A 19-year-old woman complains of severe pain in her pelvis after a vaginal delivery of her first child. One day after her delivery, she is unable to get out of bed due to the pain. On examination, she has no loss of sensation or motor weakness in the lower extremities. Pain to palpation is noted over the anterior pelvis. Anteroposterior (AP) pelvis X-ray shows a 5-cm symphysis pubis diastasis without fracture.
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The symphysis pubis is a fibrocartilaginous joint that connects the left and right superior pubic rami. The symphysis pubis widens during pregnancy as a normal response to child birth. The widening is generally 2 to 3 mm and rarely exceeds more than 1 cm. Progesterone and relaxin are natural hormones that help the strong supporting ligaments stretch as a normal physiologic response to childbirth. Any widening usually regresses after delivery and rarely becomes symptomatic. Symphysis diastasis of greater than 1 cm represents complete disruption of the joint, which is usually symptomatic. Complete disruption may be heard as a popping sound during delivery. A complete disruption causes pain over the symphysis pubis that is made worse with walking.
AP pelvis X-ray is the best study to diagnose symphysis pubis diastasis. A careful physical examination is also necessary to rule out sacroiliac joint (SI) involvement. The SI joint is usually not involved unless the diastasis exceeds 4 cm. Treatment is almost always non-operative. Patients may be weight bearing as tolerated and use a walker for support if needed. Pelvic binders and sleeping in a lateral position can also help with symptoms. Pain usually subsides in 8 weeks but can last as long as 8 months. The diastasis usually reduces over time and becomes asymptomatic. Surgery may be indicated in patients with persistent symptoms and a large diastasis.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Khorashadi L, Petscavage JM, Richardson ML. Postpartum symphysis pubis diastasis. Radiol Case Rep. 2015;6:542.
- Jain N, Sternberg LB. Symphyseal separation. Obstet Gynecol. 2005;105:1229-1232.