How can I avoid pelvic pain in pregnancy? Someone asked me this question recently and I’ve been wondering since then how could I give a simple and precise answer to it. But it doesn’t exist. Pregnancy related pelvic pain is far from being a simple topic and solutions are far from being precise.

Let’s take a look first at risk factors. Despite the fact that increased pelvic mobility is common to all pregnant women, why some of us develop PGP and others don’t? Believe it or not, it is still a scientific mystery. Epidemiological studies agree that you will most probably develop PGP if you have a history of low back pain or previous trauma to the pelvis[i]. Age, height, weight or previous use of contraceptive pills don’t seem to have an actual influence on it. Anyhow, these studies identify what the majority of women suffering from PGP have in common, but don’t say anything about the cause of it nor assure that someone who hasn’t suffered from low back pain or pelvic trauma won’t be affected. As a side note, Cecile Röst, a Dutch PT, found out after research that women with PGP were twice as likely to have participated in sports such as swimming, gymnastics or horse riding[ii].

PGP is still a difficult topic to explain, evaluate and treat. Nevertheless, some of the science points to pelvic instability as the main culprit of the painful symptoms that a quarter of pregnant women experience in the pelvic joints. The hormone-induced ligament laxity in the pelvis must be compensated with adequate muscle action, but in some women this simply doesn’t happen. The incorrect muscle response results in asymmetric joint movement and/or muscle spasm, and these eventually result in pain (sometimes disabling pain). The muscle imbalance that we usually find in practice in most PGP patients tends to be: excessive tension in the muscles of the back of the legs, excessive tension & weakness in the adductor muscles (the inner thigh muscles) and decreased hip strength –including weak buttocks-. The effects of these muscle imbalances on pelvic stability –and pelvic floor health- are huge (and long to explain on a blog post). Why is this pattern so common? Even though everybody is different and we all have our own peculiar asymmetries, there are four widespread habits that might be behind it:

1) Heeled shoes: the detrimental whole-body biomechanical changes induced by the use of heels as small as 2cm are long to explain but well researched[iii].

2) Excessive sitting: you don’t need to be a couch potato to spend an average of 10 hours a day sitting. And most likely not in an optimal position.

3) Excessive exercise: to make up for 10 hours of sitting –and not moving- we spend 1 hour per day pushing our (damaged) bodies to the limit. And most likely not in optimal ways.

4) Lack of squatting: toilets are more comfy.

What can I do if I think I am at risk?

We don’t want to interfere in the hormonal work: hormones play a crucial role in increasing pelvic mobility to widen the birth canal. What we need to do is to work on the muscle response to that widening. And the earlier we start working on it, the better the prognosis.

Can I follow a set of simple rules to avoid pelvic pain during pregnancy? Yes, indeed. The same basic rules you should follow to avoid low back pain and/or pelvic floor dysfunction[iv]:

Ditch your heels. Any heel. See the running shoes on your right? That counts as a high heel for any activity that doesn’t involve running. That shoe is designed to run, not to walk. The mechanics of running are completely different from the mechanics of walking. I still remember the brutal spasm of my inner thigh muscles (‘pubic symphysis dysfunction’) after a 6 km walk on a pair of fancy running shoes at 20 weeks. Go for barefoot-like shoes as long as it is possible. Avoid flip-flops or any other unsupported shoe as an alternative.
Don’t spend sitting more than 10-15 minutes in a row. Or in any sustained position for that matter. It is the last thing you will want to care about on the last months of pregnancy, but I still have to mention it.
Walk. Cycling shouldn’t be a substitute of walking.
Stretch your calves, hamstrings (the muscles on the back of your thighs), hip rotators and inner thigh muscles (hip adductors) daily (I’ll go more in depth about this in following posts).

Just these four recommendations can and will make a huge difference. If you are already in pain, these few rules can also help you.

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[i] Vleeming A1, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008 Jun;17(6):794-819. doi: 10.1007/s00586-008-0602-4. Epub 2008 Feb 8.

[ii] Röst, C. Relieving Pelvic Pain During and After Pregnancy: How Women Can Heal Chronic Pelvic Instability. Hunter House Publisher, 1998.

[iii] Esenyel M1, Walsh K, Walden JG, Gitter A. Kinetics of high-heeled gait. J Am Podiatr Med Assoc. 2003 Jan-Feb;93(1):27-32.

[iv] Bowman, K. Alignment Matters: The First Five Years of Katy Says. Propriometrics Press, 2013.

Can I avoid pelvic girdle pain during pregnancy?

What can I do if I think I am at risk?