Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction Following Childbirth

Danielle R. Steilen-Matias, MMS, PA-C., Ross Hauser, MD.

Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction Following Childbirth

In this article, we will discuss little known but effective treatments for Pelvic Floor Disorders (Pelvic Floor Dysfunction), Pelvic Girdle Pain, and Symphysis Pubis Dysfunction. These treatments may help women who have been struggling with symptoms for, in some instances, many years without significant relief.

The connection between Pelvic Floor Dysfunction and childbirth is seemingly beyond debate. The majority of new studies center on reducing the risk of Pelvic Floor Dysfunction after vaginal delivery. This followed a wave of studies that examined the long-term effects comparing a single vaginal and cesarean delivery. Many studies suggest the use of forceps and other childbirth procedures may cause significant damage to the mother resulting in long-term problems.

In fact, the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, released Practice Bulletin No. 165. The summary is found here: Prevention and Management of Obstetric Lacerations at Vaginal Delivery

In this bulletin, more obvious reasons for Pelvic Floor Dysfunction after childbirth are addressed:

But is it only lacerations and more easily recognizable injuries during childbirth that are causing the problem? What if the cause of the problem is seemingly invisible?


Pain develops during pregnancy

These are the types of emails we receive. They do not need an introduction, they tell the story on their own:

I am 25 weeks into my third pregnancy. At the birth of my son (second pregnancy), my pelvis separated during the vaginal delivery. My son was well over 9 pounds.  I had extreme difficulty walking, and developed symphysis pubis dysfunction. It took me over a year to recover. Now 25 weeks into this pregnancy, the pain is much worse. My doctors do not understand what is going on with me and do not seem to have the ability to offer any help.

I can’t sleep, walk, get in and out of a chair or a car or bed. The one thing that everyone seems on board with is that I get a C-Section this time around. I do not know that I want that either because in my last pregnancy I also developed diastasis recti and am at high risk for developing hernias.

If pelvic floor pain lingers and no known source is found

If pelvic floor pain lingers and no known source is found, injured, loose or weak ligaments and instability of the pelvis should be considered. The numerous ligaments that surround and stabilize the pelvis undergo relaxation due to the hormone relaxin that is secreted during pregnancy. This hormone does just what it says – it relaxes the ligaments in the pelvis to allow the baby to pass through the birth canal. In some cases, the relaxed ligaments may not return to their normal properties and the woman is left with pelvic ligament laxity and instability, which can include the hip(s) in some cases. This can be especially true for women who already have joint hypermobility.

Numerous ligaments surround the pelvis and help to keep it stabilized. When these ligaments become weak, they are unable to maintain pelvic stability and can cause pain. Injury to the pubic symphysis, pubic ligaments, or any of the ligaments that stabilize the lower back (especially sacroiliac joint) would cause the pelvic floor muscles to contract continually against an unstable base.

In pelvic floor dysfunction, the musculature is in spasm, and muscles that are constantly contracting or in spasm will generate pain.

In pelvic floor dysfunction, the musculature is in spasm, and muscles that are constantly contracting or in spasm will generate pain. Muscles spasm because they are trying to provide stability in an unstable region. Injury to the ligaments in childbirth or sports injury (see below) and their successful treatment can be the turning point in Pelvic Floor Dysfunction.

Pelvic problems came on suddenly, no warning, and I never had this problem in my other deliveries

Pain with exercise after childbirth

I have always exercised during pregnancy and got back to running and exercising as soon as I could after the birth of my first two children. I never had a problem. My third baby is now three months old. I did my same routine after my first two, vaginally delivered pregnancies, minor, first degree lacerations, I got on my treadmill to start warming up my muscles with a slow-paced walk so I could jog again. 

Something was different this time. Walking on the treadmill was difficult, not painful but causing a lot of soreness. I chalked this up to the fact that I was older, almost 40, and was an “older,” mother. I rested for a day or two and tried again. Something was really different. My whole pelvic area started to hurt as if I had injured myself. I felt pressure in my vagina. Fortunately, I did not have urinary problems or leakage.

My gynecologist sent me to physical therapy to strengthen my pelvic floor muscles to prevent prolapse from developing. My muscles do not seem to have any strength in them, I am seeing very slow improvement. No one can figure this out, it is like I have an “invisible cause,”  I am contacting you because in my research I came across ligament laxity as a possible cause of my problems.

