Sacroiliac Pain During Pregnancy
- 22% of pregnant women report having some
form of pain that originates from the pelvis itself. Between 5 and 8% of this percentage
experience disability and severe pain (Daly, et al). A common source of pelvic pain during
pregnancy includes the Sacroiliac joints.
- The pregnant patient often presents with
an excess lumbar lordosis as a result of the increased abdominal weight. Ligaments also become more lax as a result of
hormonal changes and the sacroiliac joints often exhibit an asymmetry in the
amount of laxity. With these factors
combined there is increased stress at the low back and pelvis, as well as
compensations throughout the trunk and extremities. Orthopedic conditions, pain, and disability
can occur as a result of these factors. (Goldsmith, et al). Other risk factors for pelvic pain in
pregnant women are multiparity, obesity, previous cesarean birth, young
maternal age, manual labor occupation, and stress (Bjelland et al).
Patient Presentation
- Pain
occurs in episodes and is aggravated by twisting motions such as turning in bed
or within 30 minutes of the SIJ’s being loaded during sitting, standing,
walking, or ascending/descending stairs.
- Nighttime may be when the pain is worst
as a result of loading throughout the day. (Keriakos et al)
- The pubic symphysis can also be involved and
should be screened for by asking the patient about any pain in the groin area.
- Pregnant patients may or may not
attribute the mechanism of injury to a traumatic event, such as a fall (Cusi,et
al). Pelvic girdle pain is often characterized as being a stabbing or sharp
pain on one side that occurs within 1cm inferomedial to one the posterior
superior iliac spine. This is considered
to be the Fortin Finger Test. To meet
these criteria for a positive test, the patient must use one finger to directly
indicate the area of pain on their body on more than one occasion. It is suggested to be performed immediately
after Patrick’s Test and to be followed by other diagnostic tests (Fortin et al).
Pelvic girdle pain can refer to the inner thigh, hip, or groin area and
patients may complain of a “clicking” in the pelvis.
Examination
- A subjective history including the severity and irritability as well as functional limitations and participation restrictions is necessary. Be sure to include the nature of the onset of pain.
- A body chart of all related symptoms is
useful and should be corroborated with palpation of bony structures including
the pubic symphysis and SI joints. There
are many tests to help the clinician determine if the pelvis is the true origin
of pain.
- A
leg length discrepancy, observed dysfunctional active motion at the SI joints, distraction and compression of the sacroialiac joints, posterior pelvic pain
provocation test, and hip adductor manual muscle test can help the clinician to
rule in sacroiliac dysfunction in the pregnant patient when these tests are
positive and assist in ruling out pain referral from the lumbar spin. Active straight leg raise is contraindicated
during pregnancy since it involves active hip flexion in supine.
- To determine functional limitations, the
patient specific functional scale can be utilized.
Special considerations of the pregnant patient
- After the 1st trimester (12
weeks), the supine position should be limited to 1-3 minutes at a time and
prone is contraindicated. Active hip
flexion in supine should be avoided as well.
- Ultrasound treatment near the trunk is
contraindicated and electrical stimulation is a relative contraindication that
should be discussed with the physician.
Common treatments
- Muscle energy techniques/strengthening to improve stability of the pelvis, specifically targeting multifidus and transverse abdominus.
- Sacroiliac belts which should be placed over the greater trochanters.
- Bjelland, EK, Eskild, A, Johansen, R, and Eberhard-Gran, M. Pelvic Girdle Pain in Pregnancy: The Impact of Parity. American Journal of Obstetrics and Gynecology 203(2):146 e1-6, 2010.
- Cusi, M. Paradigm for Assessment and Treatment of SIJ Mechanical Dysfunction. Journal of Bodywork and Movement Therapies (2010) 14,152-161.
- Daly, JM, Frame, PS, and Rapoza, PA. Sacroiliac Subluxation: A Common Treatable cause of Low Back Pain in Pregnancy. Family Practice Research Journal 1991; 11:149-159.
- Fortin, JD, Dwyer, AP, West, S, and Pier, J. Sacroiliac Joint: Pain Referral Maps upon applying a new Injection/Arthrography Technique. Part I: Asymptomatic Volunteers. SPINE Volume 19, Number 13, pp 1475-1482, 1994.
- Goldsmith, LT, Weiss, G, and Stienetz, BG. Relaxin and its role in pregnancy. Endocrinology and Metabolism Clinics of North America 1995; 24:171-186.
- Keriakos, R, Bhatta, SR, Morris, F, Mason, S, and Buckley, S. Pelvic Girdle Pain and Puerperium. Journal of Obstetetrics and Gynaecology Oct 2011; 31(7); 572-80.
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