Post-partum Pelvic Girdle Pain

Patient Education

Many women have complaints of back pain during and after pregnancy.  One study showed that up to 45% of pregnant women have musculoskeletal low back and/or pelvic pain.1  Musculoskeletal pain describes pain coming from the bones, joints, ligaments and muscles as opposed to pain coming from internal organs.

Pelvic girdle pain (PGP) is a term used by some health care providers to describe low back pain / pelvic pain arising in the area between the posterior iliac crests (the top most part of the pelvic bones in the low back / buttock area) and the gluteal folds (creases at the bottom of the buttocks).  This area includes the sacroiliac joints and the pain may radiate into the back of the thighs.2,3

Pelvic girdle pain that begins during or soon after pregnancy and that does not resolve after pregnancy is called post-partum pelvic girdle pain (PPGP).2

The sacroiliac (SI) joints are located between the spine and the hip joints. The SI joints are responsible for absorbing and transferring the large amounts of force that are generated in the spine and lower extremities during physical activities.  The SI joints are particularly vulnerable to injury because of their location and their orientation.  The SI joints provide the crucial balance between pelvis stability and pelvis mobility.

Post-partum pelvic girdle pain (PPGP) (which may include the SI joint(s)) will resolve in most women within 4 months after giving birth,4 but 20% of women who experience this pain during and immediately after pregnancy report continuing pain 2 and 3 years postpartum.5  The underlying causes of PPGP are not well defined, with the explanation most likely being a combination of hormonal, biomechanical, and traumatic factors.6

Hormonal: Relaxin is a hormone that the body produces in increased amounts during pregnancy.  This hormone helps increase the flexibility of the ligaments that support the SI joints.  This facilitates the widening of the birth canal that occurs during delivery.

Biomechanical: As pregnancy progresses, some of the core muscles (transverse abdominals and pelvic floor) are stretched due to the increasing size and weight of the fetus.  Stretch of these muscles lead to a decrease in the ability of these muscles to stabilize the pelvic joints

As the fetus grows during pregnancy, the center of gravity shifts forward and remains forward in the post-partum period.  This typically results in a forward rotation of the pelvic bones, leading to increased load, decreased functional stability and increased wear and tear of the SI joints.7

Traumatic: 52% of women with pregnancy related low back and pelvic pain have pelvic floor dysfunction including a change in the firing of the muscles (change of motor control).8  This may be due to direct injury of the pelvic floor muscles or injury to the nerves that innervate the pelvic floor muscles during pregnancy and/or delivery.  A biomechanical study by Pel showed increased stability of the SI joints with contraction of the pelvic floor and the transverse abdominal muscles together.9

Diagnosis of PPGP/SI joint pain is usually made with history and physical examination.  Physical examination typically includes a series of provocative tests (physical maneuvers performed by the examiner that stress the SI joints in different directions).  Diagnosis is confirmed with a diagnostic SI joint injection.  During the injection procedure, a small amount of numbing medicine (a local anesthetic such as lidocaine) is injected into the SI joint under fluoroscopic guidance.  If the injection results in a significant decrease in SI joint pain (more than 75% pain relief) for an hour or two after the injection, then this is considered a positive or confirmatory diagnostic injection.  

There has been some research on the non-surgical treatment of PPGP including physical therapy and other conservative measures such as injections and RFA.  Physical therapy is performed to increase the functional stability of the pelvic (SI) joints. Physical therapy treatment of sacroiliac joint pain should ideally address the underlying muscle and ligament problems. Treatments with a physical therapist will typically focus on restoring normal pelvis and core muscle stability (Transversus Abdominis, Multifidus and Pelvic Floor muscles) as these muscles are responsible for what is known as Force Closure of the pelvis,6 which creates a dynamic active compressive force and stabilization of the SI joints.  Physical therapy is a therapeutic option that may provide relief for some women, but has also been shown to exacerbate symptoms in others.

This treatment along with exercises to improve general spinal stability, improve body mechanics, correct postural problems, strengthen and/or stretch specific muscles to balance the muscle groups that surround, attach to, and support the SI joints, combined with general physical conditioning are considered “best practice.” There is little formal research to support these recommendations as the treatments are highly individualized to the specific patient making it difficult to draw conclusions across a broad range of patients.

