INTRODUCTION — Pregnancy is a time of many anatomic and physiological changes. The gravida must nurture and host the fetus, but also adapt to a new body habitus and alterations in the hormonal milieu. Not surprisingly, these changes impact the musculoskeletal system, which can develop a variety of problems, such as generalized arthralgias, back pain, separation of the pelvic bones, transient osteoporosis, and tendonitis.
Pain related to the musculoskeletal system in pregnant patients will be reviewed here. Neurologic disorders, myopathies, and inflammatory muscle diseases are discussed separately. (See "Neurologic disorders complicating pregnancy".)
NORMAL PREGNANCY CHANGES — During pregnancy, patients gain 25 to 35 pounds, on average, have a shift in their point of gravity, and undergo multiple hormonal changes and biomechanical alterations that strain the axial skeleton and pelvis.
The weight gain and hormonal changes of pregnancy contribute to the following musculoskeletal alterations:
●Force across some joints is increased up to twofold .
●Exaggerated lordosis of the lower back, forward flexion of the neck, and downward movement of the shoulders typically occur to compensate for the enlarged uterus and change in center of gravity. Stretching, weakness, and separation of abdominal muscles further impede neutral posture and place even more strain on paraspinal muscles.
●Joint laxity in the anterior and posterior longitudinal ligaments of the lumbar spine creates more instability in the lumbar spine and can predispose to muscle strain. Joint laxity in the knee also may also occur; these changes can be long lasting .
●There is widening and increased mobility of the sacroiliac joints and pubic symphysis in preparation for the fetus' passage through the birth canal.
●Vaginal lengthening, genital hiatal widening, and posterior vaginal relaxation occur .
●A significant increase in the anterior tilt of the pelvis occurs, with increased use of hip extensor, abductor, and ankle plantar flexor muscles . Stance is widened to maintain trunk movement . This can result in changes in gait .
●Fluid retention can cause compression of certain vulnerable structures such as the median nerve.
●Ligamentous laxity can affect stability of all weight-bearing joints from the pelvis to the foot.
Many of these changes appear to be mediated by the hormone relaxin, which is produced by the corpus luteum, decidua, and placenta. The concentration peaks during the first trimester, when relaxin is thought to be involved with placental implantation and growth. Later in pregnancy, relaxin contributes to relaxation of the myometrium, separation of the symphysis pubis and softening of the cervix . Laxity in the joints of the extremities, however, appears to be due to other factors. This was illustrated in a study of joint laxity during pregnancy in which 19 of 35 patients (54 percent) demonstrated a ≥10 percent increase in wrist laxity from the first to the third trimester, but the increase did not correlate with relaxin levels . Furthermore, subjective joint pain was associated with increased estradiol and progesterone levels but not with elevated relaxin concentrations.
LOW BACK PAIN AND DISC DISEASE
Definition, epidemiology, and etiology — Low back pain is typically defined as musculoskeletal pain between the 12th rib and the gluteal fold that is not attributable to obstetric (eg, preterm labor), gynecologic (eg, ovarian cyst), urologic (eg, renal stone), or gastrointestinal (eg, irritable bowel) disorders . It is a common problem among pregnant patients, with more than 60 percent of pregnant patients reporting pain in some studies [10-13]. Risk factors include preexisting back pain, back pain in a previous pregnancy, multiparity, and high body mass index .
In most cases, back pain is due to mechanical factors resulting from altered posture, muscle weakness, joint laxity, and/or vertebral facet joint irritation. Fluid retention within connective tissue can also contribute . Degenerative spondylolisthesis (ie, the slipping forward of the body of one lumbar vertebrae on the vertebrae below) is aggravated by pregnancy. The L4 to L5 level is particularly vulnerable in patients who have been pregnant . Of note, neuraxial anesthesia for labor and/or delivery does not cause long-term back pain. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Backache'.)
Disc herniation is rarely the cause of back pain during pregnancy . Approximately 10 percent of nonpregnant patients of childbearing age without back pain have asymptomatic lumbar disc herniation visible on magnetic resonance imaging of the lumbosacral spine, and 40 percent have disc bulges . The incidence of these abnormalities appears to be the same in nulliparous nonpregnant, multiparous nonpregnant, and pregnant patients .
Alarm findings — As low back pain is common, often worsens as pregnancy progresses, and typically resolves postpartum, it can be challenging to differentiate pregnancy-related pain from other pathologies. In general, we refer patients with the following symptoms or signs for further evaluation, typically with their primary care physician, orthopedic surgeon, or neurologist:
●Severe pain that interferes with function, particularly nonpositional persistent back pain at night.
●Increased pain with cough, sneezing, and Valsalva.
•While stress incontinence is common during pregnancy, sudden bladder incontinence or bowel incontinence or retention should warrant further investigation with imaging and referral to a neurologist, orthopedic surgeon, or neurosurgeon.