Pain years after episiotomy and forceps delivery

I delivered twice, two big boys, both of them weighed in at more than 10 pounds at birth. The first boy I had an episiotomy and he was delivered by forceps. My other son was delivered without the episiotomy but he too was delivered by forceps. The birth of my first son was very difficult. I did not think I would be able to ever walk again. As the years passed and my boys grew I was able to heal as best I could and could do very physically demanding chores. One day, while I was doing some heavy work and lifting around the house, a sudden pain jolted me in my low back and vagina. The pain was red hot and I could barely stand. I went from doctor to doctor and no one could offer any help beyond anti-inflammatories for sacroiliitis and my pubic symphysis pain.

I had difficulty with bowel movements and urination. I was diagnosed with Pudendal Neuropathy and had nerve blocks that did not help. I had botox to the vaginal muscles, epidurals, SI joint, and Facet joint injections none of them worked.

It is patients like this that we see who also carry with them a long list of diagnosis including:

In the video below Danielle R. Steilen-Matias, MMS, PA-C discusses Pelvic Floor Dysfunction following childbirth and the ligament laxity connection.

Many women we see in our office have been advised to physical therapy following the birth of their child to help avoid pelvic floor prolapse and urinary problems, especially if these women are considered high risk for post-partum problems. But for some, physical therapy is not helping as much as they would like in alleviating their continuing and developing pelvic pain problems.

In this video, mother of two, Danielle R. Steilen-Matias, MMS, PA-C of Caring Medical discusses the problems of ligament laxity and non-responsive or hurtful physical therapy and exercise.

Points discussed during the video

What are we seeing in this image?

In the following images, we are going to start presenting a case that the myriad of problems some of these women suffer from is pelvic instability. That this instability is coming from weak and damaged ligament and tendon attachments to the bones. What is happening is that the ligaments and tendons, the strong connective tissue that should be holding the pelvis together is not. This is causing pain and inflammation along the pubic symphysis, the SI joint, the hip, the low back. We will also suggest treatments for this below.

The levator ani muscle is the main component of the pelvic floor. As seen in this image, it is formed by three muscles: the pubococcygeus, the iliococcygeus, and the puborectalis. It is easy to see how these muscles would spasm to hold the pelvic floor together in cases of ligament or muscle-tendon attachment damage or Pelvic Floor Dysfunction.

pelvic floor dysfunction


To say the pain is coming from a single diagnosis of Pelvic Floor Disorders, or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.

We just briefly described our treatment plan that may incorporate the Pelvis, SI joint, hip, and low back. Below we will cover some of the research. Before we do, we will cover some of the treatments that may be more familiar to you. The ones that you have been prescribed and recommended to. If you are researching and reading this article, it may be safe to say: “the treatments that did not work for you.”

The challenges and pain women have soon after or for years after vaginal delivery are usually not problems that sit in isolation.

At least not in our many years of experience in seeing women with postnatal or postpartum musculoskeletal disorders. To say the pain is coming from a single diagnosis of Pelvic Floor Disorders, or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.

To say the pain is coming from a single diagnosis of Pelvic Floor Disorders,or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.

To say the pain is coming from a single diagnosis of Pelvic Floor Disorders, or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.

All the doctor did was tell her something she already knew

What is my diagnosis?

A patient came into our office for her first visit. She had been searching for some time to find the cause of her vaginal/pelvic problems. She related a story where after seeing many doctors and many specialists she finally found a health care practitioner who was willing to give her a diagnosis: vulvodynia.

This patient revealed at first joy at receiving the diagnosis because this meant that a plan of attacking her problem could be made based on the fact that she had vulvodynia.

When she heard exactly what vulvodynia was, the patient felt despair. Not because of the diagnosis but because the diagnosis was dismissive of her, vulvodynia, she learned, simply means that she was complaining of “Vulva” meaning vaginal, and “dynia” means pain. She was complaining of vulvodynia or “vaginal pain.” All the doctor did was tell her something she already knew. She had vaginal pain.

