Pelvic pain - causes, diagnosis, treatment.

Pelvic girdle pain (PGP) refers to musculoskeletal problems affecting the pelvis. It primarily affects the sacroiliac joints, the pubic symphysis and associated ligaments and muscles.

This is a common situation during pregnancy, but it can occur at other times in life. The condition is disabling and has a significant impact on daily function and quality of life, and can also lead to job loss.

Definition of BOTP

There are varying definitions of OTP, and historically there have been discrepancies in terminology regarding pelvic pain and/or low back pain, especially in pregnant women. European recommendations (and most experts adhere to them) define OTP as:

“Pelvic pain associated with pregnancy, trauma, arthritis and osteoarthritis. Pain is felt between the posterior superior iliac spine and the gluteal folds, especially in the sacroiliac joint (SIJ). The pain may radiate down the back of the thigh, and may also occur in combination with pain in the symphysis.

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In his clinical guidelines for the treatment of OTP in the postpartum population, Clinton (2017) uses the following definition: “Pain in the posterior pelvis, between the iliac crests, down to the gluteal folds, and especially in the SIJ. It involves dysfunction of the SIJ and can occur together with or separately from pain in the pubic symphysis.”

Another term that is also used is pregnancy-associated low back pain (PALP) and should not be confused with GALP. LBP is characterized by dull pain, more pronounced when bending forward, with concomitant limitation of movements of the lumbar spine. When palpating the erector spinae muscle, the pain worsens.

Differential diagnosis

In the prenatal population, OTP can be a consequence of various inflammatory, infectious, traumatic, tumor, degenerative or metabolic disorders. A physical therapist should proceed with caution or consider referring a patient to a physician if there is a history of any of the following conditions:

• Trauma history.
• Unexplained weight loss.
• History of cancer.
• Steroid use.
• Drug use.
• Immunodeficiency virus or immunosuppressive condition.
• Neurological symptoms/signs.
• Fever and/or systemic malaise.
• Special considerations for OTP should include: Symptoms caused by placental abruption.
• Referred pain (due to urinary tract infection) to the lower abdomen/pelvic or sacral area.

Symptoms

Manifestations of ossalgia depend on the underlying disease. Most often these are periodic pains of moderate intensity.

Leg pain. Pain syndrome occurs due to excessive stress. The result is poor circulation and varicose veins. In addition, pain in the legs can signal diseases such as bursitis, gout, arthrosis, heel spurs and osteoporosis.

The bones of my hands hurt a lot. This symptom, as a rule, indicates damage to muscles, nerve endings and ligaments. Carrying unbearable weights also contributes to the development of ossalgia. Osteomyelitis, trauma, metabolic disorders and arthrosis are the most common causes of pain in the upper extremities.

“Skeletal” pain occurs against the background of previous injuries, diseases of the spine, osteochondrosis, inflammatory and oncological diseases.

If your whole body, muscles and bones are aching, then most likely the cause is a viral infection, influenza or an inflammatory disease of the respiratory tract. However, this condition can also be a symptom of the development of anorexia, tumor or injury.

"Wandering" pain. Doctors use this term when the pain does not have a permanent location. The syndrome is usually diagnosed in old age and indicates the presence of arthritis. Associated manifestations: swelling, redness of the area around the joint, increased local temperature.

Prevalence of pain BOTP

Worldwide, 5-10% of people suffer from chronic low back pain. It leads to:

• High treatment costs.
• Long periods of sick leave.
• Decreased quality of life.
• Invasive interventions (surgeries).
• Disability.

Lumbar nerve root compression sometimes mimics SIJ involvement. In a study by Visser et al. (2013) 41% of the study population had damage to the SIJ or SIJ joint in combination with lumbar radiculopathy.

It is also known that the SIJ is the source of low back pain in 10-30% of cases.

Frequency of occurrence of BOTP

• Occurs in 56-72% of pregnant women.
• 20% of women report severe symptoms during 20-30 weeks of pregnancy.
• 7% of women with BOPP will experience problems throughout their lives.
• 33-50% of pregnant women report BOTP before 20 weeks of pregnancy, with prevalence reaching 60-70% in late pregnancy.

With such a high prevalence, it is clear that OTP is a serious problem worldwide. Physical therapists are well positioned to offer such patients assistance in getting rid of this disease.

The main problem is that there is currently no gold standard for testing and determining whether a person is suffering from OTP or pain due to SIJ disease. Therefore, further research in this area is needed.

Risk factors for TBTP

Risk factors for developing pelvic girdle pain may include:

• History of pregnancy.
• Orthopedic disorders.
• Hypermobility of joints.
• Dysfunction of the hip and/or lower extremities, including dysfunction of the gluteus medius and pelvic floor muscles.
• History of pelvic trauma.
• History of low back and/or pelvic girdle pain, especially during previous pregnancies.
• Excess body weight.
• Smoking.
• Job dissatisfaction.
• Lack of faith in the possibility of recovery.
• Early onset of pain.
• Multiple places of pain.
• A large number of positive tests for pelvic pain provocation.

Risk factors for the development of persistent OTP in the postpartum period

A recent systematic review and meta-analysis identified the following risk factors for persistent OTP after delivery:

• History of low back pain.
• Body mass index more than 25 before pregnancy.
• BOTP during pregnancy.
• Depression during pregnancy.
• Heavy workload during pregnancy.

Treatment

Pre-hospital assistance

Patients with pelvic fractures are placed on a backboard and given an anesthetic. In other cases, rest is recommended, sometimes taking analgesics, using local warming and anti-inflammatory drugs is acceptable. Pain in the pelvic bones often indicates the presence of serious pathologies that require prompt diagnosis and early treatment, so if this symptom is present, you should immediately seek professional help.

