Recognising Pelvic Girdle Pain: Difference between revisions
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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. | 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 | == 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.<ref name=":0" /> The physiotherapist should proceed with caution or consider medical referral if there is a history of any of the following<ref>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.</ref>: | |||
In the | * History of trauma | ||
* Unexplained weight loss | |||
* History of cancer | |||
* Steroid use | |||
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. | * Drug abuse | ||
* Human immunodeficiency virus | |||
History of trauma | * Immunosuppressed state | ||
* Neurological symptoms/signs | |||
Unexplained weight loss | * Fever | ||
* Systemically unwell | |||
History of cancer | * Special considerations for Pelvic Girdle Pain should include: | ||
** Symptoms due to uterine abruption | |||
Steroid use | ** Referred pain due to urinary tract infection to the lower abdomen/pelvic or sacral region | ||
* Other factors that may require medical specialist referral include: | |||
Drug abuse | ** No functional improvement | ||
** Pain not reducing with rest | |||
Human immunodeficiency virus | ** Severe, disabling pain | ||
* Diastasis Rectus Abdominis (DRA) | |||
Immunosuppressed state | ** Pelvic floor weakness associated with weakness of abdominal wall in DRA | ||
** 66% incidence of DRA in antepartum population in third trimester | |||
Neurological symptoms/signs | ** DRA occurs in 39% of the postpartum population after 7 weeks to several years | ||
* Other orthopaedic problems | |||
Fever | ** Presence of hip dysfunction | ||
** Possibility of femoral neck stress fracture due to transient osteoporosis | |||
Systemically unwell | ** Hip bursitis/ tendinopathy | ||
** Chondral damage/loose bodies | |||
Special considerations for | ** Capsular laxity | ||
** Femoral acetabular Impingement | |||
Symptoms due to uterine abruption | ** Labral irritations/tears | ||
** Muscle strains | |||
Referred pain due to urinary tract infection to the lower abdomen/pelvic or sacral region | ** Referred pain from L2/3 radiculopathy | ||
** Osteonechrosis of the femoral head | |||
Other factors that may require medical specialist referral include: | ** Paget’s disease | ||
** Arthritis – rheumatoid, psoriatic and septic | |||
No functional improvement | ** Lumbar spine dysfunctions | ||
** Spondylolisthesis | |||
Pain not reducing with rest | ** Discal patterns of symptoms that fail to centralise | ||
** Neurological screening that indicate presence of lower motor neuron or upper motor neuron signs | |||
Severe, disabling pain | ** 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 | ||
Diastasis Rectus Abdominis | |||
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 | Differentiation between PGP and PLBP – useful to use a patient pain distribution diagram | ||
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PLBP – concentrated in lumbar region, above the sacrum | PLBP – concentrated in lumbar region, above the sacrum | ||
Prevalence of Pelvic Girdle Pain | == Prevalence of Pelvic Girdle Pain == | ||
Worldwide between 5 – 10% of people develop chronic low back pain. This leads to<ref>Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.</ref>: | |||
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 | |||
Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73. | |||
It is also widely accepted that the SIJ is a pain generator in 10-30% of low back pain cases | It is also widely accepted that the SIJ is a pain generator in 10-30% of low back pain cases |
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Introduction[edit | edit source]
Definition of Pelvic Girdle Pain[edit | edit source]
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."[1]
Clinton et al (2017)[2] 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."[2]
Causes of Pelvic Girdle Pain[edit | edit source]
- 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[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.[2] The physiotherapist should proceed with caution or consider medical referral if there is a history of any of the following[3]:
- 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[edit | edit source]
Worldwide between 5 – 10% of people develop chronic low back pain. This leads to[4]:
- 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
Add content from other PP page
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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References[edit | edit source]
- ↑ 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.
- ↑ 2.0 2.1 2.2 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.
- ↑ 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.
- ↑ Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.