John-Paul D. Hezel1
(1)
Carl J. Shapiro Department of Orthopaedics, Division of Sports Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Stoneman 10, Boston, MA 02215, USA
John-Paul D. Hezel
Email: jphezel@bidmc.harvard.edu
Keywords
Plantar fasciitisPatellofemoral pain syndromeMechanical back painMcKenzie therapyPregnancy-related pelvic girdle painFemoroacetabular impingementDe Quervain’s tenosynovitisCarpal tunnel syndrome
Case #1: Foot Pain and Pain Medications
NS is a 35-year-old female G1P0 now 31 weeks pregnant who presents with left heel pain. She states that it began insidiously about 1 month ago and was not related to any specific event. She reports some pregnancy-related back pain but denies any numbness, tingling, or other radicular symptoms into the feet. The pain is located on the plantar aspect of the foot, is worse in the morning and after sitting at her desk for a while, and is relieved by rest and non-weightbearing. She denies prior foot or ankle injuries.
Her past medical and family history is unremarkable, she has no known drug allergies, and her current medications include prenatal vitamins. She works as an accountant and lives at home with her husband. She denies tobacco or alcohol use. Her review of systems is negative other than for her presenting symptoms.
On physical examination, NS is 5 foot 3 inches tall and weighs 175 pounds, which is a 25-pound gain since prepregnancy. She is a well-appearing female, accompanied by her husband, in no apparent distress. She ambulates with an antalgic gait favoring her left lower limb. She has a wide base of support and purposefully walks on her left toes, refusing to heel-strike. She has full plantar flexion, dorsiflexion, eversion, and inversion range of motion and strength in the ankle. There is tenderness to palpation directly over the medial plantar surface of the heel. There is no other bony or soft tissue tenderness and no erythema or swelling. Her calcaneal squeeze test is negative for reproduction of her symptoms, and she has good distal pulses and capillary refill. X-rays were deferred.
Discussion
Weight gain during pregnancy leads to a multitude of anatomic changes that affect the lower limb. These biomechanical factors likely play a larger role in limb pain than do hormonal changes [1]. Increased lordosis of the low back and relaxation of the peripelvic muscles, primarily the hip abductors that are responsible for stability of the lower limb, can lead to a redistribution of forces through the knee and into the foot. Women become more flat-footed, leading to greater pronation [2] and alteration of pressure points throughout the plantar surface [3]. In combination with pregnancy-related pedal edema [4], ligamentous laxity in the foot and ankle also places more strain on soft tissues. The plantar fascia, a thick band of connective tissue running from the heel to the toes, often becomes stretched or inflamed, a condition known as plantar fasciitis. In the general population, plantar fasciitis is related to overuse or can be instigated by an injury, changes in activity patterns, or poor footwear, though the natural history of the disease is not understood [5]. Obesity is present in 70 % of nonpregnant individuals with heel pain [6], so in pregnant women who have gained weight, the altered kinetic chain and compression directly on the plantar fascia can lead to acute inflammation or chronic disorganization of the tissue, causing severe pain with weightbearing. The most common complaint is pain when taking the first couple of steps in the morning or after a period of inactivity [7], such as when getting up from a desk at work. The relative immobilization of the foot leads to tightening of the connective tissues, and only after moving around or stretching do they begin to loosen up.
When working up a gravid woman with foot pain, plain films are reserved to rule out a fracture from a traumatic event or if looking for degenerative changes, evidence of osteonecrosis, or dislocation. The majority of times, diagnosis based upon physical examination is sufficient. There is tenderness directly over the plantar fascia and pain is often reproduced in the heel with walking. Tenderness in the posterior heel along the insertion of the Achilles onto the calcaneus is more suggestive of Achilles tendinosis or enthesopathy than plantar fascial pain, though the two pathologies can coexist. Pinching the calcaneus between the thumb and index finger is important to help differentiate between plantar fasciitis and a calcaneal stress fracture. If the squeeze test is positive and the history is consistent with a possible bony abnormality, an MRI may be indicated to rule out the stress injury. Calcaneal stress fractures or reactions can be treated with a walking boot until pain abates. These are relatively uncommon, however, and in the vast majority of plantar heel pain, the fascia is the pain generator.
Managing foot pain during pregnancy is completely conservative. The mainstay of treatment is proper footwear, finding a comfortable walking shoe that gives support to the heel and to the arch. Full-length off-the-shelf inserts with a medial arch support may help correct pes planovalgus and realign the ankle, redistributing forces on the plantar surface of the foot, though there is no established evidence that they decrease pain [8]. Stretching of the foot in a dorsiflexed position, using a belt or band or towel, before getting out of bed in the morning alleviates pain with that first step, and manual and active stretching of the gastrocnemius and soleus is beneficial [9]. If the woman can tolerate exercise, structured physical therapy to learn hip stability and balance drills is also recommended. Treating the entire leg, not just the foot, can accelerate relief of symptoms and help prevent other musculoskeletal pain. Massage to the foot, to the calf, and into the thigh and hip, foot ice baths, elevation, relative rest, night splinting, and rolling a ball or frozen water bottle on the bottom of the foot are other methods of treatment that have some success. In the extreme cases, a walking boot for 7–14 days may help with acute pain. It is important to direct the patient to remove the boot periodically throughout the day, as stiffness in the ankle and atrophy of the calf from long-term disuse can lead to unintended pain and weakness. Corticosteroid injections have been shown to give short-term relief of plantar fascial symptoms up to 6 months [10], so while these injections do not fix the problem, they may be necessary to keep women active and on their feet.
