Recognising Pelvic Girdle Pain

Original Editor - Deborah Riczo, Wanda van Niekerk
Top Contributors - Wanda van Niekerk, Kim Jackson, Tarina van der Stockt, Lucinda hampton and Jess Bell

Introduction

Pelvic girdle pain (PGP) refers to musculoskeletal disorders affecting the pelvis.

• It primarily involves the sacroiliac joint, the symphysis pubis and the associated ligaments and muscles.
• It is a common condition during pregnancy and postpartum, more common in women in general than in men.
• It is a disabling condition and has an impact on daily function and quality of life, contributes to depression, anxiety, work absenteeism, and disability.

The vast majority of studies on pelvic girdle pain look at women during pregnancy and postpartum due to the prevalence of PGP in this population.

People struggling with PGP are commonly managed by physiotherapists.

Definition of Pelvic Girdle Pain

There are various definitions of Pelvic Girdle Pain and historically there have been discrepancies around the terminology regarding pelvic pain and/or low back pain, specifically in the pregnant population. The European guidelines define pelvic girdle pain as:

"Pelvic pain that arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal folds, particularly in the vicinity of the sacroiliac joint. The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis."

Clinton et al. agrees with the above definition in their clinical practice guidelines for pelvic girdle pain in the antepartum population.

Another term that is also used is pregnancy-related low back pain (PLBP) and should not be confused with pelvic girdle pain (PGP).

• Pregnancy-related low back pain is characterised by a dull pain, more pronounced in forward flexion, with associated restriction in lumbar spine movement. Palpation of the erector spinae muscles exacerbates pain.

Women who have both PLBP and PGP are more likely to continue to have problems after pregnancy.

The above definition of pelvic girdle pain is most often used in the physiotherapist literature, but others use “pelvic girdle pain” to include areas of pain in the pelvis from visceral origin.

Other Causes of Pelvic Girdle Pain

In 2019, Palmer et al. described other causes of pelvic pain:

• Endometriosis
• Dysmenorrhea
• Vulvodynia
• Crohn’s disease
• Irritable bowel syndrome (IBS)
• Ulcerative colitis
• Septic arthritis
• Osteomyelitis
• Sexually transmitted diseases/infections (STDs or STIs)
• Abdominal aneurysms
• Cancer

Physiotherapists who specialise in pelvic health are trained to recognise these other causes of pelvic pain. For the purpose of this page, "pelvic girdle pain" (PGP) will be used to refer to the musculoskeletal causes of pelvic girdle pain

Causes of Pelvic Girdle Pain

Causes of pelvic girdle pain may include the following:

• Changes in hormones, tissue laxity, weight distribution/gain, muscle weakness/tightness associated with pregnancy and postpartum
• Trauma
• A fall
• A motor vehicle accident
• Falling downstairs
• Stepping into a hole
• Sports injuries 
• Arthritis or osteoarthritis

Differential Diagnosis

In the antepartum population, pelvic girdle pain can be associated with signs and symptoms of various inflammatory, infective, traumatic, neoplastic, degenerative or metabolic disorders. The physiotherapist should proceed with caution or consider medical referral if there is a history of any of the following:

• History of trauma
• Unexplained weight loss
• History of cancer
• Steroid use
• Drug abuse
• Human immunodeficiency virus or immunosuppressed state
• Neurological symptoms/signs
• Fever and/or feeling systemically unwell
• Special considerations for Pelvic Girdle Pain should include:
  • Symptoms due to uterine abruption
  • Referred pain due to urinary tract infection to the lower abdomen/pelvic or sacral region
• Other factors that may require medical specialist referral include:
  • No functional improvement
  • Pain not reducing with rest
  • Severe, disabling pain

Other differential diagnoses for pelvic girdle pain, after the above pelvic pain disorders have been ruled out may include:

