Review Article

Low Back Pain and Pelvic Girdle

Pain in Pregnancy

Abstract
Danielle Casagrande, MD Pregnancy has a profound effect on the human body, particularly the
Zbigniew Gugala, MD, PhD musculoskeletal system. Hormonal changes cause ligamentous joint
laxity, weight gain, and a shift in the center of gravity that leads to
Shannon M. Clark, MD
lumbar spine hyperlordosis and anterior tilting of the pelvis. In addition,
Ronald W. Lindsey, MD vascular changes may lead to compromised metabolic supply in the
low back. The most common musculoskeletal complaints in
pregnancy are low back pain and/or pelvic girdle pain. They can be
diagnosed and differentiated from each other by history taking, clinical
examination, provocative test maneuvers, and imaging. Management
ranges from conservative and pharmacologic measures to surgical
treatment. Depending on the situation, and given the unique
challenges pregnancy places on the human body and the special
consideration that must be given to the fetus, an orthopaedic surgeon
and the obstetrician may have to develop a plan of care together
regarding labor and delivery or when surgical interventions are
indicated.

From the Department of Orthopaedic

Surgery and Rehabilitation
(Dr. Casagrande, Dr. Gugala, and
Dr. Lindsey) and the Department of
Obstetrics and Gynecology (Dr. Clark),
University of Texas Medical Branch,
Galveston, TX.
Dr. Clark or an immediate family
member is a member of a speakers’
bureau or has made paid
presentations on behalf of Duchesnay
USA. None of the following authors or
any immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Casagrande,
Dr. Gugala, and Dr. Lindsey.
J Am Acad Orthop Surg 2015;23:
539-549
http://dx.doi.org/10.5435/
JAAOS-D-14-00248
Copyright 2015 by the American
Academy of Orthopaedic Surgeons.
P regnancy has profound physio-
logic effects on a woman’s body,
affecting not only the cardiovascu-
lar, endocrine, and renal systems,1
but also the musculoskeletal system,
specifically the axial skeleton. Dis-
tinct hormonal changes accompa-
nied by an increase in body mass and
the presence of the gravid uterus
cause a shift of the center of gravity,
thereby exerting additional static
and dynamic loads on the axial
skeleton.
Recommended weight gain during
pregnancy is 25 to 35 lb (11 to 16 kg),
of which approximately half is gained
in the abdomen.2 As a result, the
enlarging abdomen (Figure 1) elicits
postural compensations (Figure 2)
that frequently culminate in the
development of low back pain (LBP),
the most common musculoskeletal
complaint during pregnancy,3 and/or
pelvic girdle pain (PGP). Gestational
LBP typically begins in the second
trimester, on average at 22 weeks of
pregnancy. About half of women
with initially manifesting LBP during
pregnancy continue to have pain 1
year postpartum,4 and 20% are
symptomatic 3 years after delivery.5
The prevalence of LBP during preg-
nancy ranges from 20% to 90%;
most studies report a prevalence
.50%.6,7 PGP typically begins by
the end of the first trimester, peaking
between the 24th and 36th gesta-
tional weeks; this usually resolves
spontaneously within 6 months
postpartum; however, in 8% to 10%
of women, the pain continues for
1 year to 2 years postpartum.8,9 The
incidence of PGP in pregnancy ranges
from 4% to 76%, depending on the
definition used, which often includes
LBP. When defined as pain located
from the level of the posterior iliac
crest and the gluteal fold over the