Conservative therapy

Patients with fractures undergo an intrapelvic block, apply skeletal traction, or are prescribed bed rest using a special position. Therapeutic tactics for other lesions depend on the characteristics of the disease. The following methods are used:

• Protective mode
  . Patients are advised to limit physical activity. Sometimes it is necessary to use crutches or a cane.
• Drug therapy
  . Taking into account the characteristics of the pathology, antibiotics, NSAIDs, analgesics, chondroprotectors and other drugs can be prescribed.
• Physiotherapy
  . UHF, drug electrophoresis, magnetic therapy and other techniques are indicated. Exercise therapy, massage, and manual therapy are prescribed.

For malignant neoplasia, radiation therapy or chemotherapy may be used.

Clinical picture of BOTP

The clinical presentation varies from patient to patient and may also change during pregnancy.

You can read about chronic pelvic pain here.

Pain

• Pain may begin around the 18th week of pregnancy and peak in intensity between the 24th and 36th weeks.
• As a rule, the pain goes away by the 3rd month after birth.
• Pain is localized between the posterosuperior iliac spine (PSI) and the gluteal fold, especially in the area of ​​the SIJ and/or pubic symphysis.
• The pain may be local or radiating.
• Fortin's area is a rectangular area that extends from both VEPOs 3 cm laterally and 10 cm caudally. The person will often use one finger and point to the painful area, usually within this rectangular area.
• It was initially thought that pain below the knee could not be related to SIJ dysfunction, but Fortin et al. (2003) showed that pain from the SIJ can extend below the knee and be associated with SIJ dysfunction. Visser et al. (2013) also reported an association between SIJ dysfunction and intervertebral disc-related radicular pain.
• The pain may radiate down the back of the thigh and may occur in combination with (or alone) pain in the pubic symphysis.
• The pain may be described as stabbing, dull, shooting or burning.
• The intensity of pain on the VAS is on average about 5-6 points.
• It is useful to use a patient's pain distribution chart to differentiate between BOTP and BPBP. BOTP is localized under the PVPO in the buttocks, posterior thighs and groin (in particular, above the pubic symphysis).
• BSP is concentrated in the lumbar region, above the sacrum.

Functional complaints

Problems with movements such as

• Getting out of the car.
• Getting up from a chair.
• Limitation of mobility.
• Climbing stairs or walking.
• Standing for 30 minutes or longer.
• Standing on one leg or transferring body weight from one leg to the other.
• Rolling over in bed.
• Decreased ability to do housework.
• Pain/discomfort when lifting heavy objects.

Forecast

Bergström et al. (2014) examined BPB and BOTP 14 months after pregnancy. The study included a cohort of 639 women with low back or pelvic girdle pain that occurred during pregnancy.

Participants completed questionnaires about pain status and self-reported health and family situations. Follow-up was carried out 6 months after the initial assessment, and of the 639 participants, 200 women reported postpartum low back pain or LBP. After 14 months, 176 of them filled out the questionnaires again. 19.3% of women were in remission, and 75.3% reported recurrent low back pain. At 40 months after the initial assessment, 15.3% of participants reported persistent low back pain and LBP.

According to a 2021 study, Bergstrom et al. reported that 40.3% of study participants reported varying degrees of pain. The following factors were identified to be associated with a statistically significant increase in the likelihood of reporting pain 12 years after childbirth:

• Increased duration of pain.
• How study participants assessed their health.
• The presence of damage to the sciatic nerve, pain in the neck and/or thoracic spine.
• Sick leave within the last 12 months.
• Use of prescription and/or over-the-counter medications.

Bergstrom et al. (2017) concluded that for a subgroup of women with pregnancy-associated POTP, spontaneous recovery without recurrence is unlikely. The strongest predictors of poor long-term outcomes were:

• Persistence and/or duration of pain syndromes.
• Prevalence of pain – this may also contribute to long-term sick leave and disability pensions.

The development of a screening tool to identify women at risk of developing pregnancy-related OTP is necessary to enable early treatment.

Wuytak et al. (2018) conducted a systematic review and identified potential prognostic factors up to one year postpartum. Only three studies were included in the final review and the quality of the evidence for all factors was rated as low or very low. This could be explained by lack of replication since none of the factors were examined in more than one study. Given the uncertainty of the results and the inherent tendency for bias, the following prognostic factors were identified in women who were less likely to recover at 12 weeks postpartum:

• History of low back pain.
• Pain in three or four places in the pelvic area.
• Overweight.
• Six months after birth, BOTP is likely to persist in the following cases: using crutches during pregnancy;
• severe pain in all three places of the pelvis during pregnancy;
• presence of other pain conditions;
• obesity;
• younger age at menarche;
• history of previous low back pain;
• high comorbidity index;
• smoking (conflicting evidence);
• mode of delivery in the subgroup of women who had to use crutches during pregnancy, with women who had an instrumental birth or caesarean section being more likely to have persistent POTP;
• emotional distress during pregnancy.

Drug treatment of bone pain - important information for the patient

Ossalgia is bone pain that accompanies the underlying pathology.
Ossalgia can occur at any age and be a symptom of both viral pathology and diseases of the musculoskeletal system, blood diseases and tumor formations. Bone pain is usually treated by an orthopedist. The course of therapy is prescribed after a thorough examination of the patient and consultation with specialized specialists (endocrinologist, hematologist, traumatologist). Common causes of ossalgia:

• excessive physical activity;
• excess weight;
• metabolic disease;
• long-term use of hormonal drugs;
• lack of vitamin D in the body;
• infectious diseases;
• blood diseases;
• injuries, fractures;
• physical inactivity;
• stress, overwork.

The causes of severe pain in the pelvic bones can be pathologies of the hip joint, as well as systemic, infectious and oncological diseases.