A common question during pregnancy is about the safety of over-the-counter pain medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and naproxen, may pose danger to the fetus [11], particularly during the third trimester. For this reason, the Federal Drug Administration has categorized all NSAIDs as Class D after 24 weeks, meaning that there is some evidence of NSAIDs causing human fetal risk [12]. They should only be used in the case of life-threatening illness or when the use of safer drugs is ineffective or not an option. In contrast, acetaminophen (Tylenol) has not been associated with significant fetal risk and is categorized as Class B during all three trimesters [13]. This designation means that there are no good randomized controlled trials in human subjects and that no adverse effects have been found in animal reproduction models. Though there has been some correlation made between acetaminophen use in pregnant women and increased incidence of ADHD in 7- to 11-year-olds [14], acetaminophen has been widely accepted as the pain medication of choice and should be the initial pharmacotherapy if needed during pregnancy.
Case #2: Knee Pain and Exercise Guidelines
AW is a 31-year-old female runner G1P0 now 21 weeks pregnant who presents with right knee pain. It began insidiously about 3 weeks ago as she increased her per week mileage for an upcoming marathon. She is an accomplished long-distance runner, having completed six marathons during her twenties. She usually begins training 4 months before a race, but when she found out she was pregnant, she decided to accelerate her regimen to compete before her second trimester was complete. Her pain was initially exacerbated only with running, but now it hurts when going up and down stairs. She also reports stiffness when getting up from sitting more than 30 min, which is common in her work as an accountant. She denies swelling, instability, or mechanical symptoms. She denies any prior injuries and has never experienced knee pain before this month.
AW’s medical history is uncomplicated and she is only taking vitamins as prescribed by her obstetrician. Other than running, she bikes occasionally and strength trains once a week, focusing primarily on ballistic activity. She changes her running shoes every 400 miles and prefers a stiff shoe. She recently switched brands because she was finding her old pair was causing irritation of her Achilles.
On examination, AW is a well-appearing female who walks with a nonantalgic gait. She demonstrates a compensated Trendelenburg sign on single-leg stance bilaterally, but it is worse on the symptomatic right side. She has pes planovalgus with valgus tilt of her ankle when viewed from behind. She has full extension of the knee but some discomfort on full flexion. All special tests – including those for the cruciate and collateral ligaments and menisci – are negative. There is no joint effusion and only mild tenderness over the medial joint line.
X-rays are negative for fractures, dislocations, degenerative changes, or other bony abnormalities.
Discussion
Patellofemoral pain (PFP) is the most common running injury, accounting for between 25 and 40 % of all knee pain [15]. The classic teaching is that it is caused by maltracking of the patella in its femoral groove during repeated flexion of the knee. The lateral quadriceps is thought to overpower the medial quadriceps, pulling the patella laterally. Often the articular cartilage on the undersurface of the kneecap can wear away, a related disorder called chondromalacia patella, which is often used interchangeably with PFP and runner’s knee but that means something a bit different in terms of pathology. There is some evidence that patellofemoral arthritic changes contribute significantly to PFP, primarily in the setting of patella alta [16]. The most common symptoms of patellofemoral pain syndrome or “runner’s knee” are generalized anterior knee pain with running, difficulty going down stairs, and stiffness with the knee flexed for an extended period, described usually as pain when getting up from a seated position [17].
Though quadriceps weakness does likely play a role in PFP, quadriceps tightness is often more prevalent in patients with anterior knee pain. Knee restriction places more pressure on the patella, causing stiffness after a period of immobility. Trigger points in the quadriceps can also decrease joint range of motion and refer pain to the knee joint, despite the knee itself having no structural problem. Treatment for PFP thus begins with regaining or maintaining knee flexion when compared to the asymptomatic side. Active quadriceps stretching, soft tissue mobilization with a foam roller or PVC pipe, manual tissue work with a therapist or chiropractor, and dry needling to release active trigger points are all initial strategies to regain this motion.
The knee is like a middle child: it takes all the abuse from the older sibling, the hip, and the younger sibling, the foot and ankle. The gluteal musculature, particularly the gluteus medius, is critical in stabilizing the lower limb during single-leg stance and ambulation, which is essentially a series of repetitive single-leg activities. The foot and ankle, meanwhile, control alignment of the tibia and subsequently the entire leg and thigh. Weak gluteus medius can lead to a loss of stability and alter pelvic mechanics [18], and a weak or flat foot can lead to a loss of proper alignment, both placing more stress on the knee and leading to anterior joint pain. Women with PFP have been shown to have greater more pelvic drop [19], indicative of weak gluteals, and more hip adduction [20], which may correlate mechanically to weak abduction. Rehabilitation of PFP focuses on correction of biomechanical abnormalities, beginning with the hip, foot, and ankle. Hip abductor and core stability, balance, foot intrinsic strengthening, correction of any dorsiflexion or plantar flexion contracture, and proprioceptive training are mainstays of a therapy program, with some evidence that hip plus knee exercise is better than knee exercise alone [21]. Those with pes planovalgus or rearfoot eversion may benefit from off-the-shelf orthotics with a medial arch support to help control tibial alignment, as there may be a link between tibal rotation and PFP [22].
