“Pelvic and Pubic Symphysis Pain in Pregnancy and Postpartum” – with Dr. Jaclyn Bonder

This episode of Healthful Woman features Dr. Jaclyn Bonder, associate professor of Clinical Rehabilitation Medicine at Cornell with expertise in pelvic, pregnant, and postpartum pain. She explains what physiatry is and how it differs from physical therapy as well as common pelvic pain issues her patients face and how they can be treated.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Jaclyn Bonder, welcome to the podcast. So happy to have you on.

Dr. Bonder: Thank you. I’m happy to be here. Thanks for having me.

Dr. Fox: So, as you know, but our listeners might not, you’re an associate professor of Clinical Rehabilitation Medicine at Cornell in New York City, and you have a expertise and an interest in women’s health, pelvic pain, and pregnant and postpartum pain. So I thought you would be an unbelievable resource for our listeners. Thank you for taking the time. How are you doing today?

Dr. Bonder: I’m good. I’m good. I’m looking forward to the spring and February finally being here and taking masks off and enjoying being outside as much as possible in the next couple of weeks.

Dr. Fox: Awesome. Now, just so our listeners understand, what exactly is rehabilitation medicine, sometimes called physiatry? Like there’s a lot of names. What exactly do you do?

Dr. Bonder: Sure, that’s a very good question. Most people have never heard of physiatry or know what a rehab medicine doctor is or a physical medicine and rehabilitation doctor, which we have a couple of different names. And most people don’t know what one is until you’ve actually gone and see one. And sometimes even after that, people aren’t aware because we often get called sports medicine doctors or pain doctors. So there’s really a lot of different names that we are ended up giving. So physiatry or physical medicine and rehabilitation is our official title. Our board certification is in physical medicine and rehabilitation. And what that really is, is basically a specialty that kind of combines the neurology and orthopedics. And so we learn a lot about the neurologic system, as well as the orthopedic system, and the musculoskeletal system and kind of use that to evaluate, treat, and diagnose patients with different types of musculoskeletal and neurologic conditions.

But different than the orthopedist, we don’t do surgery. So everything that we usually offer is kind of non-operative. And so trying to treat musculoskeletal disorders from a functional standpoint, trying to get athletes back onto the field and kind of rehabbing back from an injury or pregnant women, rehabbing them out of their pain and kind of helping them get through functionally through their pregnancy, if they’re having some pains or to help them get through their daily life and activities to feel better and kind of move through their regular workday or, you know, taking care of their kids they have at home already. So there’s neurological physiatrist that kind of specialize more in taking care of, like, MS or multiple sclerosis patients that kind of have side effects or a downstream result of their weakness and things like that from there. So there’s physiatrists that kind of help from that standpoint, too. But it really, in summary, is kind of a combination of a little bit of neurology and a little bit of orthopedics doing non-surgical management of pain and other disorders.

Dr. Fox: I think a lot of people get confused and they sort of think that what you do is the same as what a physical therapist would do. Obviously, it’s totally different training. You went to medical school, you’re a physician, and then you did specialty training, whereas physical therapists, their training has changed over the years. How exactly are your roles different in taking care of a patient or helping a patient recover from an injury or a condition?

Dr. Bonder: That’s a good point as well. Someone comes to our office and they don’t actually know what we are or what we do. A lot of times they do think that we are the physical therapist. A lot of times doctors will say, “Oh, you know, you probably need some physical therapy. Here, go see Dr. Wagner or go see Dr. so and so,” when they come to us and they think they’re seeing the physical therapist, but we’re actually not. Like you said, I’m a medical doctor. So I went to medical school and then did my training. And the difference is, is that we’re able to evaluate a patient medically in terms of other medical conditions that might be affecting someone’s issue that they’re seeing us for and kind of taking into account all the other medical issues that they may have.

And then we can also kind of, you know, evaluate and diagnose the problem or their testing, whether that’s imaging or laboratory data, kind of help differentiate between what might be causing their symptoms and then coming up with a treatment plan. And part of that treatment plan may be physical therapy. And that’s when we will often refer to a physical therapist. And I often say that we speak the same language as the physical therapist. We learn a lot about physical therapy and all the modalities that they use and the types of exercises they may do. In our training, we learn all of that. And so it’s just one aspect of what we may prescribe and what we may use as treatment to kind of help patients. And it often is the first thing that we prescribe when relevant because I always say that, you know, exercise is medicine. You know, it’s a type of medicine and it’s a type of treatment that is low risk and it can be very helpful for a lot of patients.

