So then, SPD, now I am going to be honest (as always) and say this is not my favourite topic. This injury can get very complicated and I do not see enough of it for me to consider myself an expert. I also dislike that the name is interchanged with ‘Pelvic Girdle Dysfunction’ as that is such a generic term!
This post is designed to explain a few bits about what can happen and how pain can occur, I’ll also explain what the next step would likely be if conservative care fails.
The pelvis is made up of 6 pieces, the Ilia (2), the Ischia (2) and the Pubic bones (2). Once fused together, the joints between these bones have very little role in the motion of the pelvis so can be relatively ignored during this topic. The joints involved at the pelvis which dictate motion at the Pubic Symphysis (PS) are the hips and the Sacro-Iliac joints. The pubic symphysis is a cartilagenous joint which consists of a fibrocartilagneous interpubic disc, similar to the discs between the vertebrae you find in your spine.
A basic summary of the role the hips play are in relation to the musculature which impart motion at the hips. There are a multitude of muscles acting on the hips and pelvis which work in the transverse, sagittal and frontal planes. Many of these can dictate what is happening at the pelvis. All are worth checking, a few of the more commonly involved ones with SPD are the adductors as they have direct connections to the PS.
The Sacro-Iliac joints (S.I.s)
The SIs are very often involved in SPD, if one of the SIs are restricted, it can lead to an asymmetry in the pelvis. This is what some practitioners refer to as a ‘twist’ in the pelvis, as the pelvis is working asymmetrically and can cause issues elsewhere. The PS is the joint on the other side of the pelvis, you can imagine how the forces would change at this region during daily activities as a result of the asymmetry at the SI joints. As with anything mechanical this leads to increased friction or wear on one side, causing irritation at the joint (even if it is more mobile, it still translates ground reactive force).
What causes the restriction at the SI joints? Anything from a short leg, tight QLs, tight hamstrings, history of lower back trauma or degeneration, increased pelvic tilt. All of these would have to be investigated and put in to the picture as to how the SPD has arisen.
A Chiropractor or Osteopath can release the SI and PS joints, but unless you address the related muscle tightness in the surrounding areas then the joints could get restricted once again and lead to further issues.
Pubic Symphysis displacement
As with a lot of joints the PS is susceptible to being displaced. Anything with a displacement over 40 mm wide or 2mm vertical dsiplacement is considered abnormal. If the patient is not pregnant, then an X-ray can be used to determine the level of displacement and the Flamingo stress position is a position that can be used to highlight the displacement.
Pubic Symphysis Osteo-arthritis
The joint can also become arthritic for a variety of reasons, this can lead to constant aching pain which can be treated medically with analgesic injections alongside manual therapy. This is more common in sports such as football due to the level of shearing that occurs, (see below).
SPD and Pregnancy
One thing to take in to consideration with a pregnant patient with SPD is that in their second trimester women have an increase in the relaxin hormone. This leads to very mobile joints and can be a contributor to discomfort at the PS and means the practitioner must be gentle and alter their treatment choice to suit the individual. Even with the patient being extra mobile in certain joints as a result of the relaxin, the patient can still get joints that are restricted. I have seen this many times in relation to the SI joints. Often it is these joints which can be the biggest contributors to the SPD as it is more often a functional issue in women as pregnancy exacerbates any pre-existing underlying functional asymmetrys.
Home physiotherapy exercises are very useful to avoid aggravation alongside joint mobilisation. There are loads of great tips on home care here on the NHS website.
Rarely SPD can last in to the post pregnancy stage (Peripartum), if this is the case, it is worth having further investigations as the PS can separate by over 40mm. This requires advice from a medical consultant and sometimes surgery.
SPD and Sport
Check out the below pictures as to what the pelvis experiences during sports, note the shearing force that occurs at the pubic symphysis. If this shearing is too great due to instability or asymmetry at the joint then this can lead to irritation or early wearing at the disc and joint.
SPD is a very individual dysfunction, it is worth getting your pelvis checked over by an experienced expert to find out why you are suffering. I would recommend seeing someone who is very experienced in mobilising the pelvic joints as loosening the muscles alone will not be enough to make a difference and incorrectly moving the joints can cause more aggravation.
Unfortunately sometimes in sports the SPD can be due to arthritis at the joint, an x-ray (like the one above) will show if this is the cause. It is not common to get arthritis when you are under the age of 60, though sports specific early onset arthritis does occur and as a Footballer myself it can be a very frustrating complaint for those who struggle with it.
One way of releasing the PS joint yourself which you may have seen or tried is by briefly squeezing a football between your knees whilst lying down with your knees bent up. This can sometimes provide relief though it is not something I would recommend unless a specialist has deemed it a suitable exercise. It also does not solve restriction at the SI joints at the back of the pelvis, these are a lot harder to release without an expert in manipulative therapy.
If pregnant and symptoms persist, work with your manual therapist and doctor to improve your pelvic function while maintaining a level of pain control. Peri-partum symtoms should improve, if not then see below.
If not pregnant, continue working with your manual therapist but also try and get a pelvic X-ray, if possible get the flamingo views also (not many people will do these) as they can show levels of displacement. This should give you an answer as to why pain may be persisting and if a more invasive option is required then you should be informed once results come through.
I hope this has helped you understand a little bit more about dysfunction at the Pubic Symphysis.