Let’s talk about pubic bone pain during pregnancy. This is a subject I know all too intimately, as I experienced it with both of my pregnancies. Fortunately, for my second time around I had learned how to prevent it from being the excruciating disabling experience of the first pregnancy, to a minor inconvenience the second.

It’s all about knowing what you should and should not do.

Pubic bone pain is more than painful. It can greatly impact the experience of pregnancy and birth. It is not a well understood condition among the medical community as the research is relatively new. Therefore it can be challenging to receive a diagnosis as well as helpful and accurate information about it. Unfortunately this leads to the pain being dismissed as unavoidable or lumped into the catchall term of “pelvic girdle pain”. Despite this, it is a condition which should be addressed and taken seriously.

How do you recognize it? 

Pain at the pubic bone. It can be felt as a sharp pain occurring with movement, or a dull ache after movement. Pain may also radiate to the upper thigh, perineum, and/ or sacral joint. There may be a sensation that the pelvis is “tearing apart”. The degree of pain can vary depending upon how the condition is addressed. There may also be different pain in the hip joint or surrounding areas.

What is it called? 

Pubic Symphysis Dysfunction or SPD. It may also be called Symphysis Pubis Dysfunction, Symphysis Pubis Diastasis, or any number of more outdated terms such as pubo-sacroiliac arthropathy, pelvic insufficiency, symphysis pain syndrome, pelvic joint syndrome, and pelvic relaxation syndrome. Whatever it is called, SPD is a type of Pelvic Girdle Pain and may sometimes be referred to as simply that. 

What is Pubis Symphasis Dysfunction? 

Indicated by pain caused by excessive movement at the pubic joint, called the Pubic Symphysis. During pregnancy, the hormones relaxin and progesterone are produced at higher levels. These cause the soft tissue of the body to soften and have more laxity. There are several ligaments inside the abdomen which hold the pelvis together. As these ligaments relax they allow the pelvic bones to be susceptible to abnormal movement, sometimes resulting in pain. When the bones move they can become misaligned or otherwise not go back to how they are supposed to be. 

Is SPD common?

It occurs in approximately one third, or 33% of pregnancies.

When does it occur? 

For the majority of people it begins in the 2nd trimester. This is due to relaxin beginning to increase in production around the 10th week of pregnancy. However, a small number begin to notice it in the first trimester, and others in the last. It may occur earlier in people who have previosly been pregnant.

What triggers the pain? 

Excessive movement in the pubic joint. This can occur during activities such as walking, walking up or down stairs, exercise, hiking, getting up from a chair or out of a car, standing for a long time, standing on one leg, during weight bearing activities (picking things up, strength training, yoga, dance), turning over in bed, and opening the legs too wide. As many of these are daily movements we cannot necessarily avoid. It is important to identify what triggers your pain so it can be addressed.

What can you do about it? 

A LOT!

The old advice was to keep your legs closed, which frankly is ridiculous and not very helpful. The modern advice is to learn what you really should avoid, and what you can do to prevent triggering the pain. Many things which are often claimed to be contraindicated, are in reality helpful… when done with specific intention to the SPD. 

Why should you address SPD? 

When the pelvis moves and potentially remains misaligned it affects all of the surrounding soft tissue. This includes muscles around the hips, legs, pelvic floor, abdomen, and low back. When a bone is out of place in this way, the muscles around it can become chronically short or long. Muscles in such a state tend to hold excess tension (become tight) and can lose strength (a weak muscle).

Tight and weak, short and long muscles contribute to imbalance in the body. Such imbalances can lead to pain or muscle soreness all of which may be felt in the areas surrounding the pubic area like the glutes, hips, pelvic floor, and low back.

Muscle imbalances also contribute to fetal positioning. This is how the baby is positioned in the womb which is an important aspect for birth. A good position places the baby facing the right way with their head aimed right at the birth canal. A poor position can lead to complications with birth.

For example my first birth where I had severe SPD, my baby needed assistance to exit. His head was aimed at my hip rather than at the birth canal. Fortunately all worked out, but not after some interventions. With my second pregnancy where I addressed the SPD and prevented it from becoming an issue, my baby was in a great position and exited as easily as a birth can be.
This DOES NOT mean that everyone will have this same outcome as pregnancy and birth are very nuanced with numerous contributing factors. What we do know is that balanced muscles around the womb contribute to good fetal position, and good fetal position contributes to easier births. 

Pubic bone pain is associated with depressive symptoms. Inability to cease the pain can lead to depression in some people, and people with depression are shown to have a correlation with increased pain symptoms.