So the PTS or the physical therapists will then go on to kind of work with a patient more regularly and see them weekly and help come up with exercises and make sure they’re doing the exercises correctly. And they certainly can do a lot of evaluation too. But even sometimes their evaluations and their diagnoses that they come up with are a little bit more of a mechanical-based diagnoses that we don’t necessarily learn about in medical school. So, you know, things that kind of really take into motion of the body is more of a kinesthetic or kinesiology-based diagnosis.

Dr. Fox: Interesting. And then how did you get interested in this field when you’re in medical school?

Dr. Bonder: So in terms of rehab medicine or we shorten it sometimes for PM&R, I was actually going to go to physical therapy school when I was in college. I thought about going to physical therapy school and I looked into doing that. And I did a bunch of volunteer work and realized that when I was doing all that, that I was feeling more the medical aspect of things that I was interested in. And so I decided to pursue medicine and go into medical school. So because of that physiatry or PM&R really became a natural specialty for me that I decided that I was kind of going to do very early on. And I’ll thank my mom and give her a plug here. But she was the one who introduced me to a physiatrist and what it was because someone told her to go see one, you know, almost 30, 35 years ago.

And so she saw one for different back pain and things where we lived. And she was like, “Oh, I think that this would be great for what you do or what you are interested in.” And so that’s how I really learned about it. And then was lucky enough to go to NYU for medical school, which has a big rehab program and one of the first, actually the first, rehab program in the country. In medical school, though, I kind of decided, I declared that I was going to go into rehab medicine, but then OB-GYN rotation came along. And I got really interested in that too and really enjoyed my OB-GYN rotation and ultimately decided to combine the two. And that’s how I got to this kind of specialty and niche of women’s health PM&R and women’s health rehab and seeing the population that I see.

Dr. Fox: So when you were doing your training in rehab medicine, you sort of had a sense at the time that you may end up specializing or sub-specializing in treating women, you know, in general, and also pregnancy and postpartum.

Dr. Bonder: Correct. There was a brief time in medical school where I was like, “Oh, maybe I’ll go into OB-GYN instead of rehab medicine,” but then it kind of pulled me back into the rehab medicine side for many different reasons. And when I finally got into residency, I had this idea that I was going to kind of specialize in women’s health like or I don’t remember when exactly it came to me. But I had this kind of thought process that I would be able to maybe combine the two.

Dr. Fox: Oh, that’s so cool. And how is your practice now? Like, what percentage of your patients are, A, women and, B, pregnant or postpartum? Is it 100%, 80%, 50%?

Dr. Bonder: My practice is mostly women. I’d say it’s about 80%, 85% women. The small percentage of men that I see is I see men with pelvic pain and pelvic floor dysfunction and pelvic floor issues. And those are the only men that I traditionally will usually see unless I find fathers like, “Can you see me?” But usually, that doesn’t happen. Even then sometimes I’m like, “No, you don’t want to see me because I do it so rarely these days, but you can get different and more specific care from someone else.” But anyway, so the majority of my population and patient population is certainly women. And then in terms of pregnant and postpartum, I’d say 50/50 in terms of pregnancy and postpartum and then more of like this specific kind of pelvic pain and pelvic floor issues and things that I also see.

But the pregnancy and postpartum issues are really my love and my passion. And really how I decided to go into women’s health was really to work with that population. And then I’ll see other general musculoskeletal issues here and there but really no practices. Most of my patients are some sort of pelvic pain, pelvic floor dysfunction, and then the pregnancy and postpartum-related issues.

Dr. Fox: Yeah, I think a lot of people don’t realize how common it is for pregnant women, and I’m including postpartum, to have pelvic pain. I mean, certainly, women who have been pregnant know this. But for anyone who’s never been pregnant, men or women, I think they find it to be surprising how common it is. And, I mean, we’re referring patients to you all the time. I mean, you’re like our go-to person, like our speed-dial person, because it’s just so common. And not a lot of people know how to treat it because like you said, do you see neurologists? Do you see an orthopedic surgeon? Do you see someone who says they’re a sports medicine doctor? And they don’t really touch on all the areas that need to be assessed. And you’re like one of the people who really looks at it globally and can actually do a full assessment and you’re willing to see pregnant women. It’s a difficult population for people because they don’t usually see pregnant people. They don’t know what to do about it.

Dr. Bonder: I think the term pelvic pain is also really hard because the definition is so vague, or really what is the pelvis? What is pelvic? What is vaginal? What is rectal? You know, what is bony? So, I always tried to differentiate between this idea of, like, pelvic girdle pain versus pelvic pain. And thinking like pelvic girdle pain is more of like a musculoskeletal origin of pain. And pelvic pain is more gynecological or lower abdomen or bladder or vaginal or rectal, which certainly could be musculoskeletal. But, yeah, it’s hard because I think just to use the term pelvic pain is very, very big. It’s not like shoulder pain. It’s pretty clear what your shoulder is versus pelvic pain it can be really difficult to define. And pelvic pain in a pregnant woman can be very, very different than pelvic pain in a, you know, 75-year-old.