An SI belt, a non-elastic strap placed temporarily around the pelvic joints, has also been found to reduce the sensation of abnormal movement and may aid with symptom reduction.10,11  Other non-surgical treatment options include injection of medications (steroids) into the joint to decrease inflammation and pain, and radiofrequency ablation (RFA). RFA is a procedure where heat or cold is used to temporarily deaden the sensory nerves over the SI joints in order to decrease their ability to transmit pain signals coming from the SI joint.

If a patient continues to have disabling SI joint pain after 6 months or more of appropriate non-surgical treatment, then the patient may benefit from an iFuse minimally invasive surgical (MIS) procedure to fuse the SI joint. The iFuse procedure, available since 2009, has been shown to provide improvement in pain, disability and quality of life in many high-quality studies including two randomized controlled trials (RCTs).12,13  Patients with SI joint pain that began in the peri-partum period that received the iFuse procedure showed significant long-term reduction in pain and marked improvement in physical function and in quality of life.14

The sacroiliac joint is a source of pain in approximately 75% of women with persistent PPGP.14  For carefully selected women with chronic post-partum related SI joint dysfunction that hasn’t responded to conservative treatment, MIS SI joint fusion performed with the iFuse Implant System may be a valuable treatment option.

 

For more information about the SI joint and low back pain, visit: SI-BONE.com

 

 

References

  1. Wu WH, Meijer OG, Uegaki K, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575-589. doi:10.1007/s00586-003-0615-y.
  2. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract Off J World Inst Pain. 2010;10(1):60-71. doi:10.1111/j.1533-2500.2009.00327.x.
  3. Gutke A, Ostgaard HC, Oberg B. Predicting persistent pregnancy-related low back pain. Spine. 2008;33(12):E386-393. doi:10.1097/BRS.0b013e31817331a4.
  4. Ostgaard HC, Andersson GB. Postpartum low-back pain. Spine. 1992;17(1):53-55.
  5. Norén L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J. 2002;11(3):267-271. doi:10.1007/s00586-001-0357-7.
  6. Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794-819. doi:10.1007/s00586-008-0602-4.
  7. DonTigny RL. A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction. In: Movement, Stability, and Low Back Pain: The Essential Role of the Pelvis. Second. Elsevier; 2007:265-278.
  8. Pool-Goudzwaard AL, Slieker ten Hove MCPH, Vierhout ME, et al. Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):468-474. doi:10.1007/s00192-005-1292-7.
  9. Pel JJM, Spoor CW, Pool-Goudzwaard AL, Hoek van Dijke GA, Snijders CJ. Biomechanical analysis of reducing sacroiliac joint shear load by optimization of pelvic muscle and ligament forces. Ann Biomed Eng. 2008;36(3):415-424. doi:10.1007/s10439-007-9385-8.
  10. Damen L, Spoor CW, Snijders CJ, Stam HJ. Does a pelvic belt influence sacroiliac joint laxity? Clin Biomech Bristol Avon. 2002;17(7):495-498.
  11. Vleeming A, van Wingerden JP, Dijkstra PF, Stoeckart R, Snijders CJ, Stijnen T. Mobility in the sacroiliac joints in the elderly: a kinematic and radiologic study. Clin Biomech. 1992;7(1):170-176.
  12. Polly DW, Swofford J, Whang PG, et al. Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. Int J Spine Surg. 2016;10:Article 28. doi:10.14444/3028.
  13. Dengler J, Kools D, Pflugmacher R, et al. 1-Year Results of a Randomized Controlled Trial of Conservative Management vs. Minimally Invasive Surgical Treatment for Sacroiliac Joint Pain. Pain Physician. 2017;20:537-550.
  14. Capobianco R, Cher D, SIFI Study Group. Safety and effectiveness of minimally invasive sacroiliac joint fusion in women with persistent post-partum posterior pelvic girdle pain: 12-month outcomes from a prospective, multi-center trial. SpringerPlus. 2015;4:570. doi:10.1186/s40064-015-1359-y.

The iFuse Implant System® is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes conditions whose symptoms began during pregnancy or in the peripartum period and have persisted postpartum for more than 6 months.

Talk to your doctor to see if the iFuse Implant System is right for you. There are potential risks associated with the iFuse Implant System. It may not be appropriate for all patients and all patients may not benefit. For information about the risks, visit: www.si-bone.com/risks

For comprehensive information about iFuse and some causes of SI Joint pain and dysfunction, please visit

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