Let me set the scene for you -you’re about 7 months pregnant (although it can happen sooner or later than this), it’s 2:30 in the morning, and you have to get up to use the bathroom for the 10th time in a row! You roll to your side to get up, lift your top leg up to help you sit up in bed, and then BAM -you feel this hot, piercing, burning jolt of pain shoot through the middle of your pubic bone as you’re trying to sit up in bed! If you have ever felt that kind of pain, know that you are not alone and that many pregnant women (including myself and some of my clients) have experienced the same thing. This topic has been popping up lately in several different circles of mine, so I thought it was time to write about it.
What is Pubic Symphysis Diastasis?
Well -what exactly is this pain that I am referring to? Most likely, the pain that you are feeling is a result of a Diastasis or widening of the symphysis pubis (the joint that connects the two halves of your pelvis together in front). This is a normal process that happens in pregnancy to enable the birthing process. It can be attributed to hormonal changes (increased production of Relaxin), a lengthening and weakening of your pelvic ligaments, the fascia in your thoracic and lumbar spine, and muscles of your core and pelvis. For with most women the pubic symphysis gap normally is 4-5 mm wide, and it can widen 2-3 mm more during the last trimester of your pregnancy. Pubic symphysis dysfunction is characterized by diastasis of the pubic symphysis widening to 9-10 mm or more.
Symptoms of Pubic Symphysis Diastasis
The symptoms of pubic symphysis diastasis are very similar to those of pubic symphysis dysfunction and can include:
- Tenderness of the pubic symphysis with touch
- Lower abdominal pain
- Low back or posterior pelvic pain
- Tightness in the muscles that surround the hips and pelvis like the glutes, inner thigh muscles and hip rotator musculature.
- Pain in one or both of the sacroiliac (SI) joints.
- A â€œclickingâ€ feeling in the pubic symphysis with certain movements such as walking.
- Pain in the area with certain movements and activities.
- A waddling or altered gait.
Activities That Can Aggravate Pubic Symphysis Diastasis
A lot of what I talk about on the blog is fitness-related, but it’s not just about being careful about what you do inside of the gym. You need to do things right during your everyday life as well. The following activities are some of the more common things that can aggravate public symphysis diastasis:
- Standing on one foot too long
- Sitting for long periods of time
- Getting in and out of the car
- Going up and down stairs
- Walking, running
- Heavy lifting or lower body strength training
- Bending over
- Any sort of repetitive tasks
- Household work like cleaning, mopping, vacuuming, etc.
- Wide stance exercises and positions (yes -that can include sex J), single leg, and spilt stance exercises.
- Birthing positions in which the legs are spread wide apart
I’m Experiencing This Type of Pain -Now What?
First and foremost, if you are experiencing ANY type of pelvic or lower back pain, you may want to seek the help of a physical therapist that specializes in pelvic floor health. They can assess many of the factors that are contributing to your pelvic pain such as whole body and pelvic alignment, the symmetry of both the position and movement between your pelvic joints, muscular imbalances surrounding your pelvis, fascial restrictions, etc.
Treatment for pubic symphysis diastasis involves a combination of several different modalities including but not limited to alignment correction, stabilization exercises, techniques for positioning and transitioning between movements, soft tissue work, joint mobilization, ice application, and more. You will find that the information that we cover in this article isn’t only for addressing the pain associated with pubic symphysis diastasis, but also addressing your system as a whole because the pain is only a symptom of what is going on elsewhere in your body. Let’s dive in a talk about several different exercises below that you can do at home or in the gym to help reduce and alleviate your symptoms.
I know I always talk about your alignment -because it’s just that important! Alignment shifts can help tremendously with stabilizing the spine and pelvis by setting up the deepest inner core muscles in a more optimal position for better recruitment, management of intra-abdominal pressure, and support of the spine and pelvis. So in EVERYTHING you do throughout the day, whether that is working out, or performing activities at home or at work, be mindful of your alignment:
- Stand or sit tall with chin slightly tucked.
