Management of Postpartum Back Pain at 3 Months
Begin with specific trunk muscle training targeting the transversus abdominis and multifidus muscles, as this intervention has demonstrated effectiveness in reducing both pain and activity limitation in postpartum women with back pain. 1
Understanding the Clinical Context
Postpartum back pain at 3 months is extremely common and often underrecognized. The incidence of first-onset low back pain ranges from 19% to 53%, with a mean incidence of 31.6% in the postpartum period. 2 This is not a trivial problem—it affects daily activities, interferes with infant care, and can persist for months to years if not properly addressed. 2, 3
A critical pitfall is assuming this pain will spontaneously resolve. While back pain does generally resolve postpartum for most women, those with persistent pain at 3 months are at significant risk for long-term disability, particularly if they had back pain prior to pregnancy, experienced early symptom onset, or had higher pain severity during pregnancy. 2
Initial Assessment Priorities
Perform a focused mechanical assessment to classify the pain subtype, as this directly impacts prognosis and treatment:
- Pelvic girdle pain (PGP): Identified through pelvic pain provocation tests 4
- Lumbar pain: Assessed via mechanical examination of the lumbar spine 4
- Combined pain: Both PGP and lumbar components present 4
This distinction matters clinically: Women with combined pain have the worst prognosis, with only 33% recovering compared to 66% with PGP alone and 72% with lumbar pain alone. 4 Combined pain classification is itself a predictor for persistent postpartum pain. 4
Essential Physical Examination Components
- Pelvic and leg length assessment: Unresolved pelvic rotation and dislocation can result in short leg syndrome, a frequently missed cause of persistent postpartum lower back pain 5
- Trunk muscle endurance testing: Low endurance of back flexors is a predictor for persistent pain 4
- Hip muscle strength evaluation: Using dynamometry if available 4
- Gait speed assessment 4
Evidence-Based Treatment Algorithm
First-Line Intervention: Specific Muscle Training
Implement individualized specific deep muscle training of the transversus abdominis and multifidus muscles. 1 This approach showed a trend toward reduced pain and activity limitation across all subjects in a controlled study design. 1
The training protocol should focus on:
- Deep trunk stabilizer activation
- Progressive resistance as tolerated
- Integration into functional activities and infant care tasks
Complementary Non-Pharmacological Approaches
Consider these evidence-supported modalities as adjuncts:
- Posture adjustment and education 3
- Physical therapy/physiotherapy 3
- Acupuncture 3
- Osteopathic manipulation: Particularly valuable when pelvic assessment reveals rotation or leg length discrepancy 5
Pharmacological Management (When Needed)
If pain significantly limits function despite exercise interventions:
- Analgesics: Various options available, though evidence is limited for specific recommendations in this population 5, 3
- Avoid routine steroid injections unless specific structural pathology is identified 5
Addressing Kinesiophobia
Screen for kinesiophobia (fear of movement) as it is present in women with postpartum back pain and may impede recovery. 1 Use the Tampa Scale for Kinesiophobia if available. 1 Address this through:
- Education about the safety of movement postpartum
- Gradual exposure to feared activities
- Reassurance that exercise-based treatment is safe and effective
Red Flags Requiring Further Investigation
While most postpartum back pain is mechanical, evaluate for:
- Lower extremity nerve injury: Incidence ranges from 0.3% to 2.3% up to 6 months postpartum 2
- Progressive neurological deficits
- Severe, unremitting pain unresponsive to position changes
- Constitutional symptoms suggesting infection or systemic disease
Prognosis and Counseling
Set realistic expectations: For women still experiencing pain at 3 months postpartum, spontaneous resolution is less likely without intervention. 2, 4 However, with appropriate specific muscle training and physical therapy, significant improvement is achievable. 1
Risk factors for persistent pain include:
- Pre-pregnancy back pain history 2
- Combined PGP and lumbar pain 4
- Older age 4
- Work dissatisfaction 4
- Low back flexor endurance 4
Common Clinical Pitfalls to Avoid
Do not attribute persistent postpartum back pain to epidural anesthesia. Recent literature clearly refutes this association, though it remains a common patient perception. 5, 3
Do not assume all postpartum back pain is the same entity. Subtype classification (PGP vs. lumbar vs. combined) has prognostic and treatment implications. 4
Do not overlook pelvic and leg length assessment. Short leg syndrome from unresolved pelvic rotation is a treatable cause that is frequently missed. 5
Do not delay intervention. Early identification and treatment in women at risk for persistent pain is possible and should be implemented. 4