• Diastasis Rectus Abdominis (DRA)
  • Pelvic floor weakness associated with weakness of abdominal wall in DRA
  • 66% incidence of DRA in antepartum population in the third trimester
  • DRA occurs in 39% of the postpartum population after 7 weeks to several years
• Other orthopaedic problems
  • Presence of hip dysfunction
  • Possibility of femoral neck stress fracture due to transient osteoporosis
  • Hip bursitis/ tendinopathy
  • Chondral damage/loose bodies
  • Capsular laxity
  • Femoroacetabular impingement
  • Labral irritations/tears
  • Muscle strains
  • Referred pain from L2/3 radiculopathy
  • Osteonecrosis of the femoral head
  • Paget’s disease
  • Arthritis – rheumatoid, psoriatic and septic
  • Lumbar spine dysfunctions
  • Spondylolisthesis
  • Disc injury patterns with symptoms that fail to centralise
  • Neurological screening that indicates the presence of lower motor neuron or upper motor neuron signs
  • Bowel/bladder dysfunction should be considered in combination with multiple sensory, motor and diminished reflexes as this could indicate cauda equina syndrome, large lumbar disc, etc.

Prevalence of Sacroiliac Pain, a Type of Pelvic Girdle Pain

Between 5 – 10% of people develop chronic low back pain worldwide. This leads to:

• High treatment costs
• Extended periods of sick leave
• Individual suffering
• Invasive interventions such as surgeries
• Disability

Sacroiliac pain, a type of pelvic girdle pain, has been known to be undiagnosed or mistreated in people with low back pain. It is estimated to occur in 10-30% of persons with non-specific low back pain. Some studies have found this incidence even higher.

In a 2013 study by Visser et al., 40 percent of the study population had a sacroiliac joint or sacroiliac joint and disc component. Visser et al. noted that lumbar nerve root compression can mimic sacroiliac joint radiculopathy and thorough evaluations of the spine, hips and sacroiliac joint should be done to get an accurate diagnosis.

Prevalence of Pregnancy-Related Lumbar Back Pain (PLBP) and Pelvic Girdle Pain

• 56% to 72% of the antepartum population
• 20% of antepartum population report severe symptoms during 20 -30 weeks of gestation
• 7% of women with pelvic girdle pain will experience lifelong problems
• 33% to 50% of pregnant females report PGP before 20 weeks of gestation and prevalence may reach 60 to 70% in late pregnancy

Considering this high prevalence, it is evident that pelvic girdle pain remains a significant problem globally. There is, however, no gold standard testing protocol; currently various combinations of provocation tests and imaging are used in research to diagnose pelvic girdle pain. Physiotherapists are best placed to offer and provide individuals with guidance and help in this area. Further research is needed to guide physiotherapy interventions.

Risk Factors for Pelvic Girdle Pain

Clinton et al. (2017) list the following risk factors based upon strong evidence:

• Prior history of pregnancy
• Orthopaedic dysfunctions
• Increased body mass index (BMI)
• Smoking
• Work dissatisfaction
• Lack of belief in improvement in the prognosis of pelvic girdle pain

They also list these risk factors that might lead to the development of pelvic girdle pain:

• Joint hypermobility
• History of multiparity (i.e have had more than one child)
• Periods of amenorrhea
• Hip and/or lower extremity dysfunction including the presence of gluteus medius and pelvic floor muscle dysfunction
• History of trauma to the pelvis
• History of low back pain and/or PGP, especially in previous pregnancies

In pregnancy, Ceprnja et al. note that a history of low back pain and/or pelvic girdle pain and a family history of pregnancy-related pelvic girdle pain. is associated with pregnancy-related pelvic girdle pain was consistent with previous studies.

Risk Factors for Persistent Pelvic Girdle Pain Postpartum

In a recent systematic review and meta-analysis the following risk factors for persistent pelvic girdle pain postpartum have been identified:

• History of low back pain
• BMI more than 25 pre-pregnancy
• Pelvic girdle pain in pregnancy
• Depression in pregnancy
• Heavy workload in pregnancy

Clinical Presentation of Pelvic Girdle Pain

The clinical presentation varies from patient to patient and can also change over the course of a pregnancy.

