Coccydynia (Tailbone Pain)

Piriformis Syndrome

Back pain in children

Back Pain in Pregnancy

Back Pain after Pregnancy

 

 

Coccydynia (Tailbone Pain)

 

Coccydynia refers to any type of persistent tailbone pain.

 

The tailbone, located at the very bottom of the spine, is medically known as the coccyx. Coccydynia is typically felt as a localized pain that usually worsens when sitting or with any activity that puts pressure on the bottom of the spine.

The condition is much more common in women than men. It is usually caused by trauma to the tailbone or surrounding area, such as a backward fall or childbirth. On rare occasions, an infection or tumor can also cause pain in the coccyx.

 

 

Symptoms

Tailbone pain is usually accompanied by other, more specific symptoms that can sometimes indicate how pain is occurring. Coccydynia may be further characterized by one or a combination of the following symptoms:

●      Localized pain and tenderness. Pain is generally confined to the tailbone, and does not radiate through the pelvis or to the lower extremities.

●      Increased pain with sitting. Coccydynia is generally more intense when weight is placed on the tailbone, as in when a person leans backward in a sitting position.

●      Pain that is worse when moving from sitting to standing. When moving from a seated position to standing or vice versa, the rotation of the pelvic bones (and muscle movements that assist this rotation) may be painful.

●      Pain that may increase with bowel movement or sexual intercourse. Some patients experience heightened pain during sexual intercourse or defecation, due to the proximity of the coccyx to the anus and genitals.

 

Causes

 

Direct trauma to the tailbone is the most common cause of coccydynia, and usually leads to inflammation surrounding the coccyx, which contributes to pain and discomfort.

There are many cases reported in which pain begins with no identifiable origin (called idiopathic coccydynia).

Possible Causes of Coccydynia

A diagnosis of coccydynia will usually identify one of the following underlying causes of pain:

●      Local trauma. A direct injury to the coccyx is probably the most common cause of coccydynia. A fall on the tailbone can inflame the ligaments and injure the coccyx or the coccygeal attachment to the sacrum.

●      Repetitive stress. Activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surfaces for long periods of time, may cause the onset of coccyx pain.

●      Childbirth. During delivery, the baby's head passes over the top of the coccyx, and the pressure against the coccyx can sometimes result in injury to the coccygeal structures (the disc, ligaments, and bones).

●      Tumor or infection. Rarely, coccydynia can be caused by a nearby tumor or infection that puts pressure on the coccyx.

●      Referred coccyx pain. In rare cases pain will be referred to the coccyx from elsewhere in the spine or pelvis, such as a lumbar herniated disc or degenerative lumbar disc.

Risk factors for coccydynia include:

●      Obesity. Pelvic rotation, including movement of the coccyx, is usually lessened in individuals who are overweight, leading to more continual stress being placed on the coccyx and increasing the chances of developing coccyx pain.

●      Gender. Women have a higher chance of developing coccydynia than men, due to a wider pelvic angle as well as trauma to the coccyx endured during childbirth.

Diagnosis

 

Coccydynia is typically diagnosed by gathering a thorough medical history and completing a physical exam. These two standard diagnostic practices are usually sufficient in obtaining a diagnosis and evaluating treatment options, but in some cases, diagnostic tests such as scans or injections may be used.

Initial Diagnostic Methods for Coccydynia

A complete medical history collected will likely include information on current symptoms, as well as when and how symptoms developed. A doctor may also look for environmental or lifestyle factors for the patient’s pain, such as recent injury, exercise habits, or obesity.

After a medical history is collected, a doctor will begin a physical exam. A thorough physical examination for coccyx pain may include:

●      Palpation to check for local tenderness. A doctor will feel by hand (called palpation) to identify swelling and tenderness around the coccyx. Palpation may also be used to identify potential coccygeal spicules (bone spurs), cysts, or tumors.

●      Intrarectal exam and manipulation. In some cases, a doctor may choose to manipulate the coccyx manually through the rectum, in order to assess limited or excessive mobility of the sacrococcygeal joint. Intrarectal manipulation may also be used to assess any muscle tension in the pelvis connecting to the coccyx.

The most consistent finding on examination is usually tenderness upon palpation of the coccyx. If the coccyx is not tender to palpation, then the pain is likely referred from another part of the spine.

 

Diagnostic Tests for Coccydynia

●      Dynamic X-ray imaging tests. A dynamic X-ray produces two images—one of the patient sitting and another of the patient standing. A doctor will compare the images and measure the angle of pelvic rotation as well as the coccyx’s change in position from sitting to standing. If these measurements are outside of the normal range (between 5 and 25 degrees), too much or too little coccygeal movement can be identified as the cause of pain.

●      Coccygeal discogram. Similar to the same procedure done on the lumbar spine, a coccygeal discogram consists of an injection of local anesthesia in the sacrococcygeal region. The injection targets a specific area in the spine, such as an intervertebral joint or disc, to identify the precise location where pain is being caused.

●      CT or MRI scans. A static image of the coccyx taken by MRI or CT scan (one that does not illustrate pelvic rotation or movement) may be used if the suspected cause of pain is a fracture, tumor, or abnormal mobility of the sacrococcygeal joint. Static images, however, are usually not helpful for diagnosing coccydynia and are used sparingly when a source of coccydynia cannot be clearly identified using other means.

 

Treatment

 

Many studies find that non-surgical treatments are successful in approximately 90% of coccydynia cases. Treatments for coccydynia are usually noninvasive and include activity modification.

The first line of treatment typically includes self-care that can be done without the assistance of a medical professional, such as some of the following:

●      Non-steroidal anti-inflammatory drugs (NSAIDs), help reduce the inflammation around the coccyx that is usually a cause of the pain.

●      Ice or cold pack. Applying ice or a cold pack to the area several times a day for the first few days after pain starts can help reduce inflammation, which typically occurs after injury and adds to pain.

●      Heat or heating pad. Applying heat to the bottom of the spine after the first few days of pain may help relieve muscle tension, which may accompany or exacerbate coccyx pain.

●      Activity modification. Alterations to everyday activities can help take cumulative pressure off of the tailbone and alleviate pain. These activity modifications may include using a standing desk to avoid prolonged sitting, using a pillow to take the weight off the coccyx, or adjusting posture so weight is taken off the tailbone when sitting.

