Pelvic Girdle Pain
The pelvis consists of large bones (ilium, pubis and sacrum), interconnected by very strong ligaments, and controlled by the large and powerful hip and trunk muscles. The pelvis provides a platform for the spine to sit on and also the socket’s for the hip joints. The sacroiliac joints provide the link between the pelvic bones and the sacrum at the back, while the pubic symphysis provides the connection of the pelvic bones at the front of the pelvis.
Both the sacroiliac joints and the symphysis pubis are not designed for movement, but rather to safely transmit large forces from the legs to the trunk and vis versa. Because of this, the joints move very little (ie. 1-2 mm), and in later life (over 50 years) the sacroiliac joints actually fuse in most people.
What is pelvic girdle pain?
Pelvic girdle pain is a broad term that refers to pain related to the pelvic structures. This might include the joints (sacroiliac joints, pubic symphysis as well as the surrounds ligaments and muscles. Other names for pelvic girdle pain include – sacroiliac joint pain, buttock pain, pubic symphysis pain and groin pain.
Pain relating to these structures is usually felt around the buttock and/or groin region. This is usually related to pain provoked during weight bearing activities, such as standing, walking, stepping and running. It may also be provoked by movements and loading of the legs, such as lifting the leg and transferring load, such as when rolling in bed and when moving from sitting to standing.
How common is it?
Pelvic girdle pain is more common in females than in males. It is particularly common during the middle to later stages in pregnancy, where up to 80% of women may report pain in the low back and pelvic structures. For a small group of women (20%) this may become disabling and distressing.
Pelvic girdle pain can also occur in some forms of inflammatory arthritis, such as sacroiliitis or ankylosing spondylitis. This affects 0.5% of the population. In these conditions, pain arises from inflammation of the sacroiliac joints or pubic symphysis.
Pelvic girdle pain can also arise from a traumatic injury such as a blow to the pelvis related to a fall or accident.
There are a lot of MYTHS about pelvic girdle pain including:
✖ It’s always a sign of tissue damage and needs urgent medical attention
✖ Scans are always needed to diagnose the pelvic girdle pain
✖ Experiencing pelvic girdle pain means your pelvis is unstable, ligaments are lax or the pelvic bones are out of place
✖ Activities that provoke pain should always be avoided and rest is needed
✖ Loading your pelvis and participating in activities like running, lifting and twisting are dangerous and can injure the pelvis
✖ You need to tense the core to protect the pelvis
✖ If you have pelvic girdle pain it won’t go away.
✖ Surgery, injections and strong drugs are effective to treat pelvic girdle pain
The FACTS about pelvic girdle pain often surprise people. These include:
✔ Unless there are signs of a fracture from a trauma or inflammatory arthritis, scans are not usually helpful or required.
✔ While the pelvic ligaments become lax during pregnancy, this is a normal process and there is no evidence that ligament laxity is a predictor for pelvic girdle pain.
✔ The pelvic joints are incredibly stable and strong and don’t go out of place.
✔ While it is important to keep the muscles around the hips and pelvis strong – over tensing them (ie. bracing the core or holding tense upright postures) can be unhelpful.
✔ Rest is not a helpful treatment for pelvic girdle pain unless you have a fracture.
✔ The strongest predictors for pelvic girdle pain during pregnancy include a previous history of back pain, high levels of stress, poor sleep, inactivity and low mood.
✔ Most people who develop pelvic girdle pain during pregnancy get better within 3 months after giving birth.
✔ Developing a positive mindset is one of the strongest predictors good outcomes for pregnancy related pelvic pain.
✔ Physiotherapy that includes education, relaxation techniques, graded strengthening and physical activity is effective in treating pelvic girdle pain.
What are the risk factors for pelvic girdle pain?
Pregnancy related pelvic girdle pain: Pelvic girdle pain can arise in the middle and later stages of pregnancy. The main risk factors include: a previous history of back pain, high levels of stress, poor sleep, inactivity and low mood. These factors can result in sensitivity of the pelvic structures.
Trauma related pelvic girdle pain: blow to the pelvis such as landing heavily on the sacrum can be very painful, resulting in sensitivity to the pelvic structures.
What does serious pelvic girdle pain look like? (1% of population)
- If you have had a traumatic injury to the pelvis like a fall off a ladder, seek medical advice to ensure you don’t have a fracture.
- If you are over 50, have had a previous history of cancer, aren’t feeling well, and have developed pelvic girdle pain for no apparent reason and it isn’t settling, then get checked by your doctor first.