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Low Back Pain and Pelvic Girdle Pain in Pregnancy
Figure 1
The progression of abdominal girth during pregnancy. (Copyright Gregory
Katsoulis, Cambridge, MA.)
anterior and posterior elements of the
bony pelvis, the prevalence has been
reported as ranging from 16% to
25%.9 However, the precise defini-
tion of PGP often overlaps with that
of LBP, inherently making all fre-
quency indices obligatory estimates
in the literature.
Considering the high incidence and
prevalence of pregnancy-related LBP
and PGP, this review specifically ad-
dresses these gestational musculo-
skeletal conditions, including their
clinical differences, etiologies, diag-
nosis, and orthopaedic management.
Low Back Pain and Pelvic
Girdle Pain in Pregnancy
Etiology
Joint laxity increases during preg-
nancy10 as a result of increasing levels
of relaxin, progesterone, and estro-
gen.11-13 Relaxin, a hormone pro-
duced by the corpus luteum and the
placenta, increases from early preg-
nancy, peaks at the end of the first
trimester, and then remains consis-
tently elevated until late pregnancy.14
In one study, women experiencing
the most incapacitating LBP had the
highest amount of relaxin.15 Estro-
gen potentiates relaxin receptor sen-
sitivity, thereby enhancing its effect
540
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
on joints.12 Joint laxity is considered
one of the etiologies of LBP and
PGP in the pregnant patient. Unlike
asymptomatic pregnant patients,
pregnant women with moderate or
severe posterior pelvic pain exhibit
significant asymmetric sacroiliac joint
laxity.16 Additionally, in women with
pregnancy-related lumbopelvic pain,
greater pubic symphysis mobility
has been reported during pregnancy
and puerperium compared with
asymptomatic pregnant women.17
In many women, pregnancy-related
joint pain is associated with increased
concentrations of estradiol and pro-
gesterone;18 however, a definitive
causative relationship has not been
established.14,18
An enlarging gravid uterus stretches
and weakens abdominal muscles,
thereby placing additional strain on
lumbar muscles that compensate for
the loss of abdominal muscle tone
and strength.12 Furthermore, the
pelvis rotates sagittally about the
second sacral segment, which acts as
a fulcrum (Figure 3). Resultant
compensatory hyperlordosis occurs
as the gravid uterus causes the
woman’s center of gravity to shift
forward. This action creates an
additional flexion moment on the
lumbar spine that culminates in an
increased load on the lumbar spinal
Journal of the American Academy of Orthopaedic Surgeons
musculature. In addition, anterior
pelvic tilt increases as the center of
gravity shifts anteriorly, causing
a greater load through the sacroiliac
ligaments as these structures attempt
to resist this forward pelvic rotation.
As the pregnancy progresses, these
sacroiliac ligaments become lax and
allow increased forward pelvic
rotation and lumbar spine hyper-
lordosis, which subsequently place
even more strain on the pelvis and
low back3 (Figure 4). Axial loading
of the spine, which causes com-
pression of the intervertebral disks,
may also contribute to LBP; exces-
sive compression may result in the
expulsion of fluid from the disks and
decreased height.6 One study dem-
onstrated that activity-related spinal
compression is greater and post-
activity recovery is longer in preg-
nant women with LBP compared
with asymptomatic pregnant or
nonpregnant women.19
Vascular changes may also con-
tribute to back pain during preg-
nancy. The gravid uterus can place
considerable compression on both
the aorta and the vena cava when
a woman is in the supine position. In
addition to the potential risk of
venous thromboembolism, the sub-
sequent venous stasis and decreased
regional oxygen saturation may lead
to hypoxemia that compromises the
metabolic activity of the neural
structures, thereby causing LBP.12,20
Prevalence and Associated
Factors
Lumbopelvic pain essentially encom-
passes three entities: (1) pregnancy-
related LBP (herein referred to as
LBP); (2) pregnancy-related PGP
(herein referred to as PGP); and (3)
combined pregnancy-related LBP and
PGP.21 It usually begins around the
18th week of pregnancy and peaks
between weeks 24 and 36.21 At 12 to
18 weeks’ gestation, the prevalence
of lumbopelvic pain in pregnant
 Danielle Casagrande, MD, et al

patients was reported as 62%, with Figure 2

33% experiencing PGP, 11% expe-
riencing LBP, and 18% experiencing
both.22 In another report, 50% of
gestational lumbopelvic pain was
caused by PGP, 33% by LBP, and
17% by both.21 Toward the end of
pregnancy, at around 35 weeks, the
prevalence of LBP and PGP were
71.3% and 64.7%, respectively.23
Strong predictors of lumbopelvic
pain are strenuous work, previous
lumbopelvic pain, and a history of
pregnancy-related LBP or PGP.21 An
increased incidence of LBP has been
reported in pregnant women with
advanced maternal age, a history of
back pain during a previous preg-
nancy, increased parity, a higher
body mass index, and a history of
joint hypermobility.24,25 A history of
back pain during a previous preg-
nancy is an especially strong pre-
dictor of experiencing back pain in
subsequent pregnancies, with an
85% likelihood.6 Interestingly, there
does not appear to be an association
between LBP and maternal weight
gain during pregnancy or the height
or birth weight of the baby.24
In addition to the risk factors
described earlier, previous pelvic
trauma is also associated with the
occurrence of PGP.26,27 Factors that
do not appear to be associated with
PGP include weight, height, age, and
smoking.27 Pregnant patients with
PGP are usually more disabled than
those with LBP, exhibit much higher
pain scores, and are more difficult to
treat.8
Illustration describing musculoskeletal compensations during pregnancy.

