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Pregnancy is a time of tremendous change and growth, both for baby and mom. A woman’s body undergoes many structural adaptations to accommodate the growing baby and prepare for birth, and she may develop any of several painful conditions as a consequence of some of those changes.
Symphysis pubis dysfunction (SPD) is one such condition that can be related to the changes occurring during pregnancy. SPD occurs when there is excessive movement (instability) of the pubic symphysis, the joint that connects the pubic bones at the front of the pelvis. During pregnancy this joint widens in preparation for delivery, and some women experience pain and dysfunction as a result of the expansion.
SPD is commonly associated with pelvic girdle pain (PGP), and the terms are often used interchangeably. Pelvic girdle pain describes pain at the posterior aspect of the pelvic ring in addition to the anterior. Some studies cite the incidence of SPD as being as low as one in 300 women, while others have cited numbers as high as 31 percent, a wide range due in part to the unknown number of cases that go unreported and the fact that pain is often considered a “normal” finding in pregnancy.1
Suffice it to say that if you coach pregnant or postpartum women, you’re likely to encounter a woman with SPD, and it’s important to understand what she’s experiencing and to know how to safely and effectively guide her through her training.
Symptoms of Symphysis Pubis Dysfunction
Women with SPD will often experience the following symptoms:
A sharp pain usually centered at the front of the pelvis.
Pain that can also often extend to the rest of the hip, the lower back, down the legs, or into the lower abdomen.
Some women will describe being able to hear or feel a sensation of clinking, clunking, grinding, or grating of the pubic symphysis or sacroiliac joint.
Discomfort that is aggravated by standing on one leg, hip abduction and adduction, activities like getting out of a car, walking up stairs, and carrying a child on one hip.
Pain that can range from mildly uncomfortable to debilitating enough to alter her exercise, work, family, and professional life, as well as sleep.
A waddling gait.
What causes Symphysis Pubis Dysfunction?
The exact cause is unknown, but SPD is thought to occur during pregnancy for a variety of reasons including the hormonal and biomechanical changes during pregnancy. While most cases resolve after pregnancy, the condition can linger after giving birth. Due to sometimes-debilitating symptoms, SPD can take an emotional toll. As her coach, showing empathy can go a long way when working with a client experiencing SPD, who may also benefit from the support of a mental health professional.
How can you help a client with SPD?
When in doubt, refer out. Diagnosing and treating pain are beyond the scope of trainers, coaches, and other fitness professionals. However, understanding what SPD is, and what your client is experiencing can help you create a safe and supportive training environment for her.
SPD is common during pregnancy. However, along with other conditions involving pain, it is not “normal.” If your client that presents with symptoms suggestive of SPD and she isn’t already seeing a healthcare provider about it, encourage her to make an appointment with a pelvic floor physical therapist, or refer her to one if you have a trusted therapist in your referral network. A pelvic floor physical therapist can appropriately assess, diagnose, and treat the condition.
Her physical therapist may recommend the use of a support belt, provide manual treatments, or prescribe exercise and movement recommendations. A trusted pelvic floor physical therapist can be an invaluable resource for you and your clients. Communicating directly with your client’s physical therapist helps to bridge the gap between her rehabilitation and fitness programs.
While it’s always wise to communicate with your client’s physical therapist for specific considerations pertaining to her training program, being aware of general recommendations for women with SPD is also important. Most often, women with SPD are advised to avoid all squatting or lifting at all, but for the mother of a toddler, or a woman who has always loved participating in fitness, these recommendations are often unrealistic. Instead, taking an individual approach with a foundational understanding of the condition of SPD is likely to provide better results.
Just as important as knowing what to do and what not to do is understanding strategy and the way a woman is performing each movement. Strictly following a formula won’t work with this (or any) population, but following a few essential guidelines when training a woman with SPD can make a world of difference for her.
