Pelvic girdle pain

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Pelvic girdle pain
Specialty OB/GYN

Pelvic girdle pain (abbreviated PGP) can be described as a pregnancy discomfort for some women and a severe disability for others. PGP can cause pain, instability and limitation of mobility and functioning in any of the three pelvic joints. PGP has a long history of recognition, mentioned by Hippocrates [1] and later described in medical literature by Snelling. [2]

Contents

The affection appears to consist of relaxation of the pelvic articulations, becoming apparent suddenly after parturition or gradually during pregnancy and permitting a degree of mobility of the pelvic bones which effectively hinders locomotion and gives rise to the most peculiar and alarming sensations.

— Snelling (1870), [2]

Classification

Prior to the 20th century, specialists of pregnancy-related PGP used varying terminologies. It is now referred to as Pregnancy Related Pelvic Girdle Pain that may incorporate the following conditions:

"The classification between hormonal and mechanical pelvic girdle instability is no longer used. For treatment and/or prognosis it makes no difference whether the complaints started during pregnancy or after childbirth." Mens (2005) [3]

Signs and symptoms

A combination of postural changes, the position and weight of the baby, unstable pelvic joints under the influence of pregnancy hormones, and changes in the centre of gravity can all add to the varying degrees of pain or discomfort. In some cases it can come on suddenly or following a fall, sudden abduction of the thighs (opening too wide too quickly) or an action that has strained the joint.

PGP can begin as early as the first trimester of pregnancy. Pain is usually felt low down over the symphyseal joint, and 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. Women with PGP may begin to waddle or shuffle, and may be aware of an audible clicking sound coming from the pelvis. PGP can develop slowly during pregnancy, gradually gaining in severity as the pregnancy progresses.

During pregnancy and postpartum, the symphyseal gap can be felt moving or straining when walking, climbing stairs or turning over in bed; these activities can be difficult or even impossible. The pain may remain static, e.g., 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. It is also possible that a woman may experience a combination of symptoms.

Any weight bearing activity has the potential of aggravating an already unstable pelvis, producing symptoms that may limit the ability of the woman to carry out many daily activities. She may experience pain involving movements such as dressing, getting in and out of the bath, rolling in bed, climbing the stairs or sexual activity. Pain may also be present when lifting, carrying, pushing or pulling.

The symptoms (and their severity) experienced by women with PGP vary, but include:

Severity

The severity and instability of the pelvis can be measured on a three level scale.

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 hypermobile.

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 type often occurs after giving birth to a child weighing 3000 grams or more, in cases of hypermobility, 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 pelvis are screwed together. (Mens 2005) [3]

Psychosocial impact

PGP in pregnancy seriously interferes with participation in society and activities of daily life; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks. [4]

In some cases women with PGP may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to develop postpartum depressive symptoms. [5] Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse. [6]

Causes

Sometimes there is no obvious explanation for the cause of PGP but usually there is a combination of factors such as:

  1. The pelvic joints moving unevenly.
  2. A change in the activity of the muscles in the pelvis, hip, abdomen, back and pelvic floor.
  3. A history of pelvic trauma.
  4. The position of the baby altering the loading stresses on the pelvic ligaments and joints.
  5. Strenuous work. [7]
  6. Previous lower back pain.
  7. Previous pelvic girdle pain during pregnancy.
  8. Hypermobility, genetical ability to stretch joints beyond normal range.
  9. An event during the pregnancy or birth that caused injury or strain to the pelvic joints or rupture of the fibrocartilage.
  10. The occurrence of PGP is associated with twin pregnancy, first pregnancy and a higher age at first pregnancy. [8]

Mechanism

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. PGP disorder is complex and multi-factorial and likely to be also represented by a series of sub-groups driven by pain varying from peripheral or central nervous system, [9] altered laxity/stiffness of muscles, [10] laxity to injury of tendinous/ligamentous structures [11] to 'mal-adaptive' body mechanics. [12]

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 PGP.

Anatomy

The pelvis is the largest bony part of the skeleton and contains three joints: the pubic symphysis, and two sacroiliac joints. A highly durable network of ligaments surrounds these joints giving them tremendous strength.

