Recognising Pelvic Girdle Pain

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Introduction[edit | edit source]

Definition of Pelvic Girdle Pain[edit | edit source]

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.[1] The European guidelines and most adhered to 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."[2]

Clinton et al (2017)[3] uses the following definition in their clinical practice guidelines for pelvic girdle pain in the antepartum population : "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."[3]

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.[4] Palpation of the erector spinae muscles exacerbates pain.[4]

Causes of Pelvic Girdle Pain[edit | edit source]

Pelvic girdle pain (PGP) refers to musculoskeletal disorders that affects the pelvis, and primarily involves the sacroiliac joint, symphysis pubis and associated ligaments and muscles, and considering these structures within the broader kinetic chain.[5]

  • Pelvic girdle pain is 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.

Other causes of pelvic pain may include:

  • 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[edit | edit source]

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.[3] The physiotherapist should proceed with caution or consider medical referral if there is a history of any of the following[6]:

  • 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
    • Disc injury patterns with 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

Prevalence of Pelvic Girdle Pain[edit | edit source]

Worldwide between 5 – 10% of people develop chronic low back pain. This leads to[7]:

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

Lumbar nerve root compression sometimes mimic Sacroiliac joint radiculopathy. In a study by Visser et al (2013)[8] 41% of the study population had a Sacroiliac joint or Sacroiliac joint and disc component.[8]

It is also widely accepted that the Sacroiliac joint is a pain generator in 10-30% of low back pain cases.[9]

Prevalence of Pregnancy-related Lumbar Back Pain (PLBP) and Pelvic Girdle Pain[edit | edit source]

  • 56% to 72% of the antepartum population[10][11]
  • 20% of antepartum population report severe symptoms during 20 -30 weeks of gestation[10][11]
  • 7% of women with pelvic girdle pain will still experience lifelong problems[10][11]
  • 33% - 50% of pregnant females report PGP before 20 weeks of gestation and prevalence may reach 60 -70% in late pregnancy[12]

Risk factors for Pelvic Girdle Pain[edit | edit source]

  • 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 positive pelvic pain provocation tests

Risk factors for persistent Pelvic Girdle Pain Postpartum[edit | edit source]

In a recent systematic review and meta-analysis the following risk factors for persistent pelvic girdle pain postpartum have been identified[13]:

  • 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[edit | edit source]

  • 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
  • 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

Functional Complaints[edit | edit source]

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[edit | edit source]

Wuytak et al (2018)[14] 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 postpartum[14]:

  • History of low back pain
  • Pain in three to four pelvic locations
  • Overweight
  • Six months postpartum, pelvic girdle pain or PGS 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 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[edit | edit source]

Sub Heading 3[edit | edit source]

Resources[edit | edit source]

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References[edit | edit source]

  1. ↑ Bergström C, Persson M, Mogren I. Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy–pain status, self-rated health and family situation. BMC pregnancy and childbirth. 2014 Dec 1;14(1):48.
  2. ↑ Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal. 2008 Jun 1;17(6):794-819.
  3. ↑ 3.0 3.1 3.2 Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic girdle pain in the antepartum population: physical therapy clinical practice guidelines linked to the international classification of functioning, disability, and health from the section on women's health and the orthopaedic section of the American Physical Therapy Association. Journal of Women's Health Physical Therapy. 2017 May 1;41(2):102-25.
  4. ↑ 4.0 4.1 Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Practice. 2010 Jan;10(1):60-71.
  5. ↑ Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of anatomy. 2012 Dec;221(6):537-67.
  6. ↑ Koes BW, Van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal. 2010 Dec 1;19(12):2075-94.
  7. ↑ Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.
  8. ↑ 8.0 8.1 Visser LH, Nijssen PG, Tijssen CC, Van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. European Spine Journal. 2013 Jul 1;22(7):1657-64.
  9. ↑ Booth J, Morris S. The sacroiliac joint–Victim or culprit. Best Practice & Research Clinical Rheumatology. 2019 Feb 1;33(1):88-101.
  10. ↑ 10.0 10.1 10.2 Wu WH, Meijer OG, Uegaki K, Mens JM, Van Dieen JH, Wuisman PI, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal. 2004 Nov 1;13(7):575-89.
  11. ↑ 11.0 11.1 11.2 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.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 14.0 14.1 Wuytack F, Daly D, Curtis E, Begley C. Prognostic factors for pregnancy-related pelvic girdle pain, a systematic review. Midwifery. 2018 Nov 1;66:70-8.
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