- Rib cage should be stacked over your hips. No jutting out of the rib cage (think military stance).
- Nice natural curve in the lumbar spine.
- Bum untucked -no clenching, gripping of the cheeks, or tucking tailbone underneath.
Correct Positioning & Transitional Movements
As I mentioned earlier, some of the very common movements and positions that you put yourself through on a daily basis can place tremendous amounts of stress on your pubic symphysis. So take care with how you move and transition your body from one position to the next and keep the following tidbits in mind:
- With transitional movements (getting in and out of the car, getting in and out of bed, etc.), try to keep your knees as close together as possible.
- When walking, try to take smaller steps and be careful about not letting the pelvis sway back and forth too much.
- Place a pillow in between your hips, knees, and ankles to keep the hips and legs level.
- When going up or down a flight of stairs, step up sideways and one at a time.
- Limit or avoid any single leg, wide stance, or split stance exercises (i.e. split squats, sumo deadlift, single leg squats, etc.).
- Consider wearing a pregnancy sacroiliac belt or compression wear to provide support and compressive forces to the pelvic joints. This was a huge help for me during all three of my pregnancies!
Stabilization exercises will reduce stress on the joint and improve stability of the spine and pelvis. Stabilization exercises include those exercises that will strengthen the deeper abdominal muscles, pelvic floor, glutes, hip abductors, and hip adductors. Below are some simple exercises that you can start doing to strengthen your pelvis and reduce pelvic and pubic pain:
Transverse Abs and Pelvic Floor Connection & Engagement
In order to engage your transverse abs (â€œTVAâ€), we need to make sure that you are connecting with it first. To start identifying and â€˜engaging’ your transverse abdominus, you need to find the right muscles, and â€˜connect’ with them. You can do this by either sitting on the edge of a chair or on a stability ball -make sure to spread the flesh from underneath you so that you are sitting on your sitz bones, lying on your back, or lying on your side.
Now, place one hand on the side of your rib cage. Breathe in through your nose, fill your lungs with air and let your ribcage expand. I want you to also feel for your pelvic floor softly expanding or relaxing with your inhale breath. Then exhale like you are breathing through a straw or blowing up a balloon. Empty out your lungs while simultaneously contracting/pulling the pelvic floor up (think you are trying to scoop up a marble or blueberries into your vagina -I know -a bit strange with the imagery, but -) and contracting the lower abdominals. Think about making the space between your hip bones shorter. That contraction you feel in the lower abdominals during your exhale is your transverse abdominus (TVA) contracting. Continue your breathing sequence for 5-10 more breaths.
To recap, we want to:
– Feel the pelvic floor expanding and relaxing on each inhale breath.
– On the exhale breath, we want to feel the pelvic floor contracting or lifting up into our body and our transverse abs contracting between the hip bones.
Seated Foot Lift
You can do this exercise either sitting on a chair or on a stability ball. If you are using a stability ball then make sure that your hips are higher than your thighs when seated on the ball. You can also place the ball in a corner or place your hands on the ball for more stability. In a seated position, I want you to think about sitting tall with nice alignment. Take a nice big inhale breath into the ribcage, relax the pelvic floor. Now exhale through pursed lips, and through your exhale pull up the pelvic floor, contract the transverse abs, then lift one foot slightly off the ground. Hold this position for about 2-3 seconds before lowering your foot, and repeat with the other foot. Keep alternating sides for 8-10 repetitions on both legs, and aim for 2-3 sets. Try not to let your pelvis shift into the hip that is in contact with the ground, or hike up the hip of the leg that you are lifting. Instead, think about remaining as stable as possible by engaging your core muscles.
