Recognising Pelvic Girdle Pain

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Definition of Pelvic Girdle Pain

There are various definitions of Pelvic Girdle Pain. 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 (2017) uses the following definition: "Pain in the posterior part of the pelvis, between the iliac crest, down to the gluteal folds and particularly in the area of the Sacroiliac joint. It includes sacroiliac dysfunction or sacroiliac region syndrome, and it can occur with or separately from symphysis pubis pain."

Causes of Pelvic Girdle Pain

• Common during pregnancy and postpartum
• Can be as a result of trauma such as:
  • a fall
  • a motor vehicle accident
  • falling downstairs
  • stepping into a hole
• Sports injuries
• Result of arthritis or osteoarthritis

Pelvic girdle pain is not just confined to women, although the vast majority of studies are done around pelvic girdle pain in pregnancy and postpartum.

In a recent clinical review Palmer et al referred to pelvic girdle pain as being the big umbrella term and that it can therefore also include causes of anterior pelvic pain such as:

• Endometriosis
• Dysmenorrhea
• Vulvodynia
• Crohn’s disease
• Irritable Bowel Syndrome (IBS)
• Ulcerative colitis
• Septic arthritis
• Osteomyelitis
• Sexually Transmitted Diseases (STD’s)
• Abdominal aneurysms
• Cancer

Physiotherapists that specialises in pelvic health are trained in recognising these other reasons for experiencing pelvic pain. For the purpose of this page when referring to pelvic girdle pain this will entail the musculoskeletal reasons for pelvic girdle pain.

Differential Diagnosis

In the ante-partum 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
• Immunosuppressed state
• Neurological symptoms/signs
• Fever
• 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
• Diastasis Rectus Abdominis (DRA)
  • Pelvic floor weakness associated with weakness of abdominal wall in DRA
  • 66% incidence of DRA in antepartum population in 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
  • Femoral acetabular Impingement
  • Labral irritations/tears
  • Muscle strains
  • Referred pain from L2/3 radiculopathy
  • Osteonechrosis of the femoral head
  • Paget’s disease
  • Arthritis – rheumatoid, psoriatic and septic
  • Lumbar spine dysfunctions
  • Spondylolisthesis
  • Discal patterns of symptoms that fail to centralise
  • Neurological screening that indicate 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

Differentiation between PGP and PLBP – useful to use a patient pain distribution diagram

PGP – located under the PSIS in gluteals area, the posterior thigh and the groin (specifically over the pubic symphysis)

PLBP – concentrated in lumbar region, above the sacrum

Prevalence of Pelvic Girdle Pain

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

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

It is also widely accepted that the SIJ is a pain generator in 10-30% of low back pain cases

Booth J, Morris S. The sacroiliac joint–Victim or culprit. Best Practice & Research Clinical Rheumatology. 2019 Feb 1;33(1):88-101.

Prevalence of Pelvic or 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 Wu, W.H., Meijer, O.G., Uegaki, K. et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J 13, 575–589 (2004). https://doi.org/10.1007/s00586-003-0615-y % of women with pelvic girdle pain will still experience lifelong problems

Mens JM, Huis YH, Pool-Goudzwaard A. Severity of signs and symptoms in lumbopelvic pain during pregnancy. Manual therapy. 2012 Apr 1;17(2):175-9.

33% - 50% of pregnant females report PGP before 20 weeks of gestation and prevalence may reach 60 -70% in late pregnancy

Robinson HS, Mengshoel AM, Veierød MB, Vøllestad N. Pelvic girdle pain: potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum. Manual therapy. 2010 Dec 1;15(6):522-8.

Lumbar nerve root compression sometimes mimic SIJ radiculopathy In a study by Visser et al, 41% of the study popu.ation had a SIJ or SIJ and disc component. Visser LH, Nijssen PG, Tijssen CC, van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. Eur Spine J. 2013;22(7):1657-1664. doi:10.1007/s00586-013-2660-5

Risk factors for Pelvic Girdle Pain

Prior history of pregnancy

Orthopaedic Dysfunctions

Joint hypermobility

History of multiparity

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

Increased Body Mass Index (BMI)

Smoking

Work dissatisfaction

Lack of belief in improvement in the prognosis of pelvic girdle pain

Early onset of pain

Multiple pain locations

High number of pelvic pain provocation tests

Risk factors for persistent Pelvic Girdle Pain post partum

In a recent systematic review and meta-analysis the following risk factors for persistent pelvic girdle pain post partum 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

Wiezer M, Hage-Fransen MA, Otto A, Wieffer-Platvoet MS, Slotman MH, Nijhuis-van der Sanden MW, Pool-Goudzwaard AL. Risk factors for pelvic girdle pain postpartum and pregnancy related low back pain postpartum; a systematic review and meta-analysis. Musculoskeletal Science and Practice. 2020 May 5:102154.

Clinical Presentation of Pelvic Girdle Pain

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

Onset of pain may occur around the 18th week of pregnancy and may reach peak intensity between the 24th and 36 the week of pregnancy.

Pain resolves by 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. (Vleeming 2008)

Pain can be local or local with radiculopathy

Fortin’s area – rectangular area that runs from the PSIS 3cm lateral and 10 cm caudal

One finger method - Person will often use one finger and 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 radiate in the posterior thigh and can occur in conjunction with/or separately in the the symphysis

Pain may be described as stabbing, dull, shooting or burning sensation

Pain intensity on VAS averages around 50 -60mm

Functional Complaints

Issues with transitional movements such as:

Difficulty getting out of a car

Difficulty getting up or out of chair

Difficulty with mobility

May have difficulty with stairs

May have difficulty with walking

Difficulty with standing on one leg – fail blow transfer – going from one leg to another

Rolling over in bed – often the worst symptom

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Prognosis

Wuytak et al (2018) 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 investigate 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 post partum:

History of low back pain

Pain in three to four pelvic locations

Overweight

Six months post partum, pelvic girdle pain or PGS is more likely to persist in:

Use of crutches during pregnancy

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 subgroup of women who had to use crutches during pregnancy, with women who had instrumental birth or caesarean section more likely to have persistent (severe) PGS

Emotional distress during pregnancy

Conclusion

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