●Neurologic deficits on examination: weakness, sensory deficit, abnormal reflexes. Of note, patients with significant deficits are sent for immediate evaluation either in an emergency department or by an appropriate clinician (eg, neurosurgeon).
●At high risk of infection (eg, recent epidural anesthesia) or on immunosuppressive therapy and patients at risk for a compression fracture (eg, trauma or chronic glucocorticoid use) should also be referred for emergency evaluation.
●Systemic symptoms such as fever, chills, weight loss.
Serious causes of low back pain and risk assessment of patients with low back pain are presented in detail separately. (See "Evaluation of low back pain in adults", section on 'Serious etiologies' and "Evaluation of low back pain in adults", section on 'Risk assessment for acute back pain'.)
History and physical examination — Back pain may occur at any time during the gestation, but is most prevalent in the second half of pregnancy. The patient usually describes pain that is aggravated by activity and relieved by rest. It occurs in the lower back, but may radiate down the back of the thighs or, less often, over the lower part of the abdomen and anterior thighs . The pain is often worse at night, especially with turning, and may interfere with sleep.
We begin the physical examination by palpating the lower spine, paraspinal muscles, sciatic notches, and sciatic nerves to assess for tenderness, muscle spasms, or radiating pain. Nerve root irritation may be associated with tenderness in the following muscles (figure 1) :
●S1 irritation affects calf muscles.
●L5 irritation affects the extensor hallucis muscle (which affects the toe walking test) and the anterior tibial muscles.
●L4 irritation affects the quadriceps and the anterior tibialis (which affects heel walking with foot dorsiflexion).
Low back pain is generally characterized by lumbar pain above the sacrum, which is made worse by pregnancy-associated forward flexion of the waist, and decreased range of motion of the lumbar spine. In contrast, sacroiliac pain is made worse by hip rotation. With the patient supine, compression of the iliac crests may reproduce pain related to sacroiliac joint dysfunction. (See 'Pelvic girdle pain' below.)
For comparison, discogenic pain is frequently worse on flexion of the back, such as when touching the toes from a standing position. Chronic discogenic pain worsens with flexion, but with an acute herniation, the patient can rarely even stand up straight, as the herniation protrudes posteriorly and is compressed by extension. In facet pain, the pain is worse when the spine is extended and is localized to the level of the irritated facet.
Physical examination should also evaluate for the presence of significant muscle weakness, sensory impairment, or deep tendon reflex changes suggesting radiculopathy. A detailed description of the physical examination in patients with back pain can be found separately. (See "Evaluation of low back pain in adults", section on 'Physical examination'.)
Diagnostic studies — In most cases, the definitive physiologic cause of back pain symptoms cannot be established. Laboratory tests are not useful and imaging studies are not generally indicated, except in cases with significant neurologic findings. Magnetic resonance imaging (MRI) is usually performed if an invasive intervention, such as epidural steroid injection or surgery, is contemplated and in complicated cases. The indications for MRI of the lumbosacral spine in pregnant patients with low back pain are the same as in nonpregnant patients. (See "Evaluation of low back pain in adults", section on 'Imaging'.)
Pain — The American College of Obstetricians and Gynecologists suggests the following interventions to ease back pain during pregnancy :
●Wear low-heeled (but not flat) shoes with good arch support.
●Get help when lifting heavy objects.
●Place a board between the mattress and box spring if your bed is too soft.
●Squat down, bend knees and keep the back straight when lifting.
●Sit in chairs with good back support, or use a small pillow to provide support.
●Sleep on the side with pillows between the knees for support.
●Apply heat, cold, or massage to the painful area.
In addition, if it is necessary to stand or sit for a prolonged period, taking breaks and placing one foot on a low stool relieves pressure on the lower back. (See "Treatment of acute low back pain".)
Additional interventions have been tried; a multimodal approach appears most helpful .
●Rest – Periods of rest with hip flexion can reverse the lordosis and temporarily decrease pain. The patient should lie in the lateral recumbent position, with the knees and hips bent. A pillow can be used to support the weight of the uterus or placed between the knees to reduce the mechanical burden on the back .
●Exercise – The available evidence suggests that exercise is helpful in reducing low back pain associated with pregnancy. A meta-analysis of 34 trials that included over 5100 pregnant patients with back and pelvic pain reported that exercise may reduce pregnancy-related low back pain and improve functional disability . A different meta-analysis of 11 trials (n = 2347) reported that exercise reduced the risk of low back pain, but not pelvic pain, and decreased the likelihood of sick leave due to lumbopelvic pain . Lastly, a meta-analysis of four trials (n = 566) found that exercise, support belts, and acupuncture may be helpful . The purpose of back exercises is to strengthen the trunk muscles to stabilize the spine. Back flexion exercises strengthen the abdominal muscles and also reduce the lumbar lordosis, while extension exercises strengthen the paraspinal muscles. Walking is generally prescribed to relieve some of the hamstring tightness and to lessen chronic discogenic symptoms. (See "Patient education: Low back pain in adults (Beyond the Basics)".)