The pubic symphysis has a fibrocartilage joint which may contain a fluid filled cavity and is avascular; it is supported by the superior and arcuate ligaments. The sacroiliac joints are synovial, but their movement is restricted throughout life and they are progressively obliterated by adhesions. The nature of the bony pelvic ring with its three joints determines that no one joint can move independently of the other two. [13]

Relaxin hormone

Relaxin is a hormone produced mainly by the corpus luteum of the ovary and breast, in both pregnant and non-pregnant females. During pregnancy it is also produced by the placenta, chorion, and decidua. The body produces relaxin during menstruation that rises to a peak within approximately 14 days of ovulation and then declines. In pregnant cycles, rather than subsiding, relaxin secretion continues to rise during the first trimester and then again in the final weeks. During pregnancy relaxin has a diverse range of effects, including the production and remodelling of collagen thus increasing the elasticity of muscles, tendons, ligaments and tissues of the birth canal in view of delivery.

Although relaxin's main cellular action in pregnancy is to remodel collagen by biosynthesis (thus facilitating the changes of connective tissue) it does not seem to generate musculoskeletal problems. European Research has determined that relaxin levels are not a predictor of PGP during pregnancy. [14] [15] [16] [17]

Gait changes

The pregnant woman has a different pattern of "gait". The step lengthens as the pregnancy progresses due to weight gain and changes in posture. Both the length and height of the footstep shortens with PGP. Sometimes the foot can turn inwards due to the rotation of the hips when the pelvic joints are unstable. On average, a woman's foot can grow by a half size or more during pregnancy. Pregnancy hormones that are released to adapt the bodily changes also remodel the ligaments in the foot. In addition, the increased body weight of pregnancy, fluid retention and weight gain lowers the arches, further adding to the foot's length and width. There is an increase of load on the lateral side of the foot and the hind foot. These changes may also be responsible for the musculoskeletal complaints of lower limb pain in pregnant women.

During the motion of walking, an upward movement of the pelvis, one side then the other, is required to let the leg follow through. The faster or longer each step the pelvis adjusts accordingly. The flexibility within the knees, ankles and hips are stabilized by the pelvis. Normal gait tends to minimize displacement of centre of gravity whereas abnormal gait through pelvic instability tends to amplify displacement. During pregnancy there may be an increased demand placed on hip abductor, hip extensor, and ankle plantar flexor muscles during walking. To avoid pain on weight bearing structures a very short stance phase and limp occurs on the injured side(s), this is called Antalgic Gait.

Treatment

A number of treatments have some evidence for benefits include an exercise program. [18] Paracetamol (acetaminophen) has not been found effective but is safe. [18] NSAIDs are sometimes effective but should not be used after 30 weeks of pregnancy. [18] There is tentative evidence for acupuncture. [18]

Some pelvic joint trauma will not respond to conservative type treatments and orthopedic surgery might become the only option to stabilize the joints.

Prognosis and epidemiology

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. PGP can take from 11 weeks, 6 months or even up to 2 years postpartum to subside. [19] However, some research supports that the average time to complete recovery is 6.25 years, and the more severe the case is, the longer recovery period. [20]

Overall, about 45% of all pregnant women and 25% of all women postpartum have PGP. [21] During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. [22] There is no correlation between age, culture, nationality and numbers of pregnancies that determine a higher incidence of PGP. [23] [24]

If a woman experiences PGP during one pregnancy, she is more likely to experience it in subsequent pregnancies; but the severity cannot be determined. [25]

Related Research Articles

<span class="mw-page-title-main">Perineum</span> Region of the body including the perineal body and surrounding structures

The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis and the coccyx, including the perineal body and surrounding structures. There is some variability in how the boundaries are defined. The perineal raphe is visible and pronounced to varying degrees. The perineum is an erogenous zone. This area is known as the taint or chode in American slang.

<span class="mw-page-title-main">Pubic symphysis</span> Cartilaginous joint between the front of the left and right hip bones

The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubic symphysis. In females, the pubic symphysis is close to the clitoris. In most adults it can be moved roughly 2 mm and with 1 degree rotation. This increases for women at the time of childbirth.