Patellofemoral pain is more common in women than men [23], because of factors that affect the general population and because of anatomic changes that occur naturally from pregnancy itself. Additional weight puts more stress on the joints; hormonal changes lead to ligamentous laxity and subsequent weakness, especially in the hips and pelvis; and postural changes caused by the gravid uterus can alter gait mechanics [24].
One of the most common questions that runners and other active women have during pregnancy is whether or not they can continue to exercise. While there are no specific guidelines on what women can or cannot do while pregnant, it is widely accepted that they should follow the same recommendations as for nonpregnant women and men: 30 min of moderate-intensity exercise at least 5 days a week [25]. The American Congress of Obstetricians and Gynecologists (ACOG) recommend that in uncomplicated pregnancies, recreational and competitive athletes maintain their level of exercise and modify as medically indicated [26]. This differs from ACOG’s recommendation for sedentary women, who instead require a full medical evaluation before beginning an aerobic training program.
Evaluation of a runner with knee pain begins with analysis of walking gait and then with the patient standing barefoot on a single leg, looking for proper balance, signs of hip weakness, and low or high arches of the feet. It is important to check range of motion and strength of the hip, knee, and ankle, paying close attention to any differences between the symptomatic and asymptomatic sides. Palpate the knee for an effusion, which would suggest intra-articular damage, and look for tenderness along the medial and lateral joint lines, patellar and quad tendons, and popliteal fossa. Special tests are used to help rule out ligament sprains or meniscal and articular cartilage injury. Palpation of soft tissues may reveal taut bands and trigger points that can refer pain to the knee and contribute to symptoms.
In the absence of trauma, infection, effusion, mechanical symptoms such as locking, instability or feelings of giving way, suspected arthritis or fracture, or intractable pain, there is no need for plain films or advanced imaging.
Case #3: Back Pain and Imaging Guidelines
HA is 36-year-old G2P1 CrossFit athlete now 25 weeks pregnant who presents with low-back and buttock pain. Her pain is bilateral, though slightly worse on the left side. It had been progressive over the past couple of months, but it worsened suddenly a week ago when squatting in the gym. She did not drop the weight, and she denies feeling a pull, but when the lifting session was complete, she felt more sore than normal. She denies any numbness or tingling but does have occasional pain down the back of the left leg. Pain is worse with walking and bending and relieved by rest. She denies prior injuries, though she describes a history of back pain during her last pregnancy. It was similar in nature, was controlled with positional changes at home and at work, and resolved a couple of weeks after she gave birth. Unfortunately, she states that her current symptoms are much worse than her previous episode.
HA’s past medical history is positive for exercise-induced asthma that is well controlled with warming up before a workout and an occasional inhaler. Medications also include multivitamins. She is happily married and works out with her husband twice a week. Her daughter is 4 years old. Family history is unremarkable, as is her additional review of symptoms.
Physical examination reveals a gravid female who walks with a nonantalgic gait with a wide base of support. She exhibits slight anterior pelvic tilt and exhibits good stability on single-leg stance. Pain is reproduced with forward flexion of the lumbar spine, which is limited, and relieved with extension. She has full motor strength in the lower limbs, intact sensation to light touch in all dermatomes, 2/4 deep tendon reflexes at the patellae and Achilles, and no upper motor neuron signs. She has a negative supine straight leg raise. There is tenderness throughout the lumbar paraspinal musculature and over the sacroiliac joints bilaterally. Remaining sacroiliac joint tests are negative for reproduction of pain.
HA refused x-rays because of her pregnancy.
Discussion
Weight gain and stretching of the abdominal cavity by the gravid uterus increase lumbar lordosis and lumbosacral stiffness, weaken core musculature, exaggerate hip flexion, protract the cervical spine, and depress the shoulder blades, all placing more strain on the lumbar paraspinal muscles, particularly during weightbearing. Interestingly, though gait mechanics have been shown to change very little in pregnancy, the hip extensors, hip abductors, and foot plantar flexors are all more active during ambulation to compensate for anterior pelvic tilt [27]. These changes, in combination with the well-established hyperlaxity of the sacroiliac joints and pubic symphysis, all place a pregnant woman at greater risk for back pain. Additional risk factors include pain before pregnancy, back pain during a previous pregnancy [28], and multiparity, though the biggest risk factor is the progression of pregnancy [29].
The majority of back pain, both in the general population and among pregnant women, is axial [28] and mechanical in nature, that is, related to movement. Causes include poor posture, muscle weakness, irritation of the joints in the lumbar spine and pelvis, ligamentous laxity, and a host of other biomechanical factors, including gait abnormalities and prior injuries leading to compensation. Rarely is an anatomic cause found, meaning that back pain can most often be treated according to the resulting dysfunction and constellation of symptoms rather than based upon a specific pathology. While pregnant women are at risk for spondylolisthesis, slippage of one vertebrae over another, there is no greater prevalence of disc herniation in this population [30]. The history and physical examination are thus used to rule out the uncommon pathology, such as symptomatic disc herniation, and to determine modifiable risk factors, extent of functional loss, and anatomic asymmetry and weakness, all with the goal of developing an individualized treatment plan.
