We all know one or two of those superhero mamas that REALLY enjoy being pregnant. You know, the ones that can eat anything without feeling nauseous during their first trimester or the ones that are able to run 20 miles a week until they deliver. Yes, pregnancy is a beautiful part of life and yes, we are happy for those ladies that can get through their pregnancy without any major aches, but what about those mothers-to-be that experience pain when walking, climbing stairs or changing positions in bed?
Pelvic girdle pain during pregnancy is common and can oftentimes interfere with mobility and quality of life. Many women with pelvic girdle pain echo the above complaints. What exactly is pelvic girdle pain, why does it occur and how can it be managed to make pregnancy more comfortable? Let’s first do a quick review of the structure and function of the pelvis.
The pelvic girdle is a bowl-shaped structure that sits at the base of the trunk. It is composed of three bony groups: the innominates (ilium, ischium and pubis), sacrum and coccyx. With the support from the pelvic ligaments, these bones fit nicely together to form the major joints of the pelvis: pubic symphysis, sacroiliac, and sacrococcygeal joints. The pelvic girdle is primarily responsible for transferring weight and providing stability during movement, serving as an attachment point for ligaments and muscles, supporting and protecting abdominopelvic viscera, and forming the bony portion of the birth canal. Check out Shannon’s blog for more detailed information on pelvic anatomy.
As we can see, the pelvis is an important structure to consider during pregnancy. It not only houses the fetus but is also responsible for keeping the body stable as the baby bump grows. This can sometimes be a difficult task when relaxin is introduced into the system. Relaxin is a hormone that is released by the ovaries and placenta during pregnancy, with the primary function of slacking the ligaments in the pelvis and softening the cervix. Though essential in preparing the body for vaginal delivery, increased laxity in the pelvic ligaments can create greater motion at the joints and affect pelvic stability. It is true that each joint has varied degrees of motion, however, this increased motion and decreased stability can lead to pelvic girdle pain during and/or after pregnancy. The most commonly reported ailments include pubic symphysis pain, sacroiliac joint pain and sacrococcygeal pain.
Pubic Symphysis Pain/Dysfunction
The pubic symphysis is a fibrocartilaginous disk that joins the right and left pubic bones. Individuals with pubic symphysis pain may report a dull ache or sometimes sharp pain at or along the pubic symphysis or pubic bones. Additionally, pain may radiate down the front/inner thighs. Women may experience symptoms with walking, weighted and unweighted single leg activities (i.e. climbing stairs, putting on pants) and asymmetrical positioning ( i.e. sitting cross-legged, carrying items on one side).
Sacroiliac Joint Pain/Dysfunction
The sacroiliac joints are formed by two pelvic bones, the sacrum and the ilium. We have both right and left sacroiliac joints and they are located along the back of the pelvis. Women may characterize their pain as deep at the joint with radiation of symptoms along the low back and hip/buttock. Oftentimes, the pain is exacerbated by similar activities as pubic symphysis dysfunction.
Sacrococcygeal Joint Pain/Coccydynia
The sacrococcygeal joint is created by the sacrum and the coccyx. This tiny little joint sits at the base of the spine. The coccyx is the smaller triangular bone (learn more about it here) and given it’s big role as an attachment point for many pelvic ligaments, the sacroccygeal joint can become quite mobile. The quality of the pain may be dull or sharp and may become aggravated with direct pressure at the joint, increased intraabdominal pressure (i.e. sneezing, coughing), sitting and walking.
Women with pelvic girdle pain are often frustrated because they can experience symptoms with simple daily activities. Fortunately, many resources exist to help keep pregnancy comfortable. If you are experiencing any pelvic girdle pain, consulting with a physical therapist is a nice first step. Though we cannot directly address the hormones or growing babe, physical therapists can (1) provide education (i.e. on body mechanics, birthing positions), (2) recommend tools/techniques (i.e. pelvic stability belts, taping), (3) perform manual therapy (i.e. joint mobilization,myofascial trigger point release, connective tissue manipulation), and (4) prescribe individualized home exercise programs (i.e. deep core strengthening, neuromuscular re-education, aquatic exercise). Many women do well with a combination of these treatments. So, if any of these ailments sound familiar, give your local PT a call or come visit us – we love our mamas-to-be! You can read more about the pelvic floor physical therapy evaluation here.
*Pro tip: If these nuisances persist or develop post-partum, do not be alarmed. The relaxin hormone continues to circulate while breastfeeding and is sometimes present at low levels once breastfeeding ceases. Thankfully, treatment recommendations are similar.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Thanks for your Blog. Just curious on your thoughts. I have always described the role of relaxin in pregnancy much like you did in your blog however I just read the Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines in the May 2017 WH journal which stated the following in the pathophysiology section: “Changes in the ability to manage load transfers due to joint laxity may account for the development of PGP in this population. A change in adequate force and/or form closure of the pelvic girdle was previously postulated to occur by the presence of the hormone relaxin; however, current studies suggest no correlation between relaxin and PGP.37,38” Wondering how to, or if necessary to, change our message because of this information. Would love your thoughts.
Author Nicole Davis says:
Hi Jill! Thank you for forwarding the current CPG for PGP in the Antepartum Population! After thumbing through the research, I too was unable to find specific studies that directly correlate relaxin levels and PGP. However, there are several studies that suggest increased motion at the pelvic girdle joints are associated with PGP (i.e. Mens et. al’s Mobility of the pelvic joints in pregnancy-related lumbopelvic pain: a systematic review) and recent studies that associate relaxin levels with increased joint laxity and pain at other peripheral joints (i.e at the shoulder, thumb CMC). More quality studies are needed to assess the relationship between relaxin levels and PGP. It may be more appropriate to educate patients on these two points of 1) joint laxity and PGP and 2) relaxin levels and joint laxity/pain at peripheral joints while qualifying that increased relaxin levels may have the potential to effect joint laxity and PGP but the research is still undecided. Hope this helps! Best, Nicole
Good this content.