Symptoms and Diagnosis
The differential diagnoses of LBP and
PGP greatly overlap (Table 1), but
a careful clinical history and physical
examination can aid in making
a definitive diagnosis5,9,28,29 (Table 2).
Pregnancy-related PGP is usually
experienced between the posterior
iliac crest and the gluteal fold near one
or both sacroiliac joints, occasionally
radiating into the posterior thigh. It
may occur in conjunction with or
separately from the pubic symphysis,
with possible radiation into the
anterior thigh.27 Pain is intermittent,
may be precipitated by prolonged
sustained postures, and usually oc-
curs within 30 minutes of common
daily activities, such as walking, sit-
ting, or standing.8 Pregnancy-related
LBP is described as pain in the
lumbar region, above the sacrum,
and it may radiate into the leg. The
pain is often dull and exacerbated
by forward flexion. Spinal move-
ment is often restricted in the lum-
bar region, while palpation of the
erector spinae muscles intensifies
symptoms.8 PGP can be clinically
diagnosed and distinguished from

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Low Back Pain and Pelvic Girdle Pain in Pregnancy
Figure 3
Illustration demonstrating anterior pelvic tilt and compensatory hyperlordosis.
LBP by several pain provocation
tests (Table 3). These tests have
high specificity and low sensitivity;
therefore, it is recommended that all
of these tests be performed when-
ever possible.8,27,29
Pregnancy-related posterior pelvic
pain is defined as PGP without pubic
symphysis pain, and making the
clinical differentiation from LBP in
pregnancy can be challenging. In
contrast to LBP, posterior pelvic pain
is characterized by a stabbing pain in
the buttocks, distal and lateral to the
area of L5 to S1; the pain may or may
not radiate to the posterior thigh or
knee. Posterior pelvic pain is often
associated with weight bearing, the
presence of pain-free intervals, nor-
mal range of motion at the hips and
spine, no nerve root impingement,
and a positive posterior pelvic pain
provocation test.30
542
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Imaging
If symptoms are severe or are associ-
ated with neurologic compromise,
further evaluation may be indicated.
MRI is considered the safest and
preferred imaging modality during
pregnancy.6,8,9,28 Concerns have
been raised by some clinicians
regarding MRI-induced fetal terato-
genicity, acoustic damage, and
heating effects.31,32 However, cur-
rent data have not demonstrated
adverse effects following 1.5-T MRI
exposure; the safety at 3-T exposure
has not been thoroughly studied.31
Despite these findings, the Interna-
tional Commission on Non-Ionizing
Radiation Protection recommends
delaying elective MRI until after the
first trimester because of potential
risks.33 The American Congress
of Obstetricians and Gynecologists
Journal of the American Academy of Orthopaedic Surgeons
(ACOG) states that during preg-
nancy, other imaging procedures not
associated with ionizing radiation
(eg, ultrasonography, MRI) should
be considered instead of radiography,
when appropriate,34 and notes that
MRI has not been associated with
known adverse fetal effects. Finally,
the American College of Radiology
2013 guidelines recommend that
MRI should be used in pregnant pa-
tients, regardless of gestational age,
when the benefits outweigh the risks,
even in the first trimester.35 Although
studies regarding fetal risk with ga-
dolinium contrast are lacking, most
radiologists avoid its routine use in
pregnancy.31
Unlike MRI, radiography uses
ionizing radiation. The amount of
radiation absorbed by the fetus de-
pends on the gestational age; at 2 to 8
weeks, a dose of ,10 cGy (ie, expo-
sure equivalent to a three-view spine
series) poses no significant risk for
fetal abnormalities. The risk for
anomalies increases 1% per 10-cGy
increase.6 The fetus is most vulnera-
ble at 8 to 15 weeks’ gestation, with
ionizing radiation potentially leading
to intrauterine growth retardation
and central nervous system defects.
With increasing radiation doses
.100 mGy [10 cGy], spontaneous
abortion is possible at 3 to 4 weeks’
gestation, and the risk of congenital
malformation is increased if exposure
occurs at 5 to 10 weeks’ gestation.
Ionizing radiation also poses a carci-
nogenic risk. According to the Inter-
national Commission on Radiological
Protection, about 1 in 500 fetuses
exposed to $30 mGy [3 cGy] of
radiation will develop cancer.36
Fluoroscopy use during spinal sur-
gery may place the fetus at significant
risk and should be avoided whenever
possible. If absolutely required for
emergent or urgent surgical proce-
dures, its risks can be minimized with
proper uterine shielding and by
reducing exposure time, collimating
the beam width and exposure area,
 Danielle Casagrande, MD, et al