Examination of a patient with back pain begins with watching her walk. It is important to take note of asymmetries such as pelvic drop on one side compared to the other, lack of knee or hip flexion, inability to clear one or both feet, hyperlordosis of the lumbar spine, and the base of support (i.e., how wide the feet are spread during ambulation). In the standing position, one must check single-leg balance and make sure that she can go up onto her toes and heels [31]. An inability to do so may be a sign of L5 or S1 nerve root impingement, particularly if the deficit is one-sided and accompanied by dorsiflexor or plantar flexor weakness on strength testing. Manual motor strength of all lower limb myotomes, light touch sensation of all lower limb dermatomes, and deep tendon reflexes at the patella and Achilles are imperative to rule out nerve root compression or peripheral nerve injury. An upgoing great toe when checking a Babinski reflex is a sign of upper motor neuron disease and should be evaluated more closely if only found on one side.
One can determine range of motion of the lumbar spine in the standing position by having the patient bend forward with the knees straight and then by leaning backward, hinging from the lumbosacral spine and hips. If pain is elicited in one direction more than the other, attempt is made to centralize the pain to the low back by having the patient perform repeated flexion or extension, whichever movement does not cause reproduction of her pain. For example, if she has more pain with forward flexion, then she is instructed to perform multiple extensions (10–15 repetitions) either while standing or by doing prone push-ups with the hips stabilized on the exam table, such as when doing the upward dog position in yoga. These extensions should not be done if radicular symptoms are elicited. Immediately following the extensions, forward flexion is rechecked to see if her range of motion improves and if her pain is lessened. If so, it would be a sign that McKenzie therapy, use of a directional preference and pain centralization [32], may help control her symptoms, as this method has been shown to be quite effective in patients with mechanical back pain [33].
With the patient lying down on her back, a supine straight leg raise is performed. A positive test is reproduction of sciatic-like pain, numbness, or tingling down the back of the leg between 30° and 70° of hip flexion, suggestive of a disc herniation. This test is not positive if it elicits only back pain or tightness in the hamstring. While the patient is supine, the hips are examined for range of motion and for any sign of intra-articular pathology such as a labral tear. Palpation of the pubic symphysis, which may be quite tender, the hip flexors, and adductor compartment also gives clues to the pain generator.
The patient is then placed on her side to test for hip abductor strength, the greater trochanter is palpated for signs of bursitis or tendinopathy, and the gluteal muscles are palpated for trigger points. Finally, with the patient prone, the sacroiliac joints, the lumbar paraspinal musculature, the spinous processes, the quadratus lumborum (QL), and the piriformis are all palpated individually, again looking for the etiology of pain. Tightness or trigger points in QL or piriformis can cause isolated low-back pain or can radiate pain down the back of the leg, mimicking disc herniation. If found, these trigger points respond very well to dry needling and trigger point injections.
In a patient with back pain, it is also imperative to rule out SI joint pathology, especially given that the SI joint is widened during pregnancy. Common SI joint tests such as FABER (flexion, abduction, external rotation) have not been shown to be sensitive. Palpation of the posterior-superior iliac spines and the “dimples” just above the buttocks approximates the SI joints and can help isolate the pain. There are also a series of tests that when positive have been shown to lead to the diagnosis of SI joint dysfunction [34]. An injection of local anesthetic into the SI can help confirm that diagnosis, and it can then be treated with SI belts or girdles to redistribute pressure in the low back, hips, pelvis, and legs [35]. Soft tissue modalities and acupuncture may also be effective.
Though x-rays and MRI are rarely needed when working up back pain in pregnancy, they are safe both for the prospective mother and fetus. According to ACOG, radiation from x-rays “is at a dose much lower than the exposure associated with fetal harm” while MRI is “not associated with risk” to the fetus [36]. This discussion is critical to have with pregnant women given the anxiety surrounding radiation of any kind. Counseling about the risk helps develop a treatment plan in accordance with clinical indications and expectations of the prospective mother.
Guidelines for radiologic workup of back pain in pregnancy are the same as for men and nonpregnant women. Red flags indicating the need for an MRI in the setting of back pain include recent trauma, osteoporosis, insidious onset of unexplained weight loss (or failure to gain weight during pregnancy), unexplained fever or other signs of infection, immunosuppression, prolonged use of corticosteroids, intravenous drug use, prior back surgery, progressive weakness, disabling pain, and focal neurological deficits. These deficits include saddle anesthesia and bowel/bladder incontinence, suggestive of cauda equina; focal weakness, hyperreflexia, increased muscle tone, upgoing plantar response, and sustained clonus, suggestive of spinal cord compression; and weakness, hyporeflexia, atrophy, and fasciculations, suggestive of severe nerve root or peripheral nerve compression. MRI is also indicated when planning an interventional or surgical procedure such as epidural injections or laminectomy/fusion.
Treatment of low-back pain in pregnancy requires a multidimensional approach. The mainstay is activity modification with identification of movement patterns that can be corrected over a short time frame with altered positioning to relieve stress on the lumbar spine. A few sessions of physical therapy can help implement these changes and teach the patient a basic stretching and strengthening program, and 12-week program of therapy has been shown to reduce pain during the second half of pregnancy [37]. Rest plays a role, but can often be counterproductive, leading to more stiffening of muscles and joints.
ACOG recommends the use of low-heeled shoes with arch supports, using lumbar support when sitting, placement of a board between the box spring and mattress for if the bed is soft, squatting to use the knees when bending to pick up heavy objects, sleeping on the side with a pillow between the knees for additional support, and the use of heat, ice, or massage to relieve painful areas [38].
