• Emily Reul, PT, DPT

Pubic Symphysis Pain

Updated: Feb 6

Hi friends! This week’s topic is the pubic symphysis. You may have never heard of the pubic symphysis because it is not as commonly injured as other areas of the pelvic floor.



The pubic symphysis is the joint where your two pubic bones come together in the front of your pelvis. It has a disc between the pubic bones and is supported by the surrounding ligaments and muscles (Becker, 2010). This joint has some movement, but it is very small when compared with the movement of other joints like the shoulder or the knee. This joint is important in absorbing forces while the pelvis moves, especially during single leg activities like walking, climbing stairs, or even standing with most of your weight shifted to one side. (Becker, 2010)


This short video on pelvic anatomy will give you a better idea of where the pubic bones are.


Partly because of its location the pubic symphysis, and its related issues, are not well-researched.


What Happens When the Pubic Symphysis Is Injured?

When the pubic symphysis in injured, or not functioning properly, there may be pain. The pain may be located at the pubic symphysis (front of the pelvis) or it may radiate to other areas of the body like the abdominals, perineum, testicles/scrotum, low back, or the front/inside of the thighs (Urraca-Gesto, 2015; Elatter, 2016; Howell, 2012; Norvilaite, 2020). This pain is often worse when walking, performing hip abduction (bring it out to the side), or doing activities that require you to stand on one leg—even for short periods of time (Urraca-Gesto, 2015; Elatter, 2016; Becker, 2010). This can cause walking that looks like waddling (Norvilaite, 2020).


Some individuals may also experience a clicking, snapping, or grinding sensation that is heard or felt in front of the pelvis. (Howell, 2012). Individuals may also experience dyspareunia (pain with sex) due to pubic symphysis injury (Howell, 2012).


How Is the Pubic Symphysis Injured?

The pubic symphysis can be injured in several different ways. One of the most common is during pregnancy and delivery. During a vaginal delivery, 2.8% of women have a diastasis of the pubic symphysis that can be caused by instability of the pelvis or as a result of fetal shoulder dystocia (Urraca-Gesto, 2015). A diastasis is simply a fancy word for separation. Diastasis of the pubic symphysis is not to be confused with a diastasis rectus abdominus (this is a separation of the abdominal muscles which is common during pregnancy and postpartum). A diastasis of the pubic symphysis is diagnosed when there is a 10 mm separation or greater between the pubic bones (Urraca-Gesto, 2015; Norvilaite, 2020).


During pregnancy or the postpartum period, individuals may still experience pubic symphysis pain and dysfunction related to the pregnancy even if they do not have a diastasis pubic symphysis. Studies have found 31.7% of pregnant individuals reported pain or dysfunction related to the pubic symphysis (Howell, 2012). During pregnancy, hormones like Relaxin can make the pubic symphysis wider and move just a little bit more (Becker, 2010; Norvilaite, 2020). On average, the pubic symphysis is 3mm wider in pregnant individuals compared with those who are not pregnant, but the width can vary greatly between individuals (Becker, 2010).


It is important to keep in mind that a larger separation does not always mean you will have pain or other symptoms. The width, or degree of separation, and the severity of symptoms is not directly related—meaning just because you have a wider separation does not mean that you will experience pain, and the larger the separation does not necessarily mean there will be more pain (Becker, 2010).


Pregnancy is not the only cause of injury. Trauma from accidents, like a side impact car collision, can also cause injury to the pubic symphysis (Becker, 2010). Injury can occur in athletes especially in sports (e.g. soccer) with kicking, rapid acceleration/deceleration, or sudden directional changes (Elatter, 2016). Other health conditions like congenital disorders (e.g. bladder exstrophy), metabolic disorders (e.g. hyperparathyroidism), or neoplasms (most commonly metastatic disease) can all cause issues with the pubic symphysis (Becker, 2010).


How Can We Treat A Pubic Symphysis Injury?

Some great news is that for individuals who are having pubic symphysis issues related to pregnancy, symptoms will often go away after delivery of the baby (Howell, 2012). Only 25% of individuals who had pubic symphysis pain will have it 4 months postpartum (Howell, 2012). However, this does not include those who have had a diastasis of the pubic symphysis.


Regardless of the way the pubic symphysis is injured, there is good research to support physical therapy as a great conservative treatment option (Urraca-Gesto, 2015; Norvilaite, 2020; Elatter, 2016). A physical therapist will focus on stabilization and strengthening exercises for the core, hips, and pelvic floor muscles. Most individuals will be able to get rid of symptoms within six months of starting physical therapy (Urraca-Gesto, 2015; Elatter, 2016). It is important to note that regular exercise can play a role in preventing pubic symphysis dysfunction from happening in the first place (Urraca-Gesto, 2015).


Along with physical therapy, there are many other conservative treatment options available, and many times a combination of treatments will provide the best results.


Your physician may prescribe NSAIDs as a form of pain relief (Norvilaite, 2020; Elatter, 2016).


Positioning can be important. When resting, it can be helpful to lie on your side to help with pain and avoid positions or movements that increase pain (Urraca-Gesto, 2015; Norvilaite, 2020).


Other conservative treatment options may include modalities like ice, TENS, massage, and acupuncture—although more research is needed to support the effectiveness of these options (Urraca-Gesto, 2015; Norvilaite, 2020; Elatter, 2016).


Steroid injections may be recommended, but there is conflicting research on whether these are beneficial long-term (Elatter, 2016). Pelvic girdle belts are sometimes recommended, but these also have conflicting evidence on their benefits (Urraca-Gesto, 2015; Howell, 2012).


Surgical treatments for pubic symphysis dysfunctions are often used as a last resort when conservative treatments have not been successful (Norvilaite, 2020; Elatter, 2016). For a diastasis of the pubic symphysis, surgery is typically recommended if the gap is more than 4 cm (Urraca-Gesto, 2015; Norvilaite, 2020).


Are you ready to heal from a pubic symphysis injury? Here are some great resources to get started:


For Healthcare providers, check out all our continuing education courses here to help you better serve your clients. You can purchase courses individually or join our Ambassador Program and most of our courses are included with your membership!



What experiences or tips do you have that can help others? We would love to hear them. Please join the conversation in the comments section below.  


Written by Emily Reul, PT, DPT


References

1. Becker I, Woodley SJ, Stringer MD. The adult human pubic symphysis: a systematic review. J Anat. 2010;2017:475-487.

2. Elattar O, Choi H, Dills V, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8(4):313-323. doi: 10.1177/1941738116653711. Epub 2016 Jun 14.

3. Norvilaite K et al. Postpartum pubic symphysis diastasis-conservative and surgical treatment methods, incidence of complications: two case reports and a review of the literature. World J Clin Cases. 2020 January 6; 8(1):110-119.

4. Howell ER. Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. J Can Chiropr Assoc. 2012;56(2):102-111.

5. Urraca-Gesto MA et al. Diastasis of symphysis pubis and labor: systematic review. J Rehabil Res Dev. 2015;52(6) 629-640.

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