Dr. Fox: Let’s talk about the pelvic girdle pain in pregnancy. So, first of all, why does it happen in pregnancy specifically? And what is exactly going on for women who have this pain? What are the possible causes?

Dr. Bonder: So pelvic girdle pain if you look it up by definition is really any pain kind of from the waist or kind of what we normally call the iliac crest but like it’s kind of where most people think their waist starts to the gluteal fold, which is kind of that area where you’re kind of buttock, you know, meets your thigh and then anything kind of in-between. And so whether it’s in the front or the back, that is something that I will usually call pelvic girdle pain. And so anything in between there can really cause symptoms of musculoskeletal pain. And so within that area, it’s the pubic bone and the pubic joint. It’s the hip joints. It’s those the joints we called the sacroiliac joints, which is the joints in the buttock area. It can sometimes be the low back and the lower lumbar region. And then there’s a lot of muscles in that area, too, that can be the source of symptoms. And whether it’s weakness in those muscles causing joint pain or joint pain-causing muscle strain and muscle pain it, you know, kind of all interplays. And that’s kind of where I come in in terms of figuring out a diagnosis versus just saying, “Oh, it’s low back pain in pregnancy,” or, “It’s SI joint pain and pregnancy,” or, “Sacroiliac pain,” and figuring out what might be interwoven.

Dr. Fox: Right. And what is the reason that it’s more common in pregnant women?

Dr. Bonder: Probably the most common reason why it’s more common in pregnant women and why we see it in pregnant and postpartum women is because of the increased instability of the pelvic joints during pregnancy as a result of the relaxing hormone that gets released during pregnancy, which is what makes which is exactly what it sounds. It relaxes the ligaments. And so it makes everything a little bit more loosey-goosey. And so things start to open up, your pelvis starts to open to accommodate the baby in the uterus. And then the ribs start to expand, and everything kind of opens up. But the pelvic girdle pain comes from that expansion of your hips and your pelvis to accommodate the pregnancy and prepare for delivery ultimately.

And then what ends up happening is that most of those joints in your pelvis are joints that I’m kind of referring to that we see a lot of that you and I both kind of talk about a lot is these sacroiliac joints, which are the joints in the buttock like I mentioned in the backside, and then the pubic bone or the pubic symphysis joint, which is more of, like, the pubic bone. And those joints are usually very, very stable joints. They’re not joints that are meant to move like your shoulders or your hips or your knees and then, you know, go in circles or move around or be able to move in different directions.

And so those joints are normally very stiff and stable and meant to kind of help keep your pelvis in mind when you move. But during pregnancy, they’re more unstable than they usually are. And so when they become unstable, your muscles need to start to kick in a little bit more than they usually do to kind of stabilize those joints. And if your muscles are weak, you may start to get pain in those muscles. And then because those joints are more unstable, they start to get a little unhappy and start to get inflamed. And you may get pain from that too in the joint itself.

Dr. Fox: Yeah. I mean, I think that’s a really good explanation. And you know what? I try to sort of, when I’m explaining it to my patients what’s going on, I sort of say, like, you know, that the pelvis, which is essentially like a circle, you know, and eventually the baby has to go through there, it’s made of two like C-shaped structures that meet in the middle. And in the front, they touch at this pubic symphysis, and in the back, they sort of each attach to your spine. And that sort of…those interactions really shift a ton in pregnancy. And they need to because a baby’s got to get through there, you know, sort of biologically. And so they have to get, you know, as you said, loosey-goosey, which for our listeners, that’s a medical term. Sorry for being so technical with you.

Literally just this afternoon a patient said to me, “Oh, my God, like I feel like my leg is falling off and my hips are like going in weird directions and it hurts and it’s just…” She was essentially explaining, you know, in her words exactly what you’re describing. I, of course, you know, gave her your name a number and said we’re podcasting tonight. So she was interested to hear that. But this happens all the time. And is there any reason that we know of why some women this would cause a lot of pain and other women not? Is it just sort of luck, or are there sort of risk factors that women come into pregnancy with that would put them at a higher chance of having this kind of pain?

Dr. Bonder: Sure. So I think that as far as we know, there was a couple of risk factors. And the two that I can think of, you know, immediately that are probably the highest are, one, you know, if someone has some hypermobility of their joints prior to pregnancy, and so, you know, I liken that to saying like, oh, when you were told as a kid you were double-jointed or your joints are really hyper-extended or you know. And so a lot of times that comes in this form of like, “Oh, I could do these weird tricks with my legs when I was a kid,” or, “I can bend my thumb back to my wrist.” I mean, there’s different ways to check for it.

