Please note : Symphysis Pubis Dysfunction (SPD) is now being referred as Pelvic Girdle Pain (PGP). They are both the same condition. There is no difference between the two. However this has been a fairly recent change and "symphysis Pubis dysfunction" or "spd" is still commonly used and may be the name you come across when you visit your GP or attend for antenatal care.
What is Pelvic Girdle Pain/Symphysis Pubis Dysfunction(SPD)?
Pelvic Girdle Pain/Symphysis Pubis Dysfunction is a condition which causes pain in one or more joints of the pelvis and difficulty walking. It is most commonly associated with pregnancy but can also occur in women who are not pregnant and men too, sometimes as a result of injury or trauma.
The diagram of the pelvis above demonstrates the position of the sacro iliac joints and the symphysis pubis joint. These joints are supported by strong ligaments and over 35 muscles which attach at various points to the pelvis and spine.
The pelvis is shown on its own for simplicity sake but in practical terms the pelvis is closely linked with the spine and the hips as the sacrum forms the base of the spine and the pelvis accommodates the hip joints, one on either side. Therefore the way that the pelvis functions can also be affected by any problem affecting these areas such as a previous injury to the lower back or a hip problem.
What are the symptoms of SPD, PGP?
It can start at any point through your pregnancy, and there are no hard and fast rules either, some women get an uncomfortable throb in the groin other women have such severe pain they find it difficult to walk, the symptoms can range from any of the following
· pubic pain
· pubic tenderness to the touch; having the fundal height measured may be uncomfortable
· lower back pain, especially in the sacro-iliac area
· difficulty/pain rolling over in bed
· Difficulty/pain with stairs, getting in and out of cars, sitting down or getting up, putting on clothes, bending, lifting, standing on one foot, lifting heavy objects, etc.
· sciatica type symptoms (pain in buttocks and down the leg)
· “clicking” in the pelvis when walking
· waddling gait
· difficulty getting started walking, especially after sleep
· feeling like hip is out of place or has to pop into place before walking
· bladder dysfunction (temporary incontinence at change in position)
· knee pain or pain in other areas can sometimes also be a side-effect of pelvis problems
Tightness in the upper back
The pain is usually made worse by separating your legs, walking, going up or down stairs or moving around in bed. It is often much worse at night and can stop you getting much sleep. Getting up to go to the toilet in the middle of the night can be especially painful.
What causes Pelvic Girdle Pain/Symphysis Pubis Dysfunction?
No one knows the exact cause but a number of different factors have been identified which include
In pregnancy there is an increase in the amount amount of the hormone relaxin which causes softening of the ligaments throughout the whole body. As a result the muscles around the lower back and pelvis have to work harder to support the body and in some cases these muscles over work resulting in pain.
Postural changes occuring in pregnancy due to the growing size and weight of the baby
The pelvic floor muscles which normally support the pelvis not working as efffectively as normal because of the weight of the baby sitting on the pelvic floor.
The abdominal muscles and the rib cage being stretched by the growing baby
Differences in movement between the joints of the pelvis particularly the sacro iliac joints at the back of the pelvis can be associated with pain
Research has found that in all post natal women there is some amount of widening of the symphysis pubis joint at the front of the pelvis and this varies greatly from women to women. Interestingly no link has been found between the amount of widening and pelvic pain either during pregnancy or post natally. Women with gaps which are considered within normal limits can and do experience pain.
Why do some people get pelvic girdle pain in pregnancy and not others?
There is no clear answer as to why many women develop pelvic girdle pain. It was traditionally thought that it was purely the pregnancy hormones especially relaxin that were the cause of pelvic girdle pain/symphysis pubis dysfunction(SPD) and this is still quoted as the reason on many pregnancy and baby websites. Other factors, such as differences in the way that the sacro iliac joints at the back of the pelvis move1 and differences in the way that the muscles are controlled have been shown to be important.
Women who have previously had either pain in their lower back, an injury to their pelvis or pelvic girdle pain in a previous pregnancy are more likely to be affected.
Things which have NOT been shown to be associated are
The oral contraceptive pill
Length of time since the last pregnancy
How is Pelvic Girdle Pain/Symphysis Pubis Dysfunction(SPD) Diagnosed?
