1. Pubic Symphysis Dysfunction

2.  Defined as pain, instability and dysfunction of the symphysis pubis joint. Approximately 14-22% of pregnant women experience this dysfunction and most recover within a few weeks after delivery. Onset usually occurs by 17-19 weeks gestation and peaks by 24-36 weeks. Some women have persisting pain 1-3 months post delivery and may last for up to 2 years postnatal.

3. Causes  Abnormal biomechanics during pregnancy are caused by altered posture and may lead to an increased range of motion in the pelvis or cause asymmetrical movement in the pelvic joint leading to increased susceptibility to shear. It is normal for widening of the pubic symphysis to occur during pregnancy, however, for some women these changes along with mechanical factors result in pain. The amount of symphyseal separation does not always relate to the degree of disability or intensity of symptoms. Possible causes include:  Muscle weakness  Increased fetal and pregnancy-related weight gain  Metabolic and hormonal changes leading to ligamentous laxity  Anatomical pelvic variations

4. Risk Factors  Pubic symphysis dysfunction in previous pregnancy  Multiparity  High BMI  Heavy workload or poor workplace ergonomics  General joint hypermobility  Lack of regular exercise  Early menarche

5. Symptoms  Shooting pain in symphysis pubis area  Radiating pain into the lower abdomen, back, groin, perineum, thigh and/or leg  Pain with walking, unilateral weight bearing or hip abduction  Pain relieved by rest  Clicking, snapping or grinding heard or felt within the symphysis pubis  Dyspareunia  Occasional difficulty voiding  Unmotivated Fatigue

6. Signs  Tenderness over symphysis pubis and/or sacroiliac joint  Palpable gap in the symphysis pubis  Suprapubic edema  Positive Flamingo test

7. Differential Diagnosis  Urinary tract or other infection  Ectopic pregnancy  Tumor  Round ligament pain  Femoral vein thrombosis  Nerve compression  Pubic osteolysis  STD  Endometriosis  Abscess  Osteomyelitis  Osteoporosis

8. Special Tests  Flamingo test/maneuver: Patient standing on one leg. Pain in the weight-bearing extremity is a positive test for a lesion of the symphysis pubis.  Sacroiliac Joint Stress Tests: Compression, Distraction, and FABER

9. Outcome Measures  VAS (Sensitivity 93%, Specificity 74%)  FIM (Sensitivity 85%, Specificity 64%)  MMT  Goniometry

10. Interventions  Activity modification: limit single limb stance  Encourage use of pelvic binder  Functional training: Educate patient regarding save, pain free mobility during bed mobility and transfer training.  Avoid excessive hip abduction  Kegel exercises- increase strength and control of pelvic floor musculature. Instruct patient to draw up pelvic floor as though she is trying to stop the flow of urine. Biofeedback can be used to allow the patient to see when they are performing the exercise correctly.  Strengthen hip and abdominal muscles

11. References  Dutton, Mark. Orthopaedic Examination, Evaluation, and Intervention. Ed. Nagleieri, Catherine Johnson and Christie. second edition 2008. Print.  Guidelines for the Perinatal and Intra-Partum Management of Women with Pregnancy Related Pelvic Girdle Pain (PGP) Formerly Known as Symphysis Pubis Dysfunction (SPD) Nottingham University Hospitals. September 2010.  Howell E. Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. Journal Of The Canadian Chiropractic Association. June 2012; 56(2):102-111.  Huber L, Richman S. Symphysis Pubis Separation. CINAHL Rehabilitation Guide, EBSCO Publishing, 2013 Jan 25.