<span class="mw-page-title-main">Kegel exercise</span> Pelvic floor exercise

Kegel exercise, also known as pelvic floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many times a day, for several minutes at a time but takes one to three months to begin to have an effect.

<span class="mw-page-title-main">Sacroiliac joint</span> Joint of the pelvis and spine

The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The joint is strong, supporting the entire weight of the upper body. It is a synovial plane joint with irregular elevations and depressions that produce interlocking of the two bones. The human body has two sacroiliac joints, one on the left and one on the right, that often match each other but are highly variable from person to person.

<span class="mw-page-title-main">Symphysis</span> Fibrocartilaginous fusion between two bones

A symphysis is a fibrocartilaginous fusion between two bones. It is a type of cartilaginous joint, specifically a secondary cartilaginous joint.

  1. A symphysis is an amphiarthrosis, a slightly movable joint.
  2. A growing together of parts or structures.
<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Osteitis pubis</span> Medical condition

Osteitis pubis is a noninfectious inflammation of the pubis symphysis, causing varying degrees of lower abdominal and pelvic pain. Osteitis pubis was first described in patients who had undergone suprapubic surgery, and it remains a well-known complication of invasive procedures about the pelvis. It may also occur as an inflammatory process in athletes. The incidence and cause of osteitis pubis as an inflammatory process versus an infectious process continues to fuel debate among physicians when confronted by a patient who presents complaining of abdominal pain or pelvic pain and overlapping symptoms. It was first described in 1924.

Pelvimetry is the measurement of the female pelvis. It can theoretically identify cephalo-pelvic disproportion, which is when the capacity of the pelvis is inadequate to allow the fetus to negotiate the birth canal. However, clinical evidence indicate that all pregnant women should be allowed a trial of labor regardless of pelvimetry results.

<span class="mw-page-title-main">Pubis (bone)</span> Most forward-facing of the three main regions making up the os coxa

In vertebrates, the pubis or pubic bone forms the lower and anterior part of each side of the hip bone. The pubis is the most forward-facing of the three bones that make up the hip bone. The left and right pubic bones are each made up of three sections, a superior ramus, inferior ramus, and a body.

<span class="mw-page-title-main">Hypermobility (joints)</span> Human condition: joints that stretch further than normal

Hypermobility, also known as double-jointedness, describes joints that stretch farther than normal. For example, some hypermobile people can bend their thumbs backwards to their wrists, bend their knee joints backwards, put their leg behind the head or perform other contortionist "tricks". It can affect one or more joints throughout the body.

<span class="mw-page-title-main">Pelvic fracture</span> Broken bone in nonacetabular portions of pelvis

A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones, or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.

<span class="mw-page-title-main">Symphysis pubis dysfunction</span> Medical condition

Symphysis pubis dysfunction (SPD), commonly known as pubic symphysis dysfunction or lightning crotch, is a condition that causes excessive movement of the pubic symphysis, either anterior or lateral, as well as associated pain, possibly because of a misalignment of the pelvis. Most commonly associated with pregnancy and childbirth, it is diagnosed in approximately 1 in 300 pregnancies, although some estimates of incidence are as high as 1 in 50.

<span class="mw-page-title-main">Pubic symphysis diastasis</span> Medical condition

Pubic symphysis diastasis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture that measures radiologically more than 10 mm. Separation of the symphysis pubis is a rare pathology associated with childbirth and has an incidence of 1 in 300 to 1 in 30,000 births. It is usually noticed after delivery but can be observed up to six months postpartum. Risk factors associated with this injury include cephalopelvic disproportion, rapid second stage of labor, epidural anesthesia, severe abduction of the thighs during delivery, or previous trauma to the pelvis. Common signs and symptoms include symphyseal pain aggravated by weight-bearing and walking, a waddling gait, pubic tenderness, and a palpable interpubic gap. Treatment for pubic symphysis diastasis is largely conservative, with treatment modalities including pelvic bracing, bed rest, analgesia, physical therapy, and in some severe cases, surgery.