Additionally, misalignment of the pubic bones can get stuck that way and stay that way after birth. When the bones are not aligned properly, the muscles attached to them cannot work as they should. Issues related to a misaligned pelvis include pelvic floor dysfucntion such as urinary or fecal incontinence, pain with sex, and organ prolapse, as well as pain in the back of the pelvis surrounding the sacrum, piriformis pain syndrome, low back pain, and core dysfunction.

Yoga can help!
Yoga is all about creating balance and space in the body. In pregnancy, balance and space is needed more than ever! It’s exactly what supports the many symptoms of pregnancy while supporting a baby within the womb setting both of you up for birth. When yoga is practiced with intention for SPD it can be incredibly beneficial. When it is practiced with disregard to SPD, it will most likely make the condition worse.

Balance 

Balance is when the skeleton is aligned and all of the muscles are working together for optimal function. They are balanced with strength, flexibility, and how they activate when you move.

Space

Space is created when tension is released and muscles can reach their full potential for mobility. You might think of this like how stretching out a balloon makes it easier to blow up. 

Yoga and SPD

There are many poses which can help SPD. There are also some which make it worse. There are some poses which can be very helpful, but done the wrong way can make it worse. Often it is subtle changes in the pose and your intention which makes a world of difference. This may require you to reframe your mind around how you approach yoga.

For example, the adductors which are the muscles of the inner thigh, attach to the pubic bone. When the legs move those muscles, if too tight, will pull on the pubic bones causing movement in the pubic joint. Using the principles of balance and space, yoga helps to release tension in those muscles reducing the chance for the joint to be affected.

Of course this same concept applies to all movement, not just yoga poses. So we must consider how you move outside of yoga throughout the day. The poses not only help our physical body, but also our mental body by improving our awareness so that we can recognize what is helping and what is hindering. This is what sets yoga apart from just stretching. 

Can’t I just have my Chiro or PT pop it back into place? 

Yes, you can…. But it likely won’t stay that way. It’s a quick fix, and one that can help alleviate pain temporarily. Just as with any other spinal or skeletal adjustment, the soft tissue also needs to be addressed. There is a reason the joint is being pulled out of place. That is through tight muscles pulling on the joint, movements which are contributing to that pull, and weak or unstable muscles which are not holding the pelvis together. An adjustment can help, but it is only one small part of how to address the dysfunction.

What about strength training? 

Certainly strength training can help. It does need to be specific to what your body needs to stabilize the pelvis. It needs to have the purpose of balancing strength with length. A strong muscle can be a short muscle, and a short muscle may pull on the joint even more. Yoga can help with this as it combines lengthening with strengthening. Whatever strength training you choose, it is best to work with someone who is familiar with SPD.

Sacroilliac Belt / Pregnancy Belts

These are thick elastic belts which are worn around the abdomen and/ or pelvis to provide support. They can be a very useful tool to reduce SPD pain. A Sacroilliac Belt is different from a Pregnancy Belt, but can also look very similar. Pregnancy Belts generally have a larger panel designed to support the belly, while a Sacrolilliac Belt does not. Due to this, a Pregnancy Belt may not be worn in a way that supports the pelvis, whereas a Sacrolilliac Belt is designed specifically for this purpose. Which one you use depends on you and what feels best on your body. When choosing a belt for the intention of reducing SPD symptoms, you must select one that will be worn comfortably around the pelvis. It should be positioned in the space at or just below the “hip bones” called the Illiac Crest, and above the Femur Bones (that is the widest part of the hip). This placement of the belt will help to hold the joints of the pelvis together and may help reduce the excessive movement which contributes to the pain. The belt should be worn during any and all activity that triggers your pain.

A belt can be very useful, but it should also be recognized for what it does. You may think of it as a cast, such as when you break a bone. Casts are very useful for preventing the bone from moveing allowing it to heal. Yet, when the cast comes off, the muscles have generally weakened from not being used while the cast limited their purpose. This means, a belt may be very useful while preventing pain from increasing and allowing the joints to heal (such as after pregnancy), but it does not replace core training and other measures to prevent the SPD from being triggered. There are some who claim a belt will help to activate the muscles required to stabilize the pelvis and therefore recommend to wear the belt 24/7. This may be true in some cases, however even it does help activate the muscles, it is at some point going to teach the muscles they don’t need to activate anymore as the belt is doing the work for them. You can think of the cast analogy here.

So what triggers SPD pain?