reducing image magnification, se- Figure 4

lecting appropriate radiation output,
and using equipment that includes
pulsed fluoroscopy and image storage-
recall.31 In a simulation study,
Theocharopoulos et al37 demon-
strated that fluoroscopically guided
spinal treatments exposed phantom
fetuses lying outside the primary irra-
diated region to ,4 mGy [0.4 cGy]
during all gestational stages, incurring
risks of cancer and congenital mal-
formation that are lower than spon-
taneous incidence rates. However,
when the phantom fetus was directly
exposed to the fluoroscopy beam, the
dose could reach as high as 105 mGy
[10.5 cGy]. It was also determined in
this simulation study that at least
35 minutes of fluoroscopy would be
required to induce adverse fetal effects.
Although user-dependent, trans-
vaginal/transperineal ultrasonogra-
phy has been advocated in diagnosing
and monitoring the progress of pubic Algorithm demonstrating the etiology of lumbopelvic pain in pregnancy
symphysis pain and diastasis.9 Ultra- (mechanical).
sonography is also used for guided
placement of epidural catheters in
pregnant patients. Ultrasonography According to the European guide- neuro-emotional technique, and spi-
has no known significant risks to the lines, issued by Working Group 4, nal manipulation had no significant
fetus or the mother because tissue MRI is the suggested imaging effect on LBP and physical function.
temperature increases would not be modality for evaluation of PGP in Low-quality evidence suggested that
expected to exceed 32.9°F (0.5°C).31 pregnant patients,27 whereas ACOG nocturnal pain may be better relieved
Nonetheless, energy exposure has been recommends use of MRI or ultraso- by a specially designed pregnancy
arbitrarily restricted to 94 mW/cm2 by nography when appropriate.34 support pillow compared with a reg-
the FDA.36 ular pillow.38 For PGP, moderate-
CT is not recommended for evalua- quality evidence suggested that
tion of nontraumatic LBP or PGP but
Treatment of Pregnancy- acupuncture more effectively reduced
may be indicated when trauma is sus-
related Low Back Pain and evening pain than did exercise, but
tained in these regions. The estimated Pelvic Girdle Pain both methods of management were
dose of a single pelvic CT during the more effective than the usual prenatal
first trimester is lower than the thresh- Conservative Management care alone. In a comparison of acu-
old dose at which fetal risk significantly Pennick and Liddle38 conducted puncture with sham acupuncture,
increases, but the risk of childhood a systematic review of 26 random- function and evening pain, but not
cancers may increase by a factor of ized, controlled trials that examined the average pain score, were
two. The risk of adverse effects in the treatments for LBP, PGP, and com- improved with acupuncture. Evening
fetus is increased with multiphase CT bined LBP and PGP during pregnancy. pain relief did not significantly differ
studies and repeat scans. An increased For LBP, low-quality evidence showed between deep or superficial acu-
risk of spontaneous abortion exists if that exercise significantly reduced pain puncture. Low-quality evidence sug-
the radiation dose is .0.1 Gy [10 cGy] and disability and that water exercise gested that adding a rigid belt to
within the first 2 weeks after concep- significantly reduced pain-related sick exercise improves average pain but
tion, but there does not appear to be leave. The authors concluded that use not function.38 For lumbopelvic pain,
an increased risk thereafter.31 of different support belts, exercise, moderate-quality evidence showed

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Low Back Pain and Pelvic Girdle Pain in Pregnancy

