What are the treatment options for buttocks and girdle pain with muscle spasm in the 3rd trimester of pregnancy?

Treatment of Buttocks and Girdle Pain with Muscle Spasm in Third Trimester

For buttocks and pelvic girdle pain with muscle spasm in the third trimester, initiate conservative management with pelvic support garments, activity modification, and manual therapy (physiotherapy, massage, or chiropractic care), as these are safe, evidence-based first-line treatments that avoid pharmacologic risks to the fetus. 1, 2, 3

Understanding the Condition

Pelvic girdle pain (PGP) affects nearly 20% of pregnancies and involves pain at the anterior and/or posterior aspects of the pelvic ring, with prevalence peaking in months 6-7 of gestation 1. The underlying mechanisms include:

• Ligamentous laxity: Pregnancy hormones (relaxin, progesterone, estrogen) reduce ligament rigidity, weakening joint stability and increasing demand on stabilizing muscles 1
• Biomechanical changes: Increased abdominal mass shifts the center of gravity anteriorly, creating additional load on the musculoskeletal system and increasing lumbar lordosis 1, 4, 2
• Postural instability: The anterior shift in center of mass increases postural sway and reduces stability, particularly problematic in the third trimester 4

First-Line Conservative Management

Pelvic Support Garments

• Use pelvic support belts to provide external compression and stabilization of the pelvic ring 3, 5
• These garments help compensate for ligamentous laxity and reduce load transfer pain 3

Activity Modification

• Avoid overhead lifting due to increased postural instability 4
• Avoid floor-level lifting after 20 weeks as abdominal protrusion makes this impractical 4
• Limit bending at the waist to <1 hour/day, as exceeding this increases preterm labor risk nearly 3-fold 4
• Reduce heavy lifting (10-20 kg more than 20 times per week), which significantly increases musculoskeletal complications 1, 4
• Minimize prolonged standing or stooping, which exacerbates venous insufficiency and may induce fetal hypoxia 4

Manual Therapy and Physical Therapy

• Massage therapy and chiropractic care (including spinal manipulation) are highly safe and effective for mechanical low back and pelvic pain in pregnancy 2
• Physiotherapy with stabilizing exercises can alleviate symptoms and prevent progression 3, 5
• These interventions should be multimodal and individualized by a trained therapist 3, 5

Non-Pharmacologic Adjunctive Therapies

When conservative measures are insufficient, add:

• TENS therapy (transcutaneous electrical nerve stimulation) for pain relief 6
• Kinesio taping for muscular support 6
• Acupuncture as a complementary therapy 6
• Lymphatic drainage if edema is present (but only if not caused by preeclampsia) 6

Pharmacologic Management (When Necessary)

Important caveat: In the third trimester, medication options are more limited due to fetal risks.

Safe Options in Third Trimester:

• Acetaminophen (paracetamol) can be used carefully throughout pregnancy, including the third trimester 6
• Opioids may be considered for severe pain when benefits outweigh risks, though use should be limited 6

Medications to AVOID in Third Trimester:

• NSAIDs (ibuprofen, diclofenac) are contraindicated in the third trimester due to serious fetal risks including premature closure of the ductus arteriosus, oligohydramnios, and pulmonary hypertension 7, 6
• COX-2 inhibitors are not recommended during pregnancy 6

For Neuropathic Component (if present):

• Amitriptyline, duloxetine, or venlafaxine are considered safe if neuropathic pain is a significant component 6

Clinical Pitfalls to Avoid

• Underreporting: Women often don't report PGP to prenatal providers, leading to insufficient clinical attention 1
• Inappropriate exercise prescription: Contrary to traditional teaching, research shows that the transverse abdominal muscle is often excessively active (not weak) in long-lasting pregnancy-related PGP, so exercises aimed at enhancing TrA contraction may not be appropriate 8
• Delayed intervention: Early multimodal conservative treatment prevents progression to severe disability and chronic postpartum pain 3, 5
• NSAID use in late pregnancy: This is a critical safety issue that must be avoided 7, 6

Prognosis and Follow-up

• For most women, back pain resolves spontaneously after delivery 1
• Women at highest risk for persistent postpartum pain include those with back pain prior to pregnancy, early symptom onset, higher pain severity, or both low back pain and PGP simultaneously 1
• There is increased risk of recurrent PGP in subsequent pregnancies 5