Case #4: Hip and Pelvic Pain and the Use of Contrast Media
VC is a 27-year-old G1P0 former college soccer player now 29 weeks pregnant who presents with right groin pain. The pain began insidiously 3 weeks earlier when she noticed it when getting out of a car. Her groin hurts now when walking but mostly when getting up from lying down. She denies clicking, catching, locking, or popping, and there was no inciting event. She reports a history of “hip” pain during her sophomore year of college when she was diagnosed with a tear of the labrum. She managed her symptoms conservatively with exercise and did not require injections or surgery at the time. VC states that her current symptoms are different than those experienced in the past.
Her past medical and family history is unremarkable, and her pregnancy to date has been uncomplicated. She takes a standard course of vitamins and has no allergies to medications. She lives in a duplex with her husband and has only occasional pain when going up and down stairs. Her review of systems is positive for a “pins and needles” sensation in the right thigh, but she denies shooting pain down the leg, bowel or bladder incontinence, or any other joint pains.
On examination, this is a gravid-appearing female, unaccompanied, who walks with a nonantalgic and symmetric gait. She can heel and toe walk, though when hopping up and down her right leg, she has pain in the groin. She has full range of motion of the hips with some pain on internal rotation, adduction, and flexion of the hip, negative scour test, and negative supine straight leg raise. She has tenderness to palpation over the pubic symphysis, and her symptoms are reproduced with active sit-ups. There is tenderness over the right adductor tendon as it inserts onto the pubic bone. There is no erythema or swelling. Lumbar spine examination is negative. There are no palpable peripelvic trigger points.
VC did agree to proceed with x-rays, which were unremarkable for fractures, dislocation, or joint space narrowing. She did have slight osseous bumps over both femoral head and neck junctions, consistent with cam-type deformities. Joint spaces were well maintained, and there was no suggestion of osteonecrosis of the femoral head.
Discussion
It is well established that the hormone relaxin peaks during the first trimester of pregnancy and helps to widen the pubic symphysis and both sacroiliac joints in preparation for delivery [39]. It is not well established, however, whether this hormonal effect leads directly to pelvic pain or whether additional biomechanical, metabolic, genetic, or degenerative factors play separate roles. In reality, pregnancy-related pelvic girdle pain (PPGP) is likely caused by a combination of all these and other factors that affect women during and after pregnancy [40]. There is no consensus as to the constellation of symptoms with which women present, though it is generally accepted that sharp, stabbing, dull, or shooting pain posteriorly in the SI joints or anteriorly in the pubic symphysis – or both – is usually the primary complaint.
Groin pain, on the other hand, can come from the hip joint itself or surrounding structures, including but not limited to muscles, tendons, connective tissue, and adjacent joints, most notably the pubic symphysis. Evaluation of groin pain begins with ruling out an inguinal or abdominal hernia, low-back disorders, bone infection such as osteomyelitis, bone tumors, urinary or gastrointestinal disease, rupture of the pubic symphysis, and round ligament pain [40]. The round ligament attaches to the uterus, and as the fetus grows, stretching of the ligament can cause transient sharp lower abdominal pain that radiates into the groin. It is treated with pelvic tilting [41]. A thorough history of prior malignancy, signs of local or systemic infection, inflammatory arthropathy, previous trauma, or recent weight loss is critical. Direct examination of the lumbar spine and SI joints and strength, sensory, and reflex testing of the lower limbs help to rule out disc herniation, mechanical low-back pain, or posterior pelvic abnormalities.
The primary differential for groin pain includes muscle or tendon strain, hip flexor bursitis, femoroacetabular impingement with a labral tear, hip joint degenerative changes, hypermobility, rectus abdominis-adductor aponeurosis injury, or pubic symphysis dysfunction. The pubic symphysis measures 3–6 cm in nonpregnant individuals and can separate an additional 2–3 cm during pregnancy. Persistent widening over more than 10 cm is called diastasis, though the exact measurements do not correlate to severity of symptoms. Pain from symphyseal separation localizes to the lower abdomen or suprapubic area but can also radiate into the buttocks, down the legs, or into the groin on one or both sides [42]. Women often complain of pain on weightbearing, going up and down stairs, and turning in bed. They often wake up in the middle of the night. There is conflicting literature on the incidence of pubic symphysis separation causing pain, but the mainstay of diagnosis is palpation. Deep pressure over the pubic symphysis may evoke local discomfort or cause referral. A step-off may also be felt. Women may also have pain with sit-ups and activation of the adductors, which attach just adjacent to the symphysis. X-rays are not necessary in making the diagnosis, though with pain recalcitrant to conservative management, imaging, especially after delivery of the child, may be warranted to differentiate between degenerative changes, osteitis pubis, diastasis, or inflammatory arthropathy.
Treatment for women with pubic symphyseal pain includes a pelvic belt or girdle, activity modification, strengthening of the hip abductors and adductors to better support the pelvis, sleeping in the lateral decubitus position, graded exercise program, and corticosteroid injections into the joint [43].
In the absence of recent trauma or specific injury, muscle or tendon strain is unlikely. Hip flexor bursitis is also less common in pregnant females. In those with a history of hip problems or those who have new-onset groin pain with positive labral signs, it is possible and likely that the hip joint is the culprit. Femoroacetabular impingement occurs when the femoral head-neck junction consistently comes in contact with the acetabulum, due to an osseous abnormality on either the femur or pelvis. Overuse and repeated hip flexion and adduction, such as when playing soccer and hockey, can lead to tearing of the labrum, a cartilaginous structure that adds depth and cushioning to the joint. Pregnancy can exacerbate symptoms, and maternal positioning during delivery can lead to new tearing [44].