It is diagnosed by your own description of where you are experiencing pain and what other symptoms you have combined with a series of tests designed to look at the stability, movement and pain in your pelvic joints and an assessment of how your muscles and nerves function.
What stage in the pregnancy do you get it?
Pelvic Girdle Pain can start at any stage of your pregnancy or after delivery. Many women notice their symptoms for the first time around the middle of their pregnancy.
What is the cure for Pelvic Girdle Pain/Symphysis Pubis Dysfunction?
There is no hard and fast cure for pelvic girdle pain/symphysis pubis dysfunction.(spd). Many women have reported improvement in their symptoms following a combination of manual or hands on therapy to treat any underlying joint dysfunction or joint misalignment followed by an exercise programme.
Research which studied postnatal women with pelvic girdle pain has shown that an individually designed programme of exercises to improve the stability of the pelvis is of benefit2.
A pelvic support belt to provide support to the pelvis can also be useful as a temporary measure along with an exercise programme. If you experience increased pain when using the belt, go back and see your physiotherapist as this may indicate a joint misalignment problem. If the only treatment you are offered is a belt and you are still having problems with pain and/or mobility go back and ask to be reassessed.
Having treatment from a physiotherapist with experience and knowledge of managing pelvic girdle pain/symphysis pubis dysfunction can make a huge difference.
Other therapies that may be useful include osteopathy and chiropractic but it is essential that you see a registered practioner who is experienced in treating pelvic girdle pain.
Treating tight overactive muscles using massage or similar techniques from a soft tissue therapist can also be a very helpful part of treatment.
Can I give birth naturally or will I require a C-Section?
Natural Birth is generally advised as the best option for the vast majority of women with pelvic girdle pain (PGP) with the exception of a very small percentage of women with severe symptoms who are unable to maintain any comfortable birthing position and in whom C-section may be considered as an option. It is important that your midwife and any person involved in your labour and delivery is made aware of the PGP, as certain positions are best avoided during delivery. Try to avoid giving birth lying on your back. Your physiotherapist or midwife can help you to devise a birth plan which takes your PGP symptoms into account. Ensure that your birth partner is aware of how your PGP affects you and what positions are comfortable for you. Our pregnancy page has further information.
Is there anything I can do to ease the pain?
Listen to your body, if something hurts, don’t do it, don’t be tempted to “push past the pain” as this can flare up your pain and it can take longer to settle down.
Move little and often. Rest regularly; although you may not feel very sore now, it can be worse once you do relax
Don't push through the pain. Don't be afraid to ask for help.
Avoid heavy lifting or pushing (supermarket trolleys can be particularly painful).
When dressing, sit down to put on clothing such as your knickers or trousers. Pull the clothing over your feet and then stand up to pull them up. Don't try to put your legs into trousers, skirts or knickers whilst standing up.
If you need to climb stairs, do so one step at a time, step up onto the step with your strongest, or least painful leg then bring your other leg up to meet it, repeat with each step.
Sometimes, sleeping on a softer surface can help. Try placing a duvet under your sheet.
when swimming avoid breaststroke, and take care with other strokes, ask your physiotherapist for advice. Exercises in water can be helpful and sometimes just immersing in the water can give good pain relief. Many women have reported water an effective method of pain relief in labour
Ask your physiotherapist for advice on ways to reduce pain during normal day to day activities
Acupuncture and TENS can be useful for pain relief.
Have a look at our page on pain management page for further information
How soon will I recover from my SPD symptoms after the birth?
Many women find that their pain levels and mobility will improve after the birth of their baby although this does vary considerably, with some women noticing an immediate improvement in symptoms, while others may experience a more gradual recovery over days or weeks. A small percentage of women will have ongoing symptoms, especially if the condition is untreated. One study which looked at the first 2 years after giving birth found that untreated, 7% of women had symptoms which persisted for 2 years.
Your ligaments will take some time to tighten up again as the effect of the pregnancy hormones gradually wears off and your muscles, especially your tummy and pelvic floor will have been stretched by the pregnancy and delivery so avoid over doing things in the first few months after your baby is born.Be especially careful with lifting and avoid heavy lifting. Follow advice from your physiotherapist regarding exercises to strengthen these areas and how to plan a gradual return to activities.
