Question
I had my daughter september 05. During that time I had terrible leg aches and hip pain - mostly during the night, the Doctors told me it was hormonal and pregnancy related. A year has now past and I am still having leg aches and hip pain. My back pain has also now started to flare up. Is there a possibility that it still could be related to the pregnancy. I also had mild pubis synphysis in my first pregnancy in 1999. Please could you give me some answers. I am currently waiting to be seen by a physiotherapist.

Thanks

Anne  

Answer
Dear Anne,

Yes, I am positive that it was pregnancy related.  In fact it would have been great for you to have been under chiropractic treatement during your pregnancy. It sounds as though you may have sciatic type pain or sacroilliac joint pain.  I would recommend you get a chiropractic evaluation from a well credentialed chiropractic physican in your area.  Let me explain why, including pregnancy recommendations.

All of the symptoms you have described can originate from sacroilliac dysfunction, because the sacroiliac joint,(SI)has pain patterns that encompass the entire leg depending on the dysfunction of the joint, the ligamentous complex and associated muscles. It gets its nerve supply from L3 to the S2 nerve roots. There is also a type of pain called sclerotogenous pain which does not generate from the nerves, but rather from the ligament, cartilage and disk.  This pain is diffuse and covers broad areas. It is possible that you could have some overlap however of sacroillic pain as well as sciatic. Sciatic type pain is pain that radiates commonly from the buttock, down the back of the leg and  below the knee.

Moving on, the majority of the stability of the SI joint comes from the ligaments.  They are probably the strongest in the body and a ligament serves to limit joint movement.  The actual movement that occurs within the SI joint is very small.  Most of the research I have read indicated that the SI joint moves only 1-3mm.  For many years it was thought that the joint did not move at all, but it is a true synovial joint.  **Pregnancy has an effect on ligaments by making them weaker.  (description below)

Concerning manipulation or adjustment of the joint, it is very common to use the side posture adjustment to address the SI joint. Technically you are moving the joint with manipulation, but again we are talking about very slight movement.  There are other ways to adjust the SI joint however without as much of a stretch to your torso and the lower lumbar and pelvic musculature. The doctor could use a drop table adjustment where you lay on your stomach, or your back.  He could also use an instrument to vibrate the joint space as well as some "PNF" stretching in the low back.  He could also elect to adjust the sacrum to the pelvis instead of the pelvis to the sacrum which would mean a different hand placement for the doctor on your body.  All of these thing will accomplish the same task, but have different effects depending on the patient's general condition.  These are points you should discuss with the chiropractic physician of your choice.  In the immediate future, you should be using ice to help reduce the inflammation around the joint...approx 20 minutes at a time, once per hour and never directly on the skin.

The key to chiropractic manipulation is not the actual movement of the joint, rather the quick release of pressure within the synovial fluid of the joint...that is what makes the popping sound.  It is a release of gasses that happens quicky and escapes the synovial capsule, just like when you open a champagne bottle quickly.

When this happens joint receptors are firing signals to the brain.  These are called mechanoreceptors because they respond to movement and mechanical stimuli.  There are also proprioceptors which transmit information to the brain about body position and awareness.  Both of these transmitters send information to the spinal cord and brain which will inhibit the pain receptors in the joint which are called nociceptors.  It is a neurological and physiological relationship reducing inflammation and pain transmission.

Now, chiropractic care is absolutely safe during pregnancy.  This is actually a growing and expanding part of our clinic.  We are getting 1-2 referrals a week into our clinic from local OB/GYN's in our community due to the effectiveness in eliminating, reducing and managing low back pain for pregnant women.

Manipulation of the SI joint as well as the lumbar joints is a bit different with pregnancy.  First of all light pressure and force should be used due to the actual ligamentous laxity that you mentioned.  When pregnant, a woman's body releases a hormone called relaxin that effects all ligaments, but specifically pelvic ligaments to allow for the expansion of the pelvis and birth canal. The round ligament of the uterus is also effected and should be addressed as well.  (see below)

When a woman starts to "show" around the fourth to fifth month, it is important to stop side posture adjustments and move to more conservative manipulative techniques such as prone and supine drop table adjustments or instrument assisted adjustments. This is because the myofascial slings in the pelvis can become torqued or twisted in a manner that actually increases labor difficulty and restricts the movement of the baby in the birth canal.  Also, the belly is becoming larger and will obstruct normal patient positioning for that type of adjustment.

It is also important to have a chiropractic table with a break away pelvic/abdominal piece...this allows the belly and consequently the baby to remain unresrticted during the adjustment, and it is much more comfortable for the mother as well. **After the fourth-fifth month, Never lay on your stomach for an adjustment without this type of table, or without the use of a pregnancy cushion! -It creates too much stress on the internal environment of the fetus.**  

In addition it is important for pregnant women to have their symphysis pubis adjusted as well as the low back/SI. This would have helped your pain there during preganacy!  (Remember the entire pelvis becomes more relaxed as your approach birth.)  This adjustment is performed with the woman flat on her back with her hips bent at 45 degrees and the knees at 90 degrees.  It is a light force adjustment that allows the pubic joint at the front of the pelvis to remain unrestricted and allows for an easier delivery. Also the doctors hand placement is not compromising for the woman, the doctors hands are at the knees for this adjustment.

Many chiropractic physicians are not trainned in this type of adjustment, so it is important to ask about advanced trainning they may have received...make them explain it to you.  If they can't explain it to you, get another chiropractor who can concerning pregnancy.  Look for chiropractors who have advanced trainning in cranio-sacral therapy, pediatrics, and fascial unwinding.  Chiropractors that have been trained by Dr. Carol Phillips or Dr. Upledger are good choices.

Now back to the round ligament.  Some women have fetuses that are not positioned correctly for an unobstructed move into the birth canal (occiput posterior position).  A technique of adjusting for this problem is called the "Webster Technique."  This technique aids in opening up the pelvic basin for delivery.  By doing so it will allow the baby to turn inside of the birth canal so that it is positioned properly for delivery.  This is accomplished with an adjustment to the sacral base on either the right or the left- determined by the presentation of the patient- as well as a myofascial release of the round ligament of the uterus on the opposite side of the body.  Again ask your chiropractor about their training and make sure they explain it to you...many doctors do not know how to perform the Webster Technique properly.

Anne, I hope this sheds some light on your concerns regarding treatment options and ongoing symptomatology.  As you can see from above previous pregnancies as well as future can place extreme demands on a woman's anatomy, especially the low back.  If you have any further questions or comments please feel free to respond back.  In addition, more information on the SI joint can be found by reading any of Dr. Andry Vleemings research, you can look it up on Medline or Pubmed through the internet. I would also highly recommend a book written by Dr. Stuart McGill as a reference for low back dysfunction called LOW BACK DISORDERS, Evidence-based prevention and rehabilitation.  I am sure you can find it at your local college library.  It is a great text.

Respectfully,
Dr. J. Shawn Leatherman