Table 1 improved with osteopathic manipula-

tion and with a combination of manual
Differential Diagnoses for Low Back Pain and for Pelvic Girdle Pain in
Pregnancy9,28,29 therapy, exercise, and education. Acu-
puncture improved pain and function
Low Back Pain28,29 Pelvic Girdle Pain9
better than did the usual prenatal care
Osteoarthritis Painful visceral pathologies of the pelvis or physiotherapy and was more
Lumbar spine Urogenital effective when started at 26 weeks’
Sacroiliac joint Gastrointestinal gestation rather than at 20 weeks’
Hip Syphilitic lesion of pubis gestation. Ear acupuncture, compared
Stress fracture Lumbar disk herniation with sham acupuncture, also signifi-
Sacrum Lumbar radiculopathy cantly improved the outcomes.38
Ilium Spondylolisthesis/spondylolysis
Femur Rheumatism Pharmacologic Management
Lumbar disk herniation Sciatica
The safety of a medication during
Lumbar radiculopathy Spinal stenosis
pregnancy is indicated by the cate-
Spondylolisthesis/spondylolysis Lumbar spine arthritis
gory assigned to it by the FDA39
Rheumatism Tuberculosis
(Table 4). Acetaminophen in oral or
Sciatica Urinary tract infection rectal form is a category B drug that
Spinal stenosis Rupture of symphysis pubis is the first-choice analgesic for mild
Lumbar spine arthritis Sprain of sacroiliac joint back pain because it has no known
Tuberculosis Osteitis pubis teratogenic properties (intravenous
Urinary tract infection Chorioamnionitis form is category C). NSAIDs, such as
Rupture of symphysis pubis Femoral vein thrombosis ibuprofen and naproxen, are cate-
Sprain of sacroiliac joint Preterm labor gory C drugs in the first trimester (0
Osteitis pubis Placental abruption to 14 weeks) and the second tri-
Chorioamnionitis Round ligament pain mester (14 to 28 weeks); in the third
Femoral vein thrombosis Bone or soft-tissue tumors trimester (28 to 42 weeks), they are
Preterm labor considered category D drugs because
Placental abruption fetal risks have been demonstrated.39
Round ligament pain The ductus arteriosus is essential for
Bone or soft-tissue tumors normal fetal circulation; however,
Ankylosing spondylitis the structure can close prematurely
Fibromyalgia when NSAIDs are used at or near
Red degeneration of leiomyoma term and can lead to pulmonary
Pregnancy-related osteoporosis hypertension.20 Therefore, use of
Cauda equina
NSAIDs during pregnancy should be
short-term and restricted to the
Osteomyelitis
first and second trimesters. Full-
Lumbar facet arthropathy
dose aspirin is a category D drug
Osteonecrosis of the hip
throughout all three trimesters and
Appendicitis
has been associated with increased
Pyelonephritis
perinatal mortality, neonatal hem-
Hydronephrosis
orrhage, decreased birth weight,
Renal calculi
prolonged gestation and labor, and
Aortic aneurysm possible birth defects.39 Low-dose
aspirin can be used in pregnancy
and is considered safe with respect to
that an 8- to 20-week exercise evidence demonstrated that exer- the risks of fetal malformation and
program reduced the risk for pain, cise significantly improved function major developmental impairment.
but a 16- to 20-week training pro- and significantly reduced lumbopel- Cyclobenzaprine, a muscle relax-
gram was no more effective than the vic pain-related sick leave. Pain ant, is an available category B medi-
usual prenatal care. Low-quality and function were also significantly cation that can be used in pregnancy,