Round ligament pain (RLP) is pain associated with the round ligament of the uterus, usually during pregnancy. RLP is one of the most common discomforts of pregnancy and usually starts at the second trimester of gestation and continues until delivery. It usually resolves completely after delivery although cases of postpartum RLP have been reported. RLP also occurs in nonpregnant women.

<span class="mw-page-title-main">Hip bone</span> Bone of the pelvis

The hip bone is a large flat bone, constricted in the center and expanded above and below. In some vertebrates it is composed of three parts: the ilium, ischium, and the pubis.

<span class="mw-page-title-main">Sacroiliac joint dysfunction</span> Medical condition

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

<span class="mw-page-title-main">Pelvis</span> Lower part of the trunk of the human body between the abdomen and the thighs

The pelvis is the lower part of the trunk, between the abdomen and the thighs, together with its embedded skeleton.

<span class="mw-page-title-main">Uterine incarceration</span> Medical condition

Uterine incarceration is an obstetrical complication whereby a growing retroverted uterus becomes wedged into the pelvis after the first trimester of pregnancy.

Signs and symptoms of pregnancy are common, benign conditions that result from the changes to the body that occur during pregnancy. Signs and symptoms of pregnancy typically change as pregnancy progresses, although several symptoms may be present throughout. Depending on severity, common symptoms in pregnancy can develop into complications. Pregnancy symptoms may be categorized based on trimester as well as region of the body affected.

Hanne Albert is a Danish physiotherapist with a Ph.D. in medical science. Her main research interest is in lower back pain and pelvic girdle pain. Albert's studies have revealed that bone œdema could be caused by a bacterial infection and treated with antibiotics.