Evaluation of the hip involves checking flexion, internal and external rotation, and abduction and adduction of the joint. Impingement testing is performed by flexing the hip to 90° than internally rotating and adducting the leg across midline, compressing the femoral head-neck junction against the acetabulum. Reproduction of pain is suggestive of FAI. The scour test is performed by flexing the hip to 90° and then directing a vertical force down the femur, simultaneously rotating or “scouring” the joint through its 360° of circular motion. Reproduction of familiar pain or a catch is positive for a likely labral tear. Pain with a straight leg raise at 20° of hip flexion may also indicate hip joint pathology.
Diagnosis of impingement and labral pathology is confirmed with MRI arthrogram of the hip [44]. The contrast injection allows for visualization of the labrum, which is not always delineated clearly without dye. Contrast media has not been studied in pregnant women, but given its potential risk as evidenced by laboratory and animal studies, it is best to avoid arthograms and intravenous contrast unless the benefits outweigh the risks [36]. In the case of possible hip labral tears, the woman can be treated based on clinical features, reserving advanced imaging for after labor and delivery. Instead of MRI, patients in extreme pain can undergo a diagnostic and therapeutic injection of anesthetic and corticosteroid into the femoroacetabular joint. If the patient feels better after the joint is numbed, it is a positive test for an intra-articular pain generator. Manual therapy to relax surrounding soft tissue and physical therapy for hip and abdominal strengthening and stability are also conservative measures used to avoid more aggressive studies and management. MRI without contrast has been shown to be safe, as detailed above, so if osteonecrosis of the femoral head [45] or other more significant bony disease is suspected, MRI may be warranted.
Given all of the biomechanical changes associated with pregnancy, muscles may be activated differently and lead to trigger points in the peripelvic region. Psoas trigger points can mimic impingement, as passive flexion of the hip contracts already contracted muscle, reproducing pain with very specific referral patterns in the groin and down the front of the thigh. Release of these trigger points with dry needling or via manual therapy can provide immediate relief.
Finally, as women gain weight and the uterus compresses the abdomen, the lateral femoral cutaneous nerve, which runs below the inguinal ligament and into the thigh, can be compressed, a condition known as meralgia paresthetica. Women complain of paresthesias into the upper to mid-anterolateral thigh, and there is decreased sensation to light touch in the nerve’s distribution. This condition is exacerbated in the third trimester and is usually self-limited, not requiring any specific treatment, though manual therapy has been shown to help [45].
Case #5: Wrist Pain and the Safety of Corticosteroid Injections
TC is a 38-year-old right-handed G3P3 female, now breastfeeding 8 weeks after delivering her third child, who presents with left wrist pain. It began insidiously about 3 weeks before her delivery and has progressed in the postpartum period. The pain is located on the thumb side of the wrist and is exacerbated by picking up a fork or knife or by lifting her newborn. She reports some minor swelling but denies any trauma, fevers or chills, or other worrisome symptoms. She denies numbness or tingling into the hand but does have some radiation of pain down the thumb. TC has been diagnosed by two orthopedic surgeons with tendinitis and was told that she will need surgery. She has tried three different types of wrist braces without any relief of her symptoms.
TC’s past medical history is negative for any musculoskeletal problems during either of her previous two pregnancies. She is very active, lifting weights three times a week with a personal trainer and running twice a week. The use of barbells and kettle bells does not worsen her symptoms. She takes ibuprofen as needed and has no drug or environmental allergies. She lives at home with her husband and kids and is currently on maternity leave. She drinks socially and has never smoked. Family history is positive for cancer and diabetes.
Physical examination reveals a healthy-appearing female with full range of motion throughout the cervical spine and left shoulder, elbow, and wrist. She has full 5/5 motor strength in all muscle groups of the upper limb except for pain-limited weakness in the thumb abductors. Her sensation to light touch is intact in all upper limb dermatomes and peripheral nerve distributions, including over the median nerve. She has tenderness to palpation with mild swelling over the distal radius. There is no erythema, and her radial pulse is intact with good capillary refill in the fingers. She has a positive Finkelstein’s test but negative carpal compression, Tinel’s over the median nerve at the carpal tunnel, and Phalen’s. She has no carpal instability, and her pain is not exacerbated by radial or ulnar deviation of the wrist.
X-rays of the wrist are negative for fractures, dislocations of the carpal bones or the distal radioulnar joint, or any degenerative changes.
Discussion
De Quervain’s tenosynovitis is characterized by inflammation and thickening of the sheath around the first dorsal compartment of the wrist where the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) are located [47]. Pain is present on the thumb side of the wrist, usually over the radial styloid, and can be associated with swelling, redness, and radiation of pain into the forearm or the thumb. The cause is unknown, though it is common during the third trimester of pregnancy and especially in the postpartum period when breastfeeding [48]. Women complain of pain when picking up their children or with any movement of the wrist toward the small finger. There may be a sensation of clicking, snapping, or locking of the tendons as they pass over the distal radius. Diagnosis is confirmed by a positive Finkelstein’s test in which the patient makes a fist over the thumb and ulnar deviates the wrist, while the practitioner places an ulnar-directed stress over the second metacarpal [47]. Pain is reproduced at the radial styloid and often into the thumb, where patients may also exhibit pain and weakness with resisted extension and abduction. This pain should be differentiated from osteoarthritis of the first carpometacarpal (CMC) joint by performing a careful first CMC grind test [50] and looking at x-rays, which are also important to rule out a fracture.
