Pubic Symphysis Dysfunction

Original Editor ­ Rachael Lowe  Top Contributors - Karsten De Koster, Laura Ritchie, Andeela Hafeez and Rachael Lowe


Contents

Introduction

“A symphysis pubis dysfunction is a common and debilitating condition affecting woman. It’s painful and it can have a significant impact on quality of life, which can lead to complications as depression.[1]In British population we can see an incidence of 1:36 to 1:300.[1][2] A study of Owens K. et al. shows that this injury arises in the first trimester of pregnancy for 9% of women, in the second for 44%, in the third for 15% and postnatal for 2%.[3][4] Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.[3][5]

Clinically Relevant Anatomy


The symphysis pubic is found on the anterior side of the pelvis. It is also the anterior boundary of the perineum.[6][7] In cooperation with the sacroiliac joints the symphysis forms a stable pelvic ring. This ring allows only some small mobility.[8][9] 



The pubic symphysis is a cartilagenous joint which consists of a fibrocartilagneous interpubic disc [1][6][5][7] (which had transversal and helical fibers) and the surrounding ligaments uniting the bodies of the pubic bones in the median plane. With children this disc is very small and the hyaline cartilage is very wide but it evolves conversely.[6] With men the disc is higher, smaller and narrower.[6] Normally with women the symphysis pubic gap is 4-5 mm wide and it widens 2-3 mm during the last trimester of pregnancy. This is necessary to facilitate the delivery of the fetus.[1] With symphysis pubis dysfunction the joints become more relaxed and allow instability in the pelvic girdle. When the gap is equal to or more than 10 mm there’s a diastasis of the symphysis pubic.[1]

Mechanism of Injury / Pathological Process

Aslan et al. say that the aetology of SPD is unknown.[5] Pregnancy leads to an altered pelvic load, lax ligaments and weaker musculature. This leads to spino-pelvic instability, which manifest itself as symphysis pubic dysfunction.[1][10]


In early stages of the pregnancy the corpus luteum secretes a lot of relaxin and progesteron.[1] From the 12th week of the pregnancy this function is continued by the placenta and decidua.[1] Relaxin breaks down collagen in the pelvic joint and causes laity and softening. Progesterone has a similar effect. But relaxin has no correlation with the degree of symptoms of symphysis pubic dysfunction.[1][11][12] A Norwegian study showed that genetic susceptibility to joint dysfunction is possibly caused by an aberration of relaxine.[13] It would seem that the presence of laxity as the result of a hormonal link is undisputed.[1] However there is no full disclosure for this.

Clinical Presentation

Symphysis pubic dysfunction is a condition that causes excessive movement of the pubic symphysis in the anterior or lateral direction and causes pain.[14] Both factors are possibly due to a misalignment of the pelvis. It’s frequently associated with pregnancy and childbirth. Therefore the mid-wife is the first who gets to know the complaints.[1] In recent years we can see an increased level of cases of pubic symphysis dysfunction. This is possibly due to the increased age of getting a child.[1]


As previously stated, pain is a symptom of this disease. It can be a burning, shooting, grinding or stabbing pain.[1][14] This can be a mild pain, but this can progress to a severe and prolonged pain. The pain is usually relieved by rest.[1]The pain often radiates to the back, abdomen, groin, perineum and leg.[1] The pain disappears commonly after giving birth, but this is not the case for everyone. This emphasizes the importance of an individual treatment.[1] There are many other symptoms like a discomfort sense onto the front of the joint. Another symptom is the ability to hear some click of the lower back, hip joints and saccroillial joints if the patients position changes.[14] Another symptom is the difficulty in some movements like the ab- and adduction. It limits people in their daily lives. There’s a typical gait, like the difficulty to climb stairs and problems with weight-bearing activities.[1][14]


Some people say there is a link between a depression and this dysfunction.[1] This is possibly due to the physical discomfort.[1]Symphysis pubic dysfunction can be the result of a diastasis, a rupture, an osteomy or a fracture.[15]Some causes of symphysis pubic dysfunction are: pregnancy/ partus, a sports injury and prostatectomy. In a sporting injury this is caused by falling with the legs in hyper-abduction, such as in horse-riding.[15]