But so some women who have that kind of increased hypermobility beforehand and before pregnancy, we certainly see even more hypermobility during their pregnancy that might put them at risk for that and that kind of feeling of your leg is falling off or, like, I said, loosey-goosey. The other thing is that, in general, the biggest risk factor for some sort of pelvic girdle pain during pregnancy is really pelvic girdle pain of some sort prior to pregnancy. So if you’ve had pain in these areas before you got pregnant, it really does increase your risk factor for having that kind of pain during the pregnancy. So that’s where I start to try to talk to people if I see them before they’re gonna get pregnant, and they have this pain, or they’re thinking about getting pregnant is kind of talking to them about potentially or kind of rehab or what we call sometimes prehab, which is like pre-rehabbing, and kind of getting in shape for pregnancy before you even are pregnant.

Dr. Fox: So someone comes to your office and they’re, you know, in the middle or towards the end of pregnancy, and someone like me sent them to you and they come in complaining of pain, how do you evaluate them? You know, what is it that you go through, the steps you take, you know, either the questions you ask or the exam that you do or a test that you might do that help you, number one, define what’s going on, and B, what you’re going to do about it?

Dr. Bonder: In terms of the question that I ask, it’s a lot about… Obviously, there’s a bunch of standard questions that we often ask the patients with pain about in terms of things like, “What makes it better? What makes it worse? Do you feel it anywhere else? Does it radiate anywhere? Is it felt in one spot and sometimes you feel it all the way down your leg? You know, does it wake you up at night?” You know, kind of key questions that are important in terms of pain, in general. And then, of course, if there are certain activities that make it worse, what are those activities? If there’s certain things that they can point to that make it better, what are those things? Because a lot of times, the answers to those questions can help direct us in a diagnosis of what might be going on. And so that’s kind of usually where I’ll start is asking them a bunch of questions about their pain in general, of course, asking their history, history of pain in these areas. Like I mentioned before, sometimes there’s a risk factor. And then, of course, taking your routine medical history of patients.

You know, luckily, most pregnant women come in and are pretty young and healthy and don’t have a lot of major medical issues. But there are some times, you know, certain comorbid conditions, you know, whether it’s a rheumatologic or autoimmune cause of other types of joint pain that we should know about and things of that nature to take into consideration. And then, in terms of an exam, you know, based on what we kind of talked about as a history kind of guides the exam in terms of what to look for. But usually, what I do is an exam where I’m looking at the patient’s lower back and their kind of alignment of their pelvis. Then I will look at their hip joints. I kind of systematically go through the whole pelvic girdle kind of looking at their joints to make sure that we’re highlighting what we need to kind of really address.

And so someone might have pain in their left sacroiliac joint in their backside. But on exam, they may have pain that I can reproduce or find or cause in their right hip. And so, you know, like you said before, sometimes that ring, or you called it a circle, but sometimes I refer to it as a ring, that connects in different places, you know, you may have pain in one place that you’re feeling on a daily basis but it could actually be because you might have some more instability in the hip joint that normally is stable too. And so that they all kind of work interchangeably.

So on exam, I’ll often look for different signs of instability reproducing certain pain with certain exam maneuvers and certain specific maneuvers that kind of help to figure out the actual diagnosis and then come up with a treatment plan based on what we find on the exam. And usually, like I mentioned earlier, the treatment plan especially for pregnant and postpartum women is usually some sort of rehab or physical therapy and based on whatever might be causing their symptoms. I guess I forgot to mention going back is, you know, also looking at those muscles and the muscle strength and figuring out what muscles may be weak or tight in certain places that can then also cause pain too and directing a rehab program based on that.

And so, you know, that’s where I will often explain that, you know, yes, PT can be…you know, you can send someone to physical therapy and that physical therapist may be really, really helpful and really smart and able to figure all of this out. But sometimes, you know, having a diagnosis and kind of putting the physical therapists and putting patients in the right direction of what to treat from the evaluation can be really helpful. And then it’s also important to kind of note if things are not getting better, you know, what to do next. I always say that pregnancy is nine months. You know, you don’t want to be uncomfortable for that long.

And so if you’re having pain, and we send you for treatment of it and it’s not getting any better, then we need to reassess it because typical pain during pregnancy that we send for rehab or for physical therapy usually does improve. And so if it’s not, then we start to look for other causes. And there are sometimes other things that we have to look into that may be contributing to people’s symptoms.

Dr. Fox: How often do you have to order imaging like an MRI or an X-ray or something? Is that typical or atypical?