544 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

but methocarbamol, a category C
drug, should be avoided if possible
because its fetal risk has not been fully
established.7 Opioids may be used for
severe pain.20,40 Codeine, a category C
drug, has been associated with respi-
ratory malformations.40 The Collab-
orative Perinatal Project found no
congenital anomalies associated with
hydrocodone, meperidine, metha-
done, morphine, or oxycodone use
during pregnancy. These drugs, along
with fentanyl and hydromorphone,
are rated as category B drugs.40
However, all opioid analgesics are
rated as category D by the FDA if
they are used for extended periods or
in large doses near term. Therefore,
opioid analgesics should not be
administered near term and are
strictly limited to short-term use.20,40
The use of epidural steroids during
pregnancy is controversial even though
a single dose appears to be of low risk
to the fetus. Epidural steroids are best
reserved for the pregnant patient who
has the new onset of symptoms that are
consistent with lumbar nerve root
compression (ie, unilateral loss of deep
tendon reflex, sensory/motor change in
a dermatomal distribution).40 A recent
review reported efficacy for the
epidural analgesia treatment of PGP
in pregnancy when delivered either
in a single shot or as a temporary
method of pain relief following
extended administration during pe-
riods of increasing pain.9
Surgical Treatment
The role of spine surgery for LBP and
PGP in pregnancy is limited. When
indicated, it requires careful coordi-
nation between the orthopaedic sur-
geon and the obstetrician; guidelines
have been established in a study by
Han et al.41 In the first trimester, the
prone position may be used, whereas
in the second trimester, the lateral
decubitus position in either direction
(depending on the direction of the
lesion) is preferred. In the third
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Table 2
Characteristics of Low Back Pain and Pelvic Girdle Pain in Pregnancy5
Low Back Pain
First presentation may be prior to
pregnancy
Pain localized to lumbar region
Range of motion of lumbar region is
decreased
Tenderness to palpation over lumbar Tenderness to palpation over sacroiliac
paraspinal muscles
Often no issue with walking or standing Often pain with walking or standing
Pain is constant
Provocation test for pelvic pain is
negative
trimester, the left lateral decubitus
position should be used because of
the risk of compression of the inferior
vena cava with the right decubitus
position. If the surgical field is located
inferiorly in the left decubitus posi-
tion and the patient is in the third
trimester, the table can be tilted to
assist in the surgical approach.41
After 34 weeks’ gestation, a deci-
sion should be made whether deliv-
ery is indicated prior to surgery. If
there is progressive neurologic deficit
at ,34 weeks’ gestation, antenatal
corticosteroids should be given, and
decompression surgery should be
planned in consultation with the
obstetrician. In a truly urgent state,
both procedures (ie, childbirth and
spine surgery) can be performed
under the same anesthesia. When
antepartum surgery is considered,
the patient should be advised of the
risks and benefits to herself as well as
to the fetus.41
Category B perioperative anti-
biotics (ie, ampicillin, cephalosporin)
may be used prophylactically in the
pregnant spinal patient. Epidural
anesthesia is recommended for short
surgical spine procedures, and gen-
eral anesthesia is recommended for
longer surgical spine procedures,
such as fusions.41
Danielle Casagrande, MD, et al
Pelvic Girdle Pain
Typically presents for first time during
pregnancy
Pain localized between posterior iliac
crest and gluteal folds, predominantly
around sacroiliac joint
Range of motion of lumbar region
remains normal
joint and gluteal musculature
Pain is intermittent
Provocation test for pelvic pain is
positive
Although there is no consensus,
intraoperative fetal heart monitoring
is not indicated before 20 weeks’
gestation; its indications are unclear
between 20 and 23 weeks’ gestation.
After 23 weeks’ gestation, however,
intraoperative fetal heart monitoring
is recommended for the detection of
potential abnormalities, thus alerting
the obstetrician to take urgent action
to protect the fetus.41
Ideally, pain should not be a sole
indication for surgery in patients with
routine spinal disorders. However,
surgery can be performed during
pregnancy if the pain is incapacitat-
ing or refractory to conservative
management measures, and/or if
neurologic compromise is imminent.
Spondylolisthesis
Spondylolisthesis secondary to
a defect in the pars interarticularis most
commonly occurs at L5, which can
subsequently translate or “slip” for-
ward in relation to the end plate of
S1. Degenerative spondylolisthesis,
however, is a similar process that
typically occurs at L4-L5 and is
more common in women.3 In sus-
ceptible women, pregnancy may be
a major independent factor for
the development of degenerative
545
Low Back Pain and Pelvic Girdle Pain in Pregnancy

Table 3
Provocative Tests for Diagnosing Pelvic Girdle Pain8
Test Maneuver Indication of Positive Test