References

  1. ↑ Owens Kelly, Pearson Anne, Mason Gerald (2002). "Pubic Symphysis Separation". Fetal and Maternal Medicine Review. 13 (2): 141–155. doi:10.1017/s0965539502000244.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  2. 1 2 Pain In Childbearing, Key Issues In Management, Margaret Yerby, Lesley Page.
  3. 1 2 About Pelvic Girdle Instability. Definition and Concept. Jan M.A. Mens.
  4. ↑ Noren Lotta RPT; Ostgaard Solveig; Nielsen Thorkild F; Ostgaard Hans C (1997). "Reduction of Sick Leave for Lumbar Back and Posterior Pelvic Pain in Pregnancy". Spine. 22 (18): 2157–2160. doi:10.1097/00007632-199709150-00013. PMID   9322326. S2CID   20763566.
  5. ↑ Gutke A, Josefsson A, Oberg B (Jun 2007). "Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms". Spine. 32 (13): 1430–6. doi:10.1097/brs.0b013e318060a673. PMID   17545912. S2CID   20342821.
  6. ↑ Albert HB, Godskesen M, Korsholm L, Westergaard JG (2006). "Risk factors in developing pregnancy-related pelvic girdle pain". Acta Obstet Gynecol Scand. 85 (5): 539–44. doi: 10.1080/00016340600578415 . PMID   16752231. S2CID   24963131.
  7. ↑ Juhl Mette; Kragh Andersen Per; Olsen Jørn; Nybo Andersen Anne-Marie (2005). "Psychosocial and Physical Work Environment and Risk of Pelvic Pain in Pregnancy. A Study within the Danish National Birth Cohort". Journal of Epidemiology and Community Health. 59 (7): 580–585. doi:10.1136/jech.2004.029520. PMC   1757090 . PMID   15965142.
  8. ↑ Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ (Jun 1996). "Understanding peripartum pelvic pain. Implications of a patient survey". Spine. 21 (11): 1363–9. doi:10.1097/00007632-199606010-00017. hdl: 1765/71226 . PMID   8725930. S2CID   26166115.
  9. ↑ Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework Manual Therapy, Volume 12, Issue 2, May 2007, Peter B. O'Sullivan and Darren J. Beales.
  10. ↑ European guidelines for the diagnosis and treatment of pelvic girdle pain.Eur Spine J. 2008 Feb 8 Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B.
  11. ↑ Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstetricia et Gynecologica Scandinavica Volume 81 Issue 5 Page 430-436, May 2002, Andry Vleeming, Haitze J. de Vries, Jan M. A Mens, Jan-Paul van Wingerden
  12. ↑ Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework. Manual Therapy, Volume 12, Issue 2, May 2007, Pages 86-97 Peter B. O'Sullivan, and Darren J. Bealesa.
  13. ↑ SPD: The Clinical Presentation, Prevalence, Aetiology, Risk Factors and Morbidity. Malcolm Griffiths.
  14. ↑ Petersen LK, Hvidman L, Uldbjerg N (1994). "Normal Serum Relaxin in Women with Disabling Pelvic Pain During Pregnancy". Gynecol Obstet Invest. 38 (1): 21–3. doi:10.1159/000292438. PMID   7959320.
  15. ↑ Björklund K, Bergström S, Nordström ML, Ulmsten U (Apr 2000). "Symphyseal Distention in Relation to Serum Relaxin Levels and Pelvic Pain in Pregnancy". Acta Obstet Gynecol Scand. 79 (4): 269–75. doi:10.1034/j.1600-0412.2000.079004269.x. PMID   10746841. S2CID   46502468.
  16. ↑ Hansen A, Jensen DV, Larsen E, Wilken-Jensen C, Petersen LK (Mar 1996). "Relaxin is not related to symptom-giving pelvic girdle relaxation in pregnant women". Acta Obstet Gynecol Scand. 75 (3): 245–9. doi:10.3109/00016349609047095. PMID   8607337. S2CID   33668783.
  17. ↑ Albert H, Godskesen M, Westergaard JG, Chard T, Gunn L (Jul 1997). "Circulating levels of relaxin are normal in pregnant women with pelvic pain". Eur J Obstet Gynecol Reprod Biol. 74 (1): 19–22. doi:10.1016/s0301-2115(97)00076-6. PMID   9243195.
  18. 1 2 3 4 Verstraete, EH; Vanderstraeten, G; Parewijck, W (2013). "Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal". Facts, Views & Vision in ObGyn. 5 (1): 33–43. PMC   3987347 . PMID   24753927.
  19. ↑ Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM (Feb 1999). "Symptom-Giving Pelvic Girdle Relaxation in Pregnancy. I: Prevalence and Risk Factors". Acta Obstet Gynecol Scand. 78 (2): 105–10. doi:10.1034/j.1600-0412.1999.780206.x. PMID   10023871. S2CID   12727231.
  20. ↑ Symptom-giving p Pelvic Girdle Relaxation of Pregnancy, Postnatal Pelvic Joint Syndrome and Developmental Dysplasia of Hip. ISSN   0001-6349 Acta Obstet Gynecol Scand 1997; 76: 760-764. Alastair H. MacLennan, Suzanna C. MacLennan.
  21. ↑ W. H. Wu, O. G. Meijer, K. Uegaki, J. M. A. Mens, J. H. van Dieën, P. I. J. M. Wuisman, H. C. Östgaard. "Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence European Spine Journal Vol 13, No. 7 / Nov. 2004
  22. ↑ Elden H; Ladfors L; Olsen M Fagevik; Östgaard H-C; Hagber H (2005). "Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trail". BMJ. 330 (7494): 761. doi:10.1136/bmj.38397.507014.e0. PMC   555879 . PMID   15778231.
  23. ↑ Stones R William; Vits Kathleen (2005). "Pelvic Girdle Pain in Pregnancy". BMJ. 331 (7511): 249–250. doi:10.1136/bmj.331.7511.249. PMC   1181256 . PMID   16051994.
  24. ↑ Bjorklund K, Bergstrom S (Jan 2000). "Is Pelvic Pain a Welfare Complaint?". Acta Obstet Gynecol Scand. 79 (1): 24–30. doi: 10.1034/j.1600-0412.2000.079001024.x . PMID   10646812. S2CID   22247450.
  25. ↑ Kumle, Merethe; Weiderpass, Elisabete; Alsaker, Elin; Lund, Eiliv (2004). "Use of Hormonal Contraceptives and Occurrence of Pregnancy-Related Pelvic Pain: A Prospective Cohort Study in Norway". BMC Pregnancy and Childbirth. 4 (1): 11. doi:10.1186/1471-2393-4-11. PMC   446199 . PMID   15212688.

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