Exercise after delivery: How to avoid injury

October 3, 2019 Swedish Women's Health Team

By Emily N. Peterson, M.D.Swedish Family Medicine Obstetrics 

Sometimes it is hard for a patient to follow their doctor’s medical advice. Doctors are no better when they are the ones seated on the exam table.

Two weeks after delivering my child, I decided to go for a run.  I’m a family practice doctor and I typically advise my pregnant patients to wait six weeks after vaginal delivery before slowly returning to exercise. I also recommend to women that they listen to their bodies as they return to exercise, stopping if they are in pain. I’m a prime example of a non-compliant patient. Not only did I go for a run, but I increased my mileage more quickly than I should have, ignoring the pull I was feeling in my groin while I ran. So much for listening to my body.

I typically advise my pregnant patients to wait six weeks after vaginal delivery before slowly returning to exercise. I also recommend to women that they listen to their bodies as they return to exercise, stopping if they are in pain.

Fast-forward a year later, and I had developed chronic bilateral groin pain with a burning over my pubic symphysis (the bone 6 inches below your belly button). I was able to walk only short distances on flat ground and I was no longer able to run, ride my bike, or carry heavy objects (i.e. my child) without unrelenting pain. Eventually I was diagnosed with osteitis pubis and my lengthy journey for treatment began.

What is osteitis pubis?

Osteitis pubis (OP) is a non-infectious inflammation of the pubic symphysis (the joint between the right and left pubic bones) causing varying degrees of lower abdominal pain, groin pain, and pain over the pubic bone. When the pubic symphysis dysfunction occurs during pregnancy, you can have similar symptoms and it can lead to osteitis pubis after birth. But pregnant women are not the only population that suffers from OP. OP can also affect athletes, especially those who do a lot of running, cutting, kicking (think soccer, rugby, ice hockey, and long distance running). You may also be at risk if you’ve had recent gynecologic surgeries, urologic surgeries, trauma to the area or currently have a rheumatologic (autoimmune) condition.

Osteitis pubis (OP) is a non-infectious inflammation of the pubic symphysis (the joint between the right and left pubic bones) causing varying degrees of lower abdominal pain, groin pain, and pain over the pubic bone. During pregnancy, many women may dismiss groin pain as part of the natural discomfort of pregnancy. 

In one study that included soccer players, 3-5% of total athletic injuries were due to osteitis pubis. It may be hard for your doctor to diagnose osteitis pubis because groin pain can also be  attributed to adductor strain (strain of the muscles in the inside of your upper thigh that insert on your pubic symphysis). Imaging can help with diagnosis because x-rays will show a widening of the joint space, lytic changes (boney destruction at the joint), and instability. An MRI will show bone edema, osteophytes and erosion when you have osteitis pubis.

Osteitis pubis during pregnancy

During pregnancy, many women may dismiss groin pain as part of the natural discomfort of pregnancy. After all, when you are carrying an extra 25-35 pounds of weight around your middle and a small child inside your uterus, it’s going to be uncomfortable.

Discuss any pelvic pain with your doctor. You may be able to start treatment to alleviate symptoms and prevent unrelenting chronic pain postpartum.

If you are pregnant, be sure to discuss any pelvic pain with your FP/OB, midwife, or OB provider. You may be able to start treatment, including physical therapy that can help alleviate your symptoms and prevent the rare occurrence of unrelenting chronic pain postpartum. It’s worth it, right?

Alleviating the pain

In addition to physical therapy (if your doctor prescribes it), I recommend avoiding split leg maneuvers (like walking and stair climbing) and for some people, wearing a sacroiliac (SI) joint belt although it can increase the need to urinate from every 30 minutes to every 15 minutes—sorry ladies!

If you need more relief, you may need a  steroid injection in your pubic symphysis. This procedure can be performed by a family practice physician or sports medicine doctor and is helpful for about 50% of patients, sometimes requiring repeat injections for maximum pain relief.

My osteitis pubis experience

Unfortunately, none of the treatment options above helped me. After 8 physical therapists, one chiropractor, one steroid injection, two platelet-rich plasma (PRP) injections into my adductors, two prolotherapy sessions (sugar water injections) into my adductors, a negative inflammatory and autoimmune workup, and months on crutches and with no clear improvement, I was heading in the direction of pubic bone fusion.

Pubic bone fusion, where plates and screws are used to stabilize the pubic symphysis, is a last resort for OP patients. It can include up to 12 weeks of post-op non-weight bearing rest and/or walking with crutches and has the potential to fail or need revision afterward.

Fortunately, as I was preparing for my surgery, I met a progressive physical therapist OP and helped me walk again without pain. Within 12 sessions I was off crutches, able to walk with minimal pain, and finally able to pick up my child again for the first time in months without experiencing excruciating pelvic pain.

The moral of the story? Listen to your doctor. My case was extreme and could have possibly been avoided. Don’t exercise for at least 6 weeks postpartum even if you feel like a million bucks. And consult your doctor and maybe even a physical therapist if you are experiencing pubic or pelvic pain during pregnancy. If you are an athlete and you are experiencing persistent groin pain, don’t ignore it and talk to a physician. 

 

Emily N. Peterson, M.D., is a Swedish family medicine and obstetrics physician specializing in pregnancy and childbirth, pediatrics and primary care. She loves to utilize the growing knowledge and data available in the medical world to empower patients and provide them with the best care possible. She is passionate about all aspects of patient care and feels grateful to be in a profession that is so fulfilling, where she is able to make long lasting relationships with her patients and care for them throughout their lives. Dr. Peterson practices at Swedish Edmonds Birth & Family Clinic.

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This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.

Resources

“Osteitis pubis in elite athletes: Diagnostic and therapeutic approach”, Antonios G Angoules. May 26th, 2015. World J Orthop.

Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scan J Med Sci Sports 1999;9;98-103.

Beatty T. Soteitis pubis in athletes. Curr Sports Med Rep. 2012; 11;96-98.

The OP Clinic. Jason A’Abreo. https://www.theopclinic.com/

 “Treatment of Osteitis Pubis in Non-Athlete Female Patients”, Open Orthop J. 2011; 5: 331–334. Published online 2011 Sep 12.

 “Management of osteitis pubis in athletes: rehabilitation and return to training – a review of the most recent literature”, Open Access J Sports Med. 2019; 10: 1–10. Published online 2018 Dec 24.

About the Author

Whether you are seeking gynecological advice, need help navigating your way through the menopause stage of life or researching a recent breast cancer diagnosis, the Swedish Women's Health Team is committed to helping women find the information they need to live happy and healthy lives.

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