Though compression of the median nerve at the wrist – carpal tunnel syndrome – is also prevalent in pregnant women [51], it differs from de Quervain’s in the location and nature of pain and peresthesias. Whereas de Quervain’s pain is usually isolated to the wrist and thumb, pain with carpal tunnel syndrome extends into the first radial three-and-a-half digits and is usually accompanied by numbness and tingling in the same distribution. Pain often wakes patients up at night and is related to overuse, though in pregnancy, increased peripheral edema is thought to compress the nerve [51]. Manual compression of the median nerve at the carpal tunnel reproduces pain, numbness, and tingling throughout the nerve’s distribution in the hand and fingers. Reproduction of paresthesias into the radial three-and-a-half digits when tapping the median nerve over the carpal tunnel, weakness of the thumb abductors, and loss of sensation in the median nerve distribution – tested over the palmar tip of the index finger – also suggest the presence of carpal tunnel syndrome. Electromyography and nerve conduction studies are used to confirm the diagnosis in preoperative patients, though these invasive tests are usually unnecessary during pregnancy.
Both de Quervain’s tenosynovitis and carpal tunnel syndrome in pregnancy are self-limited [49, 51], but given the intense pain and functional deficits that can occur, conservative treatment in warranted. Initial management of de Quervain’s is use of a thumb spica splint to stabilize the APL and EPB and limit snapping and friction of the tendons during ulnar deviation [52]. It has been suggested, however, that symptoms resolve most effectively with a corticosteroid injection to the tendon sheath of the first dorsal compartment, and practitioners may use this as first-line treatment [49]. Splints to limit wrist flexion in those with carpal tunnel syndrome may improve symptoms at night, though injections have also proven useful in this population. Corticosteroid injections during pregnancy have been shown to be safe with no ill effects to the fetus or the mother, as long as no medical contraindications exist [49]. While any injection carries the risk of infection, bleeding and hematoma, pain, and nerve injury, with a wrist injection, the most common side effect is hypopigmentation and fat atrophy [53], the risk of which should be clearly discussed with the woman prior to injection. Discoloration and atrophy of subcutaneous fat occur when a portion of the steroid is injected just beneath the dermis rather than into the sheath. Direct visualization of the tendons or nerve with musculoskeletal ultrasound may help decrease the incidence of these complications. Regardless, hypopigmentation and fat atrophy resolve spontaneously by around 6–12 months postinjection [53].
References
1.
Vullo VJ, et al. Hip, knee, and foot pain during pregnancy and the postpartum period. Fam Pract. 1996;43(1):63–8.
2.
Gijon-Nogueron GA, et al. Anthropometric foot changes during pregnancy: a pilot study. J Am Podiatr Med Assoc. 2013;103(4):314–21.CrossRefPubMed
3.
Nyska M, et al. Plantar foot pressures in pregnant women. Isr J Med Sci. 1997;33(2):139–46.PubMed
4.
Alvarez R, Sokes IA, et al. Dimensional changes of the feet in pregnancy. J Bone Joint Surg Am. 1988;70(2):271–4.CrossRefPubMed
5.
Cutts S, et al. Plantar fasciitis. W Ann R Coll Surg Engl. 2012;94(8):539–42.CrossRef
6.
Irving DB, Cook JL, Menz HB. Factors associated with chronic plantar heel pain: a systematic review. J Sci Med Sport. 2006;9:11–22.CrossRefPubMed
7.
Mohammad AT, et al. Plantar fasciitis. J Res Med Sci. 2012;17(8):799–804.
8.
Hawke F. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;3, CD006801.
9.
Martin RL, et al. Heel pain—plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1–23.CrossRefPubMed
10.
Crawford F, Thomson C. Interventions for treating plantar heel pain. Chocrane Database Syst Rev. 2003;3, CD000416.
11.
Antonucci R, et al. Use of non-steroidal anti-inflammatory drugs in pregnancy: impact on the fetus and newborn. Curr Drug Metab. 2012;13(4):474–90.CrossRefPubMed
12.
Briggs GG, Freeman RK, Yaffe SJ, editors. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 5th ed. Baltimore: Williams & Wilkins; 1998. p. 577–8, 627–8.
13.
Black RA, Hill DA. Over-the-counter medications in pregnancy. Am Fam Physician. 2003;67(12):2517–24.PubMed
14.
Thompson JM. Associations between acetaminophen use during pregnancy and ADHD symptoms measured at ages 7 and 11 years. PLoS One. 2014;9(9), e108210.CrossRefPubMedPubMedCentral
15.
Boling M, et al. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010;20:725–30.CrossRefPubMedPubMedCentral
16.
Stefanik JJ, et al. Association between patella alta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis: the multicenter osteoarthritis study. Arthritis Care Res. 2010;62:1258–65.CrossRef
17.
Post WR. Clinical evaluation of patients with patellofemoral disorders. Arthroscopy. 1999;15(8):841.CrossRefPubMed
18.
Barton CJ. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47(4):207–14.CrossRefPubMed
19.