●Referral to physical therapy – If the patient has failed conservative measures, such as heat, cold, massage, rest, and home exercise, it is appropriate to refer to physical therapy .
●Complementary therapies – A systematic review of eight trials on complementary and alternative medicine for low back pain and/or pelvic pain in pregnancy reported reduced visual analog pain scores for patients treated with acupuncture based on three trials . However, variations in the duration of treatment, gestational age at treatment, and control groups limit the ability to make definitive conclusions or practice recommendations. In the same systematic review, osteopathy and chiropractic modalities were not associated with pain reduction, but the data were based on one trial for each treatment group. Other trials have reported that acupuncture appears to be more beneficial than physiotherapy, but both can be effective [30-33]. Additionally, water-based exercise programs have shown some benefit [34,35]. (See "Overview of the clinical uses of acupuncture", section on 'Low back pain' and "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Low back pain' and "Treatment of acute low back pain", section on 'Acupuncture'.)
●Medication – If a short course of an analgesic is indicated, acetaminophen has the best safety profile in pregnancy. A report from the National Academy of Medicine did not find benefit from prolonged opioid use . (See 'Treatment of pain' below.)
Disc herniation — In patients with symptomatic disc disease, indications for disc surgery during pregnancy are incapacitating pain, progressive neurologic deficits, and bladder or bowel dysfunction . For patients who require disc surgery while pregnant, many can receive epidural or spinal anesthesia. Antenatal consultation with the surgeon and anesthesiologist may be helpful in allaying patient concerns. Cesarean birth is required only for the usual obstetric indications, but instrumental vaginal delivery may be useful to avoid increased intrathecal pressures associated with the Valsalva maneuver. Anesthesia approaches for patients undergoing spinal surgery are presented in detail separately. (See "Anesthesia for elective spine surgery in adults", section on 'Neuraxial anesthesia'.)
Prognosis — In 80 to 95 percent of cases, back pain resolves postpartum [38-40]. At two to three years after delivery, approximately 20 percent of patients continue to experience back pain [40,41]. In a study that followed 303 patients with back pain during pregnancy, the prevalence of back pain six years postpartum was 16 percent comparable to the prepregnancy prevalence of 18 percent in the same group .
An elevated body mass index (BMI) appears to be a separate variable that impacts back pain after pregnancy. A study from the Danish National Birth Cohort that included nearly 80,000 participants reported that elevated BMI, both prepregnancy and postpartum, increased the risk for later development of degenerative musculoskeletal conditions such as osteoarthritis and low back pain . Patients with BMI ≥25 kg/m2 had a nearly 30 percent risk of developing musculoskeletal conditions after pregnancy when compared with patients with a BMI 18.5 to <25 kg/m2.
Screening for depression may be helpful in patients with persistent pain . (See "Evaluation of chronic non-cancer pain in adults", section on 'Psychiatric comorbidity'.)
Postpartum low back pain — Postpartum coccydynia (pain in the coccyx, sometimes called coccygodynia, or pain in the tailbone) may be caused by pressure on the coccyx during childbirth. Pain and tenderness typically become prominent the day after delivery and are well localized to the coccyx. Patients complain of pain in the tailbone on sitting, especially when leaning back, and pain on rising and with prolonged standing. Defecation and sexual intercourse may also be painful. The evaluation and management of coccydynia are presented elsewhere. (See "Coccydynia (coccygodynia)".)
Scoliosis — Pregnancy does not appear to affect curve progression, nor does scoliosis appear to affect pregnancy outcome when scoliosis has been treated or is mild. (See "Adolescent idiopathic scoliosis: Management and prognosis", section on 'Outcome'.)
Respiratory failure and an increase in pulmonary hypertension during the second and third trimesters have been reported in rare cases of pregnancy in patients with severe curvature, particularly when there is a coexisting muscular disorder (eg, muscular dystrophy, spinal muscular atrophy) [43-45]. Most patients with scoliosis can receive neuraxial anesthesia successfully during labor . (See "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)
PELVIC GIRDLE PAIN
Definition, epidemiology, and etiology — Pregnancy-related painful pelvic joint conditions include pubic symphysis pain and/or separation, unilateral or bilateral sacroiliac joint pain, and pelvic girdle syndrome (pain in all three pelvic joints) (table 1) [47,48]. Pregnant patients with pelvic girdle pain (PGP) appear to have higher disability ratings compared with patients with low back pain or without pelvic girdle pain in pregnancy . In a prospective Danish study, 293 pregnant patients (20 percent) were found to have pelvic joint pain, which could be classified into one of four types: pelvic girdle syndrome (6.0 percent), symphysiolysis (2.3 percent), one-sided sacroiliac syndrome (5.5 percent), and double-sided sacroiliac syndrome (6.3 percent) .
