Pregnancy-related low back pain and pelvic girdle pain

Last updated 28 Mar 2026 · Inflammatory Arthritis

Introduction

Pregnancy-related low back pain (PLBP) and pelvic girdle pain (PGP) are common musculoskeletal complaints affecting 45–70% of pregnant women in Australia. These conditions cause significant disability and reduced quality of life, affecting work capacity, sleep, and mobility. While generally benign and self-limiting, the pain can be severe and interfere substantially with daily functioning and pregnancy experience.

Distinction between PLBP (affecting the lumbosacral spine and surrounding musculature) and PGP (localised to the sacroiliac joints, pubic symphysis, and hip girdle) is important, as management strategies differ slightly. Most women experience improvement with physiotherapy, activity modification, and safe analgesia, typically resolving completely within 3–6 months after delivery.

Pathophysiology and Risk Factors

Contributing Factors

Mechanical: Progressive anterior shift of the centre of gravity (especially third trimester) increases lumbar lordosis and loading on the lumbosacral spine.
Hormonal: Relaxin (elevated in pregnancy) causes ligamentous laxity and altered spinal and pelvic stability.
Postural changes: Kyphosis of thoracic spine, increased lumbar lordosis, anterior pelvic tilt place increased stress on lumbosacral and pelvic structures.
Muscular: Altered recruitment patterns of deep stabilising muscles (transversus abdominis, multifidus) reduce pelvic and spinal stability.
Risk factors: Pre-pregnancy low back pain, poor fitness, psychosocial stress, previous pelvic injury, prolonged sedentary work, high BMI.

Types of Pain

Low back pain: Pain in lumbosacral region (below rib cage, above gluteal fold), worse with prolonged sitting, standing, or bending. Typically symmetrical. Pelvic girdle pain: Localised pain at sacroiliac joints, pubic symphysis, and/or hips. Pain with walking, stairs, turning in bed. Often asymmetrical.

Clinical Presentation

Timing and Characteristics

Onset: Can occur at any time during pregnancy, most commonly from second trimester onwards (weeks 12–30). Pain characteristics: Described as aching, sharp, or stabbing. Worse with activity, particularly with walking, stairs, standing from sitting. Often worse at end of day or after activity. Morning stiffness common.

Functional Impact

Difficulty with prolonged sitting or standing. Difficulty rolling over in bed, getting up from lying or sitting. Difficulty with stairs and walking. Reduced work capacity. Sleep disturbance due to pain-related position changes.

Examination Findings

Posture: Increased lumbar lordosis, thoracic kyphosis, anterior pelvic tilt. Palpation: Tenderness over lumbosacral spine, sacroiliac joints, or greater trochanters. Muscle tightness in hip flexors, glutei, piriformis. Tests: Patrick's test (FABER) painful in PGP. Sacroiliac joint compression/distraction painful in PGP.

Investigations

Essential
Clinical History and Examination
Diagnosis is clinical. Obtain details of pain location, onset, aggravating/relieving factors. Perform focused examination of lumbar spine, hips, sacroiliac joints. Assess functional limitation.
Available
Plain Radiography
NOT recommended in pregnancy due to radiation exposure. Reserve for evaluation of suspected structural pathology after delivery if pain persists.
Available
Ultrasound
Safe in pregnancy. Can assess soft tissue structures and exclude other pathology. Not required for routine PLBP/PGP diagnosis.
Available
MRI
Safe in pregnancy (no radiation). Reserve for suspected serious pathology (cord compression, malignancy) if clinical features are atypical. Not routinely needed for PLBP/PGP.

Severity Grading

MILD

Occasional Pain

Pain with specific activities (e.g., prolonged standing, stairs) but not present at rest. Minimal impact on daily activities. Pain score <5/10.

Community or primary care; home exercises; analgesia as needed

MODERATE

Frequent Pain with Functional Impact

Pain present most days, particularly with activities. Interferes with work or daily tasks. Pain score 5–7/10. Sleep disruption.

Primary care with physiotherapy referral; activity modification; regular analgesia

SEVERE

Significant Disability

Constant pain or pain with minimal activity. Unable to work. Significant functional limitation. Pain score >7/10. Sleep severely disrupted.

Specialist physiotherapy; multidisciplinary team; maternity service involvement; consider sick leave

Directed Therapy

First-Line: Physiotherapy

Physiotherapy is the cornerstone of management for PLBP and PGP in pregnancy. Evidence strongly supports exercise-based interventions for pain reduction, functional improvement, and prevention of persistence of pain postpartum.

Core components: (1) Individualised exercise programme addressing postural control and spinal/pelvic stability, (2) Stretching of tight muscles (hip flexors, glutei, piriformis), (3) Education on body mechanics and activity modification, (4) Manual therapy (mobilisation, soft tissue release) if tolerated.

Safe Analgesia Options

💊

Paracetamol

Panadol® · Non-opioid analgesic

Pregnancy CategoryA (safe in all trimesters)

Dose1000 mg every 4–6 hours (max 4000 mg/24 hrs)

RouteOral

NotesSafest analgesic in pregnancy. First-line for pain. Use lowest effective dose for shortest duration.

PBS Status✓ PBS General Benefit

💊

Ibuprofen

Nurofen® · NSAID

Pregnancy CategoryA (first/second trimester); Contraindicated third trimester

Dose400–600 mg every 6–8 hours (max 2400 mg/24 hrs)

RouteOral

NotesEffective for musculoskeletal pain. Use only in first and second trimester. Avoid after 32 weeks gestation (risk of premature ductus arteriosus closure). Take with food.