Training Considerations for the Client with SPD
1. Set a solid foundation. During pregnancy women often adopt new postural habits due to the changing center of gravity. Painful conditions may also alter how she sits, stands, and walks. Postural changes and the process of pregnancy and delivery can influence her pelvic floor musculature, and change her ability to automatically recruit her muscles optimally. Maintaining a relative neutral position can help to optimize the performance of her inner core musculature (comprised of the diaphragm, pelvic floor muscles, transverse abdominis, and multifidus) which help to stabilize her pelvis. Your client doesn’t have to spend all of her time in a “neutral” position, but when she is under load, you should encourage her to be in this position as much as possible. Remember that women in their third trimester of pregnancy especially are already “under load” due to the increasing weight of the baby. Prioritizing body mechanics that allow for the most efficient and pain-free loading possible is especially helpful when a client is experiencing pain.
For many women, the pelvic floor is often not meeting the demands placed on it, which may be contributing to her SPD symptoms. This can also lead to more chronic issues down the line. As mentioned earlier, a pelvic floor physical therapist who can perform an assessment of her pelvic floor is a valuable asset to her health and fitness support team. That pelvic floor weakness is the only concern regarding this incredibly important set of muscles is a broad misconception. A pelvic floor need not be weak to function poorly. Many women have difficulty relaxing their pelvic floor and this, too, can contribute to dysfunction. Again, a referral pelvic floor physical therapist for the pre- or postnatal client dealing with dysfunction is highly recommended.
When working with your client, in addition her alignment, pay attention to her breathing. Does she tend to hold her breath? Is she having trouble taking a deep breath and getting a full inhale? Is she bearing down as she exhales? How she is breathing can influence the function of her core and more distal musculature.
Exhaling before and during the hardest part of a movement is a great way to encourage her inner core unit to provide much-needed stabilization during exercise and activities of daily life. The goal is to restore automatic function of the inner core unit, which is often lost during this time in a woman’s life.
A well-functioning inner core unit is a prerequisite for more advanced movement. Set (or reset) the foundation first, then build on it.
2. Be mindful of adding more instability to a pelvis that is already unstable. Due to the instability of the pelvis, is it often best for women with SPD to avoid exercises and movements that may exacerbate the excessive motion of the pubic symphysis. Examples include deep and wide squatting, lateral lunging, “heavy” unilateral lower body training, rapid or frequent changes in direction, rotation (especially) away from the midline, and high-impact activities. In short, abduction and lateral rotation of the hip should be handled with care. When and if you are working these movements into your client’s program, consider adding additional stability to the exercise for assistance.
An excellent way to add stability to an exercise is to provide an external surface for the client to use to assist herself. This can be something like holding TRX straps for support during a squat, or keeping both feet planted when she does any potentially problematic rotational movements. This strategy can be particularly useful when training movements like hip abduction.
Many clients managing SPD lack optimal function of the gluteal muscles, and finding pain-free ways for them to train this weakness (like the three drills demonstrated in the video below) can help to address what may be contributing to the potential biomechanical factors leading to the development of SPD.
Clams with assistance from a wall (abduction performed with added stability). This movement can then be progressed to a standing position.
Bridges with a ball between the knees for support (posterior chain strengthening with an increase in stability created by the adduction keeping the ball in place).
Supine hip abduction (focusing on controlled abduction and adduction with assistance from positioning and the ground itself).
These basic movements can be used to help your client build awareness of her functioning during a warm-up, cool-down, or as part of her homework.
3. Encourage strength in pain-free positions. Pregnancy is not the time to seek out personal records in strength, especially if your client is managing a painful condition, but that doesn’t mean strength training isn’t valuable to the pregnant client with SPD. Prioritizing strength and stability in pain-free positions is key. Check in with your client throughout the session. With SPD, as with pregnancy, something that felt fine last week might not feel so great today.
