Some of the common pregnancy related complaints we see in the clinic are anterior hip pain, lower back pain and pubic pain. During the gestation period the body biomechanically changes to support the growth of your baby. As a result, pregnancy-specific treatment is required to strengthen the lower back and hips.
Pubic Symphysis: This condition is more common that most women would think. It can become extremely painful and patients have reported a feeling like a ripping sensation each time they walk. There is some good and bad news related to this condition. Bad news first – it will get worse as the weeks go on if untreated and will more than likely occur in any following pregnancies. Good News! – it is manageable, and we can decrease the impact on your life to where you barely notice it. Lastly, once bub arrives, the pain leaves straight away!
Why do people get it?
Pubic Symphysis dysfunction (PSD) is a term used for any anterior hip pain. Including pelvic pain radiating to the upper thighs and perineum. I will be mainly talking about the pain experienced around the pubic symphysis (the bone you can feel just above the vagina). The cause is most commonly related to an increase in physiological pelvic ligament laxity and increased joint mobility, often resulting from increased hormone supply. With this laxity it allows instability in the pelvic girdle, which allows the two halves of the pelvis to move independently of each other. The hip girdle is like two semi-circles, held together at the back by the Sacroiliac joint (SIJ) and associated ligaments, and the public bones, which are held together with a cartilaginous joint. If the SIJ on one side is restricted in movement either by a mechanical of bony fault you will see one side of the semi- circles compensating and taking on more load and work. This will in turn create a tugging on the cartilage in between the pubic bones. Combined with increased mobility, stress may present through a joint that is normally fairly immobile. To add to this we have bubba weighing down on this structure as well!
How do we avoid this? Or how can we fix this?
Prevention is always better than reaction. With my clients I work with them on releasing the lower back, SIJ and anterior structures so they are even, relaxed and strong. We want to make sure that the new forces your body is under happens evenly and correctly. The most effective techniques are, soft tissue release (mainly Active release technique), manual manipulation and dry needling. Additionally, a specific strengthening and rehabilitation program we stay ahead of any possible PSD.
If this condition is already causing you some discomfort, we start with a fairly aggressive treatment plan which involves treating the cartilage directly, as well as the adductors, pectineus, rec fem, psoas and posterior muscles including but not limited to glutes and Q/L. I have found that using dry needling to these structures is most effective and gives me the best results. We also add some strengthening and activation exercises to assist throughout pregnancy. I have seen reductions in symptoms from the 1st week and resolution of pain within 3 weeks. (always check with your doctor prior to undertaking dry needling and treatment). We want to be proactive and identify the cause of this, and in most cases the lower back is our culprit, so we keep these muscles loose and cared for throughout the rest of the pregnancy.
Another common complaint I see in the clinic, which I don’t believe is not spoken about enough, is postnatal rehab. Most midwives and physios will talk about the immediate post birth rehab, but I am talking about rehab to get you back to your normal exercise routine. I commonly see women who have had C-sections presenting to the clinic 6-18months post baby with anterior hip pain.
Why anterior pain and why so delayed after birth?
This is when mums are really stepping up their exercise routines and re-joining their pre baby classes, increasing gym programs, starting pilates for back pain or going back to work.
The biggest culprit for pain in this area, which can also present in the lower back, is the hip flexor. This big and powerful muscle that originates from T12 -L4 (there are deep and superficial fibres of this muscle, but we will just talk broadly for now) the muscle passes close to the lumbar spine and passes through the anterior pelvis and attaches to the femur. Along the iliac fossa in the pelvis it joins with the iliacus and creates the illio-psoas.
So why is this muscle a big player with anterior hip pain?
As our lifestyles are becoming more sedentary our psoas are most frequently in a shortened state. This means the muscle is always “ON”. It is so hyper sensitive/active that the brain thinks, well why use my abs when this beast of a muscle can do the work of the anterior muscles. Your abs have just been cut through, stretched, ripped and more, so the body gives these weaker structures a rest and uses the psoas. When the psoas is doing the work of your abdominals you will notice a click or clunk in the front of your hips when you lower then down during an ab exercise. Additionally, you may find it hard to flatten your back to the ground. During more dynamic movements such as squats or lunges you may feel a pinch, ache or just lack of mobility. This can be an indication that the abs are not helping stabilise the core and allowing the lower back and psoas to do the work.
How can you fix it?
We need to switch off that psoas and the altered movement patterns it has created. I find hands on manual therapy works best. Active release technique, dry needling and joint mobilisation can help break up the adhesions and scar tissue left in those over-active muscles. Once we have “loosened” up those tissues we start on the re-activation phase. We need to re-program the nervous system to recruit the correct muscles during gross motor movements. We also need to address and break habits that have formed. Activation of the lower abdominals is key in this. A very simple tilt of the hips is the stepping-stones for this movement. Once activation is happening, we move onto more complex movements that ideally sports, or life specific for what your treatment goals are.
At Elite Health and Performance our therapists can help you with these symptoms pre and post pregnancy. Usually, once the acute symptoms are under control with your PSD, we advise a maintenance program is undertaken to keep the symptoms of the condition minor for the duration of your pregnancy. Usually this requires a session once every 4 weeks. Anterior hip pain is commonly resolved in 3-4 sessions, during which rehab and activation exercises are taught. Occasionally it takes 8 sessions, which may occur if the condition has been present for numerous months or other biomechanical complications are present.