Postpartum Pelvic Girdle Pain (PGP): Assessment, Goals & Management

1. Definition & Clinical Overview

2. Assessment

A. History-Taking

B. Validated Outcome Measures

C. Physical Examination

Postural & Movement Analysis

• Observe gait (Trendelenburg, antalgic gait, "waddling")
• Single-leg stance tolerance
• Stair negotiation pattern
• Trunk and pelvic alignment (anterior pelvic tilt, sway back)

Clinical Provocation Tests for SI Joint / Posterior PGP

A cluster of ≥ 3 positive tests increases diagnostic accuracy substantially (European Guidelines on PGP, Vleeming et al., 2008).

Pelvic Floor Assessment

• Internal pelvic floor exam (if trained pelvic health physiotherapist): assess tone, strength (Modified Oxford Scale 0–5), coordination, tenderness, scar mobility (if perineal tear/episiotomy)
• Identify hypertonia vs. hypotonicity — both impair load transfer
• Check for rectus abdominis diastasis (inter-recti distance > 2 cm at 2 cm above/below umbilicus)

Neurological Screen

• Lower limb myotomes (L2–S2), dermatomes, reflexes
• Bladder/bowel function — rule out cauda equina

Functional Movement Tests

• Single-leg squat
• Step-up/step-down
• Sit-to-stand mechanics

3. Differential Diagnosis

4. Goals of Management

Short-Term Goals (0–6 weeks)

• Reduce pain intensity by ≥ 2/10 on NPRS
• Educate on posture, body mechanics, and joint protection strategies
• Independent with home exercise program (HEP) fundamentals
• Safe infant care activities (lifting, feeding, bathing) with minimal pain
• Restore basic pelvic floor activation and relaxation
• Reduce fear-avoidance behaviors

Medium-Term Goals (6–12 weeks)

• Achieve safe single-leg stance for ≥ 10 seconds (each leg)
• Pain-free stair negotiation
• Return to walking ≥ 30 minutes without exacerbation
• Progress core and lumbopelvic stabilization exercises
• Minimize reliance on mobility aids (if used)
• Address diastasis recti if present

Long-Term Goals (3–6 months)

• Full return to functional activities, work, recreational exercise
• Return to sexual intercourse without pain (if affected)
• Return to high-impact activity/sport (if desired) with appropriate progression
• Independence in self-management strategies
• Prevention of chronic PGP (a key concern: untreated PGP has a significant rate of chronicity)

5. Patient Management

A. Education & Self-Management

• Explain the mechanism: hormonal laxity (relaxin effect persists during breastfeeding), altered load transfer, muscle inhibition post-delivery
• Activity modification: avoid provocative positions (wide hip abduction, asymmetric loading, carrying on one hip)
• Joint protection:
  • Keep legs together when turning in bed or getting out of car
  • Sit down to dress (avoid standing on one leg)
  • Carry infant centrally (baby carrier vs. hip carry)
  • Use stairs one step at a time if needed
• Reassurance: the majority of postpartum PGP resolves within 3–6 months with appropriate management (Management of Pregnancy, p. 97)

B. Pelvic Health Rehabilitation

1. Therapeutic Exercise Program

• Diaphragmatic breathing with pelvic floor co-activation
• Gentle pelvic floor contractions (if hypotonicity) OR down-training (if hypertonicity/tenderness)
• Transversus abdominis (TrA) activation ("drawing in" — gentle, not bracing)
• Supine bridging (bilateral, pain-free range)
• Pelvic tilts
• Side-lying clamshells (small range, pain-free)

• ASLR exercise (progress to resisted)
• Single-leg bridging
• Standing hip abduction
• Mini-squats / sit-to-stand
• Step-ups (low step, progress height)
• Dead bug (with breath coordination)

• Single-leg squat progressions
• Lunges
• Romanian deadlifts
• Return to running protocol (after pelvic floor clearance — typically no sooner than 3 months postpartum)
• Sport-specific drills as appropriate

2. Manual Therapy

• SI joint mobilization / manipulation (grade I–II if pain-dominant; grade III–IV if stiffness-dominant)
• Soft tissue therapy: piriformis, iliopsoas, hip external rotators, gluteals
• Perineal scar mobilization (if indicated)
• Myofascial release for pelvic floor hypertonicity

3. Biofeedback & Electrical Stimulation

• Surface EMG biofeedback for pelvic floor coordination retraining
• NMES (neuromuscular electrical stimulation) for pelvic floor hypotonicity
• TENS for pain modulation at the SI joint / sacral region

4. Supportive Devices

• Pelvic compression belt / SI belt: worn below ASIS, provides proprioceptive and compressive support; most effective in those with a positive ASLR that normalizes with manual compression
  • Use during provocative activities; wean as strength and motor control improve
  • Evidence supports short-term use — do not substitute for strengthening
• Crutches: temporarily if weight-bearing is significantly limited (especially symphysis pubis diastasis)

C. Pain Management

D. Psychosocial Management

• Screen routinely for postpartum depression (EPDS) — persistent PGP significantly increases its risk (Management of Pregnancy, p. 97)
• Address fear-avoidance and pain catastrophizing (Tampa Scale of Kinesiophobia / Pain Catastrophizing Scale if clinically indicated)
• Encourage peer support / support groups
• Coordinate with midwife, OB, or GP for holistic postpartum care
• Sleep hygiene advice (poor sleep amplifies pain perception)

E. Referral Criteria

6. Prognosis

• ~50% of women with pregnancy-related PGP recover within 3 months postpartum
• ~20% report persistent symptoms at 12 months
• Predictors of chronic PGP: high pain intensity during pregnancy, multiple prior pregnancies, previous PGP, high disability scores (ODI), psychological distress, and failure to receive early rehabilitation
• Early referral to pelvic health physiotherapy and multimodal management improves outcomes significantly (Management of Pregnancy, p. 97)

Summary Algorithm

Postpartum PGP Presentation
         ↓
RED FLAG SCREEN → If positive → Emergency/specialist referral
         ↓
COMPREHENSIVE ASSESSMENT
  • History + outcome measures (PGQ, NPRS, PSFS, EPDS)
  • Clinical provocation tests (P4, ASLR, compression)
  • Pelvic floor exam
  • Postural/movement analysis
         ↓
SET INDIVIDUALIZED GOALS (short/medium/long-term)
         ↓
MULTIMODAL MANAGEMENT
  ├── Education & joint protection
  ├── Pelvic health rehabilitation (exercise, manual therapy, biofeedback)
  ├── Pelvic compression belt (short-term)
  ├── Analgesia (paracetamol ± NSAID)
  └── Psychosocial support + depression screening
         ↓
REASSESS at 4–6 weeks → Adjust goals and treatment
         ↓
If no improvement at 3–6 months → Escalate / refer