●      Supportive pillows. A custom pillow that takes pressure off the coccyx when sitting may be used. Pillows for alleviating coccydynia may include U- or V-shaped pillows, or wedge-shaped pillows with a cutout or hole where the tailbone is. Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal and largely a matter of personal preference. A supportive cushion can be useful in the car, as well as in an office, classroom, or at home.

●      Dietary changes. If tailbone pain is caused by or worsened with bowel movements or constipation, increased fiber and water intake, as well as stool softeners, is recommended.

 

Additional Non-Surgical Treatments for Coccydynia

If tailbone pain is persistent or severe, additional non-surgical treatment options for coccydynia may include:

●      Injection. An injection of a numbing agent (lidocaine) and steroid (to decrease inflammation) in the area surrounding the coccyx may provide pain relief. The physician uses imaging guidance to ensure that the injection is administered to the correct area. Pain relief can last from 1 week up to several years. If the first injection is effective, patients may receive up to 3 injections in a year.

●      Manual manipulation. Some patients find pain relief through manual manipulation of the coccyx. Through manual manipulation, the joint between the sacrum and the coccyx can be adjusted, potentially reducing pain caused by inadequate coccyx mobility.

●      Massage. Coccydynia may be reduced or alleviated by massaging tense pelvic floor muscles that attach to the coccyx. Tense muscles in this region can place added strain on the ligaments and sacrococcygeal joint, limiting its mobility or pulling on the coccyx.

●      Stretching. Gently stretching the ligaments attached to the coccyx can be helpful in reducing muscle tension in the coccygeal area.

●      TENS unit. Transcutaneous Electrical Nerve Stimulator (TENS) units apply electric stimulation that interferes with the transmission of pain signals from the coccyx to the brain. These devices can be good option for patients who wish to keep their intake of medications to a minimum.

Coccygectomy Surgery for Coccydynia (Tailbone Pain)

For persistent pain that is not alleviated with non-surgical treatment and/or activity modification, surgical removal of all or a portion of the coccyx (coccygectomy) is an option.

 

Coccygectomy surgery is rarely recommended and performed. While the surgery itself is a relatively straight-forward operation, recovery from the surgery can be a long and uncomfortable process for the patient.

 

Surgical Approach for Coccyx Pain

Surgeons may take slightly different approaches to the operation. Perhaps the biggest difference between surgeons is that some remove only part of the coccyx, while others recommend removing the entire coccyx.

 

The operation takes about thirty minutes to perform and can be done on an outpatient basis. The most difficult part of the operation is the long healing process. Generally, it takes three months to a year after the surgery before patients see any relief from their symptoms, and sitting is difficult throughout the healing process.

Coccygectomy tends to be most successful in carefully selected cases. The following criteria have shown an increased chance of positive results after surgery:

●     Patients whose pain is caused by changes in the shape of the coccyx, such as the presence of a spicule (a small bone spur at the end of the coccyx)

●     Patients with excessive mobility of the coccyx

●     The presence of a bursa, or a fluid-filled sac at the joint between the sacrum and coccyx

●     A good response to injection treatments

 

Potential Risks and Complications of Coccyx Surgery

Perhaps the biggest risk is continued pain in the coccyx post-operatively, meaning that the patient has endured the long healing process and still has not had improvement in the symptoms. For this reason, patient selection is crucial to a positive surgical outcome.

A possible but uncommon risk of coccygectomy is injury to the rectum as the coccyx is being removed. While it is unlikely, it is possible that if this were to happen, a diverting colostomy would be necessary to allow the rectum to heal.

Other potential risks include wound healing difficulties and/or local infection, which can delay the overall healing process. Unlike most other spine surgeries, there are no significant nerve roots in the region that would be at risk.

Piriformis Syndrome

Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain).

 

Causes of Piriformis Syndrome

The exact causes of piriformis syndrome are unknown. Suspected causes include:

 

Muscle spasm in the piriformis muscle, either because of irritation in the piriformis muscle itself, or irritation of a nearby structure such as the sacroiliac joint or hip

Tightening of the muscle, in response to injury or spasm

Swelling of the piriformis muscle, due to injury or spasm

Bleeding in the area of the piriformis muscle.

Any one or combination of the above problems can affect the piriformis muscle (causing buttock pain) and may affect the adjacent sciatic nerve (causing pain, tingling, or numbness in the back of the thigh, calf, or foot).

 

Symptoms of Piriformis Syndrome

 

Most commonly, patients describe acute tenderness in the buttock and sciatica-like pain down the back of the thigh, calf and foot. Typical piriformis syndrome symptoms may include:

●      A dull ache in the buttock

●      Pain down the back of the thigh, calf and foot (sciatica)

●      Pain when walking up stairs or inclines

●      Increased pain after prolonged sitting

●      Reduced range of motion of the hip joint

Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.

 

Diagnosing Piriformis Syndrome

Diagnosis of piriformis syndrome is based on a review of the patient’s medical history, a physical examination and possibly diagnostic tests.

 

 

 

Piriformis syndrome is often a diagnosis made through a process of ruling out other possible conditions that may be causing the patient’s symptoms, such as a lumbar disc herniation or sacroiliac joint dysfunction.

Physical exam

The physical exam will include an examination of the hip and legs to see if movement causes increased low back pain or lower extremity pain (sciatica pain).

Typically, motion of the hip will recreate the pain. The exam will also identify or rule out other possible causes of the sciatica pain, such as testing for local tenderness and muscle strength.

 

Medical history

A medical history includes an in-depth review of the patient’s symptoms, such as what positions or activities make the symptoms better or worse, how long the symptoms have been present, if they started gradually or after an injury, and what treatments have been tried.

It will also include a review of conditions that may be in the patient’s family, such as arthritis.

 

Diagnostic tests

X-rays and other spinal imaging studies cannot detect if the sciatic nerve is being irritated at the piriformis muscle. However, diagnostic tests (such as X-rays, MRI and nerve conduction tests) may be conducted to exclude other conditions that can cause similar symptoms to piriformis syndrome.

 

An injection of anesthetic with or without steroids may help to confirm if the piriformis muscle is the source of the symptoms.

 

Piriformis Muscle Stretch and Physical Therapy

Stretches for Piriformis Syndrome

A number of stretching exercises for the piriformis, hamstrings and hip extensors may help decrease the painful symptoms along the sciatic nerve and return the patient’s range of motion.