●Peripartum pubic symphysis pain is common while separation of the pubis (pubic diastasis, symphysiolysis, osteitis pubis) is uncommon, occurring in less than 1 percent of pregnancies. Purported risk factors include fetal macrosomia, precipitous labor or rapid second stage of labor, intense uterine contractions, previous pelvic pathology or trauma to the pelvic ring, multiparity, and forceps delivery .
●Posterior pelvic joint pain related to the sacroiliac joint(s) is common and often included under the broad classification of low back pain. Risk factors include increased parity, previous low back pain, emotional stress, obesity, young maternal age, low educational level, early menarche, physically demanding work, and previous cesarean birth [51-54].
●Pelvic girdle pain can occur with low back pain or as a separate entity. Pain located at the pelvic girdle during and after pregnancy has been reported in 6 to 65 percent of pregnant patients and varies with study definition [12,47]. Risk factors include increasing gestation, increasing parity, obesity, and depression [12,51].
Increased mobility and/or asymmetry of pelvic joints make the pelvic area vulnerable to pain during pregnancy and/or postpartum. As noted, the symphysis pubis widens at the 10th to 12th week of gestation in response to high relaxin concentrations. This widening allows increased mobility of the pubic symphysis, which can be painful. Mechanical strain may also play a role . In observational studies, magnetic resonance imaging (MRI) of postpartum patients at high risk of pubic injury (eg, second-stage labor >150 minutes, third- or fourth-degree lacerations, instrument assisted delivery, infant birth weight >4000 g) commonly showed bone marrow edema, pubic bone fractures, levator ani tears, and abnormal widening or capsular distension of the pubic symphysis [56,57].
Presentation — Patients can present with pain in one or several of the pelvic joints (table 1).
Posterior pelvic joint pain, also known as sacroiliac joint pain, presents as a stabbing pain that occurs between the posterior iliac crest and the gluteal fold, especially in the vicinity of the sacroiliac joint, and can be uni- or bilateral . The pain may radiate to the posterior thigh and can occur with or separately from pain in the symphysis. The pain may worsen with weight-bearing, but prolonged sitting can also be painful. Pelvic floor tenderness may be present  but pelvic floor function does not appear to be affected .The diagnosis is made after exclusion of lumbar causes of pain.
Pubic symphysis pain and/or separation generally presents with suprapubic pain, tenderness, swelling, and edema with pain radiating to the legs, hips, or back . The pain is often potentiated by weight-bearing, especially with walking and climbing stairs. Turning in bed, lifting, or getting up from a chair may also cause pain. In some patients, pain can be exacerbated by increased abdominal pressure such as with coughing or sneezing. Some patients report waking up during the night because of pain .
Patients with pelvic girdle syndrome (ie, pain in all three pelvic joint regions) have pain that is experienced between the posterior iliac crest and the gluteal fold in the area of the sacroiliac joints. Pain can radiate to the posterior thigh.
Evaluation and diagnosis — The goals of evaluation are to confirm the location and exclude other causes of pain. The location of the pain, if confirmed by physical examination, generally gives the diagnosis (table 1). Of note, patients with intractable pain, fever, and neurologic symptoms (including inability to walk) in conjunction with the findings below should prompt emergency evaluation with radiographic imaging (algorithm 1).
Posterior pelvic joint pain is assessed by the posterior pain provocation test . With the patient supine and the hip flexed 90 degrees, the examiner exerts pressure on the knee and along the femur to the hip, while stabilizing the pelvis with a hand on the opposite anterior iliac spine. A positive test elicits pain in the ipsilateral buttock. This test has been found to be negative in patients with lumbar disc herniations . In addition, palpation of the sacroiliac joints, specifically the long dorsal ligament (dimples of Venus) may demonstrate nodules or tenderness to palpation. In the Patrick (Fabere) test, the hip is flexed, abducted, and externally rotated, and the affected leg is extended so that the ankle is on the opposite knee. There is normal range of motion at the hips and spine. The active straight leg raise, a test of function whereby the patient lifts the leg, finds it difficult, yet with compression finds greater ease in performing the task, has been associated with pelvic girdle pain [63,64]. These and related tests are discussed separately (table 2). (See "Approach to the adult with unspecified hip pain".)