A case story relayed by one of our patients in the Journal of Prolotherapy also describes a “revelation” that an answer to her groin pain was found that made sense. The treatment recommended, however, did not. Here is her story:

“Upon examination by the orthopedist, a pelvic reconstruction specialist, he suggested I complete a new pelvic ultrasound and weight-bearing X-rays of my pelvis, standing on one leg in a flamingo-like pose. The X-rays showed a mild separation of my pubic symphysis and a definite shift of the weight-bearing side when standing on one leg. Just as expected, the MRI also returned signs of “early-mild osteitis pubis,” or inflammation of the suspect joint (inflammation in the groin).

We had finally found the root source of my pain: pelvic instability due to an injured pelvic joint. This, my orthopedist told me, could have been a result of the hormonal changes a woman goes through during pregnancy as her body prepares for delivery and the joints open to make room for the baby. But more likely, it was aggravated by a 9+ lb baby coming down the birth canal and the long labor that I had to endure. Slowly, my back, hip, and groin pain began to make more sense. After receiving the results, the obvious question became, how do we fix this? The orthopedist suggested I consider a fusion of the symphysis pubis. My husband and I left his office, happy to find an answer, but unsure that surgery was the answer for me.”

The problems of Pelvic Girdle Pain and Symphysis Pubis: Women are grateful just to be heard much less treated

Recent research confirms what we hear from patients following childbirth who suffer from Pelvic Girdle Pain (PGP) or Symphysis Pubis Dysfunction. That these women suffer from pain that is largely ignored or dismissed by doctors. From some women, when we ask what did they do when health care providers ignored their problems, they responded, “I just lived with it. I sucked it up because I have children I need to take care of.”

Clearly, you did not need research to be told that your symptoms are being ignored. The appreciation is that the research at least acknowledges what we have seen in over 26 years years of clinic experience. You may be able to take this research to your provider to help them understand your problem.

Read the learning points:

Published in the journal Physical Therapy,(1) investigators at the School of Nursing and Midwifery, Trinity College Dublin, Ireland asked 23 women, who after their first childbirth had continuing pain in their pelvic region for at least 3 months following the birth about their pain, symptoms, and treatment:

They found that among the women:

When we ask what are the symptoms are causing distress, the woman in our office may have a long list that could include:

When asked on a questionnaire about their sex life, many women write “N/A” Non-Applicable

This is something we see very often. When we ask patients about their pelvic pain and how it impacts their sex life, an answer we will hear many times is: “I don’t have a sex life,” or “We stopped having vaginal sex,” or hopefully we will also hear “My husband understands and is very supportive.” If these are answers you would give, understated you are not alone.  A July 2020 (x) study in The Journal of Sexual Medicine examined the impact of pelvic floor disorders on female sexual function as a not well-understood problem. Partly due to difficulties in measurement and evaluation.

So the research team took 94 women with pelvic floor disorders and had them complete a series of sexual function questionnaires. These were multiple-choice questions. Then they asked the women to handwrite in more information that they wanted their doctors to know and to comment on questions that did not give them a good choice.

Emerging from the women’s notes were the importance of:

The study found that half the women said the standard questionnaires did not address many of the problems they were facing and that the questionnaire was faulty if was being used to guide clinicians in their care. To quote the research: “Over half of the women in this study felt the need to expand, explain, or eliminate responses from the questionnaires. Many subjects were no longer sexually active, which accounted for a large majority of participants leaving questions blank or responding with “N/A.” Standard sexual evaluation tools may fail to capture the complexity, spectrum, and depth, and breadth of patient experiences. ”

The condition is real, how about a treatment that works?

The confusing plight of many women with Pelvic Floor Disorders or Pelvic Floor Dysfunction can easily be seen in routine recommendations they receive from their health care providers. While these recommendations can help with symptoms, they do not address the cause of the condition which we find to be in many patients, damaged connective tissue that makes muscles weak and their pelvis unstable. Again we mention that challenges related to the pelvic floor are problems of the pelvic and spinal ligaments and the connective tissue tendon attachments to the pelvic and vaginal muscles:

These are the recommendations of treatment that many of our patients received in previous trips to other medical offices and the possibilities as to why these treatments did not work.

Other traditional treatments for pelvic floor dysfunction include:

If all these do not work, then a call is suggested to make an appointment with a psychotherapist.

Years later, the same pain and new pains, recommendations for surgeries.

When physical therapy and exercise fails, your doctor then will typically sit down with you and start to discuss the surgical options. Many of you reading this article are already familiar with “slings,” and “mesh,” that will hold your bladder and rectum in place and the recommendation to hysterectomy to remove your uterus. But does it have to get this far? We will explore this question also below.