Diagnostic Procedures

As in all dysfunctions, an early diagnosis is important to minimize the possibility of a long term problem. However, not all healthcare practioners recognise this problem. A diagnosis is often made symptomatically e.g. after a pregnancy but imaging is the only way to confirm the dysfunction (level of evidence A, grade of evidence B)[1], sometimes an MRI, x-ray, CT or ultrasound[7] are also used for diagnosis (level of evidence A, grade of evidence A).[1][14] The most important during diagnosis is a good physical examination in order to rule out some other problems such as lumbar spine problems or prolapsed discs (level of evidence 1A). [5]


Tenderness over the symphysis pubis and the sacroilliac joints are the most common clinical signs. The range of hip motion (abduction and external rotation) could be limited in function of the pain.[1]This loss of abduction function can give a waddling gait. Fry and Wellock et al. say: "Clinicians are able to palpate the symphysis but the woman’s own description of discomfort is sufficient to diagnose.”[1]


No test is diagnostic. On palpation anterior posterior/ superior inferior displacement of the upper border of the symphysis pubis or tuberculum pubicum can be felt. An active straight leg raise test may be limited or impossible to do. Bilateral trochanter compression can cause pain (level of evidence 1A, grade of evidence B).[1] The next test for symphyseal pain in pregnancy have a high sensitivity (se), specificity (sp) and inter-examiner reliability (i-er):[1] 

  • Palpate the anterior surface of the symphysis pubis, when the woman lies on her back, the test is positive when the pain persists for more than 5 seconds after removal of the hand.[1](se=60%, sp=99%and i-er=0,89 Kappa coefficient).
  • When standing on one leg the woman isn’t able to maintain the pelvis in a horizontal plane and the opposite buttocks drops. This is also known as Trendelenburg’s sign.[1] (se=60%, sp=99% and i-er= 0,63 kappa coefficient).
  • A Patrick’s FABER sign: the examiner holds one illiac spine in a flexed position, the woman is in a supine position, then she places her heel on the heterolateral knee with the leg falling passively outwards. This test is positive when there is a pain in the sacroilliac joint.[1](se=40%, sp=99%, i-er= 0,54 kappa coefficient).


Management / Interventions

There is no evidence in literature to support any particular treatment. People with pubic symphysis dysfunction use elbow crutches (grade of evidence A)[1][3][16], pelvic-support devices (grade of evidence A) [17][5][7] (although often used there is no published evidence for their efficacy)[1] and prescribed pain reliefs (be careful taking NSAIDS while pregnant)[1]. In very severe cases a wheelchair and eventually social services are recommended (level of evidence 1A).[1]


The intervention of a physiotherapist can be as useful as other treatments. He can prescribe some exercises for core and pelvic stability. Women can also discuss their birth planning with an obstetrician/ midwife/ ergo therapist to get some information about using the body in daily life and during childbirth. In severe cases surgery is indicated after the childbirth.[1]


A good birth planning is important. Women with pubic symphysis dysfunction should give birth in an upright position, with knees slightly open. It’s also important that the gap never exceeds the maximal comfort zone which is why it’s suggested that the patient wear a ribbon to both legs (grade of evidence A).[1][5] Practices such as placing the feet on the midwife's hips during birth, stirrups, and interventions such as forceps should be avoided in the delivery room if possible because they can strain ligaments further (level of evidence 1A).[1] This causes long term problems. [1]


As a physiotherapist you can give some advice to use the body in daily life, back care and to avoid activities that put undue strain on the pelvis. Here are some tips (grade of evidence A)[1][7]:

  • Avoid squatting, strenuous exercises, prolonged standing, lifting and carrying, stepping over things, twisting movements of the body, vacuum cleaning and stretching exercises!
  • Sit down while doing things if possible.
  • Sleep with a pillow between the legs. Keeps legs flexed and together to get in/ out of bed.