Dr. Bonder: Usually atypical but it’s not infrequent, not infrequent compared to what people think it would be. I think most people feel that, you know, imaging during pregnancy is not safe. Certainly, we know that, you know, too much radiation during pregnancy is not safe and we try to avoid any radiation in pregnancy. So we typically avoid X-rays and CAT scans that have a lot of, you know, radiation. But MRIs, you know, they always want to ask their OB first, so you can support me here.

Dr. Fox: Yeah, MRI is good. And we’re fine with X-rays, too. It’s CAT scans really only if you absolutely need it because there’s more radiation. But usually, you guys are gonna want an MRI anyways.

Dr. Bonder: Sure, exactly. So an MRI, you know, is safe. And so sometimes, we will order that if things are not getting better to kind of help figure out, you know, what might be going on if there’s something that we’re missing on an exam, or, you know, if someone’s getting worse, you know, we take into account what’s getting worse. Usually, for a pregnant woman, if we’re going to order an MRI, it’s usually, you know, some sort of the pelvic girdle. So of the pelvis or sometimes one hip or two hips, and occasionally, of the lower back, the lumbar spine, to rule out anything that might be coming from there that’s causing some pain.

Dr. Fox: Right. And sometimes, I mean, it can get pretty severe for some women. I mean, obviously, the majority of the pain is mild, annoying to maybe affecting their daily sort of activities. But for some women, like they can’t walk. They’ve got, you know, walkers and wheelchairs and it’s pretty horrific.

Dr. Bonder: There is a subset of patients that really end up pretty debilitated. And that’s another role that a physiatrist in general plays, whether it’s me or somebody else, but a lot of times, we kind of help, you know, get that patient through the pregnancy based on other rehab modalities. And so that’s where things like a walker or a cane or a wheelchair, if needed, and kind of urging sometimes because there’s some things that really you just need to rest but you still need to function, right? So using a walker or a cane is a way to be able to walk around still and do some daily activities, but do it without putting so much load on your pelvis and taking off load there or…

Dr. Fox: Aside from physical therapy, what other treatments might you recommend? Like, other specialists you may get involved in terms of maybe, like, acupuncture or massage or medications. What else do you use in your armamentarium to help these women?

Dr. Bonder: Sure. So I think one of the bigger things that I help with is bracing and some sort of brace support or, you know, there’s a lot of women who will come and they kind of have this typical kind of pregnancy band or that there’s, you know, a million different kinds that you can buy on online. And those can be really helpful. But there are a couple of specific ones that we often recommend, depending on a patient’s condition, usually, again, if it’s pelvic girdle pain, it’s really due to instability, but there’s often a brace that we use that’s a little bit more supportive. And we like to help support that instability. If it’s something more like pain in the lower back, I’ll often recommend a more specific belly band.

But really, it more kind of helps them take load off the lower back because sometimes there’s ones that have like suspenders and things that you can kind of really offload I kind of think more a little bit more mechanically and about truly helping the problem rather than just kind of throwing on some sort of belt and saying, “Oh, yeah, like, you know, this can take pressure off your back.” So there are some specific braces that we will recommend at times and then other treatments that we use. Like you said, acupuncture is definitely something that I often refer patients for and kind of can recommend if pain is not getting better or if they want to do it then we’ll recommend that.

There’s little I wouldn’t recommend. You know, there’s massage therapy. There’s chiropractors. I mean, there are some really good ones out there that are all very good with pregnant. I mean, you just have to find someone that really is comfortable with pregnant. Like you said, kind of, in the beginning, some people just don’t want to touch pregnant women and don’t understand the pregnancy-related changes and so you really want to find someone that is comfortable treating a pregnant woman. And so I think that’s the biggest barrier that I see sometimes is that, you know, it’s hard sometimes to find… I mean, maybe not in New York City because we have lots and lots of treatment providers, but sometimes I think in smaller communities it’s hard to find people that are really specific towards and comfortable with pregnant-related conditions.

So in terms of medications, we do do that, or I do use those sometimes, obviously, in small amounts. I’d say the two most common medications that I’ll prescribe or tell people to use is not really necessarily prescription is Tylenol, you know, which is considered safe, and then a muscle relaxer which is considered, you know, Class B in medications in terms of as much data as we have, we know that it doesn’t necessarily cause any harm to the fetus or to the mom. And so that’s a prescription-based, muscle relaxer that in some patients who, you know, have a lot of spasms, or a lot of tightness, and a lot of kind of muscle pain that makes them not be able to sleep at night, especially because that medicine can make you drowsy, sometimes we’ll use that.

