Pelvic girdle pain

SCIATICA

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(January 2010)

Pregnancy related Pelvic Girdle Pain (PGP) causes 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]
"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]

Contents
[hide]
• 1 Anatomy
• 2 Classification
• 3 Symptoms
○ 3.1 Severity
○ 3.2 Psychosocial impact
• 4 Causes
• 5 Mechanism
○ 5.1 Relaxin hormone
○ 5.2 Gait changes
• 6 Treatment
○ 6.1 Self help management
• 7 Prognosis and epidemiology
• 8 See also
• 9 References
• 10 External links
[edit] Anatomy
The pelvis is the largest bony part of the skeleton. There are three joints, the
symphysis pubis (SP), 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.[3]

White fibrocartilage from

Pubic symphysis Posterior an intervertebral
Anterior
fibrocartilage.
Sacroiliac joint Sacroiliac joint

[edit] Classification
Prior to the 20th century many Physicians who specialized in this field of
pregnancy related PGP used varying terminologies. It is now referred to as
Pregnancy Related Pelvic Girdle Pain that may incorporate the following
conditions:
• Diastasis of the Symphysis Pubis(DSP)
• Symphysis pubis dysfunction(SPD)
• Pelvic Joint Syndrome
• Physiological Pelvic Girdle Relaxation
• Symptom Giving Pelvic Girdle Relaxation
• Posterior Pelvic Pain
• Pelvic Arthropathy
• Inferior Pubic Shear/ Superior Pubic Shear /Symphyseal Shear
• Symphysiolysis
• Osteitis pubis (usually postpartum)
• Sacroiliitis
• One-sided Sacroiliac Syndrome /Double Sided Sacroiliac
Syndrome
• Hypermobility
"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)[4]
[edit] Symptoms
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 varying degrees of pain or discomfort. In some cases it can come on
suddenly or following a fall, sudden abduction of the thighs (opening to 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, 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 from the pelvis. PGP can develop slowly during
pregnancy, gradually gaining in severity as the pregnancy progresses.
During pregnancy and postpartum, 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 even
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 for the woman to carry out many daily activities. She will
experience pain involving movements such as dressing, getting in and out of the
bath, rolling in bed, climbing the stairs and sexual activity. Pain will also be
present when lifting, carrying, pushing or pulling.
The symptoms (and their severity) experienced by women with PGP vary, but
include:
• Present swelling and/or inflammation over joint.
• Difficulty lifting leg.
• 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.
• Stand 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.
• Aware of an audible ‘clicking’ sound coming from the pelvis.

[edit] 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 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. (Mens 2005)[4]
[edit] 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.[5]
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 suffer postpartum depressive
symptoms.[6] Other psychosocial risk factors associated with woman experiencing
PGP include higher level of stress, low job satisfaction and poorer relationship
with spouse.[7]
[edit] 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.[8]
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.[9]

[edit] 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,[10] altered laxity/stiffness of muscles,[11] laxity to injury of
tendinous/ligamentous structures[12] to ‘mal-adaptive’ body mechanics.[13]
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.
[edit] 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]
[edit] 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.
[edit] Treatment
Once a diagnosis of PGP has been made there are various treatments that can be
applied. One of the main factors in helping women cope with the condition is with
education, information and support. Other coping strategies include physical
medicine and rehabilitation, physiotherapy, osteopathy, chiropractic, psychologist,
prolo therapy or platelet-rich plasma therapy, massage therapy, acupuncture[18][19]
[20]
and alternative medicine. Mobility aids such as a wheelchair, walker, elbow
crutches and walking stick can be very useful. Medication dispensed by a
qualified health care provider can also be used to manage:
• Chronic pain
• Anxiety
• Depression
• Post Traumatic Stress Disorder(resulting from birth trauma/
pregnancy)
• Musculo-skeletal disorders.
Some pelvic joint trauma will not respond to conservative type treatments and
orthopedic surgery might become the only option to stabilize the joints.
[edit] Self help management
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.
Many women find floating in a heated pool relives the pain.
[edit] 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.[21]
However, some research supports that the average means to complete recovery is
6.25 years, and the more severe the case is, the longer recovery period.[22]
Overall, about 45% of all pregnant women and 25% of all women postpartum
suffer from PGP.[23] During pregnancy, serious pain occurs in about 25%, and
severe disability in about 8% of patients. After pregnancy, problems are serious in
about 7%.[18] There is no correlation between age, culture, nationality and numbers
of pregnancies that determine a higher incidence of PGP.[24][19]
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]
[edit] See also
• Childbirth
• Coccyx (tailbone)
• Diastasis symphysis pubis
• Estrogen
• Greater pelvis
• Lesser pelvis
• Osteitis pubis
• Pelvic cavity
• Pelvic fracture
• Pregnancy
• Hypermobility
• Sacroiliac joint
• Pelvimetry
• Relaxin
• Symphysis pubis
• Terms for anatomical location

