Pelvic Girdle Pain

Lessons learned from treating PGP over a 20 year career.

Pelvic Girdle Pain is a broad term which describes pain in the buttock, pubic and groin region during pregnancy.

I first treated pubic symphysis pain in sportspeople- usually men- in the early years of my career when I worked with rugby players, GAA players and elite soccer players. In many areas of medicine, the techniques which we use in day to day life trickle down from research and evidence based medicine developed in the highest levels of sports medicine. In the sports world, the accurate diagnosis of pelvic pain and the ability to develop a strategy for recovery to high level sport and high loads and forces on the pelvis are essential for a sport physiotherapist.

The first key element of treating pelvic girdle pain in women is establishing the severity and irritability of the pain –

·         How is it affecting this patient?

·         Is she able to sleep at night?

·         Is she able to eg walk where she needs to in day to day life?

·         Is she able to look after her other child(ren)?

·         Is she experiencing pain at rest?

·         Is she able to cope with the pain?

This leads into a deep dive into our more general medical training – Could there be anything more sinister causing this pain, either related to the pregnancy or otherwise? Do we need to refer the patient to their GP or hospital for investigations? Physiotherapists are trained to differentiate musculoskeletal pain from other causes of pain, much like a doctor  - and we will liase with the patient’s doctor if we deem it appropriate to do so. This is very rare, as most pelvic girdle pain patients presenting to physiotherapy have a musculoskeletal cause of their pain which can be very successfully managed at physiotherapy.

Many women experiencing pelvic girdle pain try to manage their pain at home with rest and reduced activity. This can be quite effective with mild presentations when it is initiated early. It is my experience that when a woman presents to physiotherapy and has already tried this option and it has not worked, it has already become a significantly more stressful situation, and she has began to worry that it will continue to worsen throughout the pregnancy. Given that the second trimester is a time when PGP usually starts, she may have jumped to thinking that there may be up to 3-5 months of pain ahead.

Fortunately we know that this is not the case. The vast majority of women who attend for treatment with a physio who is experienced with pelvic pain in pregnancy have excellent outcomes. We strive and expect to resolve pelvic girdle pain – not merely prevent it from worsening over time.

So how do we treat Pelvic Girdle Pain?

We take time to analyse the cause of the pain, and the main tissues involved eg referral from the lower back / sacroiliac joint pain/ muscular buttock pain  / hip joint pain / groin tendon pain / pubic joint pain / nerve referred pain.

We give specific guidelines on how far the patient is advised to walk each day / and whether activities such as swimming / yoga /pilates would be helpful for them at that stage of their pregnancy. We recognise the importance of supporting a woman to stay active and involved in physical and fitness activities and we endeavour to work with this as a central goal.

We advise them on positions to avoid or minimise – eg prolonged sitting, or weightbearing mainly on one leg in standing.

We discuss whether a pregnancy support belt would be helpful, and where to source one.

We make recommendations on the use of hot/cold therapy for their condition.

We sometimes show their partner how to do eg massage to a particular area, if having some manual work done regularly at home will be beneficial for them (this also keeps physio bills down!).

We prescribe specific exercises which will help to strengthen the important supporting muscles of the pelvis eg the gluteals. These can be modified around existing conditions also eg co-existing knee pain.

We liase with the relevant hospital care team/midwife/consultant to raise awareness of the condition prior to delivery in order to facilitate early planning for positions for labour etc. This is increasingly rare however as we find most women make huge improvements with treatment and are not fearful of worsening of their condition with labour.

We liase with the woman’s workplace where we can make suggestions eg working from home/ reducing work hours during exacerbations etc and we do this in conjunction with the woman’s GP for enhanced communication across the care team.

Confidence and Reassurance

As a young physiotherapist, I was a little apprehensive about treating pregnant women who were in pain, and I recognised that I had the potential to worsen their pain. As a result, I tended to undertreat them. I don’t think I was alone in this, as it was not an area that received a large amount of focus in our undergraduate University training at the time. Hopefully it has changed and improved since then.

Now with a Masters Degree in MSK physiotherapy, I have twenty years of experience in treating complex groin pain in athletes aswell as pelvic pain from all musculoskeletal sources during pregnancy. I have completed numerous postgraduate courses in Pelvic Girdle pain both in Ireland and abroad and thankfully I feel that those hard days are long behind me. Having had three pregnancies myself, I understand how exhausted women can be while working, minding other children and managing pain, and this is my driver now to do my best for them during their pregnancy. 

I now begin each session knowing that I have the tools to help each patient and the dramatic results we see from treating PGP make it one of the most rewarding aspects of my job as a Musculoskeletal Physiotherapist. We see a refreshed and much happier patient who is excited again about their pregnancy and feels prepared for the weeks and months ahead.

Lorraine O’Reilly

CORU State Registered Physiotherapist, MPhty (MSK Physiotherapy)

Contact: lorraine@physiofusion.ie