Pubic symphysis pain can be evoked by bilateral pressure on the trochanters or by hip flexion with the legs in extension. Rarely, a palpable groove at the level of the symphysis may be detected by internal or external examination. Of note, in a nonpregnant patient, the normal symphysis gap is 4 to 5 mm; with pregnancy, the gap increases by at least 2 to 3 mm . The diagnosis of diastasis is based on the persistence of symptoms and a separation of more than 10 to 13 mm on imaging (image 1); however, radiographic imaging is not always required as the diagnosis can be made clinically on the basis of symptoms and response to therapy. Imaging is helpful to confirm the diagnosis and determine the course of treatment (algorithm 1). Of note, the amount of symphyseal separation does not necessarily correlate with severity of symptoms or the degree of disability. One study that performed radiographs of the pelvis and lower spine, MRI, urine dipstick, and blood tests (erythrocyte sedimentation rate, C-reactive protein, complete blood count, creatinine, rheumatoid factor, antinuclear antibodies) in patients with transient or persistent pelvic joint pain and controls did not find any of these tests to be useful diagnostically .
Management — Management of PGP typically includes supportive treatment for the pain, physical therapy for stabilizing exercises, and supports or braces, if appropriate (table 1). Additional treatment options include injections and acupuncture, but their efficacy is less clear.
●Analgesia – Nonpharmacologic treatment options include application of heat or cold and manual therapy, such as massage or spinal manipulation [67,68]. (See "Treatment of acute low back pain", section on 'Nonpharmacologic therapies' and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)
If pharmacologic treatment is elected, acetaminophen can be used by both pregnant and postpartum patients, although a meta-analysis reported that it had the same effect as placebo in nonpregnant patients . Nonsteroidal anti-inflammatory drugs may be used between weeks 12 and 30 of gestation and during the postpartum period. We avoid opioid medications during pregnancy. (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Pain and fever medications' and "Treatment of acute low back pain", section on 'Pharmacotherapy'.)
●Physical therapy – Work with a physical therapist can reduce pain and improve joint stabilization. Stabilizing exercises are targeted to the muscles supporting the pelvic girdle (eg, hip adductors and abductors, gluteus maximus, transverse abdominal muscles) and are supervised by a physical therapist . While generally helpful, patients with severe pelvic girdle pain who do not improve with focused physical therapy are further evaluated for possible sacral stress fracture. (See "Exercise-based therapy for low back pain" and "Myofascial pelvic pain syndrome in females: Pelvic floor physical therapy for management".)
●Supports or braces – A brace or girdle provides compression and stability to the sacroiliac joints and improves disbursement of weight-bearing forces in the pelvis, back, hips, and legs. Braces can be used to provide support, reduce pain (including posterior pain), and treat pubic symphysis separation . Use of a pelvic belt significantly decreases mobility of the sacroiliac joints and is most effective when the belt is positioned just caudal to the anterior superior iliac spines. The decrease in mobility is correlated with an improvement in the active straight leg raise test . At least one case study has reported using an elastic pelvic brace to resolve severe (41 mm) pubic symphysis separation . When braces are used, the device should be placed to lie over the greater trochanters (picture 1).
●Injections – Patients who have failed conservative therapy, such as analgesics, physical therapy, and supports, and have ongoing pain may benefit from local slow-release corticosteroid injections. Significant anatomic injury and neurologic issues that require more aggressive intervention need to be excluded prior to performing injections. (See 'Evaluation and diagnosis' above.)
At least one trial has reported reduced pain following slow-release corticosteroid injection to the insertion of the sacrospinous ligament on the ischial spine . (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
●Acupuncture – Pregnancy-related pelvic joint pain has been treated with acupuncture, with inconsistent results [75-77]. One trial randomly assigned 386 pregnant patients with pelvic girdle pain to standard treatment or standard treatment plus stabilizing exercises or acupuncture . The addition of acupuncture to standard treatment resulted in significantly lower pain scores at six weeks; stabilizing exercises [78,79] also improved the efficacy of standard therapy. However, another randomized trial that compared standardized therapy alone with standardized treatment plus stabilizing exercises or standardized treatment plus acupuncture found no differences in recovery among the three treatment groups . While the data are conflicting, in some patients, acupuncture may provide some relief, if only placebo. As both supporting data and insurance coverage are variable, we refer patients for acupuncture based on patient request.
For patients with pubic symphysis separation, standard treatment is conservative and consists of relative rest in the lateral decubitus position, pelvic support with a brace or girdle, ambulation with a walker or crutches, and a graded exercise protocol . It is unclear whether combination therapy speeds recovery. At least one group advises surgical treatment for the subset of patients with combined anterior-posterior pelvic ring injuries . Nonsteroidal anti-inflammatory medications are helpful for controlling pain postpartum. Open reduction and internal fixation has been performed in patients with separation of ≥4 cm and those with persistent pain, but this is rarely necessary [82,83]. Treatment options are discussed in detail separately. (See "Osteitis pubis", section on 'Management'.)