And then beyond that, we’ll use other medications sparingly and often in consultation with the obstetrician to figure out what to use, sometimes steroids. So if it’s an inflammatory issue, or we think that there’s a big portion of inflammation going on, we know that things like Motrin, Advil, and Aleve can’t be used so we can use steroids, which are an anti-inflammatory as well. And so sometimes, we’ll use steroids instead of that if we really need to. And then, you know, here and there, depending on the patient’s history, we certainly don’t want to prescribe opiates but sometimes they are necessary. And in small amounts, I think, you know, are okay, too. It’s just a matter of keeping an eye on the baby, the mom, and watching for side effects.

Dr. Fox: Is there anything women can do that will help avoid this, right, either before pregnancy or in the beginning of pregnancy that you’ve found to be helpful?

Dr. Bonder: I’ve seen these kinds of conditions in the fittest of individuals who go into pregnancy, you know, in the gym five days a week, great core strength great muscle strength everywhere, doing lots of great exercises, and they come in with these symptoms. And then I’ve also seen the opposite of patients who are totally not very mobile and not very athletic. And they don’t like to go to the gym and they’re not someone who exercises regularly and they have these symptoms. So it’s hard because in general I will say that the most likely way to prevent some of these things is going into a pregnancy as “strong” as possible in terms of core strength. And when I say the core, I kind of mean the low back muscles, the upper back muscles, the abdominal muscles, and often the glute muscles, which are really part of the core too, and then, of course, your pelvic floor muscles, and kind of keeping all of that as strong as possible going into a pregnancy.

But I’ve also seen this kinda [inaudible 00:28:36] in patients who are really strong. But other than that, I can’t think of a way to really prevent it. And so I think that I’d been concerned to tell people to prevent it like don’t do anything, I mean, because that’s not great. But exercising a lot often doesn’t necessarily prevent it.

Dr. Fox: Right. And I think it makes sense. It decreases the chance, potentially, but it could happen to anyone, meaning if it happened to someone, it doesn’t mean they’re out of shape or anything.

Dr. Bonder: It’s often not anything that the person did or didn’t do. It’s really much more of kind of their body’s way of handling the pregnancy more than anything, and maybe just, you know, subtle imbalances and muscle that we can find on exam when it starts to creep up.

Dr. Fox: Right. And then another question that I know a lot of listeners might have is how does someone know… As a pregnant woman, how should they know if they should be seeing you or just sort of saying, “This is kind of normal and, you know, let’s just wait till after the baby is born.” Is that everyone should see you with that pain or only if it reaches a certain, you know, degree of pain or immobility, or how would someone make that decision for themselves if let’s say their obstetrician is not sending them to you?

Dr. Bonder: What I would basically say to that is if pain… So, of course, there’s some degree of pain that is kind of typical and expected. But if the pain gets to a point that it’s interfering with your daily life activities, you know, it’s preventing you from working like you should or walking to the grocery store, really, or taking a shower, things like that, if it’s really preventing you and gotten to the point where it’s so bad that you can’t do those daily function activities that you need to do, then to definitely come see myself or someone like myself depending on where you are to really have it assessed and kind of come up with a treatment plan because that really shouldn’t be the case. Most of that kind of pain can get better if treated correctly.

I think that another red flag would be if there’s any kind of weakness that I guess maybe that would cause difficulty with your kind of daily living but if you’re having all of a sudden type of like nerve signs, like things have nerve issues that we get worried about sometimes that can be causing pain but also things like weakness in your feet or numbness and tingling in your feet or legs or sometimes even neck pain can cause that too. We’re not talking about that today but you can have similar things in the arms. But anything that kind of seems like there’s a change in your kind of neurologic function, that would also be a reason to come. Like I said, we can kind of evaluate that more from a musculoskeletal and neurologic perspective.

Dr. Fox: Right. And then one other thing that a lot of women ask me at least, what are your thoughts about Caesarean? Do you ever recommend to women, because of what’s going on in your pelvis, you should have a C-section because if you try to deliver vaginally, you’re gonna get injured or you won’t recover or something like that?

Dr. Bonder: It’s really multifactorial. The general answer is no. I do not necessarily recommend a C-section. Especially if it’s the first pregnancy and there’s no history of anything or injury during their actual delivery or anything like that, I wouldn’t necessarily recommend a C-section. There are two or three studies that do actually show that patients who have had pelvic girdle pain or some sort of pain in the pelvic area during their pregnancy that actually those that went on to have a C-section had more prolonged pain than those who did not. So, you know, they’re not huge studies like by any sort of means, like in terms of what we consider in medicine is like a huge study that definitely proves something. But it is a little study that shows us that really, there’s no reason why you can’t try to have a vaginal delivery.

