Low pack, pelvic and pubic-symphysis pain during pregnancy - an osteopathic perspective

An osteopath treating the pregnant patient suffering with pelvic or low back pain must apply physiology and anatomy to a body in flux. Major weight increases, altered spinal curves and unique hormonal make up put a huge stress on the body over a short time. The inability to cope with these changes is often the cause of sacroiliac strains and pubic symphysis diastasis.

Unlike regular back pain, pregnant women have the extra consideration of an enlarged uterus whose strong uterosacral and round ligaments attach onto the sacrum and pubis putting extra stress through these structures.  Combined with the production of a hormone relaxin in preparation for the birth, the pelvis ironicallly has to increase its weight-bearing capabilities whilst accommodating for softer supportive ligaments. This makes the pelvic girdle a more relaxed, vulnerable piece of architecture during pregnancy.

Orthodox medicine tends to classify mechanical back and pelvic pain during pregnancy into roughly 3-5 categories according to the location of symptoms; low back pain due to either joint or disc dysfunction, sacroilliac dysfunction either unilaterally or bilaterally, pubic symphysis pain or pain in all 3 pelvic joints.

From an osteopathic perspective all these conditions are variations on a theme, that is, they are all the result of poor accommodation to the increased physical demands put on the body during pregnancy. Symptoms are likely to occur at the weakest most vulnerable joint in the kinetic chain. The job of the osteopath is to assess the patient and make a structural osteopathic analysis or "diagnosis" to determine why the body is not adapting well to the changes. Furthermore, the osteopath must decide which structures are central to treatment in order for the  body to adjust adequately and compensate during the transition.

Osteopathy does not encourage a protocol treatment and needless to say the osteopath should routinely check and treat each joint in the body, however, there are central structures that require extra attention. The sacrum, hips and perineum are the closest associated structures to the joints of the pelvis and they are expected to accommodate. Any excess tightness in any of these joints reduces their ability to absorb forces and strains the sacroiliac and pelvic joints.

The sacrum for example needs to nutate and counter-nutate (flex and extend) according to the movement of the spinal vertebrae superior to it. If the sacrum is unable to rock back and forth and twist on its vertical axis the illiolumber and pubic symphysis will be strained.  Similarly, any tightness in the hip adductors, external or internal hip rotators mean the femur and ischium tend to function as one unit. Movement of the leg results in traction and stress of the pubic symphysis.

The muscles must also be considered. Any tightness in psoas, abdominal muscles, lumber erector spinae, diaphragm and quadratus lumborum will result in further spinal and pelvic instability.

The osteopath must have an coordinated treatment approach directed at the hips, sacroiliac joints, spinal curves, lumber and abdominal muscles and uterine ligaments in order to treat the pregnant woman affectingly. If the osteopath manages to integrate these structures into a treatment plan the patient is likely to benefit in the long run from a thorough assessment that addresses the root of the problem.


Danny Sher qualified from the British School of Osteopathy (1996) and practices in Jerusalem and Modiin.
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