In 2017, doctors from the Department of Clinical Sciences, Obstetrics and Gynecology at Umea University in Sweden wrote in the journal BMC Musculoskeletal Disorders (2) that “Pelvic girdle pain is not always a self-limiting condition.” In other words, if you have Pelvic girdle pain for many years, the problem branches out to impact your health. Here is what the researchers wrote:

“Women with more pronounced persistent (Pelvic girdle pain) report poorer health status compared to women with less pronounced symptoms. The knowledge concerning the long-term consequences of Pelvic girdle pain is limited, thus more knowledge in this area is needed. “

Many of you became aware of Pelvic girdle pain during the second, sometimes the third trimester of your pregnancy. You may have reported a terrible, stabbing pain in your pelvis that startled you. When you went to the doctor you were assured that this pain would eventually go away. For many women it does. If you are reading this article, it is likely that this pain never went away for you.

In the research we are discussing, the Swedish doctors examined 295 women 12 years after childbirth.

The sling

The pelvic floor is composed of muscles and fascia that form a sling from the pubic bone to the tailbone and functions to support the pelvic organs (bladder, intestines, and uterus) during contraction and relaxation. These pelvic floor muscles attach to the pubis (anterior) and coccyx (posterior) and work to stabilize the pelvis. If functioning properly, they can help prevent urinary and fecal incontinence.

The sacrotuberous, sacrococcygeal, and sacroiliac ligaments are vital to providing stability in the “back portion” of the pelvic rim upon which the muscles attach. The pubic symphysis provides stability in the “front portion” of the pelvic rim, onto which muscles also attach. If these supporting ligaments of the pelvis become injured or stretched out, joint instability can result. This means that the pelvic bones become unstable because their primary stabilizers (ligaments) are too weak or lax to properly hold them in place.  The same can happen if the pubic symphysis becomes stretched out or sprained.

Subsequently, if the pelvic floor muscles are trying to contract and the pelvis is unstable, muscle spasms will occur. This can also happen if the pelvic floor musculature is trying to stabilize the pelvis – these muscles can spasm trying to provide stability but can be very painful and contribute to pelvic floor dysfunction.

A brief discussion on urinary incontinence – the sling and exercises are not as effective as you may think


“Stress urinary incontinence is not a deadly disease, but for the large population of women suffering from it, it is a very important issue.”

Questions of whether pelvic floor disorders cause urinary incontinence or urinary incontinence causes pelvic floor disorders and how best to treat is the subject of intense research. This was not always the case as we pointed out below. A 2018 study (3begins like this: “Stress urinary incontinence is not a deadly disease, but for the large population of women suffering from it, it is a very important issue.” In other words do not dismiss women who have this problem, help them.

Troubling is that the “sling” type surgeries for urinary incontinence are the cause of groin pain in many women post-operation. This has been documented in a series of recent studies. (4) Also troubling is the vaginal mesh procedures as a cause of significant and chronic groin pain in women. A study published in the journal Scientific Reviews in September 2017 opens with this sentence: “Complications of surgical mesh procedures have led to legal cases against manufacturers worldwide and to national inquiries about their safety.”(5)

High reward high risk for the sling

Following up on the above research, a March 2020 study in the journal Videosurgery and Other Miniinvasive Techniques (6) offers these observations on the sling in their research to assess intraoperative complications, early postoperative complications as well as the efficacy of tension-free vaginal tape: retropubic and trans-obturator tape procedures.

Tension-free vaginal tape and transobturator tape procedures are characterized by a high cure rate and improvement in the postoperative quality of life. However, it seems that the transobturator approach should be the preferred method of treatment of stress urinary incontinence due to the reduced risk of complications, shorter procedure time, and lower intraoperative blood loss.

Many people do have very good results with surgery. That is why it is considered high risk, high reward procedure. The people we see in our offices are the people who did not get that high reward from their surgery.

Avoiding the sling and focusing on weakened pelvic ligaments and weakened tendon attachments

Our article focuses on weakened pelvic ligaments and weakened tendon attachments to the muscles as A if not THE main cause of pelvic area problems in vaginal delivery mothers. If these structures are weak, lax, or loose they cannot be expected to provide the support a mother needs to strengthen her pelvic and vaginal muscles. In other words, as mentioned in this article, if you do not have soft tissue resistance, you cannot have successful exercise programs. Let’s explore a March 2019 study to help make sense of this.

