Mind the Gap – Pubic Symphysis Pain

mind-the-gap
Pelvic pain can be caused by so many different things, but the majority of issues women experience are termed ‘mechanical’ – i.e. caused by overloading or improper movement patterns.

How could anyone have improper movement patterns? Or overload their pelvis?

Think “being a mum”….!

What is Pubis Symphysis Pain?

In essence, pubic symphysis dysfunction (PSD – a subset of Pelvic Girdle Pain – PGP) is caused by irritation of the joint at the front of the pelvis – the Pubis Symphysis Joint (PSJ). It’s between the two front branches of the pelvis (the ‘pubis’), it is a special kind of joint (a ‘symphysis’ joint), and despite its simplicity and minimal movement it can be really painful!

Unlike other joints in the pelvis, this one actually has a cartilaginous disk, not unlike the disks in your spine, to allow for a gentle shock absorption. Every step we take puts the pelvis into a very slight twist – so a little ‘give’ in such a large bony structure is crucial to allow smooth movement from A to B.

pain at the pubis symphysisHowever, when the gap exceeds 9mm it is considered a ‘dysfunction’. Usually the pain is localised at the front of the pelvis and a quick application of pressure on the pubic bone is enough to confirm that it’s a problem! It can also be diagnosed by X Ray to confirm and determine a course of action in severe cases.

It also has strong ligaments above and below it to stabilise and limit the movement that goes through this joint. These in themselves can get irritated due to the loading of the joint, even without gapping beyond the normal range.

I’ll say that again – your joint doesn’t have to be scarily ‘gapping’ to experience pain, so please don’t worry! In fact the majority of cases have no excessive gapping and no need for surgery.

What is ‘Normal’ for this Joint?

Both men and women have an SPJ, and in women it’s slightly larger to harmonise with our slightly wider pelvis.
The disk is usually around 2-5mm wide, which widens to 4-8mm in the third trimester of pregnancy. This helps with delivery of the baby and is totally normal.

What Causes It?Muscle attaching to the pubis symphysis

True Gapping – pure and simple, the gap has widened beyond its normal capacity and is inflamed and painful as a result. The joint capsule (the fibrous ‘bag’ encasing the joint) will be irritated as well as surrounding structures. There may be pain at the back of the pelvis too, with tenderness over the Sacroiliac Joint (SIJ) as it takes more load as a result.

Sport – Not exclusively a mother’s problem, lots of athletes, male as well as female, experience SPD. Dancing, kicking, ice skating – anything that asks the pelvis to twist a lot, especially with some force (e.g. kicking, or landing repeatedly on one leg) – can cause overload of the joint and consequently pain.

Overuse of local muscles – Pain is so rarely just about the area affected. The Pubis Symphysis has at least (deep breath!) 13 muscles attaching to it, including your abdominal muscles, your entire pelvic floor (going through its own drama in a new mum!), and your big inner thigh muscles. It’s a pretty important junction and as a consequence a lot of different factors can throw it off balance.

Imbalance of local muscles – Pregnancy can cause all sorts of muscle imbalances which develop over the nine months as a result of a growing baby, and can continue as motherhood kicks in with force and there’s no time to get back into a regular exercise routine. It can be something as simple as weak outer hip muscles causing your inner thighs to work overtime, pulling on the already sensitive SPJ, or stretched abdominals failing to do their part in stabilising the SPJ against a swollen pelvic floor. Everyone is so different, so ensure you get an assessment individualised to you.

Ligament inflammation – it is often stated that this is a residue from pregnancy, as the hormone Relaxin allows the ligaments to ‘ease’ to allow for baby’s growth and labour. When hormones are still rushing about the body in the early days of motherhood, Relaxin can hang about for up to around 6 months after birth, perpetuating some instability in the pelvis. However, every pregnant woman releases Relaxin and less than half experience SPD at any point in their pregnancy, so there is not a direct correlation. It’s likely that ligaments affected by Relaxin are less able to cope with the loading of pregnancy, but this will be down to the individual body.

Other Pelvic Problems – Pelvic floor dysfunction, post-surgical issues, prostatectomies, fractures, etc. can all contribute to an imbalance of the pelvis and therefore a dysfunction of the PSJ.

What Hurts?

In any of these cases, typically asymmetrical activities will aggravate it, activities such as:
– going up or down stairs
– getting out of bed / our of a car one leg at a time
– lunges, side stepping, or any activity that asks the legs to do different things at one time
– It can affect sleeping, as lying on your side can add pressure to an already sore joint.

What Heals?

Rest is traditionally the go-to solution, but I’d advise that this is only one of many different factors that will help.
Certainly over-rest will lead to de-conditioning of the abdominal and pelvic muscles, potentially making the problem worse, so ensure that you remain active within your pain-free range.

More effective is to avoid or modify activities that aggravate the pain until you are assessed. Often these fall into the form of squatting, lifting and carrying, twisting to pick things up… all activities that mothers have to do every day.

The key is, wherever possible, to do things symmetrically. Avoid letting your pelvis twist too much (e.g. long strides, picking something up from next to you). Keep a pillow between your legs in bed, and use the below technique to get out of bed:

Getting out of bed technique

You can use ice packs to settle it down when it’s really aggravated, and heat packs on those muscles, often of your inner thighs, that can feel stiff and painful themselves.

What do I do if it’s not going away?

These are basic management strategies, and as only 2% of women experience SPD once their baby is born, pain during pregnancy often resolves itself. However, those who do suffer after labour can do for many months, so if you are in pain, don’t leave it too long to get help – an individualised diagnosis and treatment strategy can get you out of pain much sooner than suffering in silence.

Pain can go both ways: PSD can an refer pain elsewhere, such as throughout the pelvis, or into the lower back, and these can refer back to the PSJ. The pelvis is a complex beast! So it’s important to get fully assessed to discover the root cause or you could be going round in painful circles for a long time to come.

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