What is Symphysis Pubis Dysfunction (SPD)

If you experience pain in the groin and inner thigh during pregnancy,  you may be having preganncy-related symphysis pubis dysfunction (SPD). It is estimated that 1 in 5 pregnant women develop SPD, and physiotherapy is usually a first-line conservative management.

A common pregnancy-related pain, what is Symphysis Pubis Dysfunction?

The symphysis pubis is 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 the 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. Also known as the diastasis of the symphysis pubis (DSP).

SPD most commonly begins in the 2nd trimester (around 14–28 weeks). The onset is usually gradual, though some women report a sudden increase in pain after an activity such as walking, turning in bed, or climbing stairs. 90–95% recover within 3 months postpartum. A small percentage of women, however continue to experience pain for longer.

Why does it happen?

During pregnancy, due to hormonal changes, the ligament supporting the pelvis becomes looser to prepare for child birth. This together with increased abdominal mass and shifting of center of mass forward due to the baby will lead to instability of the pelvic girdle.

Symphysis Pubis Dysfunction Symptoms

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

• 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 downstairs, 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

Symphysis Pubis Dysfunction today is becoming more widely understood by GPs, obstetricians and midwives in Singapore. 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

Exercises for Symphysis Pubis Dysfunction (SPD) aim to improve pelvic stability, reduce shear forces at the pubic symphysis, and improve load transfer through the pelvis. The goal is gentle stability, not aggressive strengthening.

A physiotherapy assessment may be arranged so that the specialist can further advise on back care strategies, or prescribe a pelvic support belt to avoid activities that put unnecessary strain on the pelvis during pregnancy.

Women with SPD should avoid activities such as sitting cross legged which causes asymmetrical pelvic loading.

Symphysis Pubis Dysfunction (SPD) Home Advice

Here are some things pregnant women with SPD can do to significantly minimize their discomfort. Read more about Pubis Symphysis Dysfunction via our patient handout here.

• Avoid activities that cause discomfort, e.g. lifting, carrying, prolonged standing, walking and strenuous exercise
• Rest more frequently in a position that 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 a car. Try to keep your 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

About Symphysis Pubis Dysfunction (SPD) condition

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.