This really comes up more for patients who have like pubic symphysis and pubic pain or pain in the anterior or front of the pelvis rather than like the more typical sacroiliac joint kind of pain. But in general, no. I mean, I don’t recommend a C-section. A lot of this is… Especially when this all starts to creep up in the third trimester, the thought is that this pain may be adaptive to be able to accommodate the baby to have a vaginal delivery. And so that, you know, your body is doing all this, and you may be having this pain. But it’s preparing for you to have a vaginal delivery and you really should unless there’s some other reason that you can’t have one. Usually, there is no reason to kind of have a C-section or a plan for a C-section. There are obviously exceptions.

Dr. Fox: Yeah. No, I agree. I mean, I typically say the same that it’s, you know, people have all this pain, it’s not knowing that having a C-section will make you recover faster. And as you said, there’s some evidence that they make it worse. Number two, you know, the loosey-goosey pelvis, it’s there so the baby can fit. So if someone has it worse and they have an easier delivery, you know, so to speak. And if you have pain in your pelvis and then you have extra pain from a Caesarean, it may compound it. You can’t be as mobile. You can’t walk. You can’t recover as quickly. So, yeah, I also don’t typically recommend a Caesarean. And again, there’s obviously you said some exceptions to that but those are really just that, exceptions.

I wanted to focus… It’s actually a really good segue into pubic symphysis pain because this is something that’s quite unique. I think we see it a lot in pregnancy and it’s not really seen a lot, at least I don’t think so, in other populations to the same degree. And where they have pain really right in the front, it’s pretty exquisite. Some people, you know, can’t walk very well and it either happens before they deliver or after they deliver. How do you address that problem, specifically, first, during pregnancy and then second, after they deliver when it tends to be worse?

Dr. Bonder: You’re right. I mean, it is a condition that’s more commonly seen in pregnant and postpartum women than your average other, you know, non-pregnant women or men. And so in terms of addressing it, I mean, to be honest, it’s not much different than what I’ve kind of talked about already in terms of what’s going on. It really is very similar to this idea of that ring and kind of, you know, the inflammation that might be causing it you know, be coming from that in the sense that I often will talk to people about the fact that your abdominal muscles and your inner thigh muscles kind of insert onto that front pubic bone and that pubic symphysis. So a lot of times if those are weak then your pelvis is gonna be a little bit more unstable. And so that might be why you’re feeling some extra pain or more pain in that spot and that strengthening those muscles can really be helpful.

The patients that I see mostly that are worse after their delivery are the ones who either had pain prior to the delivery but it really wasn’t addressed at all. It might be someone who doesn’t, you know, have advisors on hand or isn’t familiar with these issues as much as you are as an obstetrician. But patients who get treated during their pregnancy and are able to do some rehab often I find at least that they a lot of times will do better. A lot of the patients who have such severe pain after delivery are ones who didn’t necessarily have it during their pregnancy. And so…

Dr. Fox: Right, right, it happened during the birth.

Dr. Bonder: Yeah, exactly. And so that’s why I usually say it happens, you know, during delivery for whatever reason. Maybe it’s that person whose pelvis didn’t expand slowly in the last trimester and so it kind of abruptly expanded during the delivery. You know, there are studies that show delivery with a vacuum or forceps can sometimes increase the risk of an injury to that area.

Dr. Fox: Let’s focus on the woman who did not see you during pregnancy because she had no symptoms or very, very mild symptoms. Then, she delivers and she can barely walk. And this happens. Like we have women, it’s not common but it definitely happens and they can barely get out of bed. TEhey can barely move. We’re highly confident with the diagnosis. We almost always get an X-ray only and the radiologist is like, “Whoa, like, those bones are separated.” And so we know what’s going on and we say to them, “Okay. Like this is what it is. It’s going to improve with time. It may take a while,” and we refer them to you and you see them, right? And you’re pretty confident this is the diagnosis. What do you do for them in terms of like specific recommendations? And what do you tell them in terms of the prognosis, meaning how long is it going to take for them to get better?

Dr. Bonder: First, I’ll just say that just to let everybody know that there’s a difference because on Google you’ll find something called pubic symphysis dysfunction versus pubic symphysis diathesis or diathesis pubis. And medically speaking, diathesis means separation. And so there’s a difference between dysfunction and separation in the sense that a lot of times I’ll say dysfunction really is when you have that instability and you have some pain but it’s not actually separated versus diathesis is when a joint really separates. And the separation is really what usually happens during childbirth and what we see postpartum. And like what you’re saying is women who really have a lot of difficulty walking, a lot of times they feel like their legs are really heavy. TEhey have trouble getting in and out of bed.