If you are reading this article it is likely that Pelvic floor muscle training did not work for you.

Doctors from medical universities in Italy wrote of their findings on the effectiveness of pelvic exercise in preventing or helping urinary incontinence in the medical journal Archives of Gynecology and Obstetrics. (7) Here is a summary:

“During the second and the third trimesters of pregnancy and in the first 3 months following childbirth, about one-third of women experience urinary incontinence. During pregnancy and after delivery, the strength of the pelvic floor muscles may decrease following hormonal and anatomical changes, facilitating musculoskeletal alterations that could lead to urinary incontinence. Pelvic floor muscle training consists in the repetition of one or more sets of voluntary contractions of the pelvic muscles.

By building muscles volume, Pelvic floor muscle training elevates the pelvic floor and the pelvic organs, closes the levator hiatus (the openings between the levator ani muscle group where the urethra, vagina, and rectum pass. These openings can become enlarged which allows for the condition of Pelvic Floor Prolapse), reduces pubovisceral length (tightens the stretched out connective tissue) and elevates the resting position of the bladder.”

Let’s stop here because this is what many women and their doctors believe Pelvic floor muscle training does. Indeed, it may for many women, but not for all women. If you are reading this article it is likely that Pelvic floor muscle training did not work for you.

The doctors in Italy recognized that perhaps Pelvic floor muscle training is not as effective and successful as patients and doctors think, at least in regard to urinary incontinence.  So they examined the studies that dealt with: “pelvic floor muscle training”,”urinary incontinence”, “urinary stress incontinence”, in “postpartum” and “childbirth.”

“At the present time, there is insufficient evidence to state that Pelvic floor muscle training is effective in preventing and treating urinary incontinence during pregnancy and in the postpartum. “

Here is what they found:

“Overall, the quality of the studies was low. (To support the use of Pelvic floor muscle training) At the present time, there is insufficient evidence to state that Pelvic floor muscle training is effective in preventing and treating urinary incontinence during pregnancy and in the postpartum. However, based on the evidence provided by studies with large sample size, well-defined training protocols, high adherence rates and close follow-up, a Pelvic floor muscle training program following general strength-training principles can be recommended both during pregnancy and in the postnatal period.”

In other words, there is no evidence that Pelvic floor muscle training works for everyone, but keep doing it because it may work for you.

Our entire contention is, if that you strengthen the pelvic ligaments and tendon attachments through regenerative medicine techniques such as H3 Prolotherapy injections, then you will most decidedly increase the odds that Pelvic floor muscle training will work for you because you are providing the ligament and tendon strength necessary to provide the resistance needed to make pelvic muscles strong.

Exercise and Physical Therapy may be hurting your back, neck, shoulders, and arms. Is exercise really making you worse?

In September 2019, researchers examined the question: “Can postpartum pelvic floor muscle training reduce urinary and anal incontinence? ” This research appears in the American journal of obstetrics and gynecology. (8) In this study, the goal was to test “the effects of individualized physical therapist-guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance.”

The researchers concluded: “Postpartum pelvic floor muscle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.”

Let’s take this one step further. Is it possible the physical therapy and exercise programs you are on are making you worse? There will be many women reading this article who will respond with a resounding YES. Why? because the exercise made them worse.

Let’s bring in the opinion of a specialist. Britt Stuge is from the Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway. In the March/April 2019 edition of the Brazilian Journal of Physical Therapy, (9) he published this: Evidence of stabilizing exercises for low back- and pelvic girdle pain – a critical review.

To briefly review here and none of this should come as a surprise to women suffering from these challenges but at least you have research that acknowledges your dilemma:

The ligament and tendon “damage” of vaginal delivery on your ligaments and supportive soft-tissue.

The connection between Pelvic Floor Dysfunction and vaginal childbirth is seemingly beyond debate. The majority of new studies centers on reducing the risk of Pelvic Floor Dysfunction after vaginal delivery. This followed a wave of studies that examined the long-term effects of a single vaginal and cesarean delivery.

