Back In MotionMount Gravatt

Pelvic Girdle Pain (PGP)

PGP generally arises in relation to pregnancy and is experienced by approximately 50% of women¹. It is defined as “pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints. The pain may radiate in the posterior thigh and can occur in conjunction with/or separately in the symphysis².” Pain onset typically occurs around the 18^th week of pregnancy and intensity peaks between the 24^th and 36^th week of pregnancy. PGP often resolves by the third month in the postpartum period³.

Sacroiliac Joint (SIJ) Pain

What is the SIJ and why is it often affected during pregnancy?

The SIJ is located between the sacrum and the ilium bones of the pelvis, which are connected via strong ligaments. Although the SIJ is still considered to be a synovial joint, it typically has little motion. The SI joints primary role is to allow for the transfer of forces between the spine and the lower extremity⁴. During pregnancy, mechanisms stabilising the SIJ are affected, allowing for increased motion and stress on the SIJ⁵. Decreased SIJ stability is likely due to the hormones released during pregnancy which relax the ligaments, core muscle weakness as the uterus grows and an altered gait pattern caused by an increased abdominal load. 

What is the clinical presentation?

SIJ dysfunction is often difficult to distinguish from other types of low back pain, which is why diagnosis is challenging. Patients with SIJ dysfunction will likely report one or more of the following⁶:

• Buttock pain with/without posterolateral thigh pain
• Lumbar pain
• Difficulty sitting in one place for too long due to pain
• Pain within 10cm of the posterior superior iliac spine (PSIS)⁷
• Pain climbing stairs, single leg stance (ie. dressing in standing)

How is SIJ dysfunction diagnosed?

The current ‘gold standard’ for diagnosing SIJ pathologies is via a diagnostic nerve block, whereby anaesthetic is inserted into the SIJ. If the patient achieves 50-75% pain relief on two or more occasions, SIJ dysfunction can be deducted.⁸ However, even with a gold standard, issues within the literature have arisen, with SIJ blocks potentially having a false-positive rate of 20%.⁹ Physical examination is necessary in conjunction with diagnostic nerve block in order to accurately determine SIJ dysfunction. A recent systematic review revealed that the presence of three or more positive provocative tests appears to have reasonable sensitivity and specificity in identifying the SIJ as a cause of pain.¹⁰ Of these, the compression test and the thigh thrust test hold the most discriminative power.

How can physiotherapy assist with the management of SIJ pain?

Recent evidence indicates that physiotherapy interventions are effective in reducing both pain and disability associated with SIJ pain.¹¹ In the first stage of treatment, the aim will be to reduce inflammation with icepacks and pregnancy-appropriate medication. Next, a physiotherapist will aim to improve mobility through the use of mobilisation, massage and exercise therapy. Exercises will primarily focus on lumbar and core stabilisation. In some cases, patients may benefit from the use of a sacroiliac belt or SIJ taping to offer additional pelvic support¹².  Finally, postural and ergonomic advice will assist with pain reduction and decrease the risk of reinjury.¹¹ 

Symphysis Pubis Dysfunction (SPD)

What is SPD?

SPD is defined as pain in the region of the pelvic girdle, most commonly over the pubic bone in the front or in the lower back.¹³ The condition is likely caused by the physiological pelvic ligament relaxation and increased joint mobility experienced during pregnancy. SPD has been reported in 31.7% of pregnant women, indicating high obstetric morbidity.¹⁴

What is the clinical presentation of SPD?

Patients with SPD will likely report one or more of the following¹⁵:

• “Shooting” pain in the symphysis pubis, eased by rest
• Radiating pain into the lower abdomen, back, groin, perineum, thigh, and/or leg
• Pain with walking and ascending/descending stairs
• Pain with unilateral weight bearing activities (eg. dressing in standing)
• Pain when turning in bed
• Clicking, snapping or grinding heard or felt within the symphysis pubis

How is SPD diagnosed?

Investigations are not an integral part of the diagnosis of SPD because the diagnosis is often made symptomatically. However, MRI can be used to aid differential diagnosis and to determine whether pubic symphysis separation has occurred.¹⁶ Physical examination can also assist with SPD diagnosis. Literature has shown that persisting pain for 5 seconds or longer following palpation of the pubic symphysis has high reliability¹⁷. A waddling gait, pain at the pubic symphysis while standing on one leg and reduced hip abduction range are also common physical examination findings.

How can physiotherapy assist with the management of SPD?