And so those women who, you know, they get really…rightly so, they get scared of what’s gonna happen. “I can’t work. I just had a baby. This isn’t supposed to happen.” And like you said, I mean, we will often get X-rays and it will sometimes show or often show usually this like separation of the pubic bone or the pubic symphysis. And the rehab for it is quite helpful. But initially, we often tell patients, you know, rest is very important too and kind of not to push through the pain of this. And we often tell them to kind of put on one of those braces that I mentioned earlier to kinda help push things together a little bit and try to hope that that starts to help close that gap. And then also, for this population, it’s really important to really go slow.

So I kind of always encourage patients to realize that I’m telling them like in their first two weeks of having a baby that they really shouldn’t be going out walking and they shouldn’t be in New York right now [inaudible 00:38:49]. They shouldn’t be taking a stroller out and going for walks. You really wanna do the bare minimum to let that bone kind of heal and come back together and slowly start to use the decrease in pain as a guide to doing more. It does improve. I’ll usually also prescribe anti-inflammatory medicines like ibuprofen at doses that are considered anti-inflammatory. And so I always stress that and it’s not like the patients are like, “Oh, I can bear with the pain. In fact the pain is not that bad.” And I try to tell them I’m not giving it to them for the pain purpose. It’s really to give it to them for that inflammation, which is definitely there and can persist prolonged, or even long term, without taking that medicine. That’s one of the other big treatment modalities that I’ll recommend after patients have a baby and have this kind of condition.

And then it’s slowly getting rehab and kind of getting them back into functioning and eventually back into physical therapy that kind of helps strengthen those muscles. The prognosis is usually very good. You know, there are people… I would say within the first three to six months, most people are back to doing their regular activities, can get back into the gym and get back into doing their fitness routine, maybe kind of with some guidance of like high-impact exercise and kind of modulating that a little bit, but most people can get back into their routine for sure. Of course, there’s always outliers. But I usually say by three to six months that patients are better. Certainly, I say even before three months you are able to walk and maybe, you know, go out for a mile walk or something like that. But three to six months to really getting back into your normal exercise routine and getting back into their fitness program.

Dr. Fox: Right. And then for their next pregnancy, again, you typically recommend sort of the pre-hab [inaudible 00:40:41].

Dr. Bonder: You had to ask me that, right?

Dr. Fox: This is the coup de grace. This is the big one. Someone has that. They have like a three-to-six-month recovery and they’re gonna get pregnant again. What do you do with them?

Dr. Bonder: That’s usually my biggest question from patients when I see them at that point. I mean, sometimes patients are thinking about their next pregnancy when they’re only six weeks postpartum and they’re dealing with it. They’re like, “Oh my God…”

Dr. Fox: We encourage that. It’s good for business. We like to plan ahead. So, yes, do not discourage women from that, please.

Dr. Bonder: No, no, no. I will certainly say that I never tell patients not to have another baby because of this. Assuming that you get better and recover from this when you start to think about having another baby, come back and talk to me. And we can kinda talk about ways to prevent it or ways to prolong the symptoms as much as possible as you go into another pregnancy. And then, usually, what I’ll say, I’ll see them, I’ll give them that kind of advice, and they go and they get pregnant. And then, you know, I say, “Come back to me either when you start to feel symptoms or in the beginning of the second trimester.” And so, you know, once you kinda pass that point of everything is going well with the pregnancy and everything is moving smoothly, you know, come back and see me. Of course, if you start to have pain even before that, then I tell people to come in earlier. But that’s usually what I’ll say.

Dr. Fox: Thank you so much. What a great, like, review of this. There’s so much information there. Unfortunately, there’s so much misinformation out there and I know it’s really good for us to have you locally. We can send patients to you and we know that they’re getting a really thorough evaluation and good recommendations for treatment. You know, even for people who aren’t in New York City and can’t see you, this idea that even though it’s very common, you don’t have to suffer throughout pregnancy. There are people to treat this and know what they’re doing and can help you both during pregnancy and postpartum. And if you don’t feel like you’re getting the treatment you need keep looking around because people like you exist, fortunately.

Dr. Fox: Yeah, there are, and they’re increasing a number in terms of from our specialty in general in terms of physiatrist or, you know, PM&R docs. There’s definitely more and more as we learn more and more about these conditions. And, you know, I’m at Cornell so we have residents that we train and they go off into other places. They may not be specializing necessarily in women’s health but only seeing women with these kinds of issues but they’ve learned about it in their training. And so chances are as it grows in the field and we know more information we are able to train more residents in these kinds of things, you know, chances are you can find someone to help.

Dr. Fox: Great. Thank you so much for coming on the podcast. I appreciate your time.

Dr. Bonder: My pleasure.

Dr. Fox: We’re gonna have you on again and we’re gonna talk about some other stuff I’m sure. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@helpfulwoman.com. Have a great day.

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