 

Piriformis stretches

There are a number of ways to stretch one's piriformis muscle. Two simple ways include:

 

Lie on the back with both feet flat on the floor and both knees bent. Pull the right knee up to the chest, grasp the knee with the left hand and pull it towards the left shoulder and hold the stretch. Repeat for each side.

Lie on the back with both feet flat on the floor and both knees bent. Rest the ankle of the right leg over the knee of the left leg. Pull the left thigh toward the chest and hold the stretch. Repeat for each side.

Each piriformis stretch should be held for 5 seconds to start, and gradually increased to hold for 30 seconds, and repeated three times each day.

 

 

 

Hamstring stretches

Stretching the hamstrings (the large muscle along the back of each thigh) is important to alleviate any type of sciatic pain. There are a number of ways to stretch the hamstrings:

Place two chairs facing each other. Sit on one chair and place the heel of one leg on the other chair. Lean forward, bending at the hips until a gentle stretch along the back of the thigh is felt, and hold the stretch.

Lie on the back with both legs straight. Pull one leg up and straighten by holding on to a towel that is wrapped behind the foot until a mild stretch along the back of the thigh is felt.

Again, try to work up to holding each stretch for 30 seconds and repeat three times each day.

 

Physical Therapy for Piriformis Syndrome

In addition to basic stretching, a comprehensive physical therapy and exercise program can be developed for each patient’s individual situation.

 

Range of motion exercises

A physical therapist, physiatrist, chiropractor or other qualified health practitioner can develop a customized program of stretching and range of motion exercises to help stretch the muscle and decrease spasm.

 

Deep Massage

Deep massage therapy (manual release) by a qualified specialist is thought to enhance healing by increasing blood flow to the area and decreasing muscle spasm.

Piriformis Syndrome Treatment

 

Depending on the severity of the patient’s sciatica-type pain and other symptoms, a number of treatment options may be recommended by a health care professional.

A comprehensive approach to managing piriformis syndrome may include a combination of the following nonsurgical treatments:

Ice and Heat Therapy for Piriformis Syndrome

A simple way to help relieve discomfort at home is to apply a cold compress or heating pad to the skin over the painful area.

 

Ice Packs and Ice Massage

At the onset of pain, lie in a comfortable position on the stomach and place an ice pack on the painful area for approximately 20 minutes. Repeat as needed every 2 to 4 hours.

 

It may be more helpful to combine a gentle massage with the ice. Lie on the stomach and have someone gently massage the painful area with a large ice cube. If ice is applied directly to the skin (instead of a cold pack), limit it to 8 to 10 minutes to avoid an ice burn.

 

Heat Therapy

Some people find it helpful to alternate cold with heat. If using a heating pad, lie on the stomach and place the heating pad on the painful area for up to 20 minutes. Be sure to avoid falling asleep on a heating pad, as this may lead to skin burns.

 

Medications for Sciatica Pain

Since most episodes of pain include some type of inflammation, non-steroidal anti-inflammatory medications (NSAIDs), may help decrease inflammation in the affected area.

 

Piriformis Steroids

For severe sciatica pain from piriformis syndrome, an injection may be part of the treatment.

 

Piriformis injection

A local anesthetic and corticosteroid may be injected directly into the piriformis muscle to help decrease the spasm and pain. The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy.

 

Botox injection

For persistent piriformis spasm that is resistant to treatment with anesthetic/corticosteroid injections, an injection of botulinum toxin (e.g. Botox®), a muscle weakening agent, may be useful. The goal of the injection is to help the muscle relax and help reduce pressure on the sciatic nerve.

The goal with both injections is to help the patient progress with stretching and physical therapy, so that when the effect of the injection is over the muscle will be remain stretched and relaxed.

 

Electrotherapy for Piriformis Syndrome

The application of electrical stimulation to the buttock with a transcutaneous electrical nerve stimulation (TENS) unit or interferential current stimulator (IFC) can help to block pain and reduce muscle spasm related to piriformis syndrome.

In persistent cases, the piriformis muscle can be cut to relieve symptoms, but this is rarely performed.

 

BACK PAIN IN CHILDREN

There are several unique aspects to consider when back pain occurs in a child or teenager. In rare cases, back pain may be a sign of a serious underlying condition that requires prompt medical attention.

 

Common Risk Factors for Back Pain in Kids and Teens

 

The most common risk factors for back pain in children and teens include sports participation; obesity; a sedentary lifestyle; and a family history of lower back pain, smoking, and/or psychological stress. For example, children and teens with a positive family history of lower back pain are almost twice as likely to experience back pain in childhood or adolescence versus their counterparts with no relevant family history.

Evidence suggests that those with lower back pain in childhood are at higher risk of developing lower back pain in adulthood.

 

 

School-age children who complain of back pain typically also have high levels of psychosocial difficulties, such as emotional distress and problems with behavior and/or everyday functions.

 

Types of Back Pain in Kids and Teens

Based on the underlying cause, a few types of back pain experienced by children may include:

 

Acute pain. A sharp, stabbing, and/or shooting pain may occur in event of an injury, trauma, fracture of the vertebra or vertebral growth plate, or herniated disc.

Chronic pain. A constant ache, pain that comes and goes, or posture-related pain may occur due to inflammatory spondyloarthropathies, psychological issues, or developmental problems, such as Scheuermann's disease.

Pain that worsens with spinal movement. Flexion (forward bending) increases pressure on the front part of the spinal bones, aggravating pain from conditions such as a herniated disc, discitis, osteomyelitis, or vertebral body tumor.

Extension (backward bending) of the spine increases the strain on the posterior part of the spinal bones, including the facet joints, pars interarticularis, and pedicles. A lesion or injury, such as an osteoid osteoma, osteoblastoma, or spondylolysis, in this area can cause pain while bending backward.

Night-time pain. Frequent pain that occurs at night and awakens the child is typically associated with tumors or infections, such as osteomyelitis, discitis, osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cyst, leukemia, Ewing's sarcoma, or spinal cord tumors.

Night-time back pain in children and teens warrants immediate medical attention.

 

Backpacks and Back Pain

There is some evidence to suggest that heavy backpacks may cause back pain in children.

Habitually carrying heavy backpacks over one shoulder may cause the muscles in the area to strain in order to compensate for the uneven weight, resulting in localized or one-sided pain in the shoulder and upper back.