[edit] References
1. ^ Pubic Symphysis Separation. Fetal and Maternal Medicine
Review (2002), 13: 141-155 Kelly Owens, Anne Pearson, Gerald
Mason
2. ^ a b Pain In Childbearing, Key Issues In Management, Margaret
Yerby, Lesly Page.
3. ^ SPD: The Clinical Presentation, Prevalence, Aetiology, Risk
Factors and Morbidity. Malcolm Griffiths.
4. ^ a b About Pelvic Girdle Instability. Definition and Concept. Jan
M.A. Mens.
5. ^ Reduction of Sick Leave for Lumbar Back and Posterior Pelvic
Pain in Pregnancy. Spine. 22(18):2157-2160, September 15,
1997. Noren, Lotta RPT, Ostgaard, Solveig, Nielsen, Thorkild F,
Ostgaard, Hans C
6. ^ Pelvic girdle pain and lumbar pain in relation to postpartum
depressive symptoms. Spine. 2007 Jun 1;32(13):1430-6. Gutke
A, Josefsson A, Oberg B.
7. ^ Risk factors in developing pregnancy-related pelvic girdle
pain. Acta Obstet Gynecol Scand. 2006;85(5):539-44. Albert HB,
Godskesen M, Korsholm L, Westergaard JG
8. ^ 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
2005;59:580-585, Mette Juhl, Per Kragh Andersen, Jørn Olsen,
Anne-Marie Nybo Andersen
9. ^ Understanding peripartum pelvic pain. Implications of a
patient survey. Spine. 1996 Jun 1;21(11):1363-9; discussion
1369-70.Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ.
10.^ 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.
11.^ 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.
12.^ 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
13.^ 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.
14.^ Normal Serum Relaxin in Women with Disabling Pelvic Pain
During Pregnancy. Gynecol Obstet Invest. 1994;38(1):21-3,
Petersen LK, Hvidman L, Uldbjerg N
15.^ Symphyseal Distention in Relation to Serum Relaxin Levels
and Pelvic Pain in Pregnancy. Acta Obstet Gynecol Scand. 2000
Apr;79(4):269-75. Björklund K, Bergström S, Nordström ML,
Ulmsten U
16.^ Relaxin is not related to symptom-giving pelvic girdle
relaxation in pregnant women. Acta Obstet Gynecol Scand. 1996
Mar;75(3):245-9. Hansen A, Jensen DV, Larsen E, Wilken-Jensen
C, Petersen LK.
 17.^ Circulating levels of relaxin are normal in pregnant women
with pelvic pain. Eur J Obstet Gynecol Reprod Biol. 1997
Jul;74(1):19-22. Albert H, Godskesen M, Westergaard JG, Chard
T, Gunn L.
18.^ a b Effects of acupuncture and stabilising exercises as adjunct
to standard treatment in pregnant women with pelvic girdle
pain: randomised single blind controlled trail. BMY 2005;330;761
H Elden, L Ladfors, M Fagevik Olsen, H-C Östgaard, H Hagber.
19.^ a b Pelvic Girdle Pain in Pregnancy. BMJ 2005;331:249-250 (30
July), doi:10.1136/bmj.331.7511.249 Editorial, R. William
Stones,Kathleen Vits
20.^ Acupuncture works for pelvic girdle pain in pregnant women.
Editorial, BMJ.;2005; 330 (2 April), doi:10.1136/bmj.330.7494.0-c
21.^ Symptom-Giving Pelvic Girdle Relaxation in Pregnancy. I:
Prevalence and Risk Factors. Acta Obstet Gynecol Scand. 1999
Feb;78(2):105-10. Larsen EC, Wilken-Jensen C, Hansen A, Jensen
DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM.
22.^ 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.
23.^ Pregnancy-related pelvic girdle pain (PPP), I: Terminology,
clinical presentation, and prevalence European Spine Journal Vol
13, No. 7 / Nov. 2004 W. H. Wu, O. G. Meijer, K. Uegaki, J. M. A.
Mens, J. H. van Dieën, P. I. J. M. Wuisman, H. C. Östgaard.
24.^ Is Pelvic Pain a Welfare Complaint? Acta Obstet Gynecol
Scand. 2000 Jan, 79(1):24-30 Department of Women’s and
Children Health KENNETH BJÖRKLUND, STAFFAN BERGSTRÖM .
25.^ Use of Hormonal Contraceptives and Occurrence of
Pregnancy-Related Pelvic Pain: A Prospective Cohort Study in
Norway. BMC Pregnancy Childbirth. 2004; 4: 11. Published online
2004 June 22. doi: 10.1186/1471-2393-4-11. Merethe Kumle,
Elisabete Weiderpass, Elin Alsaker, Eiliv Lund

[edit] External links

• Pelvic Instability Network Support (PINS)
• Pelvic Partnership Support Group
• Recommendations for the Nomenclature of Receptors for Relaxin
Family Peptides Pharmacol Rev 58:7-31,2006 Ross A. Bathgate,
Richard Ivell, Barbara M. Sanborn, O. David Sherwood and Roger
J. Summers
• European Guidelines on the Diagnosis and Treatment of Pelvic
Girdle Pain (pdf)
• Guidance for Healthcare Professional Pregnancy Related Pelvic
Girdle (pdf)
• Guidance for Mothers and Mothers to be with Pregnancy Related
Pelvic Girdle Pain (pdf)
 • A historical perspective on pregnancy related lower back pelvic
girdle pain
Retrieved from "http://en.wikipedia.org/wiki/Pelvic_girdle_pain"
Categories: Obstetrics | Childbirth | Health issues in pregnancy | Pain

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