PBS Status✓ PBS General Benefit

Adjunctive Measures

Pelvic support belt/brace: Can provide symptomatic relief in PGP by reducing sacroiliac and pubic symphysis motion. Should be fitted properly. Discontinue after delivery.

Manual and physical therapies: Massage, acupuncture, and spinal manipulation (if performed by trained practitioners) may provide symptomatic relief. Ensure practitioners are aware of pregnancy and modify techniques accordingly.

Activity modification: Avoid activities that exacerbate pain (prolonged standing, climbing stairs, heavy lifting). Plan activities with rest breaks. Use assistive devices (crutches, walker) if severe PGP affects ambulation.

Acute Management

Initial Presentation

When a pregnant woman presents with low back pain or pelvic girdle pain:

Detailed history: Pregnancy trimester, onset (gradual vs sudden), pain location and radiation, aggravating/relieving factors, associated neurological symptoms (leg pain, numbness, weakness), history of back pain pre-pregnancy.
Obstetric history: Any uterine pain or contractions? Vaginal bleeding? These suggest obstetric causes requiring different management.
Focused examination: Assess lumbar spine, sacroiliac joints, hips. Check for neurological signs. Red flags: neurological deficit, severe unilateral pain, fever.
Exclude other diagnoses: Pyelonephritis, appendicitis, preterm labour, placental abruption (if sudden-onset severe pain).

Monitoring and Follow-Up

Physiotherapy Referral

Timing: Refer to physiotherapy early, ideally before symptoms become severe. Early intervention improves outcomes. Frequency: Initial assessment plus 2–4 sessions over 4–8 weeks, with home exercise programme as mainstay of treatment.

Primary Care Follow-Up

At routine antenatal visits: Ask about pain and functional limitation. Assess adherence to physiotherapy and exercise. Monitor for red flags (neurological changes, severe unilateral pain, constitutional symptoms suggesting infection).

Postpartum: Most pain resolves completely within 3 months of delivery. If pain persists beyond 3 months postpartum, consider imaging (X-ray, MRI) to exclude structural pathology. Some women require ongoing physiotherapy if pain persists.

Special Populations

🤰 Pregnancy-Specific Management

First trimesterPain less common. If present, initiate early physiotherapy and safe analgesia (paracetamol). NSAIDs safe but use with caution.

Second trimesterPeak incidence of PLBP/PGP onset. Intensive physiotherapy most beneficial. NSAIDs safe until 32 weeks. Support belt can be introduced.

Third trimesterAvoid NSAIDs. Rely on paracetamol, physiotherapy, support belt. Frequent reassessment needed.

🤱 Postpartum Period

First 3 months postpartumPain typically improves rapidly. Continue gentle exercise/physiotherapy. Pain usually resolves completely by 3 months. Breastfeeding-safe analgesia (paracetamol, ibuprofen, codeine).

Aboriginal and Torres Strait Islander Health Considerations

Pregnancy-related musculoskeletal pain affects Aboriginal and Torres Strait Islander women at similar rates to other Australian populations. However, access to physiotherapy services is often limited in remote and rural communities, and cultural factors may influence help-seeking behaviour and management preferences.

Access to Physiotherapy

Limited availability of physiotherapy in remote and regional areas. Telehealth physiotherapy where internet access available. Train Aboriginal health workers or midwives to deliver basic home exercises. Provide written/video guidance for self-directed exercise.

Health Literacy

Complex information about pain management and exercise may not be accessible to all women. Use plain language and visual aids. Involve trusted community health workers in patient education. Provide translated materials if needed.

Cultural Attitudes Toward Pain

Cultural perspectives on pain during pregnancy may differ from biomedical model. Respect cultural beliefs while providing evidence-based management. Discuss benefits of early intervention and exercise.

Antenatal Care Continuity

Fragmented antenatal care in some communities may affect identification and management of PLBP/PGP. Ensure screening for pain symptoms at each antenatal visit. Integrate physiotherapy advice into routine antenatal counselling.

Stewardship and Key Points

Key Messages

PLBP and PGP are common and benign: Affecting 45–70% of pregnant women. Reassure women that conditions resolve postpartum in nearly all cases (>95% pain-free at 3 months postpartum).
Physiotherapy is first-line and most effective: Refer early before pain becomes severe. Home exercises are central to long-term benefit.
Paracetamol is safe throughout pregnancy: Use as first-line analgesic. NSAIDs safe in first and second trimester only (avoid third trimester).
Activity modification and pelvic support belts are helpful adjuncts: Avoid complete rest as immobility worsens pain and functional limitation.
Multidisciplinary approach is most effective: Involve physiotherapist, GP, and midwife. Support women psychologically as pain can be emotionally distressing.

Red Flags Warranting Urgent Assessment

Refer urgently if: Acute-onset severe pain (suggests obstetric cause or serious pathology). Progressive neurological deficit (weakness, numbness extending down leg). Signs of systemic infection (high fever, rigors). Pain accompanied by urinary/bowel incontinence or dysfunction (cauda equina syndrome risk).

References

01
Vleeming A, Albert HB, Ostgaard HC, et al. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794-819.
02
Liddle SD, Pennick V. Interventions for preventing and treating low back and pelvic pain during pregnancy. Cochrane Database Syst Rev. 2015;(9):CD001139.
03
Australian Royal College of Obstetricians and Gynaecologists (RANZCOG). Pregnancy and musculoskeletal pain. 2023 Clinical Guidelines.
04
Magee DJ, Zachazewski JE, Quillen WS. Pathology and Intervention in Musculoskeletal Rehabilitation. 3rd ed. Elsevier; 2016.