Almost every exercise can be performed in various positions. Figure out which positions work best for your client. For example, seated, kneeling, or standing evenly on both legs are often more successful than standing in a staggered, or a wide stance when performing lower body movements. Upper body movements are often more successful when performed seated, kneeling, supine, or with feet evenly set while standing. Even these “safer” positions require you to have a keen awareness of your client’s alignment and mechanics.
4. Focus on bilateral training rather than unilateral training.
When programming lower body work, prioritize bilateral movements over unilateral movements.Unilateral or wide-legged stances (pictured) are often problematic for the client with SPD. Instead, a narrow stance squat using a box for assistance may prove more achievable for a woman with SPD. Keeping both legs on the ground allows her more stability and, hopefully, more comfort.
Much of your client’ daily life with likely include unilateral activities (like walking or taking the stairs) and working on pain-free strength and stability in these positions and activities may encourage better function and hopefully, fewer symptoms overall. Single-leg activities are a common culprit of discomfort in women with SPD. It is of utmost importance that your client be able to perform single-leg exercise in her program with no pain or discomfort. Used sparingly and with the intention of addressing her routine movement demands that cannot occur bilaterally, unilateral training may have its place in a program for your client with SPD. When possible, a “kickstand” support from the non-working leg can turn an exercise that would otherwise be out of the picture into a valuable, pain- and dysfunction-free movement.
In general, however, bilateral training is likely a smarter and safer choice for someone struggling with SPD.
5. Make adjustments to stance and range of motion.
A narrow stance allows for greater stability at the pubic symphysis than a wider stance. In exercises like the squat or deadlift, for example, encouraging your client to narrow her base of support will likely allow her to perform the movement with greater success. In addition, women with SPD often feel more comfortable keeping their legs together while rolling over, getting out of a car, putting on pants, and other similar movements.
A woman managing SPD may also benefit from a decreased range of motion. For example, she would likely feel better altering her wide-stance, full-depth squat to a narrow-stance, half- or quarter-squat.
Another consideration regarding range of motion is flexibility or mobility training. Every woman’s needs will differ but many women will describe a perception of “tightness” and will feel inclined to engage in more stretching. Even for someone with SPD, it is still important to encourage functional ranges of motion, and mobility training can be valuable when done in a range of motion that does not exacerbate her SPD symptoms. Many women often find foam rolling or any other type of self-massage to be helpful, particularly on areas like the glutes, quads, and adductors.
6. Be cognizant of the session’s flow.
Because changing positions is often painful for someone with SPD, asking a client to perform a series of exercises that require her to move between getting down on the ground and standing up may exacerbate her symptoms. Consider grouping exercises that occur in similar positions to lessen the amount of times she needs to make positional changes. As an example, the circuit in the video below is comprised of a tall-kneeling Pallof press, tall-kneeling row, kneeling hinge, and tall-kneeling overhead press allow the client to work multiple movements and muscle groups while limiting the opportunity for her SPD pain to flare up.
Additionally, keeping the load in a light-to-moderate range and increasing the amount of rest is likely a wise choice for most women managing SPD. This basic circuit demonstrates training a variety of muscle groups and movements without having to change positions:
While SPD can certainly feel restrictive to a woman who wants to stay active, this condition doesn’t have to keep her out of the gym entirely! With your guidance and a thoughtfully-designed program that takes into consideration your client’s SPD symptoms, her exercise goals, and her daily life demands — along with the support of the rest of her healthcare team — she can continue to have a rewarding and active pregnancy and postpartum recovery.
When we work with clients during their pregnancies and postpartum recoveries, particularly when they are managing difficult conditions, we have the opportunity to be a supportive and positive presence during a transformative and often chaotic time. By working with our clients affected with SPD compassionately, and within our scope, we are building not just stronger bodies, but stronger relationships as well. Instead of simply seeing SPD as an obstacle, consider it an opportunity to deepen your knowledge, hone your skills, and exercise empathy with your clients!
MacLennan, A., MacLennan, S. (1997). Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and developmental dysplasia of the hip. Acta Obstetrics & Gynecology. 76. 760-764.
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