Heavy backpacks may strain the neck muscles, contributing to or worsening existing back pain, shoulder pain, and arm pain.

Improperly loading a backpack and stooping forward while walking can distribute weight unevenly within the bag, causing strain on the back muscles.

 

 

When Back Pain in Kids and Teens May Be Serious

Back pain, specifically severe pain in the lower back region in children under 10 years of age and particularly in those younger than 4 years, should be considered a red flag for serious underlying pathologies, which may include:

Vertebral fracture

Spinal tumors

Infectious diseases

Cauda equina syndrome

Spinal tumors and fractures may be associated with additional symptoms, such as fatigue, stiffness in the spine upon waking in the morning, weight loss, loss of appetite, fever, and/or local tenderness on the spine. Night pain, pain that awakens the child from sleep, and pain at rest may be specific to tumors.

Symptoms of muscular back pain in children and adolescents

Classic symptoms and signs of muscular back pain in children and teens typically include:

●      Pain exacerbated by activity or movement

●      Pain exacerbated by prolonged sitting or standing

●      Pain and tenderness in the muscles on the right and/or left sides of the spine–and not the spine itself

Muscular back pain may be acute, sharp, and stabbing; or chronic, dull, and achy depending on the degree of muscle injury.

 

Possible causes of muscular back pain in children and adolescents

There may be a history of precipitating trauma, but more often, muscular back pain in children may develop gradually over time and flare insidiously, occurring due to one or a combination of the following factors:

●      Injury while playing or participating in sports

●      Carrying a backpack on one shoulder or using excessively heavy backpacks on a regular basis

●      Using unsupported posture while sitting, standing, and/or walking

●      Sleeping on an overly soft mattress

●      Leg length discrepancy

●      Obesity

Spinal Deformity or Malalignment

The growing spinal elements may develop deformities due to external stresses or unexplained causes. Two conditions are discussed below.

 

Scheuermann's disease

In Scheuermann's disease, an abnormality causes parts of the vertebrae to grow at different rates during a child’s growth spurt, causing some vertebrae to become wedge-shaped. These changes result in an exaggerated forward curvature of the upper back, termed “Scheuermann’s kyphosis.”

 

The condition manifests around the early- to mid-teenage years and typically causes:

●     Chronic pain in the upper back

●     Flaring of pain with activity and improvement with rest

The exact cause of Scheuermann's disease is unknown, but limited evidence suggests that there may be a genetic and/or metabolic component involved.

 

Spondylolysis

Athletic adolescents may be at risk of developing spondylolysis, a defect in the pars interarticularis (the joint between the vertebral bones) due to repeated hyperextension (bending backward) and rotation of the spine. Research suggests that this condition mainly affects boys, and up to 50% of adolescent athletes with lower back pain may have this condition.

 

Spondylolysis, a defect in the vertebra’s pars interarticularis, usually occurs at the L5-S1 spinal level.

 

The symptoms and signs of spondylolysis may mimic and be mistaken for muscular back pain and can be differentiated and diagnosed by radiologic tests.

Occasionally, spondylolysis may worsen and progress into spondylolisthesis, the “slipping" of a vertebra upon the one below it. This condition can progress through adolescence.

 

Herniated or Injured Spinal Discs

The delicate spinal discs (the spine’s shock absorbers, positioned between each bony vertebra) in children and adolescents may bulge or herniate from acute trauma, such as a fall or motor vehicle accident.

 

Herniated discs in the lower back can irritate or compress the adjoining spinal nerve, causing sciatica along the path supplied by the nerve.

 

Symptoms of a herniated disc in children and adolescents

A herniated disc in children and adolescents is similar to that in adults and may be associated with sciatica—pain, numbness, and/or weakness radiating down one or both legs, pain while coughing or sneezing (Valsalva maneuver), and/or stiffness in the lower spine.

 

Discitis

Discitis is a type of infection that affects the spinal disc. Infections affecting the spine are uncommon in children but are serious problems and must be evaluated and treated promptly.

 

Discitis predominantly affects younger children between 3 years and 5 years of age. The cause of discitis remains unclear, and researchers believe it may be caused by bacterial or viral infections.

 

Symptoms of discitis in children and adolescents

Discitis often occurs insidiously and can cause the following symptoms and signs:

 

●     Refusal to sit, crawl, or stand

●     Abdominal pain and vomiting

●     Pain in the hip

●     Mild fever

●     The child may demonstrate relief of symptoms upon lifting under the armpits, thereby relieving pressure on the affected disc.

 

Other rare spinal infections that may affect children include vertebral osteomyelitis, spinal TB (Pott’s disease), and epidural abscess.

 

Spinal Tumors and Cancer

Benign and malignant tumors of the spine may develop within the spinal cord, from the vertebral bone, due to infiltration of cancer cells in the bone marrow, or from the surrounding nervous tissue.

 

Symptoms of spinal tumors and cancer in children and adolescents

Back pain at night that wakes the child from sleep is the hallmark of a spinal tumor. It must, however, be understood that not all children who wake up from sleep due to pain have a spinal tumor. Night-time back pain is especially rare in children below 5 years of age, and this symptom warrants immediate medical attention.

 

Spinal tumors and cancers also cause generalized, unexplained weight loss; loss of appetite; and a general feeling of malaise.

 

Juvenile Ankylosing Spondylitis

Juvenile ankylosing spondylitis is a type of arthritis that causes inflammation of the spine and large joints, resulting in stiffness and pain in the affected areas. The thoracolumbar junction, where the upper back connects with the lower back, and the cervical spine (neck) are the commonly involved parts of the spine.

 

The condition manifests around 6 years to 12 years of age and usually affects boys before puberty and girls after puberty. A genetic predisposition is thought to be the primary cause of juvenile ankylosing spondylitis, and some researchers have also noted bacterial infections and developmental factors to contribute to its evolution.

 

Symptoms of juvenile ankylosing spondylitis in children and adolescents

The onset of this condition causes pain and stiffness in the lower limbs, including the knees, ankles, and feet.5 As the condition progresses, the spine gets involved and some combination of the following symptoms and signs may be experienced:

 

Back pain at night that may cause the child to awaken from sleep, especially during the second half of the night

Morning stiffness of the spine that lasts for 30 minutes or more

Reduced spinal movement while bending forward and/or sideways

Pain usually improves after exercise and does not improve with rest

In the later stages, alternating pain may occur in the buttock, hip, and chest areas.