Physiotherapy treatment has been proven effective in the reduction of pelvic pain during pregnancy.¹⁸ Important components of SPD treatment include the prescription of stabilisation exercises and advice regarding activity modification eg. keeping knees together during transitional movements. Therapeutic exercise will aim to reduce the stress placed upon the joint and strengthen the muscles which assist with pelvic stabilisation. Manual therapy, particularly soft tissue massage through the adductors, is also likely to offer temporary pain relief to SPD patients. Finally, pelvic supports in the form of a trochanteric belt or Tubigrip® are often used to aid in the restoration of stability of the pelvic ring, however limited published evidence exists supporting their efficacy.¹⁶

Clinical Bottom Line

Pelvic girdle pain contributes significantly to obstetric morbidity. A physiotherapy-guided treatment plan which utilises manual therapy, stabilisation exercises and advice regarding activity modification is likely to assist in pelvic girdle pain management.

References

1. Robinson, H. S., Mengshoel, A. M., Veierød, M. B., & Vøllestad, N. (2010). Pelvic girdle pain: Potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum. Manual Therapy, 27(1), 522– 528.
2. Vleeming, A., Schuenke, M. D., Masi, A. T., Carreiro, J. E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy, 221(6), 537-67.
3. Kanakaris, N. K., Roberts, C. S., & Giannoudis, P. V. (2011) Pregnancy-related pelvic girdle pain: An update. BMC Med, 9(15). doi:10.1186/1741-7015-9-15.
4. Vleeming, A., Schuenke M. D., Masi, A. T., Carreiro, J, E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of Anatomy, 221(6), 537-67. doi: 10.1111/j.1469-7580.2012.01564.x
5. Core Concepts. (2019). Sacroiliac joint pain or posterior pelvic pain in pregnant women and physiotherapy. Retrieved from https://www.coreconcepts.com.sg/article/posterior-pelvic-pain-sacroiliac-joint-pain-in-pregnant-women/
6. Slipman, C. W., Jackson, H. B., Lipetz, J. S., Chan, K. T., Lenrow, D., & Vresilovic, E. J. (2000). Sacroiliac joint pain referral zones. Arch Phys Med Rehabil, 81(3), 334-338. doi: 10.1016/s0003-9993(00)90080-7
7. Murakami, E., Aizawa, T., Noguchi, K., Kanno, H., Okuno, H., & Uozumi, H. (2008). Diagram specific to sacroiliac joint pain site indicated by one-finger test. J. Orthop. Sci, 13(6), 492-497. doi:10.1007/s00776-008-1280-0
8. Van der Wurff, P., Buijs, E. J., & Groen, G. J. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Archives of Physical Medicine and Rehabilitation, 87(1), 4-10. doi:10.1016/j.apmr.2005.09.023
9. Simopoulos, T. T., Manchikanti, L., Singh, V., Gupta, S., Hameed, H., Diwan, S., & Cohen, S. P. (2012). A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician, 15(3), 304-44. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22622915
10. Szadek, K. M., van der Wurff, P., van Tulder, M. W., Zurrmond, W. W., & Perez, R. S. (2009). Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The Journal of Pain, 10(4), 354-368. doi:10.1016/j.jpain.2008.09.014
11. Al-subahi, M., Alayat, M., Alshehri, M. A., Helal, O., Alhasan, H., Alalawi, A., Takrouni, A., & Alfageh, A. (2017). The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: a systematic review. Journal of Physical Therapy Science, 29(9), 1689-1694. doi:10.1589/jpts.29.1689
12. Hammer, N., Möbius, R., Schleifenbaum, S., Hammer, K., Klima, S., Lange, J. S., Soisson, O., Winkler, D., & Milani, T. L. (2015). Pelvic belt effects on health outcomes and functional parameters of patients with sacroiliac joint pain. PLoS one, 10(8), e0136375. doi:10.1371/journal.pone.0136375
13. Martin, E. (2015). Concise Medical Dictionary (9 ed.). Oxford, UK: Oxford University Press
14. Depledge, J., McNair, P. J., Keal-Smith, C., & Williams, M. (2005). Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Physical Therapy, 85(12), 1290-1300. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16305268
15. Howell, E. R. (2012) Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. Journal of the Canadian Chiropractic Association, 56(2), 101-104.
16. Jain, S., Eadarapalli, P., Jamjute, P., & Sawdy, R. (2006). Symphysis pubis dysfunction: a practical approach to management. The Obstetrician and Gynaecologist, 3(2), 153-158.
17. Albert, H., Godskesen, M., & Westergaard, J. (2001). Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand, 80(6), 505-10.
18. Young, G., & Jewell, D. (2002). Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev, 1(2). doi:CD001139.