Posterior pelvic pain
provocation test
FABER test, also known
as Patrick test
Long dorsal sacroiliac
ligament test
Active straight leg
raise test
Pain provocation of the pubic
symphysis by the modified
Trendelenburg test
Patient lies supine with hip flexed to 90°. Pressure
is applied to the flexed knee along the femoral
longitudinal axis while the pelvis is stabilized with
a hand placed on the opposite anterior superior iliac
spine.
Patient lies supine with the hip flexed, abducted,
and externally rotated so that the heel comes to
rest on the opposite knee. With the patient relaxed,
the weight of the leg causes the knee to drop toward
the floor.
Patient lies on side, with both the hip and knee in slight
flexion. Directly under the caudal part of the posterior
superior iliac spine, the long dorsal sacroiliac
ligaments, bilaterally, are palpated.
Patient lies supine with the legs straight and the feet
20 cm apart. The patient raises one leg at a time, 20 cm
above the examination table, while maintaining
a straight knee.
Patient stands on one leg with the hip and knee of
the contralateral leg flexed to 90°.
The test is positive if deep pain is
produced in the gluteal region.
The test is positive if pain occurs
in the ipsilateral sacroiliac joint
or the pubic symphysis.
The intensity of tenderness is
related to the severity of the
condition.
The degree of difficulty in
performing this test is an
indicator of the severity of the
condition.
The test is positive if symphyseal
pain is experienced during this
maneuver.

FABER = flexion, abduction, external rotation

spondylolisthesis. Sanderson and

Table 4
Fraser42 reported that multiparous
FDA Classification of Drug Safety During Pregnancy39 women had a higher incidence of
Category Interpretation spondylolisthesis than did nulliparous
women. Saraste43 determined that
A Adequate, well-controlled studies in pregnant women have not
shown an increased risk of fetal abnormalities to the fetus in any
women with a previous diagnosis of
trimester of pregnancy. spondylolisthesis did not experience
B Animal studies have revealed no evidence of harm to the fetus; an increase in LBP or vertebral body
however, there are no adequate and well-controlled studies in translation (ie, slippage) during
pregnant women, or pregnancy.
Animal studies have shown an adverse effect, but adequate and
well-controlled studies in pregnant women have failed to
demonstrate a risk to the fetus in any trimester. Lumbar Disk Herniation
C Animal studies have shown an adverse effect and there are no
adequate and well-controlled studies in pregnant women, or Lumbar disk herniation occurs in
No animal studies have been conducted and there are no about 1/10,000 pregnancies and
adequate and well-controlled studies in pregnant women.
typically presents with no symptoms
D Adequate well-controlled or observational studies in pregnant
women have demonstrated a risk to the fetus. However, the
or mild LBP. Pregnant patients
benefits of therapy may outweigh the potential risk. For example, experience similar symptoms to those
the drug may be acceptable if needed in a life-threatening of nonpregnant patients, including
situation or serious disease for which safer drugs cannot be used unilateral radiating leg pain and
or are ineffective.
a positive straight leg raise test.
X Adequate well-controlled or observational studies in animals or
Weinreb et al44 demonstrated that
pregnant women have demonstrated positive evidence of fetal
abnormalities or risks. The use of the product is contraindicated pregnancy alone does not confer
in women who are or may become pregnant. a higher risk for lumbar disk herni-
ation compared with nonpregnant