 

Scoliosis

While scoliosis (abnormal curvature of the spine) is not an uncommon diagnosis among teenagers, adolescent scoliosis will rarely cause back pain. Teens with scoliosis may develop back pain from other causes, but it has not been found that people with adolescent idiopathic scoliosis are any more likely to develop back pain than the rest of the population.

 

Tethered Cord Syndrome

Tethered cord syndrome refers to the abnormal attachment of the spinal cord to the tissues that surround it.6 The abnormal attachment results in restriction of normal movement of the spinal cord and/or compromised blood flow to its terminal structures. This spinal condition can be present at birth (congenital) or acquired due to infection, scarring, or tumors affecting the lower back.

 

Symptoms of tethered cord syndrome in children and adolescents

Tethering of the spinal cord typically occurs around the lumbosacral junction (L5-S1 spinal segment).6 The symptoms and signs usually depend on the underlying cause of the tethered cord and may change with age.

 

Infants may have spontaneous leg movement, abnormal reflexes, foot asymmetry, and thinning of muscle mass in the leg (leg atrophy).

Toddlers may exhibit a delay in reaching the walking milestone or may have an abnormal gait.

School-age children may have back and leg pain that is often worsened with bending the spine forward (flexion) or vigorous physical activity, sensory deficits and weakness in the legs, painless foot burns (trophic ulcerations), and musculoskeletal deformities of the feet and spine, such as clubfoot or scoliosis.

Adolescents typically experience similar symptoms and signs as school-age children with increased sensory deficits, such as bowel and bladder dysfunction and weakness.

Other common lower back signs of tethered cord syndrome may include pink- or red-colored birthmarks (port-wine stain), swollen fatty nodules (cutaneous lipoma), and deviation of the gluteal crease, among others.

 

Psychosocial Factors

Psychosocial factors, such as depression, anxiety, behavioral issues, and pain perception, may be associated with the onset, exacerbation, and/or progress of chronic back pain in children and teens.1,7 These factors may also be related to pain in other areas of the spine, such as the neck.

 

Research suggests that physical pain and psychosocial factors may be linked through neurologic and chemical pathways in the body. Chemicals such as serotonin and norepinephrine that transmit nerve impulses during a physical injury are also known to affect a person’s mood. When there is a dysregulation or imbalance of these chemicals, physical pain may be felt in addition to a psychosocial issue, such as depression, anxiety, or stress.

 

As a general rule, back pain tends to be relatively uncommon in children and teens and any report of back pain or related worrisome symptoms warrants a consultation with a pediatrician or other qualified healthcare professional.

 

Diagnosing Back Pain in Kids and Teens

When diagnosing the underlying cause of back pain in kids and teens, a physician will usually evaluate the location of pain and the area(s) of pain distribution. A detailed history of the symptoms, past medical and surgical treatments, and family history is typically discussed with the parents or caregivers.

After a detailed physical exam, the doctor will recommend the necessary radiological and/or laboratory tests to confirm the diagnosis.

Physical Exam

The physical examination of children and adolescents with back pain begins with a visual inspection of the back in a standing posture.1

 

Physicians typically check the child’s posture and spinal curvatures in a physical exam. A deviation in the normal spinal alignment warrants further diagnostic studies.

The physician checks for

●      Overall posture; spinal symmetry, asymmetry, and/or visual malalignment (such as excessive lumbar lordotic curve or kyphosis)

●      Degree of forward and backward bending and any associated pain with these movements

●      Ability of the child to touch their toes

●      Gait assessment, including the ability to walk on the toes and heels

●      Leg length discrepancy

●      Color changes of the skin, including cafe au lait patches or freckling

Gently pressing or palpating the back can help the physician evaluate local or generalized tenderness in the back and/or the pelvis.

Clinical Tests

A thorough motor and sensory examination, including strength testing of specific muscle groups and sensory and reflex testing, is also performed.

Common tests performed at a physician’s office are:

●      One-legged hyperextension test

●      Straight leg raise (SLR) test.

●      FABER test.

The doctor may also test the skin over the lower back and/or leg(s) to check for numbness or loss of sensation, typically seen in conditions that cause nerve root irritation.

Radiographic and Imaging Tests

Depending on the level of concern, one or more of the radiographic and imaging tests described below may be performed.

X-ray

Any suspicion of bone fracture or malalignment warrants an x-ray of the region involved. X-rays do not show soft tissue injuries, such as a muscle pull or a herniated disc, and only the bony components of the spine may be examined.

Computed tomography (CT) scan

If x-ray findings are inconclusive or if more extensive imaging is needed, a CT scan may be ordered. CT scans provide excellent bony detail through multiple views and are also capable of imaging for back pain caused by specific conditions, such as a herniated disc.

Magnetic resonance imaging (MRI)

A more advanced type of scan compared to the CT scan is an MRI, which provides in-depth details of bone, joints, muscle, cartilage, and the inner layers of soft tissue surrounding the spine and the spinal cord. MRI is particularly useful for detecting tumors, infections, and disc herniation in children and teens.

 

Bone scan

A reasonable alternative to the MRI, a bone scan can help doctors identify bone and soft tissue tumors, and infections.

 

Blood Tests

If an inflammatory condition, infection, or malignancy is suspected, laboratory studies, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein measurement, may be performed.

Once the cause of back pain is determined, a structured treatment approach for the specific condition is formulated. Nonsurgical treatments are usually successful in managing back pain in kids and teens. Rarely, surgery may be needed to treat medical emergencies and specific types of fractures, tumors, or spinal deformity problems.

 

Back Pain Treatment in Kids and Teens

 

Treatment of back pain in children will be dictated by the underlying diagnosis of the cause of the pain. Surgery is considered for patients who do not respond to several weeks of nonsurgical care or those with a medical emergency.

 

Nonsurgical Treatments

Mainstream treatment options for kids and teens with back pain include rest from aggravating activities, nonsteroidal anti-inflammatory medication, and/or wearing a back brace.

For most conditions, some type of physical therapy or exercise program is usually prescribed, such as:

Physical therapy. The goal of physical therapy in children emphasizes posture correction and core strengthening.1,2 Flexibility of hamstring and hip abductor and flexor muscles are also typically checked and treated for shortness or tightness.