During childbirth, the pelvic and spinal ligaments are stretched, sometimes stretched too far. The tendon and enthesis attachments that hold the muscle to the bone are also stretched out, sometimes too far. Ligaments and tendon attachments that hold your pelvic region together. After childbirth, for some women, they did not snap back into place, your pelvis and everything within it became very unstable. The physical therapy you are trying, the exercises you are doing are not offering the results you seek because the resistance these muscles require to get strong, needs to come from the tendon attachment that holds the muscle to the bone. Many studies suggest the use of forceps and other childbirth procedures may cause significant damage to the mother resulting in long-term problems.

In fact, the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, released Practice Bulletin No. 165 addresses this concern. The summary is found here: Prevention and Management of Obstetric Lacerations at Vaginal Delivery

Here is one learning point:

But is it only lacerations and more easily recognizable injuries during childbirth that are causing the problem? What if the cause of the problem is seemingly invisible?

What are we seeing in this image?

Pudendal nerve damage or neuralgia may occur after childbirth. Symptoms include pain throughout the vaginal and rectum areas including the labia, urethra, and clitoris. This will also often cause a sensation of “fullness,” in either of both the vagina or rectum. Symptoms may also mimic bladder or urinary infections. Many women will report difficulty if not impossibility having intercourse.

Pudendal nerve

The invisible undiagnosed damage of the pelvic ligaments

Research is recognizing that ligament laxity or weakness is a major problem for post-childbirth women. Then why aren’t you getting treatment for this? Here is some research

In 2016, the same Swedish research team we cited above published these findings: It explains the traditional treatment route. Nothing is said about ligaments. It should be pointed out that this research is published in the journal Chiropractic and Manual Therapies (10) as an answer from a manipulation standpoint is being sought.

In this study, 176 women were asked whether or not they had Pregnancy-related low back pain and/or pelvic girdle pain postpartum.

It goes on for years and years and years and it wears you down

Above we described a sample story of a women who had pelvic pain for years following the birth of her sons. Her problems and those of the others described here have gone on your years and years and years. A follow up study to the one just discussed comes from the Department of Clinical Sciences, Obstetrics, and Gynecology, Umea University in Sweden. (11) What these gynecologists tried to demonstrate was that if you could categorize women into subgroups based on years of psychosocial factors, doctors may be able to help them better. Here are the learning points:

Twelve years of pain and discomfort later

Let’s point out the goal of this study was not to identify which women felt they had more pain or which women felt they had figured out a way to cope better. This study was to figure out a way to categorize these women into groups and then try to figure out what to do with them. Many of the women who come to our center are somewhat exhausted of doctors trying to figure out what to do with them.

None of these treatments are designed to strengthen spinal, pelvic, vaginal, groin area ligaments


Why is no one treating your ligaments?

If pelvic floor pain lingers and no known source is found, injured, loose or weak ligaments and instability of the pelvis should be considered. The numerous ligaments that surround and stabilize the pelvis undergo relaxation due to the hormone relaxin that is secreted during pregnancy. This hormone does just what it says – it relaxes the ligaments in the pelvis to allow the baby to pass through the birth canal. In some cases, the relaxed ligaments may not return to their normal properties and the woman is left with pelvic ligament laxity and instability, which can include the hip(s) in some cases. This can be especially true for women who already have joint hypermobility.

Numerous ligaments surround the pelvis and help to keep it stabilized. When these ligaments become weak, they are unable to maintain pelvic stability and can cause pain. Injury to the pubic symphysis, pubic ligaments, or any of the ligaments that stabilize the lower back (especially sacroiliac joint) would cause the pelvic floor muscles to contract continually against an unstable base.

In pelvic floor dysfunction, the musculature is in spasm and muscles that are constantly contracting or in spasm will generate pain. Muscles spasm because they are trying to provide stability in an unstable region.

Understanding the ligament damage – making sense of treatment and making sense of urinary problems

In a study of the three pubourethral ligaments in women, French surgeons wrote the following (12):

Treatments addressing damaged ligaments

Chronic pelvic pain, which goes on for years and years and does not responded to conservative and surgical care treatments may be a ligament problem. As in other parts of the body, the most important evaluation in analyzing chronic pelvic pain is palpation of the area. When a positive “jump sign” is elicited over the painful ligament, both the patient and the doctor know that the cause of the pain and symptoms can now be focused on a weakened ligament.