- If you have pelvic girdle pain that is related to morning stiffness that lasts more than 30 minutes and is relieved by anti-inflammatory medication, get checked by your doctor for inflammatory arthritis.
What happens for most people when pelvic girdle pain becomes persistent?
For most people with pelvic girdle pain relating to pregnancy, they recover within 3 months of giving birth. Similarly, for people with pelvic girdle pain relating to a trauma, the pain usually resolve over 6-12 weeks.
When pain persists over 3 months (ie. after giving birth or after normal tissue healing time), then it is important to look for other factors that may be contributing to the pain.
These factors can include:
- over tensing the ‘core’ muscles and over protecting or stiffening the pelvis can also be unhelpful, leading to more pelvic pain – a bit like clenching the fist all the time.
- weakness of muscles around the pelvis and hip,
- avoidance of movement and activity,
- fear of pain and or movement,
- negative beliefs about the pelvis (“my pelvis is damaged, unstable or out of place and can’t be trusted”),
- high levels of stress, worries or anxiety, low mood,
- poor sleep and fatigue.
These factors can cause changes to the nervous system making the pelvic structures very sensitive.
Assessment of the people with pelvic girdle pain:
At Body Logic Physiotherapy, we have world leading clinical researchers skilled in the assessment and treatment of pelvic girdle pain.
We ask you to fill in some screening questionnaires to help us understand your pain experience and how it impacts on you.
Then the first and most important thing for us is to take time to hear your story and pain experience in your own words. We want to know your pain history, how your pain feels to you and how it impacts on all aspects of your life so we can help you get back doing what you like. We may ask you about things like your sleep, mood and activity levels. We want to know about your short and long-term goals. We will also screen you to ensure your pelvic pain isn’t caused by serious health problems.
Following this, we will conduct a comprehensive examination. This will usually involve looking at where you hurt, how you posture yourself and move, your ability to relax your pelvic and core muscles, as well as the strength of your hip and trunk muscles that support the pelvis. We may also do specific tests to determine what pelvis structures are causing the pain. We may also check things like your sensation and reflexes and do tests to check if your nerves are sensitive.
Based on all this information, we will then explain to you in simple language the factors that are contributing to your pelvic girdle pain, and discuss the best treatments options available to you.
It’s very important to understand that pelvic girdle pain usually improves with the right treatment, even if you have had it for many years. Physiotherapists at Body Logic Physiotherapy play a very important role in the treatment of pelvic girdle pain.
Treatment of pelvic girdle pain
If your pelvic girdle pain is related to pregnancy, we can identify the factors relating to your pain and develop a plan to manage it. This will involve strategies to provide you pain relief and restore your functional capacity. This may include hands on therapies, relaxation techniques, postural training to reduce stress on pain sensitive structures, gentle exercises to engage the muscles that support the pelvis as well as strategies to keep you strong and active. In some cases during late pregnancy wearing a ‘pelvic support’ can provide some relief. After birth we can provide you with a program to gradually get strong and active again as the sensitivity of the pelvic structures settles.
If your pelvic pain is related to a trauma, we may first screen for fractures. If there are no fractures, then the key is to help you find positions of comfort, teach you to relax the muscles around the pelvis, give you gentle exercises to keep the muscles engaged and strong and plan a graduated exercise program to get you going. Acute traumatic injuries to the pelvis are a bit like other joint sprain can take 6-8 weeks to recover. The key is to do all the right things to provide the best chance for quick recovery.
If your pelvic girdle pain is persistent (longer than 12 weeks), we will work out a plan with you to identify and address the key factors involved in your pain. We will help you take control of your pain, and get back to living based on your goals. Treatment will involve education regarding the relevant factors for you. It may involve some hands-on techniques to relax you and get you moving, coaching you in body relaxation, training you to restore relaxed spinal movement, help you get strong and confident, resumption of physical activity and where relevant sleep rehabilitation.
At Body Logic Physiotherapy, we are not interested in ongoing band-aid treatments for your pelvic girdle pain. We know that the best way to manage pain is to help you understand why you have pain, and get you back in control, moving, active and living again.
For some people this may take 2-3 sessions; however, for long term problems, this may take up to 7-10 sessions over a 3-4 month period. We also offer supervised exercise rehabilitation classes and one-to-one sessions to support this process if needed.
Where required, we will also work on a coordinated approach with your care team such as GP, pain specialist and psychologist.
At Body Logic Physiotherapy, we aim to coach people to get back in charge of their health.