Post on 26-Jun-2020
Musculoskeletal Issues in Pregnancy
Adele Meron, MDPain Medicine Fellow
Physical Medicine and Rehabilitation University of Colorado School of Medicine
Disclosures
• Nearly 100% of women experience musculoskeletal discomfort during pregnancy
• 32% report low back pain to their providers
• 25% of prenatal providers prescribe specific treatment for low back pain
• 25% of pregnant women experience temporarily disabling symptoms
Hormonal Changes in Pregnancy
Relaxin Progesterone Estrogen
Physiologic Changes in Pregnancy• Anterior Pelvic Tilt• Increased lumbar lordosis• Pubic symphysis widening • Ligamentous laxity• Edema• Peripheral nerve compression• Weight gain -> increased joint load• Vascular compression
Gravid Uterus
Abdominal muscle stretch
Muscle incoordination
Loss of pelvic compression
Pelvic Instability
Pubic SymphysisDiastasisRelaxin
Ligamentous laxity
SI joint shear
Compensatory muscle adaptations
Anterior center of gravity
Anterior pelvic tilt
Increased lumbar lordosis
Lumbar strain
Lumbopelvic Pain Low Back Pain Pelvic Girdle Pain Combination LBP
and PGP
12-18 week prevalence
11% 33% 18%
35 week prevalence 71% 65%
Risk Factors: advanced maternal age, Hx of peripartum LBP, multiparity, high BMI, hx of hypermobility
Not associated: maternal weight gain, fetal size
Sources of Lumbopelvic Pain in Pregnancy
• Pelvic ligamentous strain
• Sacroiliac joint pain• Discogenic pain• Nerve root compression• Vascular compression• Hip pathology
Pubic Symphysis Pain in PregnancyPubic Symphysis Pain and Diastasis Incidence: 20-30%Presentation: stinging pain at PS with radiation into thighs. Worse with walking, stair climibing. Risk Factors:
- fetal macrosomia- hx of pelvic trauma- multiparity
Osteitis Pubis
Hip Pain in PregnancyTransient Osteoporosis • Presents in third trimester • Weight bearing hip pain• Diagnosed with MRI• Treat early with protected weight
bearing to prevent fracture
Avascular Necrosis• Presents in third trimester• Weight bearing hip pain • Diagnosed with MRI• Treat early with protected weight
bearing to prevent progression
Other MSK conditions to watch out for
• Labral tear• Meniscus injury
• Recurrent ankle sprains • ACL tear
• Lower extremity stress fractures
Identifying the source
Physical Exam
General Treatment Principles
US Guided SI Joint Injection
Peripheral Neuropathies of Pregnancy
Carpal Tunnel Injection
Discussion • How do we optimize delivery of MSK care to
our pregnant patient?
References Balakrishnan A, Schemitsch EH, Pearce D, McKee MD. Distinguishing transient osteoporosis of the hip from avascular necrosis. Canadian Journal of Surgery. 2003;46(3):187-192.Casagrande, D. M., Gugala, Z. W., Clark, S., & Lindsey, R. (2015). Low Back Pain and Pelvic Girdle Pain in Pregnancy. Journal of the American Academy of Orthopaedic Surgeons, 23(9), 539-549.Borg-Stein, & Dugan. (2007). Musculoskeletal Disorders of Pregnancy, Delivery and Postpartum. Physical Medicine & Rehabilitation Clinics of North America, 18(3), 459-476.Borg-Stein, J. A., Dugan, S., & Gruber, J. (2005). Musculoskeletal Aspects of Pregnancy. American Journal of Physical Medicine & Rehabilitation, 84(3), 180-192.Bhardwaj, A., & Nagandla, K. (2014). Musculoskeletal symptoms and orthopaedic complications in pregnancy: Pathophysiology, diagnostic approaches and modern management. Postgraduate Medical Journal, 90(1066), 450.Albert, H. B., Godskesen, M. G., & Westergaard, J. (2002). Incidence of Four Syndromes of Pregnancy-Related Pelvic Joint Pain. Spine, 27(24), 2831-2834.Albert, H., Godskesen, M., & Westergaard, J. (2001). Prognosis in four syndromes of pregnancy-related pelvic pain. ActaObstetricia Et Gynecologica Scandinavica, 80(6), 505-510.Kristiansson, P., Svärdsudd, K., & Von Schoultz, B. (1996). Back Pain During Pregnancy: A Prospective Study. Spine, 21(6), 702-708.Moghtaderi AR, Moghtaderi N, Loghmani A. Evaluating the effectiveness of local dexamethasone injection in pregnant women with carpal tunnel syndrome. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences. 2011;16(5):687-690.Wang SM, Dezinno P,Maranets I, et al. Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstet Gynecol2004;104:65–70.
Questions?