Pelvic floor exercises (e.g. Kegel's) from early pregnancy are supposed to reduce the risk to develop symphysis pubic dysfunction. Deep abdominal exercises increase the core stability and this prevents women to develop pelvic or back pain in pregnancy (grade of evidence A). Pelvic muscle floor exercises can be progressed by starting off with a small number of repitions and gradually increasing the seconds to hold on a contraction. [1][18][19]When the transversus abdominis muscle contracts, we can see a synergistic activation of the pelvic floor. [20]


The next therapies can also be of value: TENS, Ice, external heat and massage, but their efficacy isn’t yet proven (grade of evidence A).[1][5] The effects of a treatment of a chiropractor or the effects of talking to “hands on experts” can be useful.[1]


There is no evidence that caesarean is beneficial for women with symphysis pubic dysfunction. however when hip abduction is severely restricted this can be necessary (level of evidence A).[1] During labour and delivery leg abduction(=separation) should be kept to a minimum.[1] Use of epidural and spinal anesthesia have been discouraged on account of masking pubic symphysis dysfunction pain, however there is no evidence for this. Women with symphysis pubic dysfunction require longer hospital stays.[1]

Differential Diagnosis

Jain S. et al say[1]: “The differential diagnosis includes lumbago, sciata, urinary tract infection osteitis pubis and osteomyelitis. These need to be firmly excluded to ensure the diagnosis of symphysis pubic dysfunction.”[5]

Key Evidence

In the next table you can find some information of the levels of evidence of the used information to create this page on physio-pedia. In the first column you can see the name of the author of the resource, in the next you can read the level of evidence and in the last you can find the grades of evidence.

Name Author levels of evidence
Aslan E. et al. 1A
Allsop J.R. 5
Bjorklund K. et al. 1C
Coldron Y. 1A
Depledge J. et al. 1B
Elden H. et al. 1C
Guthrie L. 5
Jain S. et al. 1A
Lennard F. 1C
Lohman A.H.M. 5
MacLennan A.H. et al. 2B
Moore K.L. et al. 5
Ohtera K.L. et al. 5
Owens K. et al. 2C
Robson S.E. et al. 5
Schünke M. et al. 5
Versprille-Fischer E.S. 5
Welsh H. 1A
Whitby P. 5
Young G. et al. 1A

Resources

Primary Resources


Aslan A. and Fynes M., Symphysial pelvic dysfunction, Curr Opin Obstet Gynecol, 2007 19:133–139.
Allsop J.R., Symphysis pubic dysfunction, British Journal of General Practice,1997, 256.
Bjorklund K, Bergstrom S, Nordstrom ML, Ulmsten U. Symphyseal distension in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scan 2000;79:269–75.
Coldron Y. Margie Poldon Memorial lecture: ‘Mind the gap!’Symphysis pubis dysfunction revisited. Journal of the Association of Chartered Physiotherapists in Women’s Health 2005;96:3–15.
Depledge J. et al., Management of Symphysis Pubis Dysfunction During Pregnancy Using Exercise and Pelvic Support Belts, Physical Therapy,2005, 1290-1300.
Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H., Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial, BMJ ,2005;330:761.
Jain S. et al, Review Symphysis pubis dysfunction: a practical approach to management, The Obstetrician & Gynaecologist, 2006;8:153–158.
Lennard F. Physiotherapy for back and pelvic pain. British Journal of Midwifery 2003;11:97–102.
MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and development dysplasia of the hip. Acta Obstet Gynecol Scand, 1997;76:760–64.
Ohtera K. et al., Effect of pregnancy on joint contracture in the rat knee, J Appl Physiol,2002, 92, 1494-1498.
Owens K, Pearson A, Mason G. Symphysis pubis dysfunction - a cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol, 2002;105:143–46.
Welsh A., Antenatal care routine care for the healthy pregnant woman, National Collaborating Centre for Women’s and Children’s Health, 2008, 2nd edition, London, 113.
Whitby P., The agony of pelvic joint dysfunction. Practicing Midwife, 2003;6:14–6.
Young G, Jewell D. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev, 2002;(1): CD001139.