Yoga. The treatment of chronic, nonspecific back pain through yoga can help improve the back and abdominal muscle functions in kids and teens. Yoga has shown positive outcomes on both physical and psychosocial aspects for children and teens with back pain.

Psychosocial Intervention

A family history of lower back pain or smoking, or psychosocial stress in the family, may cause lower back pain in children and teens. Children can be stressed due to problems at school or home, and the type of response and support they get from family members and caregivers can play an important role in their perception of pain.

Psychosocial stressors typically exacerbate an already-existing back pain from a different cause. Psychosocial intervention is generally considered a supportive and alternative treatment approach for back pain in children and not a primary treatment option.

Surgery

Surgery may be recommended to address certain conditions that cause pain, such as a herniated disc, disc degeneration of the adjacent spinal segment, spondylolisthesis, or a spinal tumor. Surgery may also be considered in cases of spinal deformities, such as scoliosis, Scheuermann’s disease, or ankylosing spondylitis.

 

For disc and bone problems, lumbosacral fusion is the most common type of surgery performed in children. For kids with spondylolysis without disc degeneration and grade I spondylolisthesis or less, a direct repair of the vertebral defect may be considered.

A multidisciplinary approach works best to treat back pain in kids and teens. In this approach, physical, psychosocial, or occupational factors are addressed by a multidisciplinary team, including pediatricians, neurologists, neurosurgeons, and pediatric psychologists.

 

Back Pain in Pregnancy

 

A range of natural biological changes take place in a woman’s body during pregnancy, which directly affects the musculoskeletal system and may become a potential cause of back pain and related issues, such as leg pain.

 

Pregnancy-related changes typically involve the joints and connective tissues, making them loose, pliable, and soft. These changes result in increased stress and strain on the spinal and pelvic joints in the lower back and hips. Back pain may develop as early as the first trimester and typically increases as pregnancy continues.

 

The pain can vary from intermittently minor discomfort, to chronic and debilitating. The pain may originate in the mid and/or lower back area and typically includes the pelvis and hips. The lumbar spine (lower back) and sacroiliac joints are most commonly affected due to changes in posture, joint stability, body weight, and shape.

 

While in most cases back pain is self-limiting, resolves after delivery, and does not cause lasting issues,3 some women may continue to be affected by pain in the lumbar and/or pelvic region for several months or years. In general, women who receive postural and activity-related counseling during pregnancy are less likely to develop severe back pain symptoms.

 

Typical Features of Lower Back Pain in Pregnancy

 

Back pain affects over 50% of pregnant women. While it can occur at any time during pregnancy, back pain is usually most troublesome during the second and third trimesters.5-7 Pregnancy-related symptoms and signs affecting the lower back typically result in reduced overall function and include (but are not limited to):

 

●     Pain of varying intensity that starts or flares during movement or activity, such as while sitting, standing, walking, lifting objects, sexual intercourse, bending, and/or twisting the spin

●     Sleep disturbances due to pain while turning in bed, lack of sleep, and reduced sleep hours

●     Reduced range of motion in the lower back (lumbar spine)

●     Changes in balance and walking patterns, especially in the second and third trimesters

 

 

The effect of activity and weight on back pain

 

While pregnant women who lead a sedentary lifestyle may be at a higher risk of developing back pain, engaging in heavy physical labor or being active through the day may also lead to back pain symptoms in pregnancy.

Limited research indicates that women with increased body mass index (BMI) may be at a higher risk of developing back pain while pregnant.

 

How Pregnancy-Related Changes May Cause Back Pain

 

Women usually gain between 20lb to 25lb (on average) during pregnancy, have a shift in their point of gravity, and undergo several hormonal and anatomical changes. These natural alterations increase stresses and loads on the lower spine and pelvis, contributing to the following changes:

●      Modifications in posture. The growing uterus and increased curvature of the lower spine exert additional mechanical loads on the lower back, altering the spinal posture. This altered posture increases stress on the lumbar facet joints and lumbar spinal discs.

●      Changes in muscle tone and balance. The paraspinal muscles, which support and stabilize the lower back, shorten, and become unbalanced by the excessive stretching of the abdominal muscles in the front.

●      Discomfort in the sacroiliac joints. A 10-fold increase in the concentration of the relaxin hormone during pregnancy causes softening of connective tissue in the pelvis and lower back, which leads to discomfort in the sacroiliac joints.

●      Stress on the pelvic joint. Hormonal changes, alterations in posture and walking pattern, and stress on ligament structures may cause increased forces across the pelvic joints in pregnant women. Pregnancy-related changes cause an impaired load transfer during activities, which may result in an overload of stress on the ligaments of the pelvis.

●      Pressure on the spinal discs. A herniated disc may in turn irritate, inflame, or mechanically compress a spinal nerve root in the lower back, causing sciatica symptoms to radiate into the thigh, leg, and/or foot.

●      Transient osteoporosis. Weight-bearing, especially in the third trimester, may cause some women to develop transient osteoporosis. This bone-weakening condition develops suddenly and causes hip pain and reduced range of motion in the hips.

When to Seek Medical Attention

Back pain is often untreated and considered a normal and inevitable part of pregnancy among women. To help make pregnancy as pleasant as possible and to facilitate an easier delivery, back pain should be addressed and managed.

●      Lower back pain that lasts a long time (several weeks or months) during pregnancy is usually a predictor for postpartum back pain. Pregnant women are encouraged to seek appropriate back pain treatment to prevent the recurrence of pain at later stages.

●      Lower back pain that is associated with vaginal bleeding, lower right or left abdominal pain, groin pain, feeling faint, and tarry stools, may indicate a ruptured ectopic pregnancy, which is a medical emergency and must be treated on an urgent basis.

●      Postpartum pain that lasts longer than 6 to 8 weeks should be treated in order to avoid chronic back pain or recurring back problems after delivery. Over time, chronic pain can lead to psychological and psychosocial events that interfere with daily functioning and reduce the overall quality of life.

Cauda equina syndrome during pregnancy

Rarely, around 2% of pregnant women who have herniated lumbar discs may progress into a serious medical condition called cauda equina syndrome. In this syndrome, the herniation directly affects the cauda equina nerves that progress down from the spinal cord, disrupting nervous system signaling in the legs.