Subjective History

Symptoms indicative of PGP as described by Clinton et al (2017) based on the European Guidelines:

• Pain experienced between the posterior iliac crest and the gluteal fold, particularly in the area of the sacroiliac joint (SIJ)
• The pain may radiate in the posterior thigh
• Pain can occur in conjunction with/or separately from pain in the pubic symphysis

Pain

• The onset of pain may occur around the 18th week of pregnancy and may reach peak intensity between the 24th and 36th week of pregnancy
• Pain resolves by the 3rd month postpartum
• Pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ) and/or the pubic symphysis
• Pain can be local or local with radiculopathy
• Fortin’s area – a rectangular area that runs from the posterior superior iliac spine (PSIS) 3 cm lateral and 10 cm caudal
• One finger method - the person will often use one finger to point to the painful area, usually within this rectangular area
• Radicular component of sacroiliac pain – initially it was thought that radicular pain past the knee is not related to SIJ dysfunction but Fortin et al. showed that radicular pain from the SIJ can go past the knee and that it can be a cause of SIJ dysfunction. Visser et al. also reported a combination of SIJ and disc-related radicular pain
• Pain may be described as stabbing, dull, shooting or burning sensation
• Pain intensity on Visual Analogue Scale averages around 50 -60mm
• Differentiation between PGP and PLBP – useful to use a patient pain distribution diagram
  • PGP – located under the PSIS in the gluteal area, the posterior thigh and the groin (specifically over the pubic symphysis)
  • PLBP – concentrated in the lumbar region, above the sacrum

Functional Complaints

Issues with transitional movements such as:

• Difficulty getting out of a car
• Difficulty getting up or out of the chair
• Difficulty with mobility
• May have difficulty with stairs
• May have difficulty with walking
• Difficulty standing for 30 minutes or longer
• Difficulty with standing on one leg – failed load transfer – going from one leg to another
• Difficulty turning over in bed - often the worst symptom
• Decreased ability to do housework
• Pain/discomfort with weight-bearing activities

Prognosis

Bergström et al. investigated pregnancy-related low back pain and pelvic girdle pain 14 months after pregnancy. A cohort of 639 women with pregnancy-related back pain or pelvic girdle pain during pregnancy were included in the study. The participants completed questionnaires on pain status and self-rated health and family situations. Follow-up was done 6 months after the initial assessment and of the 639 participants, 200 participants reported having postpartum low back pain or pelvic girdle pain. Another follow-up was completed 14 months after and of the 200 that reported pain after 6 months, 176 completed the questionnaires. Of these participants, 19.3% were in remission and 75.3% reported experiencing recurrent low back pain. At 40 months after the initial assessment, 15.3% of participants reported continuous low back and pelvic girdle pain.

In a long-term follow-up study, Bergstrom et al. reported that 40.3% of the study participants reported pain to various degrees. The following factors were identified as being associated with a statistically significant increase in the odds of reporting pain 12 years postpartum:

• Increased duration of pain and/or persistency of pain
• How participants self-rated their health
• The prevalence of sciatica, neck and/or thoracic spinal pain
• Sick leave within the past 12 months
• Treatment sought
• Use of prescription and/or non-prescription medication

Bergstrom et al. concluded that for a subgroup of women with pregnancy-related pelvic girdle pain, spontaneous recovery with no recurrences is unlikely. The strongest predictors of poor long-term outcome were:

• Persistency and/or duration of pain syndromes
• Widespread pain - this may also contribute to long-term sick leave and disability pension

The development of a screening tool to identify women at risk of developing pregnancy-related pelvic girdle pain is needed in order to enable early intervention.

Wuytak et al. conducted a systematic review and identified potential prognostic factors for up to one year postpartum. Only three studies were included in the final review and the quality of evidence for all the factors was rated as low or very low. This could be attributed to the lack of replication, with none of the factors being investigated in more than one study. Considering the uncertainty about the results and the inherent susceptibility to bias the following prognostic factors have been identified in women who are less likely to recover 12 weeks postpartum:

• History of low back pain
• Pain in three to four pelvic locations
• Overweight
• Six months postpartum, pelvic girdle pain is more likely to persist in:
  • Use of crutches during pregnancy by an individual
  • Severe pain in all three pelvic locations during pregnancy
  • Presence of other pain conditions
  • Obesity
  • Younger age of menarche
  • History of previous low back pain
  • High co-morbidity index
  • Smoking – conflicting evidence
  • Mode of birth in the subgroup of women who had to use crutches during pregnancy, with women who had instrumental birth or cesarean section more likely to have persistent (severe) PGP
  • Emotional distress during pregnancy