Nakagawa TH, et al. Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single-leg squat in males and females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2012;42:491–501.CrossRefPubMed
20.
Noehren B, et al. Prospective evidence for a hip etiology in patellofemoral pain. Med Sci Sports Exerc. 2013;45:1120–4.CrossRefPubMed
21.
Van Der Heijden RA et al. Exercise for treating patellofemoral pain syndrome: an abridged version of Cochrane systematic review. Eur J Phys Rehabil Med. 2016 Feb;52(1):110–33.
22.
Noehren B, Pohl MB, Sanchez Z, et al. Proximal and distal kinematics in female runners with patellofemoral pain. Clin Biomech. 2012;27:366–71.CrossRef
23.
Witvrouw E, et al. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013. Br J Sports Med. 2014;48(6):411–4.CrossRefPubMed
24.
Branco M, et al. Biomechanics of gait during pregnancy. ScientificWorldJournal. 2014;2014:527940.CrossRefPubMedPubMedCentral
25.
Garber CE, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–59.CrossRefPubMed
26.
ACOG Committee Obstetric Practice. ACOG Committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Obset Gynecol. 2002;99(1):171–3.
27.
Foti T, Davids JR, Bagley A. A biomechanical analysis of gait during pregnancy. J Bone Joint Surg Am. 2000;82(5):625.
28.
Sabino J and Grauer J. Pregnancy and Low Back Pain. Curr Rev Musculoskelet Med. 2008 Jun; 1(2): 137–141.
29.
Tzeng YL, Su TJ. Low back pain during labor and related factors. J Nurs Res. 2008;16:231–241.
30.
Scriven MW, Jones DA, McKnight L. Current concepts review. Musculoskeletal considerations in pregnancy. J Bone Joint Surg Am. 1995;77(9):1465.
31.
Atlas S and Deyo R. Evaluating and Managing Acute Low Back Pain in the Primary Care Setting. J Gen Intern Med. 2001 Feb; 16(2): 120–131.
32.
Clare HA, Adams R, Maher CG. Systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother. 2004; 50(4):209-16.
33.
Dunsford A, Kumar S, and Clarke S. Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain. J Multidiscip Healthc. 2011; 4: 393–402.
34.
Laslet M. Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther. 2008; 16(3): 142–152.
35.
Mens JM, Huis In ‘t Veld YH, and Pool-Goudzwaard A. The Active Straight Leg Raise test in lumbopelvic pain during pregnancy. Man Ther. 2012 Aug;17(4):364-8. Epub 2012 Feb 22.
36.
American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Committee Opinion No. 656: Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Obstet Gynecol. 2016 Feb;127(2):e75-80.
37.
Garshasbi A, Faghih Zadeh S. The effect of exercise on the intensity of low back pain in pregnant women. Spine. 2005;30(8):983–91.
38.
Pennick V, Liddle SD. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2013.
39.
Ivell R. Endocrinology. This hormone has been relaxin’ too long! Science. 2002;295(5555):637.
40.
Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Medicine. 2011;9:15.
41.
Andrews CM, O’Neill LM. Use of pelvic tilt exercise for ligament pain relief. J Nurse Midwifery. 1994 Nov-Dec;39(6):370-4.
42.
Snow RE, Neubert AG. Peripartum pubic symphysis separation: a case series and review of the literature. Obstet Gynecol Surv. 1997;52(7):438.
43.
Parker JM, Bhattacharjee M. Images in clinical medicine. Peripartum diastasis of the symphysis pubis. N Engl J Med. 2009;361(19):1886.
44.
Aprato A, Massè A, Faletti C, et al. Magnetic resonance arthrography for femoroacetabular impingement surgery: is it reliable? Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology. 2013;14(3):201-206.
45.
Pellicci PM, Zolla-Pazner S, Rabhan WN, Wilson PD Jr. Osteonecrosis of the femoral head associated with pregnancy. Report of three cases. Clin Orthop Relat Res. 1984.
46.
Skaggs CD, Winchester BA, Vianin M, Prather H. A manual therapy and exercise approach to meralgia paresthetica in pregnancy: a case report. Journal of Chiropractic Medicine. 2006;5(3):92-96. doi:10.1016/S0899-3467(07)60140-2.
47.
Ilyas AM, Ast M, Schaffer AA, Thoder J. De Quervain tenosynovitis of the wrist. J Am Acad Orthop Surg. 2007;15(12):757–764.
48.
Schumacher HR Jr, Dorwart BB, Korzeniowski OM. Occurrence of De Quervain’s tendinitis during pregnancy. Arch Intern Med. 1985 Nov;145(11):2083-4.
49.
Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg Am. 2002 Mar;27(2):322-4.
50.
Merritt MM1, Roddey TS, Costello C, Olson S. Diagnostic value of clinical grind test for carpometacarpal osteoarthritis of the thumb. J Hand Ther. 2010 Jul-Sep;23(3):261-7.
51.
Zyluk A. Carpal tunnel syndrome in pregnancy: a review. Pol Orthop Traumatol. 2013 Oct 7;78:223-7.
52.
Goel R, Abzug JM. de Quervain’s tenosynovitis: a review of the rehabilitative options. Hand (New York, NY). 2015;10(1):1-5.
53.
Sawaizumi T, Nanno M, Ito H. De Quervain’s disease: efficacy of intra-sheath triamcinolone injection. International Orthopaedics. 2007;31(2):265-268.