In other words the health care specialist, like our Prolotherapy specialist and mother of two Danielle R. Steilen-Matias, MMS, PA-C, will explore the patient’s pelvic area during a physical examination to determine those areas, next to the bone that are pain generators.

The anatomy of ligaments

The sacrotuberous and sacrospinous ligaments may trap the pudendal nerve leading to nerve-related pain

Prolotherapy, PRP and adjustments.

In this video Danielle R. Steilen-Matias, MMS, PA-C. and Brian Hutcheson, DC will explain treatments.

In this video a case study is offered of a woman who had given birth five times and how this caused her pelvic pain problems and what our team did to help her.

Summary transcript and explanatory notes:

Danielle R. Steilen-Matias, MMS, PA-C.: Very often we will see people suffering from chronic public pain. Many are women who have suffered from pelvic pain since having a baby or suffering a sports injury or accident. What these patients suffer from, in many cases, is pubic or pelvic instability.  What this translates to is that these people simply do not have the pelvic ligament strength or pelvic ligament competency to hold their pelvis together. This of course can be very painful and can create a lot of dysfunction in terms of affecting surrounding nerves or muscular function.

The distance between the two pelvic halves

When somebody comes to our office and we suspect is pubic instability and pubic pain what we’ll do is use our ultrasound machine to measure the distance between the two pelvic bones

What are you seeing in this image?

From the case study presented in this video Danielle R. Steilen-Matias, MMS, PA-C

In this ultrasound image. The distance between to the two pelvic halves are measured to help determine the extent of pelvic instability the patient sufferers from. This patient had five children delivered with vaginal delivery. The distance between the two pelvic halves continued to increase until the point of pain and functional problems in daily life.

In this ultrasound image. The distance between to the two pelvic halves are measured to help determine the extent of pelvic instability the patient sufferers from. This patient had five children delivered with vaginal delivery. The distance between the two pelvic halves continued to increase until the point of pain and functional problems in daily life.


We treated the patient from March through August with Prolotherapy and Platelet Rich Plasma injections. Over time the distance between those two bones reduced significantly to a stable level she was able to improve her sleep and start working on a treadmill. Both treatments are explained below.

Prolotherapy treatments to the weakened ligaments help these areas heal and return to normal strength. Once the ligaments are strong again, the chronic pain abates. In cases of pelvic floor dysfunction, the additional symptoms such as difficulty with urination and bowel movements, as well as sexual dysfunction and abdominal pressure, can be eliminated as well.

In those with pelvic floor dysfunction and associated pain in their back, pubis, pelvic floor, genitals, coccyx, and associated symptoms, Prolotherapy can help to strengthen injured or stretched out ligaments, allowing them to reinstate stability to the pelvis and allow tight muscles to relax.

How Prolotherapy works

In this final scan, of the patient, ultrasound images show a progression of Pubic Symphysis tightening and reduction and alleviation of the patient’s symptoms. The first image and excessive separation of the pelvic halves are seen in March 2018. At each treatment, the May treatment, June treatment, July treatment and August treatment, the space between the two pelvic halves were measured. The tightening of the pelvic floor is displayed.

In this patient, the two halves of the pelvis are brought together by a tightening and strengthening of the pelvic ligaments.

Pubic Symphysis Ultrasound

In this image, 5 ultrasound images show a progression of Pubic Symphysis tightening and reduction and alleviation of the patient’s symptoms. The first image and excessive separation of the pelvic halves are seen in March 2018. At each treatment, the May treatment, June treatment, July treatment, and August treatment, the space between the two pelvic halves were measured. The tightening of the pelvic floor is displayed.

Pelvic floor pain and Symphysis Pubis Dysfunction – instability because of weakened damaged ligaments

The pubic symphysis is frequently an overlooked joint located in the front of the pelvis. It is a joint that is strongly bonded and is rarely injured in isolation. The pubic symphysis is actually a fibrocartilagenous disc supported on the top by the superior pubic ligaments. It helps unite the left and right pubic bones.

In the female, the pubis is located above the vulva. In cooperation with the sacroiliac joints, the symphysis pubis forms a stable pelvic girdle. The anatomy of the pelvic girdle is quite complex. The pelvis is a ring, and any anatomical change or force of pressure to one area will expand throughout the ring.