Common Pain Triggers

• Walking or standing for a long time
• Stairs and uneven terrain
• Getting up from a chair, sofa, or car 
• Weight-bearing activities: ie. carrying heavy items, strength training, aerobics
• Turning over in bed
• Deep Stretches
• Standing on one leg 
• Asymmetric movements: where the legs are moving in different directions
• Abduction: opening legs wide 

Keep in mind that often a trigger will not immediately cause pain. It may be hours later or even the next day when you feel pain. It is very important to keep track of what you do each day to determine what is triggering your pain.

What you SHOULD do…

Walking or standing for a long time – sit when possible. Walk shorter distances. Begin walking a short distance, observe how your body responds the next day. Gradually increase the distance avoiding distances which trigger pain. 

Stairs and uneven terrain – avoid hikes on uneven terrain. Take the elevator or ramp when possible. Step both feet onto each step, rather than alternating single steps. 

Getting up from a chair, sofa, or car– keep your legs together and stand up using both legs at the same time with equal weight distribution.. In the car, swing both legs out to the ground, then stand up.

Weight-bearing activities: ie. strength training, aerobics – Avoid straining yourself. Don’t carry anything too large or heavy. Avoid jumpy or jerking movements. 

Turning over in bed – Instead of rolling over on your back: Use your arms to push yourself up. Keep your legs together turning forward using both arms to support yourself. Then shift your hips to turn to the other side. 

Movements and Yoga Poses – 

Deep Stretches – Less is more. Focus on stabilizing through muscle activation. Use props to support your body preventing over stretching. In many instances, a passive release will be more beneficial than a stretch. An example is Butterfly Pose. Instead of folding forward, a supported reclined version will allow the adductor muscles to release to lengthen which will help prevent pull on the pubic bone. 

Standing on one leg – Avoid standing on one leg. Instead keep weight equally balanced between both legs. When practicing Tree Pose, keep the raised leg down as a kickstand, or skip this pose altogether. 

Asymmetric movements: where the legs are moving in different directions – includes walking, stairs, lunges, climbing, and more. These movements are often included in exercise including yoga. Take a shorter stance. Focus on engaging the leg muscles to pull inward toward the midline (sometimes cued in yoga as “scissoring the legs”). Avoid sinking into lunges deeply and/ or taking a passive lunge. 

Abduction: opening legs wide – Abduction occurs in poses such as Wide Angle Pose, Butterfly/ Cobblers Pose, Child’s Pose, and Prasarita Padottanasana. Each one of these should be approached with mindfulness.

Wide Angle and Butterfly Pose: avoid deep folds forward. Some hinging forward might be okay, try blocks under your hands. Some may find any folding is a pain trigger, in which case lean back supporting yourself with your arms for an abductor release. 

Child’s Pose: try lessening the distance between the legs. You may also use a supportive prop like a bolster under the torso or a folded blanket under the hips. 

Prasarita Padottanasana: lessen the width of the stance. Use blocks under the hands to prevent folding too much. If incorporating a twist or reaching to each side, let your pelvis move freely. Do Not try to anchor the pelvis by keeping it parallel to the ground. Doing so will only put all of the strain on the sacral joint which is exactly what you are trying to avoid. 

Passive Restorative Poses and Long Slow Stretches (like in Yin Yoga): When the goal is to lengthen and release a muscle (as so often it is with SPD), you need long and slow. Restorative Yoga and Yin Yoga are similar but different styles of yoga. In Restorative you are held in passive poses with the use of props with the intention to release deeply held tension in the body. Yin Yoga is also passive and utilizes props. Yin differs because you are also finding a sublte stretch. Both styles of yoga hold poses for several minutes. Restorative poses may be held for 10 – 20 minutes, while Yin poses during pregnancy should only be held for about 2 minutes. Restorative poses are generally safe and could be practiced on your own, while Yin should really be guided by an experienced teacher familiar with SPD. However, it is always best to seek the guidance of a teacher before beginning anything new especially during pregnancy.

Yoga is a personalized practice.

Pregnancy is a time for reflection on your yoga practice. What serves you NOW as a pregnant person? What poses are helpful? Which can be shelved for a while? What type of yoga practice will support pregnancy? What type of yoga is for my ego? Which cues have I learned that I need to unlearn or modify? What cues and modifications do I need to embrace? How can you adapt your yoga to best serve pregnancy?

If you want to learn more about Pubis Symphais Dysfucntion and/ or Prenatal Yoga, join me for class or schedule a One-on-One Private Session to address your specific needs.