If you are experiencing symptoms postnatally don't delay in asking for a referral to a physiotherapist with experience in treating pelvic girdle pain or be fobbed off with "its just your hormones settling down". The earlier your problems are recognised and treated the quicker your mobility will improve and your pain reduce. The physiotherapist will perform a through assessment to determine which structures are causing pain and plan a treatment programme for you. If you are having difficulty finding a physiotherapist to treat you please contact us at firstname.lastname@example.org and we will do our best to help.
Some ex-sufferers find they experience pain every month sometimes in the middle of their cycle or just before their period is due, which is felt to be due to the hormones produced which have a similar effect to the hormones during pregnancy. If this is the case it is worth going back to your GP and asking for a referral back to a physiotherapist for further assessment. Have a look at our treatment and core stability pages for further information.
I have symptoms similar to Pelvic Girdle Pain/Symphysis Pubis Dysfunction but I am not pregnant. Is this possible?
Yes. Although Pelvic Girdle Pain/Symphysis pubis dysfunction is more commonly associated with pregnancy it can occur in women who are not pregnant and men too. It is important that you ask for a referral to a physiotherapist with experience in managing pelvic girdle pain for further assessment and diagnosis of your symptoms. This may be a women's health physiotherapist, a musculoskeletal physiotherapist or sometimes a physiotherapist specialising in sport's injuries.
I have been referred to an Orthopaedic surgeon. What might I expect?
If your symptoms are not settling with treatment from an experienced physiotherapist you may be referred to an Orthopaedic Surgeon. The tests that they will do will depend on your own individual circumstances but may include:
Physical examination of your spine, pelvis and hips
Stork X rays - this involves x rays taken of your pelvis while standing on one leg and be useful for detecting movement of the symphyis pubis joint.
Ultra sound or MRI scan
Occassionally a bone scan
You may be offered a steroid injection into the symphysis pubis joint and some women find this helpful especially if used in conjunction with an exercise programme.
What is Prolotherapy?
A small proportion of people with pelvic girdle pain have true instability of the ligaments of their pelvic joints and are unable to control joint movement through exercises alone.
Prolotherapy is a treatment in which an irritant solution is injected into the ligaments to produce an inflammatory reaction. This in turn promotes the production of collagen which increases the stiffness of the ligament. Treatment is typically given every few weeks for 4-6 sessions.
This is a highly specialised area and there are a few centres in the UK which offer this type of treatment.
Click here to access some further information about prolotherapy from the British Institute of Musculoskeletal Medicine.
What about surgery for Pelvic Girdle Pain/Symphysis Pubis Dysfunction?
In a few cases of women with severe pelvic girdle pain, surgery to plate the symphysis pubis joint and sometimes also fuse the sacro iliac joints may be offered.The recent guidelines from the ACPWH and the European Guidelines on the management of pelvic girdle pain both suggest that surgery for pelvic girdle pain should only be considerd if all non surgical treatment options have failed by a professional with expert knowledge of the condition. Surgery has an unpredictable outcome and there is inadequate research in this area. If you are considering surgery and would like to be put in touch with someone who has had surgery for pelvic girdle pain please contact us by email at email@example.com
Am I eligible to apply for any benefits?
If you have had symptoms significantly affecting your mobility and/or activities of daily living for at least three months and are expected to have symptoms for another six months you may be eligible for Disability Living Allowance. This benefit is not means tested. You may be eligible for other benefits. Have a look at our Practical Advice page for further information on managing day to day activties, benefits and parking badges.
Free Membership of PINS
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1.Damen L, Buyruk HM, Guler-Uysal F, Lotgering FK, Snides OJ, Stam HJ, Pelvic Pain during pregnancy is associated with asymmetric laxity of the sacro-iliac joints Acta Obstet Gynecol Scand 2001 80(11) 1019-1024
2. Stuge B, Laerum E, Kirkesola G, Vollestad N 2004 The efficacy of a treatment program focusing on specific stabilising exercises for Pelvic Girdle Pain after pregnancy. Spine 29 (4) : 351