Pelvic girdle pain

# Background
Pelvic Girdle Pain During Pregnancy 
Historical articles show that pregnancy-related pelvic girdle pain has been recognizes for centuries. Mentioned by Hippocrates  and later described in medical literature by Snelling.  Pelvic Girdle Pain causes pain and instability in any of the three pelvic joints during and/or after pregnancy.
" The affection appears to consist of relaxation of the pelvic articulations, 
becomming apparent suddenly after parturition or gradually during pregnancy,and permitting 
a degree of mobility of the pelvic bones which effectively hinders locomotion and gives 
rise to the most peculiar, and  alarming sensations". Snelling (1870).

# Introduction
The pelvis is the largest bony part of the skeleton. There are three joints, the symphysis pubis(SP), and two sacroiliac joints.  A highly durable network of ligaments  surround these joints giving them tremendous strength.
The pubic symphysis has a  fibrocartilage joint which may contain a fluid filled cavity and is avascular; it is supported by the superior  and  arcuate ligaments. The sacroiliac joints are synovial, but their movement is restricted throughout life and they are progressively obliterated by adhesions. The nature of the bony pelvic ring with its three joints determines that no one joint can move independently of the other two. 

# Images
- Pubic symphysis
- Posterior Sacroiliac joint
- Anterior Sacroiliac joint
- White fibrocartilage from an intervertebral fibrocartilage.

# Pelvic Girdle Pain 
Pregnancy begins the physiological changes  through a pattern of hormonal secretion and  signal transduction  thus initiating the remodelling of soft tissues, catrilage and ligaments.  Over time, the ligaments could be stretched either by injury or excess strain and in turn may cause pelvic girdle instability.
"The classification between hormonal and mechanical pelvic girdle instability is no 
longer used. For treatment and/or prognosis it makes no difference whether the 
complaints started during pregnancy or after childbirth." Mens (2005) 
For most women PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weight bearing activities. One in 37  woman will experience some degree of PGP during pregnancy or postpartum. There is no correlation between age, culture, nationality and numbers of pregnancies that determine a higher incidence of PGP.   
Other Commonly used Terms are:
- Diastasis of the Symphysis Pubis
- Symphysis pubis dysfunction
- Symphysiolysis
- Posterior Pelvic Pain
- Symptom-Giving Pelvic Girdle Relaxation in Pregnancy
If you experience PGP during one pregnancy you are more likely to experience it in subsequent pregnancies; but the severity cannot be determined.

# Hormone Relaxin
It is a fact the some hormone levels increase during pregnancy, especially relaxin, estrogen and progesterone.
Relaxin is produced mainly by the corpus luteum  of the ovary and breast, in both pregnant and non-pregnant females. During pregnancy it is also produced, also by the placenta, chorion, and decidua.  The body produces relaxin during menstruation that rises to a peak within approximately 14 days of ovulation and then declines.  In pregnant cycles, rather than subsiding, relaxin secretion continues to rise during the first trimester and then again in the final weeks.  In males, relaxin is synthesized in the prostate and released in the seminal fluid.
During pregnancy relaxin has a diverse range of effects, including the production and remodelling of collagen thus increasing the elasticity of muscles,  tendons,  ligaments and tissues of the birth canal in view of delivery. This hormone also inhibits uterine contractile activity, allows nipple growth to occur, contributes to the rupture of the fetal membranes at term and is needed to support the establishment and maintenance of early pregnancy.
Relaxin works directly and indirectly on both the male and female body and has a chemical influence on the following systems:
- Striated and smooth muscles.
- Central nervous system and autonomic nervous systems.
- Connective tissues connective tissues in the form of skin, ligament, tendon and cartilage.
- The cardiac muscles.
This hormone produces changes in collagen metabolism (chemical processes occurring within a living cell that is necessary for the maintenance of life), by inhibiting collagen synthesis (prevent or decrease a period in the cell cycle) and increasing matrix metalloproteinases,  that increases collagenase  production.  Although relaxins main cellular action in pregnancy is to remodel collagen by biosynthesis, thus facilitating the changes of connective tissue, it does not seem to generate musculoskeletal problems. European Research has determined that relaxin levels are not a predictor of PGP during pregnancy.    
Concentrations of relaxin during the two days immediately preceding parturition are significantly greater than all other days.  After this time period relaxin is no longer manufactured in large amounts in the postnatal period but the effects of the hormones on the ligaments are still evident until about five months postpartum.

# Causing Factors
Sometimes there is no obvious explanation for the cause of PGP but usually there is a combination of factors such as.
- The pelvic joints moving unevenly.
- A change in the activity of the muscles in the pelvis, hip, abdomen, back and pelvic floor muscles.
- A history of pelvic trauma.
- The position of the baby altering the loading situation on the pelvic ligaments and joints.
- Strenuous work. 
- Previous  lower back pain.
- Previous pelvic girdle pain during pregnancy.
- Hypermobility,genetical ability to stretch joints beyond normal range.
- An event during the pregnancy or birth that caused injury or strain to the pelvic joints or rupture of the fibrocartilage.
- The occurrence of PGP is associated with twin pregnancy, first pregnancyand a higher age at first pregnancy.  