The pubic symphysis joint can move about 2 millimeters, and with one degree of rotation. This small amount of movement is normal, but in some women the joint may become unstable, allowing for too much movement in the pelvis. Again, because of the anatomy of the pelvic ring, instability at the symphysis pubis often also affects the sacroiliac joints and vice versa.

Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.

The fibrocartilagenous disc, that is the pubic symphysis joint, is composed of bundles of thick collagen fibers. These fibrous bundles resemble tendon cells. Since unresolved pain from symphysis pubis injury involves instability of this disc as well as ligament laxity in the pelvic girdle, a better approach is to strengthen the joints with Prolotherapy.

How chiropractic may help

The video resumes at 3:35 

Chiropractic assessment (3:35 of the video) 

Dr. Hutcheson: Being a chiropractor, we don’t have any means to be able to tighten that pelvic space so working alongside Danielle with her treatments of Prolotherapy and PRP offers tremendous benefit to all of our patients

Some of the things I would do as a chiropractor to supplement this patient’s treatment and help the patient during the process would be to work on activating all of the musculatures of the area that can help support the pelvic bones and keep them in their space and create structural integrity.

Very common in post-pregnancy is muscle weakness and atrophy caused by the release of the hormone relaxin. While this hormone allows for the relaxation of the pelvic ligaments to allow the opening of the vaginal and pelvic space so the childbirth can occur without many complications, a post-pregnancy problem is the muscles have also weakened and they have stretched and they can contribute to pelvic separation. So we would work on restoring abdominal bracing, we would get the ribs that often with pregnancy will end up flaring a bit to allow room for the baby, we will bring those ribs back into place and engage the core muscles. Often when we work together we get quicker and more permanent results and really help people.

The use of PRP injections for treating genital prolapse

Platelet Rich Plasma Therapy (PRP). Sometimes PRP is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots.

A June 2018 review of the medical literature published in the journal Clinical and experimental reproductive medicine (13), discussed the use of PRP Therapy for the treatment of genital prolapse. Here research is cited for the use of PRP for genital prolapse

The research team cited a 2017 study from Greek researchers (14):

Here are the learning points of that research:

PRP as an alternative to the sling

Also cited was a study (15) on the effects of PRP treatment on Stress urinary incontinence. What was noted in this study was that “several surgical techniques have been proposed for the treatment of Stress urinary incontinence.” That these surgeries which include “the Burch colposuspension, retropubic mid-urethral slings (TVT), trans-obturator tapes (TOT), trans-obturator tapes inside out (TVT-O), bladder neck injections and the insertion of an artificial urethral sphincter,” sought to restore urethral support, which is naturally preserved by the pubourethral ligament. Here these researchers speculated that treating the pubourethral ligament with PRP could repair pubourethral ligament damage.

Prolotherapy maybe an answer if conservative treatments have failed and you still have a sense of instability and the related symptoms we spoke of above.

If you have questions about this article, Get help and information from our Caring Medical staff


Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction Following Childbirth.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References:

1. Wuytack F, Curtis E, Begley C. The Experiences of First-Time Mothers With Persistent Pelvic Girdle Pain After Childbirth: A Descriptive Qualitative Study. Phys Ther. 2015 Apr 30. [Google Scholar]
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12 Vazzoler N, Soulie M, Escourrou G, Seguin P, Pontonnier F, Becue J, Plante P. Pubourethral ligaments in women: anatomical and clinical aspects. Surgical and radiologic anatomy. 2002 Jan 1;24(1):33-7. [Google Scholar]
13 Chrysanthopoulou EL, Pergialiotis V, Perrea D, Κourkoulis S, Verikokos C, Doumouchtsis SK. Platelet rich plasma as a minimally invasive approach to uterine prolapse. Medical hypotheses. 2017 Jul 1;104:97-100. [Google Scholar]
14 Nikolopoulos KI, Pergialiotis V, Perrea D, Doumouchtsis SK. Restoration of the pubourethral ligament with platelet rich plasma for the treatment of stress urinary incontinence. Medical hypotheses. 2016 May 1;90:29-31. [Google Scholar]
15 Dawood AS, Salem HA. Current clinical applications of platelet-rich plasma in various gynecological disorders: An appraisal of theory and practice. Clinical and experimental reproductive medicine. 2018 Jun 1;45(2):67-74. [Google Scholar]

This article was updated January 29, 2021

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