pelvic pain provocation test. (to view image go to treatments / orthopaedic tests)
     
    Posterior pelvic pain
  • A pain drawing with well-defined markings of stabbing in the buttocks distal and lateral to the L5-S1 area, with or without radiating pain to the posterior thigh or knee, but not into the foot.
  • A history of time and weight-bearing pain in the posterior pelvis, deep in the gluteal area.
  • Pain free intervals.
  • Free range of motion in the hips and spine and no nerve root syndrome.
  • Positive posterior pelvic pain provocation test results.

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