Typical symptoms of this condition include one or more of the following:

●      Inability to pass urine, a reduced urinary sensation, a loss of desire to pass urine, or a poor stream

●      Reduced or complete loss of bowel and/or bladder control

●      Worsening neurological symptoms with intolerable pain

●      Numbness in the groin, buttocks, and/or genital area (saddle anesthesia)

Cauda equina syndrome must be treated on an urgent basis to preserve leg function. Optimal management requires a multidisciplinary approach with several specialists, including the obstetrician, orthopedic specialist, neurologist, and/or neurosurgeon.

 

Lower Back Pain in Pregnancy

Mechanical instability in the lumbar spine (lower back) and pelvis commonly results in lower back pain in pregnant women.

●      The lumbar spine undergoes compensatory lordosis—an increase in the reverse C-shaped curvature—which causes excess strain on the lumbar joints, muscles, ligaments, and discs.

●      The psoas muscle in the hip, which stabilizes the spine and helps in hip and leg movements, is shortened due to the compensatory lordosis, exacerbating the lower back pain symptoms.

Lower back pain symptoms may start at any time during pregnancy. These symptoms may feel like:

●      A dull ache or sharp, burning pain in the lower back area

●      One-sided pain in the right or left area of the lower and/or mid-back

●      Pain that radiates into the back of the thigh and leg, and sometimes into the foot (similar to sciatica)

●      Foot drop, a condition characterized by the inability to lift the front part of the foot while walking

Sciatica symptoms typically occur if a lower lumbar and/or upper sacral nerve root is impinged in the lower spine due to a lumbar herniated disc, spondylolisthesis, facet joint disorder, or muscle sprain and spasm.

Women with a history of back pain, pre-existing lower back disorders, multiple pregnancies, and/or those who are in the younger or older age-groups may be at a higher risk of developing lower back pain in pregnancy.

 

Musculoskeletal Causes of Pregnancy Back Pain

During pregnancy, new changes in the mechanics of the lower back may occur, and many existing conditions may become worse, adding to the discomfort.

New changes in posture and stability of the lower back

The instability of the pelvis and lower back occurs due to the increase in the size of the uterus. These changes cause the spine to alter its shape, making the lower back more curved than usual. Muscles that stabilize the pelvis, such as the psoas, are shortened, further increasing the curvature of the lower back and causing pain.

 

Laxity of soft tissues and joints

The concentration of the relaxin hormone rises considerably during pregnancy, which increases tissue and joint flexibility in the lower back. The sacroiliac joints may become increasingly lax under the influence of this hormone. Since the sacroiliac joints are responsible for maintaining pelvic stability and transferring loads from the spine to the legs, the loosening of these joints may add to postural problems and increase the risk of back pain.

Widening of the pelvis

The concentration of the estrogen hormone also increases during pregnancy. The combined effects of relaxin and estrogen cause the pelvis to widen. This widening begins during the 10th to 12th week of pregnancy and causes the pelvis to increase in width by 10 mm or less. Pelvic pain typically becomes more in the later stages of pregnancy and may rapidly progress, causing severe pain in the lower back and thighs. The muscles and soft tissues in the area are often affected, causing pain while walking and resulting in an altered gait.

 

 

 

Neural Causes of Pain During Pregnancy

The peripheral nerves, such as the lateral femoral cutaneous nerve, in the pelvis and thigh region may become compressed, stretched, or lose blood supply, making them the primary source of pain. Swelling of the soft tissue may cause additional mechanical pressure on these nerves, causing thigh pain and referred pain in the lower back and pelvis.

Concomitant medical conditions, such as obesity, diabetes, and anatomical variations increase the risk of peripheral nerve pain in the legs.

Herniated Disc Pain in Pregnancy

Rarely, the increased stress and strain on the lower skeletal system and musculature may affect the spinal discs, resulting in herniation. A herniated lumbar disc may affect the nearby nerve roots causing sciatica symptoms to travel down the thigh and leg, and possibly into the foot. The medical term for sciatica is radiculopathy and typically affects one side of the body.

Weakening of the Hip Bone and Joint

Rarely, some women may develop a bone-weakening condition called osteoporosis in the third trimester of pregnancy. The exact cause of this condition is unknown. The symptoms may appear slowly or suddenly, affecting the tissues of the hip joint, causing pain and limited hip motion. While the symptoms may be typical, this condition is diagnosed by medical imaging tests, such as an x-ray, MRI, and/or pelvic sonogram.

Another condition that affects the hip region, avascular necrosis of the femoral head, may occur due to biological changes in pregnancy. These changes typically include weight gain and production of high levels of natural steroids, which may cause destruction of bone tissue in the femoral head (top part of the thigh bone), resulting in groin and lower back pain.

Placental Location and Back Pain

A posterior (back) location of the placenta (the tissue that provides nourishment to the fetus) is known to cause back pain in some pregnant women. In these cases, the placenta is located near the posterior wall of the uterus.

Limited research indicates that a posterior placenta may also cause poor pregnancy outcomes and preterm labor.

Ruptured Ectopic Pregnancy

Severe lower back and groin pain may occur when the fallopian tube ruptures due to an ectopic pregnancy.5 This condition is a medical emergency and occurs in early pregnancy, typically within the first few weeks or first trimester.

Infection and Back Pain

Urinary tract infections and kidney infection (pyelonephritis) may cause lower back pain. The pain is typically characterized as a dull and persistent ache accompanied by fever and/or chills. These conditions may carry a risk of preterm labor in some women.

Obstetrical Conditions that May Cause Back Pain

While not common, certain obstetrical conditions, such as spontaneous abortion, ovarian cysts, pelvic or uterine adhesions, fibroids, or collection of fluid, may cause lower back pain in pregnancy.

Back pain may also result as a sign of labor (full-term or pre-term) and is typically associated with uterine contractions that gradually increase in intensity.

Daily Activities that May Cause Back Pain

In addition to the conditions listed above, a few other factors can cause pain in the lower back or posterior pelvis. These factors typically include activities that create asymmetrical loading of the spine, pelvis, and hips. Common activities that load the spine in an uneven form include:

●      Walking and/or running

●      Rolling over in bed

●      Bending forward

●      Twisting the spine

●      Lifting objects off the floor

●      Navigating stairs

Back pain is common in pregnancy and typically resolves after delivery, but several conditions causing this symptom require medical attention to prevent future complications. Seeking medical care for pregnancy-related back pain is advisable. A physician can accurately diagnose the cause of back pain and provide the needed care for treating the symptoms.