Prognosis — The pelvis usually returns to normal by 4 to 12 weeks postpartum. Pain resolves in the majority of patients in approximately one month and approximately 80 percent of patients fully recover within six months of delivery [47,53,75]. However, recovery from pelvic symphysis separation or pelvic girdle syndrome can be prolonged (over two years) . At least one study reported that 2 to 3 percent of patients have chronic pelvic girdle pain one year following delivery . In a group of nine patients with atypical pubic pain after childbirth, a large interpubic gap (greater than 21 mm) measured sonographically was associated with a delayed recovery; two of the nine patients were still disabled 36 weeks postpartum . Severe diastasis (>25 mm) may require surgery. Symptoms may recur in subsequent pregnancies and may be worse, but this does not preclude vaginal birth [50,86]. Cesarean birth does not seem to protect from, or minimize, pelvic girdle pain, and is associated with higher rates of persistent pain postpartum . Breastfeeding does not appear to perpetuate pelvic girdle pain postpartum.
ABDOMINAL WALL PAIN — The evaluation of pregnant and postpartum patients with abdominal pain is presented separately. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)
CHEST WALL PAIN — Chest wall changes that occur during pregnancy include increases in the subcostal angle, the anterior-posterior and transverse diameters of the chest wall, and the chest wall circumference. These changes compensate for the elevation of the diaphragm during pregnancy and preserve total lung capacity, and are not associated with pain [87-91]. Anecdotally, term pregnant patients, especially those who have a short torso or a very large uterus, may complain of discomfort (soreness, tenderness) in lower rib area, often on the right. This is presumed to be due to pressure from the uterus in this area and may be relieved by wearing loose clothing and changes in position to provide more room.
There are few causes of musculoskeletal chest pain specific to pregnancy. Albeit rare, fractures of the ribs can occur with pregnancy-associated osteoporosis. As in other clinical situations, chest wall discomfort in the setting of cardiac associated symptoms (eg, exertional nature and shortness of breath) warrant immediate evaluation.
HIP PAIN — Hip pain can represent a normal response to the increased musculoskeletal demands of pregnancy, result from temporary pathology such as transient osteoporosis, or reflect serious pathology such as osteonecrosis or fracture. In addition, preexisting causes of hip pain, such as trochanteric bursitis, can worsen during pregnancy. The presenting complaint is generally nonspecific hip pain. Evaluation includes physical examination and, for pregnant patients who are severely symptomatic or have loss of function, radiographs. (See "Approach to the adult with unspecified hip pain".)
Transient osteoporosis of the hip — Transient osteoporosis of the hip is a rare finding and typically presents with pain with activity and limitation of motion of the hip. The diagnosis can be made by plain radiographs, which show generalized osteopenia , or magnetic resonance imaging (MRI), which shows a diffuse bone-marrow-edema-pattern signal with an increased signal intensity on T2-weighted images and a decreased intensity on T1-weighted images . MRI is useful for distinguishing between transient osteoporosis and osteonecrosis.
The treatment is generally conservative with prevention of weight-bearing (use of crutches) in order to circumvent femoral fracture. There have also been case reports of treating patients with bisphosphonates ; however, human data on the safety of bisphosphonates in pregnancy are anecdotal and sparse. Safe options for analgesia antepartum are more limited than after delivery. (See 'Treatment of pain' below and "Evaluation and treatment of premenopausal osteoporosis", section on 'Antiresorptive therapy with bisphosphonates'.)
In contrast to osteonecrosis, transient idiopathic osteoporosis resolves by six to eight months postpartum with conservative therapy; fractures or other serious sequelae are rare .
Osteonecrosis of the femoral head — Osteonecrosis of the femoral head during pregnancy is rare. The etiology is unclear, but may be secondary to weight gain, endogenous production of glucocorticoids by the adrenal gland , or a hypercoagulable state . Patients usually present with hip pain radiating to the groin or lateral thigh, particularly with weight bearing, but not necessarily related to activity . Limitation of motion is a late event. In one series, 13 of 13 patients had involvement of the left hip and 4 had bilateral involvement . Physical findings are extreme pain with weight bearing and range of motion. (See "Approach to the adult with unspecified hip pain".)
The diagnosis is made by imaging studies. The plain radiograph can remain normal for months after symptoms of osteonecrosis begin; the earliest findings are mild density changes, followed by sclerosis and cysts as the disease progresses. The pathognomonic crescent sign (subchondral radiolucency) is evidence of subchondral collapse. Later stages reveal loss of sphericity or collapse of the femoral head. Ultimately, joint-space narrowing and degenerative changes in the acetabulum are visible. MRI is the most sensitive imaging method for making this diagnosis.
Osteonecrosis can be a progressive disease leading to collapse of the articular surface and degenerative joint disease. Restricted weight-bearing has generally been ineffective at halting the progression of disease, thus justifying aggressive therapy. Treatment options include osteotomy, core decompression, and grafts . (See "Treatment of nontraumatic hip osteonecrosis (avascular necrosis of the femoral head) in adults".)
