Diagnostic tests and PGP
By Sarah Fishburn
Members sometimes ask us whether diagnostic tests are necessary to diagnose PGP and, if so, which are useful. Sometimes a GP or obstetrician has suggested arranging some tests to diagnose PGP but it isn’t usually the first step to a diagnosis. Knowing more about this topic may help you feel more confident and empowered to ask for what you need.
As you may be aware from our website or literature, the diagnosis of PGP can be made based on the symptoms alone: if you have pelvic pain and it is related to a pregnancy, it is likely to be PGP and should respond well to being actively treated. In other words, the first key step is to get a referral from your GP or midwife to see a manual therapist (usually a physiotherapist on the NHS).
Typical symptoms of PGP can include pain and discomfort in the front or back of your pelvis, sometimes pain down the top of the leg, difficulty walking, sitting or standing for long periods. It can also be hard to drive without pain and also to turn over in bed without discomfort. However, the symptoms can vary from woman to woman and the extent of the pain and immobility can be different, too, so that some women will have very severe symptoms where others have some pain but still go about their everyday activities without too much difficulty. You may be very convinced that you have PGP and you are probably right but it is important to be assessed by a manual therapist who will exclude any other possible diagnosis.
What is PGP?
Pregnancy-related PGP is usually down to ‘stiff’ or ‘stuck’ pelvic joints. The pelvis is made up of three bones: the sacrum at the bottom of the spine and two wide, curved bones to the front and sides. They join together at the sacroiliac joints at the back and the symphysis pubis at the front. These three joints work together and allow for some flexibility to enable you to move around normally, e.g. when you are walking, climbing stairs or turning over in bed. In PGP, one or more of these pelvic joints stops working properly; this may be because one of the joints isn’t working freely and this can result in the remaining joint or joints failing to work properly, too. There is often pain and irritation around the joints and also inflammation in the tissues around the joints. Sometimes you can experience pain in one of the pelvic joints when it is actually another of them that is stiff or stuck. In PGP, it may be the case that the pelvis is slightly out of alignment (such that one side of the pelvis appears slightly higher than the other when viewed from behind). This asymmetry can contribute to the pain experienced and the difficulty in moving normally.
About manual therapy
There are a number of different practitioners who can offer manual therapy. A manual therapist found through your GP and the NHS is likely to be a physiotherapist. NHS physiotherapists are free of charge and this can be very helpful when you are pregnant or you have just given birth because of all the extra equipment and expense that is entailed in having babies! However, sometimes an NHS physiotherapist cannot see you straightaway and for this and other reasons (perhaps a good recommendation), some women choose to see a private physiotherapist, chiropractor or osteopath. These practitioners charge for their services.
Whichever manual therapist you are considering, if you haven’t had a recommendation from a friend or family member about the benefits of this person, you might wish to phone the practitioner. During the phone call, you can discuss how they may plan to treat you before you arrange a visit to reassure you about their services and that they are familiar with PGP and get good results from their treatments. Remember that all manual therapists should be registered with a national regulatory council, and you can always check this online before you arrange an appointment if you are unsure about their training.
If you are not sure who you should see or you wish to find out if there are any manual therapists in your area who have been recommended by other Pelvic Partnership members and supporters, please visit our ‘Recommended practitioners’ web page.
There are varying approaches to treating PGP, but the main things you should expect from your therapist are:
- The therapist will ask you about your PGP and how it affects you.
- They will ask you to undress down to your underwear.
- They will look at and feel how the joints at the back and front of your pelvis move when you move (e.g. standing on one leg, bending forwards, walking, etc).
- They will feel how symmetrically the joints move when you are lying down on your back and your front (or your side if you are very pregnant).
- They will discuss their findings and agree a plan of treatment with you, explaining what they are going to do.
- Treatment is likely to include realigning joints which have moved slightly or got ‘stuck’, so that they move symmetrically again. This is a very much a ‘hands on’ treatment (referred to as ‘manual therapy’) where the practitioner will use their hands to coax the joints and supporting muscles into functioning freely. This may need to be done at each visit, until your muscles become strong enough to keep them in place without treatment. Being offered exercises to do without ‘hands on’ manual therapy is unlikely to lead to a successful recovery.
- You should walk out of each treatment session feeling improvement either in your pain or in your ability to move and function (or ideally both).
- As you recover, your exercise programme will be adapted to suit your individual needs until you get back to normal.
Where diagnostic tests may be helpful
If you have had a fall or another trauma to your pelvis (including a difficult birth) or if your symptoms do not improve quickly (within a few sessions) with treatment, it can be helpful to have further investigations to exclude Diastasis Symphysis Pubis (DSP).
This is a condition where the ligaments are permanently damaged, often by a trauma such as a fall or by forced abduction (moving apart) of the legs at a previous birth – for example, if feet are put on a midwife’s hips or shoulders (which is no longer seen as good practice and should not be done). In DSP there is a larger than normal gap (usually over 10mm) at the symphysis pubis which does not seem to get much better with manual therapy. The gap can be either horizontal or vertical and will often only show on a stork X-ray, where you are standing on one leg. Remember that even with DSP, the first step is to see a manual therapist because many women do still get better from manual therapy alone. If this is not the case for you and you have ruled out any inexperience on the part of the manual therapist, there are steps you can take to see the extent of the ‘gap’ at the symphysis pubis when you start to take stock and wonder what to try next. NB, if a gap is found, it does not automatically require an operation.
These are pelvic X-rays where you stand on one leg, have an X-ray taken and then stand on the other leg and have another X-ray taken. This shows how much the pelvis moves on each side when you are taking weight (so it shows whether it will be moving while you walk, for example). A normal pelvic X-ray does not show any movement, and therefore if you only have this view taken it is often not very helpful as it will usually show no change to your joints.
The normal range of movement (vertical or horizontal shift) is 0-3mm, and moderately abnormal is 3-10mm. Women can still function very well with this amount of movement, but it may need to be taken more into account when looking at types of exercises in the rehabilitation phase of treatment. If the shift is over 10mm this can be more difficult to manage, but if you have not yet had any manual treatment you should discuss the options with a therapist before deciding on further treatment, and it is almost always worth trying this before resorting to more invasive treatment such as surgery.
These scans show any inflammation in the joints more clearly, which can also confirm why you have pain, as inflammation is usually painful. Some inflammation can sometimes be seen on X-rays, but is usually clearer on an MRI scan. They will also show any bony changes more clearly, and may show any severe muscle or ligament damage. Even if this is identified, manual treatment may alleviate your symptoms as it helps the joints to work properly together, which reduces the irritation and inflammation over time. Also, if one of the sacroiliac joints is not functioning normally this can cause a wider SP gap, so by restoring the sacroiliac joints the gap and stability may be improved.
There are other approaches that you can then try if manual therapy alone doesn’t seem to make a difference. Prolotherapy is sometimes useful where ligaments appear to be less stable or are lax, as this procedure can help tighten the ligaments in the pelvis so that once the pelvis is realigned and stiff or stuck joints are freed, the ligaments, together with the muscles, can work to keep everything in the best position for a recovery.