# Symptoms
- PGP can begin the early weeks (wk 14-22).
- Pain is usually felt low down over the Symphysis Pubis joint, which may be extremely tender to the touch.
- Present swelling and/or inflammation over joint.
- Difficulty lifting leg.
- Pain pulling legs apart.
- Unable to stand on one leg.
- Unable to transfer weight through pelvis and legs.
- Pain in hips and/or restriction of hip movement.
- Transferred nerve pain down leg.
- Can be associated with bladder and/or bowel dysfunction.
- A feeling of symphysis pubis giving way.
- Stand with a stooped over back.
- Malalignment of pelvic and/or back joints.
- Struggle to sit or stand.
- Pain may also radiate down the inner thighs.
- You may waddle or shuffle.
- Aware of an audible clicking sound coming form the pelvis.
The symptoms of PGP limit the ability for the woman to carry out most daily activities.  She will experience pain involving movements such as dressing, getting in and out of the bath, rolling in bed, climbing the stairs and sexual activity.  Pain will also be present when lifting, carrying, pushing or pulling.

# Ligaments
Ligaments are composed strands of collagen fibers. Injured ligaments and other connective tissue may not heal properly after minor or repetitive motion injuries. Partial tears are usually much more painful than full tears, which can sometimes be painless. If ligaments are stretched, either by injury, excess strain on a joint, or by improper stretching techniques, the joint will become weaker, as the elongated ligaments are unable to properly support it. Because connective tissue such as ligaments must withstand a great deal stress in day to day activities and have a relatively low blood supply, injuries can take a very long time to heal injured ligaments tend to be less flexible, and more prone to repeat injury. Ligaments are strong structures which join two bones together, giving the skeleton strength and structural integrity. Because ligaments are so important in the stabilization of joints, they are also highly susceptible to injury.
Types of Ligament Instability
Stable.  The ligaments are structurally sound, coping well with day to day activities.
Partial Instability. The ligament become weak/ injured and the muscles try to compensate to function properly. If the muscles fail to work effectively with the ligament pain and weakness will be experienced during daily activities.
Severe Instability.  The ligaments are unable to support the joint and this gross instability cannot be compensated by muscle function. Severe pain and disability, unable to perform daily activities.

# Degrees of Pelvic Instability
Stable.  The woman does not have any signs or symptoms of pelvic instability.  The ligaments and muscles work well during daily activities.  These women usually do not have a history of lower back pain, pelvic trauma of hypermobile joints and have never been pregnant.
Partial Instability.  The ligaments alone do not support the joint sufficiently.  The ligaments become weak or injured and the muscles try to compensate to function properly.  If the stabilizing muscles of the pelvis fail to work effectively with the weak and injured ligaments, pain and weakness will be experienced during daily activities. This kind of pelvic instability often occurs after giving birth to a child weighing 3000 grams or more , hypermobility of joints during pregnancy or an incident during the birth causing some minor degree of damage to ligaments or joints of the pelvis.  Treatment is required to re-establish the muscles around the pelvis to work more efficiently.
Complete Instability.  The pelvic joints cannot function properly without the support of the ligaments and muscles.  Both are needed to maintain normal function.  When the woman has complete instability the ligaments are unable to support the joint and this gross instability cannot be compensated by muscle function. There will be severe pain and disability.  This type of pelvic instability usually only occurs after an incident during the pregnancy that has caused pelvic joint injury limiting the pelvis to remain stable; this can also occur during the delivery.

# Walking with Pelvic Instability
The pregnant woman has a different pattern of "gait".  The step lengthens as the pregnancy progresses due to weight gain and changes in posture.  Both the length and height of the footstep shortens with PGP. Sometimes the foot can turn inwards due to the rotation of the hips when the pelvic joints are unstable.  On average, a woman's foot can grow by a half size or more during pregnancy.  Pregnancy hormones that are released to adapt the bodily changes also remodel the ligaments in the foot.  In addition, the increased body weight of pregnancy, fluid retention and weight gain lowers the arches, further adding to the foot's length and width.  There is an increase of load on the lateral side of the foot and the hind foot.  These changes may also be responsible for the musculoskeletal complaints of lower limb pain in pregnant women.
During the motion of walking, an upward movement of the pelvis, one side then the other, is required to let the leg follow through.  The faster or longer each step the pelvis adjusts accordingly.  The flexibility within the knees, ankles and hips are stabilized by the pelvis.  Normal gait tends to minimize displacement of centre of gravity whereas abnormal gait through pelvic instability tends to amplify displacement.   During pregnancy there may be an increased demand placed on hip abductor, hip extensor, and ankle plantar flexor muscles during walking. To avoid pain on weight-bearing structures a very short stance phase and limp occurs on the  injured side(s), this is called Antalgic Gait.

# Psychosocial Concerns
PGP in pregnancy seriously interferes with many participations in society and activities of daily living such as housekeeping, walking, sexual life and working; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks. 
In some cases women with PGP  may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to suffer postpartum depressive symptoms. Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse.

# Recovery and Treatment
Self Help Management
- When getting into bed sit on the edge keeping knees close together, lie down on your side,lifting both legs at the same time. Reverse this to get up.
- Try not to attempt to pull yourself up from lying on your back.
- Keep knees together when rolling over in bed.
- Sleep with a pillow between the legs, add more in other areas for support.
- When getting into a car: Sit down first and then swing legs keeping them together.
- Avoid sofas and chairs that are too low or too soft.
- Try to reduce the stress on the joint.
- Avoid any movement with your knees apart.
- Take smaller steps when walking.
- Avoid stairs if possible.
- Take breaks.
- Move within the limits of pain.
- Avoid twisting, bending or squatting.
The majority of women will make a full recovery after they give birth.  For others PGP can take from 11 weeks, 6 months or even up to 2 years postpartum to subside.  One of the main factors in helping women cope with is with education, information and support.  Many treatment options are available such as, Physiotherapist, Osteopath, Chiropractor, Acupuncturist, Social Worker and Medical Specialist such as Orthopedic Surgeon.  Some pelvic joint trauma will not respond to conservative type treatments, Orthopedic Surgery might become the only option to stabilize the joints.