546 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

women. Conservative, nonsurgical
management is usually indicated for
pregnant women with radiculop-
athy, with or without LBP; this
treatment regimen includes rest, ice,
physical therapy, lumbar support,
analgesia, and/or muscle relaxants.30
MRI is the first and safest diagnostic
test for pregnant women with per-
sistent pain.45 Despite MRI findings,
surgical treatment can be postponed
until after delivery if the neurologic
symptoms are minimal or stable.
However, surgical intervention is
warranted for women who experi-
ence bowel or bladder dysfunction
or progressive motor weakness.
Less than 2% of patients with
lumbar disk herniation progress to
cauda equina syndrome, an urgent
state that presents with radiating pain
or numbness bilaterally in the legs,
paralysis, and dysfunction of the
bowel and bladder. Patients often
have a positive straight leg raise test,
reduced rectal sphincter tone, saddle
anesthesia, and decreased deep ten-
don reflexes.7 MRI should be per-
formed immediately in patients with
these symptoms. Both cauda equina
syndrome and progressive motor
weakness are absolute indications
for surgery, regardless of the stage of
pregnancy. Although classic lumbar
spine surgical methods include lam-
inectomy and diskectomy, the more
recent endoscopic diskectomy has
emerged as a viable treatment option
for debilitating disk herniation dur-
ing pregnancy.7 Because the patient
is positioned in reference to the
microscope, endoscopic diskectomy
obviates the need for general anes-
thesia, and the prone position avoids
excessive abdominal compression.29
Pubic Symphysis Diastasis
Widening of the pubic symphysis
occurs in pregnancy to accommodate
descent of the fetal head through
the birth canal; this process can begin
September 2015, Vol 23, No 9
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Figure 5
Pelvic radiographs demonstrating pubic diastasis post-delivery (A) and at 1 year
postpartum (B). (Reproduced with permission from Yoo JJ, Ha YC, Lee YK, et al:
Incidence and risk factors of symptomatic peripartum diastasis of pubic
symphysis. J Korean Med Sci 2014:29[2]:281-286.)
as early as 8 to 10 weeks’ gestation
and progress steadily throughout
the pregnancy.45 Physiologic wid-
ening #10 mm is considered
acceptable; this limited diastasis
usually causes minimal or no symp-
toms.13 Increased risk for symp-
tomatic diastasis is associated with
multiparity, fetal macrosomia, pre-
cipitous labor, powerful uterine
contractions, or previous pelvic
pathology or trauma.30 Patients may
experience a stinging pain around the
pubic symphysis or sacroiliac joints
that often radiates down their thighs.
Stair climbing, walking, standing up,
and carrying heavy objects may
exacerbate the pain.30 Symptomatic
diastasis that is ,10 mm may be
carefully observed or treated con-
servatively with a short course of
anti-inflammatory drugs or with
epidural analgesia. Treatment may
also include an intrasymphyseal
injection with hydrocortisone, chy-
motrypsin, and lidocaine once a day
for 3 to 7 days. Activity modification,
pelvic binders, and physical therapy
may also be effective additions to the
treatment regimen.30 Regardless of
treatment, pubic symphysis widening
begins to reverse shortly after deliv-
ery, with symptoms usually resolving
Danielle Casagrande, MD, et al
by the eighth postpartum week,
and the pubic symphysis normally
returns to its baseline by 12 weeks
postpartum.30,46
Frank rupture of the pubic sym-
physis is rare, with an incidence of 1
in 600 to 800 to 1 in 30,000 preg-
nancies.46 This condition is caused
by the forceful descent of the fetal
head against the pelvic ring during
delivery.46 Suggested risk factors
and/or associations include large
fetal macrosomia, protracted labor,
epidural analgesia, forceps delivery,
shoulder dystocia, and maternal
developmental hip dysplasia.46 A
sudden pain is experienced in the
region of the pubic symphysis and is
often accompanied by an audible
crack. Pain may radiate to the back
or thighs, and a gap can be palpated
at the symphysis along with abnor-
mal hemipelvis mobility with lateral
compression.20,46 If there is signifi-
cant posterior tenderness at either
sacroiliac joint, CT should be ob-
tained to fully assess the extent of
posterior ring involvement.46 Treat-
ment should initially consist of bed
rest in the lateral decubitus position
and the use of a pelvic binder. Early
partial weight-bearing mobilization
with a walker (weight-bearing
547
Low Back Pain and Pelvic Girdle Pain in Pregnancy
restrictions should be assigned to the
same side as that with the sacroiliac
pain) and periodic follow-up radio-
graphs should be obtained to confirm
symphysis and sacroiliac joint clo-
sures46,47 (Figure 5). Surgical inter-
vention should be reserved for open
pubic symphysis rupture secondary to
vaginal tearing, diastasis with the
pelvic binder in place, or symptom-
atic diastasis refractory to conserva-
tive management, or if one or both of
the sacroiliac joints are displaced,
suggesting pelvic instability.46 Surgi-
cal options may include pubic sym-
physis open reduction and internal
fixation with plates and screws or
external fixation of the pelvis, fol-
lowed by reduction and percutaneous
iliosacral screws if the sacroiliac joints
remain widened and unstable.30,46
Summary
Although the natural musculoskeletal
changes accompanying pregnancy vary
from woman to woman, LBP and PGP
will be a problem for some patients.
Because the most significant and
noticeable physical change occurs in the
abdominal region with the growing
gravid uterus, it is not unexpected that
the lumbar spine and the pelvic region
are most affected. It is important for the
patient and the physician to be aware
of these effects in order to recognize
symptoms that are outside those con-
sidered normal for pregnancy because
some conditions can have lasting,
debilitating consequences. Equally
important is that orthopaedic surgeons
recognize the musculoskeletal con-
ditions that may arise during pregnancy
so that appropriate and early treatment
may begin to minimize a patient’s
symptoms and, with certain con-
ditions, prevent long-term sequelae.
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548
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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