Seated Abductor Hold
As with the seated foot lift, you can do this exercise either sitting on the edge of a chair or on a stability ball. Since wide stance positions can trigger a pubic symphysis diastasis, we want to limit the width at which you spread your knees apart. So before you do the exercise, take a minute or so to place either one or both fists between your knees and decide which width is more manageable for you. A good place to start is with one fist’s distance and then increase from there. Now, once you have your foot stance figured out, s
it tall with rib cage stacked over your hips and then slightly lean forward from THE HIPS (not the lower back). Keep a neutral spine. Place your hands outside of your knees, and then take and inhale breath. On your exhale breath, engage the pelvic floor and transverse abs while you apply a small amount of force to the outside of your knees to push the knees in towards each other. You will want to try and resist that force by pressing out against your hands with your knees and activating your lateral hip musculature. Hold for 2-3 seconds and then release. Repeat this for 8-10 repetitions and for a total of 2- 3 sets.
Bridge or Thrust with Ball Squeeze
This exercise can be done either as bridges from the floor or hip thrusts from a chair, bench, box, etc. Choose whichever option is more comfortable for you. You will also need a small inflatable ball, a Yoga block, a rolled up blanket/towel, or small pillow to hold between your legs to activate the muscles of your inner thighs.
If you are going to be on the floor bridging, please keep the following cues in mind:
- Lay tall, but relax through the shoulders and slightly tuck your chin towards your chest.
- Let your arms lay comfortably to your sides
- Keep the small arch in your lower back at all times.
- Keep your rib cage down over your hips.
- Think about staying as one straight line from shoulders to knees at the top of the bridge.
- Use your glutes to produce the hip extension, not overarching through the lower back. Can pick your toes up off the floor to drive through heels more.
If you will be doing a hip thrust, please keep the following cues in mind:
- Only your upper back and head should be in contact with the bench. Keep your chin slightly tucked in towards chest.
- Your hips will be flexed with butt down towards the floor for start position.
- Your body moves as a single unit hinging from the hips only.
- Drive through your heels to engage the glutes and don’t overarch at the top by using your lower back.
- You can fold your arms across your chest or leave them down by your sides.
Now, regardless of whether you are bridging or hip thrusting, your breathing sequence is similar to the seated foot lift. You will inhale and expand before you lift up, and then exhale and contract your pelvic floor and transverse abs before you bridge or thrust the hips up. You will also place your inflatable ball, a Yoga block, towel, etc. between your legs and hold it there. As you lift up into your bridge or hip thrust, remember to gently squeeze the ball by contracting the inner thighs. Pause for a second or two at the top, and then inhale to lower yourself back down to the ground. Repeat for 8-10 reps for 2-3 sets total.
Stretching & Soft Tissue Work
Soft tissue work and stretching are also very important because these modalities help to loosen up and relieve any tight muscles that may be pulling on the pelvis, thus causing it to be out of alignment and contributing to the pain you may be feeling in your pubic bone. A physical therapist will be able to perform certain types of manual therapy and soft tissue work both externally and internally on you and this will help tremendously. There are also stretches and soft tissue work like foam rolling that you can do at home to complement what your therapist has done for you in their clinic. When stretching, you’ll want to pay particular attention to your calves, hamstrings, glutes, inner and outer thighs. When performing any foam rolling techniques at home or in the gym, there are certain things that you will want to keep in mind:
- You want to avoid rolling across any joints, the spine, neck, lower back, abdomen, chest, and varicose veins.
- Pregnant mamas should also avoid rolling out their inner thigh, belly (for obvious reasons J,as well as the inside of their calf muscles. You may need to modify your foam rolling routine as you progress deeper into your pregnancy, and opt instead to use something like a tiger tail or stick to â€œroll-outâ€. You can also use a lacrosse ball, tennis ball, or something like a Yoga Tune-Up ball up against the wall to get into the backside of your body. As the belly starts to get big, you will want to avoid any prone (belly towards the floor positions) on the roller.
- Only roll to your level of comfort and adjust where needed. Rolling should be tender but not totally unbearable.
- Roll slowly until you find a tender place. Stay at the spot (for about 30 seconds to 1 minute), apply slight pressure while you allow the muscles to relax and release tension within the tissues -and breathe.
- After applying tension for a bit, move on to other areas of the muscle you are working on.
So there you have it! Please let me know if these exercises help you with managing your pubic symphysis diastasis pain. I would love to hear from you!