Secundary Resources


Guthrie L., Clinical Case studies in physiotherapy, Churchill Livingstone Elsevier, 2009, Philadelphia, 372.
Lohman A.H.M., Vorm en beweging, 1995, 5the edition, Bohn Stafleu van Longhum, Houten, p(4) 276-280.
Moore K.L. et al., Clinically Oriented Anatomy, 2010, 5th edition, Baltimore, Wolters Kluwer/ Lippincott Williams & Wilkins, 332-334.
Robson S.E. et al., Medical disorders in pregnancy, Blackwell Publishing, Oxford 2008, 1st edition, 110-111.
Schünke M. et al., Prometheus, Houten,2005, 1st edition, Bohn Stafleu van Longhum, 362-387.
Versprille-Fischer E.S., Begeleiding van patiënten met bekkenbodemdisfunctie, 2008, 2nd edition, Lemma, Maarssen, (7)214-219.


Recent Related Research (from Pubmed)

References


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 Jain S. et al, Review Symphysis pubis dysfunction: a practical approach to management, The Obstetrician & Gynaecologist, 2006;8:153–158.
  2. Owens K, Pearson A, Mason G. Symphysis pubis dysfunction - a cause of significant obstetric morbidity. Eur J Obstet Gynecol Reprod Biol 2002;105:143–46.
  3. 3.0 3.1 3.2 Welsh A., Antenatal care routine care for the healthy pregnant woman, National Collaborating Centre for Women’s and Children’s Health, 2008, 2nd edition, London, 113.
  4. Owens K et al.,Symphysis pubis dysfunction: a cause of significant obstetric morbidity, European Journal of Obstetrics Gynecology and Reproductive Biology 2002;105:143–6.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Aslan A. and Fynes M., Symphysial pelvic dysfunction, Curr Opin Obstet Gynecol, 2007 19:133–139.
  6. 6.0 6.1 6.2 6.3 Lohman A.H.M., Vorm en beweging, 1995, 5the edition, Bohn Stafleu van Longhum, Houten, p(4) 276-280.
  7. 7.0 7.1 7.2 7.3 7.4 Pelvic Pain Specialists for Women; Understanding Pelvic Pains In Pregnant Women, Symphysis Pubis Dysfunction, Etonia, http://www.coreconcepts.com.sg/wp-content/uploads/Etonia-PatientEducation-SPD1.pdf, (accessed 13-11-2011).
  8. Schünke M. et al., Prometheus, Houten,2005, 1st edition, Bohn Stafleu van Longhum, 362-387.
  9. Moore K.L. et al., Clinically Oriented Anatomy, 2010, 5th edition, Baltimore, Wolters Kluwer/ Lippincott Williams & Wilkins, 332-334.
  10. Coldron Y. Margie Poldon Memorial lecture: ‘Mind the gap!’Symphysis pubis dysfunction revisited. Journal of the Association of Chartered Physiotherapists in Women’s Health 2005;96:3–15.
  11. Bjorklund K, et al., Symphyseal distension in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scan 2000;79:269–75.
  12. Ohtera K. et al., Effect of pregnancy on joint contracture in the rat knee, J Appl Physiol 92,2002, 1494-1498.
  13. MacLennan AH, MacLennan SC., Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and development dysplasia of the hip., Acta Obstet Gynecol Scand, 1997;76:760–64.
  14. 14.0 14.1 14.2 14.3 14.4 Allsop J.R., Symphysis pubic dysfunction, British Journal of General Practice,1997, 256.
  15. 15.0 15.1 Versprille-Fischer E.S., Begeleiding van patiënten met bekkenbodemdisfunctie, 2008, 2nd edition, Lemma, Maarssen, (7)214-219.
  16. Robson S.E. et al., Medical disorders in pregnancy, Blackwell Publishing, Oxford 2008, 1st edition, 110-111.
  17. Depledge J. et al., Management of Symphysis Pubis Dysfunction During Pregnancy Using Exercise and Pelvic Support Belts, Physical Therapy,2005, 1290-1300.
  18. Whitby P. ,The agony of pelvic joint dysfunction, Practicing Midwife, 2003;6:14–6.
  19. Guthrie L., Clinical Case studies in physiotherapy, Churchill Livingstone Elsevier, 2009, Philadelphia, 372.
  20. Carrière B., The pelvic floor, Thieme, Stuttgart,1st edition, 2006.