Pregnancy is a time filled with a rollercoaster of emotions - nervousness, excitement, anticipation - and unfortunately for almost one-third of expectant mothers, one where they’ll encounter a painful condition called symphysis pubis dysfunction.[1]
Often referred to as “pelvic girdle pain”, symphysis pubis dysfunction (SPD) describes the pain at the front of a joint called the symphysis pubis, where the right and left pubic bones meet. These bones are firmly connected by a small fibrocartilaginous disc with four primary supporting ligaments that allow very little movement of the joint in everyday life. In pregnancy, however, things change significantly. This is in some part connected to a hormone called relaxin pumping through the body in pregnant women to allow some relaxation and adjustments to the position of the pelvis during childbirth. With the ligaments that are responsible for providing stability to the symphysis pubis joint potentially becoming more lax as early as the first trimester[2], this can lead to pelvic pain and discomfort in some cases.
Symphysis Pubis Dysfunction Symptoms
When we see women with SPD, they can often pinpoint notable pain in the pubic region that is aggravated when getting out of the car (where one leg comes out first followed by the other), getting out of bed, climbing stairs, getting dressed, and performing activities that involve weight-bearing on one leg - like when putting pants on when getting dressed in the morning. The clinically defined symptoms of SPD include[3]:- “Shooting” pain in the symphysis pubis
- Radiating pain into the lower abdomen, back, groin, perineum, thigh, and/or leg
- Pain on movement, especially walking, unilateral weight bearing or hip abduction
- Pain with activities of daily living, including bending forward, standing on one leg, rising from a chair, going up or down stairs, turning in bed
- Pain is relieved by rest
- Clicking, snapping or grinding heard or felt within the symphysis pubis
- Dyspareunia (genital pain during intercourse)
- Occasional difficulty voiding (urinary hesitancy)
- Feeling fatigued without a clear source
What Causes Symphysis Pubis Dysfunction
While the aforementioned laxity effects of the hormone relaxin is undisputed, pregnancy itself also leads to a greatly increased pelvic load with greater muscle weakness. Additional predisposing factors[4] may include a multiples pregnancy of carrying twins, triplets or higher order multiples, a history of oral contraceptive use, high weight gain during pregnancy, high levels of stress, a history of low back pain, previous pelvic trauma, hypermobility, increased tightness in help and pelvic floor muscles, a lack of regular exercise, postpartum breastfeeding - even low job satisfaction has been identified as a potential predisposing factor.
Five Physio Tips For Symphysis Pubis Dysfunction
With physiotherapy being proven to play a beneficial role in managing SPD, here are five small but powerful tips to help you manage your SPD[5] throughout the remainder of your pregnancy to help keep you as comfortable as possible.
1. Keep Your Legs Together
Whether you’re getting out of the car or out of bed, movements that have one leg abducting away from the other and then loading that leg will irritate your symphysis pubis and bring on your symptoms. Try:- Placing a plastic bag on your seat in the car to enable you to ‘swivel’ your entire body to face both legs out of the car at the same time, and stand with even weight distribution over both legs
- Sit down while getting dressed to avoid lifting one leg in the air while remaining weight-bearing on the other
- When rolling over in bed at night, keep your knees together. This may mean going up on your knees in order to change directions - which may seem inconvenient at first, but you may find it much more comfortable than experiencing that shooting SPD pain.
2. Avoid One-Sided Loading
For many expectant mothers we see, they already spend a large part of their day doing one-sided-loading in the form of carrying another toddler or infant on one hip. Unfortunately, this is a common aggravating factor for SPD, and one you need to try to minimise as much as daily life allows. This can look like:- Getting a stand-up kitchen aid that allows your toddler to climb up to see what is happening around you when preparing meals, instead of being held on one hip
- Getting step-up stools for areas like the bathroom, if they’re currently primarily being held
- Having your partner perform tasks like getting them in their cot, or into or out from their car seats
Similarly, even if you don’t have older children, you want to avoid standing in a hip-hitching position where the majority of your weight falls on one leg for the same reasons.
3. Replace A Weekly Session Of Walking With Swimming
Expecting us to recommend stopping any strenuous activity? This is definitely a good recommendation - but the chances are that if you’re experiencing SPD, you already won't be participating in much strenuous activities. With this said, many expectant mothers still continue to walk throughout their pregnancy in order to meet exercise guidelines and prioritise their health and well-being during pregnancy. Unfortunately, if we consider what happens during walking - it’s really a lot of repetitive one-sided loading, which isn’t ideal for your pubic pain. This is where two things can help:- Reducing your stride length, as the longer you stride, the more pressure goes up through the pubis symphysis and sacroiliac joints.
- Switching a planned walk to a swim or aqua aerobics session. Being in the water will greatly reduce the pressure and strain on the symphysis pubis, so you feel less sore.
4. Wear A Pelvic Support Belt
For when you do need to walk or complete errands, wearing a lumbopelvic support belt may, in some cases, help to greatly reduce pain and improve function, depending on the reason behind the pain[6]. Though it’s important to note that belts are generally recommended alongside exercises, and not as a replacement for.
5. Complete Your Physio Exercises For SPD
When you see your physiotherapist for your SPD pain, it is highly likely that they will prescribe several exercises, ranging from pelvic floor and core stability exercises to exercises to support the hip rotators. These often start off being very simple, and do not cause any further aggravation to your pubic symphysis. Your physiotherapist can also perform an internal pelvic assessment to see if there is tightness and trigger points in the pelvic floor muscles that are contributing to pain, as well as soft tissue work in the gluteal muscles. We are also able to do scar tissue massage if a client has had a c-section, as this can cause pulling in the pelvic region too. While you’ll be given your own tailored program based on your unique circumstances and needs, it may include:
Pelvic Tilts
- Starting position: Sitting up tall on gym ball or a chair
- Breathe in and as you breathe out draw in your abdominal muscles and tilt your pelvis back so that you are sitting on your tailbone and lowest part of your spine
- Breathe in as you sit up straight again
- Repeat 15-20 times
Cat Stretch
- Starting position: On hands and knees, ensure your hands are under your shoulders and your knees are under hips
- Draw in your tummy as you arch your back up like a cat as far as comfortable
- Hold for 5 seconds before returning to neutral position
- Repeat 10-15 times
Clam Shells
- Starting position: Lying on your side with your knees and hips bent
- Gently draw in your tummy
- Lift your top knee away from your bottom knee as far as is comfortable. Please note that this is typically a very small movement with symphysis pubis dysfunction, as you do not want to separate your legs too much. Even 15-20 cm is a good distance to raise the upper knee. Keep your ankles touching
- Do not let your pelvis roll backwards
- Repeat 15 times on each side
References
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364059/
- https://www.tandfonline.com/doi/abs/10.1080/01443610500363915
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364059/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364059/
- https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1576/toag.8.3.153.27250
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364059/