Other — A variety of other orthopedic conditions can cause hip pain in pregnant and postpartum patients. Some, such as acetabular labral tear, may be related to maternal position during delivery . (See "Approach to the adult with unspecified hip pain" and "Imaging evaluation of the painful hip in adults", section on 'Imaging exams for specific clinical settings'.)
Osteomalacia in pregnant patients may present with persistent and nonspecific musculoskeletal pain and inability to bear weight. (See "Clinical manifestations, diagnosis, and treatment of osteomalacia in adults", section on 'Pregnancy'.)
LEG AND FOOT PAIN
●Thigh pain – Meralgia paresthetica is a sensory neuropathy that occurs when the lateral femoral cutaneous nerve is compressed as it penetrates the tensor fascia lata at the inguinal ligament. Symptoms include dysesthesias in the upper and middle part of the lateral thigh and are probably caused by the expanding abdominal wall and increased lumbar lordosis. Symptoms occur late in pregnancy, typically resolve within three months postpartum, and rarely require treatment. (See "Meralgia paresthetica (lateral femoral cutaneous nerve entrapment)".)
●Knee pain – Knee pain is not uncommon in pregnant patients. Postural changes and increased laxity of ligaments are contributing factors. In a prospective study including 50 females assessed during their first trimester and again at four- to five-months postpartum, a decrease in joint laxity and compliance in the coronal plane and posterior direction and increase in compliance in the anterior direction were noted . Another study also showed ligamentous laxity in the knee that occurred during the second half of pregnancy, and is not exacerbated by exercise programs with minimal to moderate weight bearing . Significant improvement occurs by four months postpartum. (See "Approach to the adult with unspecified knee pain".)
Patellofemoral disorder usually manifests itself as pain behind or around the patella, especially when going up and down stairs or with prolonged sitting. Quadriceps and hip abduction strengthening exercises can help the patella track correctly, and patella sleeves can also be helpful . The diagnosis and treatment of patellofemoral pain are discussed in more detail separately. (See "Patellofemoral pain".)
●Leg cramps – Leg cramps are common, usually occurring during the latter half of pregnancy. The cramps are due to painful muscle contractions and are generally experienced in the calves at night. They are thought to be secondary to a build-up of lactic and pyruvic acids leading to involuntary contraction of the affected muscles, but the exact etiology is unknown .
Various treatments for leg cramps have been described, including drugs, electrolytes, and vitamins.
•In a meta-analysis of interventions for leg cramps in pregnancy including eight randomized trials and 576 patients, the only trial (42 patients) comparing vitamin B with no treatment suggested a possible reduction in the frequency and intensity of leg cramps (risk ratio 0.29, 95% CI 0.11-0.73) [100,101]; the preparation used was thiamine (vitamin B1; 100 mg) plus pyridoxine (vitamin B6; 40 mg) once daily for two weeks [100,101]. Although this was a small study and the findings have not been confirmed in larger trials, the author finds that a trial of B1 plus B6 is reasonable for patients with severe symptoms.
•Other trials included in the meta-analysis comparing treatment with oral magnesium, calcium, vitamin D, and/or vitamin C with placebo or no treatment showed little or no evidence of benefit .
Stretching exercises may be an effective preventive measure. These can be performed in the weight-bearing position; they are held for 20 seconds and repeated three times in succession, four times daily for one week, then twice daily thereafter (picture 2).
If a cramp occurs, calf stretches (toe raises) as soon as the muscle cramp begins, walking, or leg jiggling followed by leg elevation may be helpful. Other nonpharmacologic remedies include:
•A hot shower or warm tub bath
•Regular exercise for conditioning, calf strengthening and stretching
•Use of long-countered shoes and other proper foot gear (see "Joint protection program for the lower limb")
●Foot pain – Pregnant patients appear to have significantly more foot pain than nonpregnant nulliparous patients. In one study, foot pain tended to be self-limited; in most patients, it resolved in less than four months . Potential causes of foot pain include weight gain, peripheral ligamentous laxity, and changes in posture and pedal pressure points [102,103]. These changes can lead to overpronation . Peripheral edema also contributes to foot discomfort in pregnancy. Treatment of foot pain is supportive: well-fitting shoes, rest and elevation, massage, stretching exercises, foot baths.
HAND AND WRIST PAIN — Carpal tunnel syndrome (CTS), consisting of pain and/or paresthesias, is a common cause of hand and wrist pain in pregnancy. de Quervain tendinopathy occurs in the postpartum period and is precipitated by repetitive lifting of an infant, especially with breastfeeding, or a young child.
