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What is Symphysis Pubis Dysfunction (SPD)

If you are pregnant and experience pain in groin and inner thighs around the start of your second trimester, there is a chance that you are suffering from Symphysis Pubis Dysfunction (SPD). In one study¹of the British population, the incidence of SPD varies from 1:360.3% to 2.77%. Thankfully, the pain goes away after delivery.

What is Symphysis Pubis Dysfunction?

The symphysis pubisis a fibrocartilaginous (a mixture of fibrous tissue and cartilaginous tissues) joint that connects the two halves of the pelvis together and keeps them steady during activity (see image). This joint is supported by a network of muscles and ligaments that allow very little movement to occur under normal circumstances. During pregnancy, the symphysis pubis widens an average of 2-3 mm from the usual 4-5mm gap. The average gap is about 7.7mm. This widening of the pelvic ring helps facilitate the delivery of baby.

Symphysis Pubis Dysfunction is when this joint becomes overly relaxed, allowing the pelvic girdle to become unstable. This leads to pain and inflammation.

In severe cases, the symphysis pubis partially or fully ruptures, increasing the gap to more than 10mm. This is known as the diastasis of the symphysis pubis (DSP).

SPD typically starts in the second trimester. The start of pain is usually gradual and can be very intense. It is usually relieved by rest. The good news is that symptoms commonly disappear shortly after delivery. A small percentage of women however, continue to experience pain for several months after delivery.

Why does it happen?

SPD is a result of a combination of factors; an altered pelvic load, hormonal and biochemical alterations causing ligament laxity and a weakening of pelvic and core musculature during pregnancy, leading to instability.

Symptoms

You may have SPD if you have one or more of the following:

• 
  Source: e-radiography.net
  Pain localised to your symphysis pubis, including shooting, stabbing and burning pains, grinding and audible clicking sensations and/or persistent discomfort.
• Pain radiating to lower abdomen, groin, perineum, thigh, leg and back
• Difficulty in walking, climbing up or down stairs, rising up from a chair, impaired weight bearing activities, e.g. standing on one leg or lifting/parting the legs, turning in bed.

Diagnosing SPD

SPD today is becoming more widely understood by GPs, obstetricians and midwives. It is diagnosed by a combination of your own description of symptoms and a battery of tests designed to look at the stability, movement and pain in the pelvic joints and structures surrounding it. Imaging, such as X-rays, is the only way to confirm the misalignment of the pelvic bones. However, due to the concerns of fetal exposure to radiation, ultrasound is the preferred modality for assessing symphyseal widening in pregnancy.

Your doctor or midwife may refer you to a physiotherapist who has experience in treating this condition.

Management

A specialist physiotherapy assessment and review should be arranged. The physiotherapist can advise on back care and strategies to avoid activities that put unnecessary strain on the pelvis and on safe exercise during pregnancy.

Exercises for the pelvic girdle and core stabilizers of the trunk will form a large part of the treatment and are aimed at improving the stability of the pelvis and back.  In some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. The physiotherapist may also prescribe a pelvic support belt to give quick relief.

Other alternative treatments include hydrotherapy (exercise in water) and acupuncture which sometimes can be useful.

SPD Home Advice

Here are some things pregnant women with SPD can do to minimize their discomfort.

• A void activities which cause discomfort, e.g. lifting, carrying, prolonged standing, walking and strenuous exercise
• Rest more frequently in a position which is comfortable, such as:
  • lying with your knees bent and supported
  • lying on your side with a pillow between your knees
  • sitting with your knees slightly apart
  • avoid sitting with legs crossed.

• Mild to moderate exercise, including abdominal wall and pelvic floor exercises, is acceptable.
• Avoid straddling and squatting movements, which means moving with knees apart (hip abduction), when:
  • getting in and out of car. Try to keep knees together.
  • getting in and out of bed. When moving in bed, try to keep legs together particularly when moving from side to side. Do not push with one foot as this will worsen the pain. Push equally with both feet to move about the bed.
• Adopt good posture, avoid bending and twisting.
• If swimming, avoid the breast-stroke with the legs kicking outwards.
•  Ice packs can be used for five minutes at a time or an ice cube can be rubbed on the symphysis pubis for 20–30 seconds

Reference:

1. Owens K, Pearson A, Mason G. Symphysis pubis dysfunction – a cause of significant obstetric morbidity.Eur J Obstet Gynecol Reprod Biol 2002;105:143–46.
2. MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and development dysplasia of the hip.Acta Obstet Gynecol Scand1997;76:760–64.
3. Jain S, Eedarapalli P, Jamjute P, Sawdy R. Symphysis pubis dysfunction: a practical approach to management.The Obstetrician & Gynaecologist 2006;8:153–158.