●CTS – The hallmark of classic CTS is pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit (figure 2). The symptoms of CTS are typically worse at night, and patients are often awakened during the night with diffuse hand numbness that can take several minutes to resolve. One study reported a prevalence of 34 percent during pregnancy . CTS is more common in the second and third trimester of pregnancy. A complete discussion of CTS in pregnancy and general management are presented elsewhere.
●de Quervain tendinopathy – de Quervain tendinopathy affects the abductor pollicis longus and extensor pollicis brevis tendons in the first extensor compartment at the styloid process of the radius (figure 3). Patients describe pain at the radial side of the wrist that is exacerbated by thumb and wrist movement. Some patients may also notice some swelling and tenderness on the radial side of the wrist. Difficulty holding or gripping objects with the affected side is also common. The pain may radiate to the thumb or forearm. Pain generally occurs in the postpartum period with lifting an infant.
Treatment is similar to that in nonpregnant patients, but nonsteroidal anti-inflammatory drugs should be avoided in pregnancy after approximately 30 weeks of gestation. (See "de Quervain tendinopathy" and "Safety of rheumatic disease medication use during pregnancy and lactation".)
ARTHRITIS — Pregnancy-related changes in circulating hormones may contribute to alterations in the immune system that may impact the activity of autoimmune diseases associated with arthritis. Patients with rheumatoid arthritis are particularly at risk of flaring in the postpartum period. Presentation and management of rheumatic diseases in pregnancy are discussed in detail in additional topics:
Other less common causes of postpartum arthritis include septic arthritis caused by mycoplasma (see "Mycoplasma hominis and Ureaplasma infections", section on 'Arthritis and osteomyelitis') and rubella vaccine-associated arthropathy.
TREATMENT OF PAIN — Treatment of musculoskeletal pain in pregnancy is often multi-modal, and can include pharmacotherapy, physical therapy, complementary therapies such as acupuncture and acupressure, and exercise. If drugs are needed to relieve pain during pregnancy, acetaminophen is the preferred medication. Nonsteroidal anti-inflammatory drugs can be used weeks 12 to 30 of pregnancy. Opioids should be avoided during pregnancy. (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Pain and fever medications'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Nocturnal (nighttime) leg cramps (The Basics)")
SUMMARY AND RECOMMENDATIONS
•Pregnancy-related changes in body weight, shape, and hormones are associated with musculoskeletal consequences, including lordosis, joint laxity, widening and increased mobility of the sacroiliac joints and pubic symphysis, and increase in the anterior tilt of the pelvis. (See 'Normal pregnancy changes' above.)
•Treatment of musculoskeletal pain in pregnancy is often multimodal and can include pharmacotherapy, physical therapy, complementary therapies such as acupuncture and acupressure, and exercise. If medication is needed to relieve pain during pregnancy, acetaminophen is the preferred agent. (See 'Treatment of pain' above.)
●Low back pain
•Low back pain is a common complaint during pregnancy. It is usually caused by mechanical factors rather than disc herniation. (See 'Definition, epidemiology, and etiology' above.)
•For most patients with low back pain in pregnancy, we use nonpharmacologic interventions (eg ,exercise, physical therapy). If medication is needed, acetaminophen appears to be a safe and effective initial choice. (See 'Pain' above.)
•Surgery is reserved for situations in which there is compromise to the spinal cord nerves. (See 'Disc herniation' above.)
●Pelvic girdle pain
•Pregnancy-related painful pelvic joint conditions include pubic symphysis pain and/or separation, unilateral or bilateral sacroiliac joint pain, and pelvic girdle syndrome (pain in all three pelvic joints (table 1)). (See 'Definition, epidemiology, and etiology' above.)
•The diagnosis of pubic symphysis diastasis is based on the persistence of symptoms and a separation of more than 10 to 13 mm on imaging (image 1). While radiographic imaging is not required, it is helpful to confirm the diagnosis and determine the course of treatment (algorithm 1). (See 'Evaluation and diagnosis' above.)
•For pain related to the pubic symphysis, initial treatment is typically with conservative interventions (rest in the lateral decubitus position, pelvic support with a brace or girdle, ambulation with a walker, and a graded exercise protocol (algorithm 1)). (See 'Management' above.)
●Hip pain – Hip pain may be related to osteonecrosis, which is a chronic progressive disease potentially requiring aggressive therapy, or transient idiopathic osteoporosis, which typically resolves in 8 to 12 months and should be treated conservatively. (See 'Hip pain' above.)
●Leg pain – Leg cramps are common in pregnant patients and are typically managed with nonpharmacologic interventions such as calf stretching. (See 'Leg and foot pain' above.)
●Hand and wrist pain – Carpal tunnel syndrome is a common cause of hand and wrist pain during pregnancy (figure 2), while de Quervain tenosynovitis often develops postpartum when lifting the infant causes irritation (figure 3). (See 'Hand and wrist pain' above.)
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