 

Management of Back Pain in Pregnancy

The treatment of back pain in pregnancy depends on the stage of pregnancy, underlying cause, aggravating factors, and the presence of other medical conditions, such as diabetes or heart problems. Both medical and psychological treatments may be warranted in some cases when the ability to perform daily activities and participation in social events is significantly affected, impairing the quality of life.

After the warning signs and symptoms are ruled out, treatment options typically include postural correction, physical therapy, medical management, and/or surgical intervention.

Postural Correction Helps Relieve Pregnancy Back Pain

Maintaining an ergonomically supported posture throughout the day can help take a considerable amount of stress and strain off the lower back tissues. Doctors also advise taking rest, limiting strain and high impact activities, and performing stretches and exercises to build strength in the pelvis, hip, and lower back. Pain-relieving medications such as NSAIDs are not considered safe during pregnancy and must be avoided.

Ergonomically supported sleep positions reduce mechanical strain in the lower back

A side-sleeping posture with the use of appropriate supportive pillows is recommended in pregnancy.

●      Using a pillow between the knees and ankles while sleeping brings the top of the knee at the same level as the hip, reducing strain on the lower back.

●      Placing a vertical pillow near the abdomen and upper body can help support the top arm and chest area.

The head and neck may be supported by a small rolled-up towel placed under the neck inside the pillowcase.

Using a lumbar roll helps avoid pregnancy back pain while sitting

Using ergonomically supported posture while sitting for extended periods can help decrease the frequency and intensity of back pain.

●      Sitting up straight and aligning the ears, shoulders, and hips in a vertical line is recommended.

●      Using a lumbar roll in the small of the back can help support the spinal curvature.

●      This roll may also help reduce pelvic pain that occurs from a sit-to-stand position.

●      Inflatable lumbar rolls are best suited for pregnant women to accommodate the change in body size and posture.

Taking short breaks every hour and briefly stretching or walking a short distance (without pain) is typically recommended.

Limiting standing and walking reduces the occurrence of back pain

If standing and/or walking causes or aggravates pregnancy back pain and leg pain, a maternity brace and comfortable walking shoes that provide shock-absorbing properties may be used. In general, any activity that includes long periods of standing and/or walking must be avoided and intermittent sitting must be performed.

Taking Rest and Applying Heat Therapy Can Help Heal Sore Tissues

Taking short periods of rest during the day helps ease muscle spasms and relieves acute pain. While taking rest, keeping both feet elevated can help bend the hips and decrease the curvature in the lower spine.

Using a heat patch in the lower back area and/or rear pelvis can help reduce soreness, decrease muscle spasm, and improve blood circulation. The heat source must be used for 15 to 20 minutes at a time and be of a tolerable temperature. Placing a barrier, such as a towel, is advisable to avoid burns.

Physical Therapy and Exercise Builds Lower Back Strength and Endurance

Maintaining an optimal level of function throughout your pregnancy and having the least amount of discomfort are the main goals of treatment for back pain during pregnancy.

Physical therapy encompasses postural modifications, back strengthening, stretching, and range-of-motion exercises. Appropriate physical therapy and exercise for pregnant women instructed by a trained therapist can help strengthen the soft tissues and muscles around the lumbar spine (lower back).

●      Flexion exercises (bending forward) help make the abdominal muscles stronger, improve core strength, and decrease the lumbar curve.

●      Extension exercises (bending backward) help increase strength in the paraspinal muscles that provide stability to the spine.

Physical therapy and exercise to reduce back pain in pregnancy include low-impact options, such as pelvic tilts, knee-to-chest stretch, straight leg raise, curl-ups, side-lying leg raise, and the Kegel exercises.

Choosing Safe Pain-Relieving Medication Avoids Fetal Complications

 

As a general rule, it is always advisable to consult a physician before taking any medication, including supplements, over-the-counter (OTC) medication, ointments, and/or inhalers, while pregnant.

 

Back Pain After Pregnancy

Persistent or newly developed pain in the lower back after pregnancy, also known as postpartum back pain, usually lasts for 6 months but may continue up to a decade. Postpartum back pain mostly occurs while performing activities that involve body movements, such as walking, lifting, bending, and/or carrying the new baby, and may be relieved with rest, exercise, and home treatments. The type and severity of pain depend on the underlying cause.

Causes of Postpartum Back Pain

The vast majority of women who experience postpartum back pain develop the symptoms due to pregnancy-related changes in the musculoskeletal system that persist after delivery. In some cases, women may undergo bodily trauma during childbirth that directly involves the lower back and pelvic bones, joints, and/or soft tissues, causing additional pain and discomfort. The type of delivery—vaginal, instrumental, or cesarean section (C-section) may also have a role to play in postpartum back pain.

Loss of muscle tone and joint instability

The effects of pregnancy on the muscles and joints in the lower body vary. A surge in the levels of relaxin, estrogen, and progesterone hormones causes considerable joint relaxation during pregnancy. After delivery, the levels of these hormones decline significantly, causing the joints to return to the pre-pregnant state. It takes an average of 6 to 8 weeks for the joints and surrounding tissues to stabilize and bear weight effectively.

The sudden decrease in hormone levels may cause localized and/or overall effects, such as:

●      A general feeling of tiredness

●      Activity intolerance

●      Pain in the lower back and hip

●      Back pain while walking or performing an exercise

If unsupported posture and body mechanics are used at this time, the risk of further trauma to the lower back and hip are higher.

Diastasis recti

The uterus enlarges during pregnancy to accommodate the growing fetus. This change causes the muscles of the abdominal wall to stretch substantially. The stretching results in loss of muscle tone in the abdominal region with the possible separation of certain muscles, such as the rectus abdominis. Women who have poor abdominal muscle tone prior to pregnancy are at a higher risk of separation of the rectus abdominis muscle. This condition is called diastasis recti and causes the muscles to become loose and have poor tone after delivery.

Diastasis recti may compromise postural stability and contribute to lower back and pelvic pain. If the pelvic floor muscles are also weak, urinary incontinence and dysfunction of the pelvic muscles may also occur.

Posterior pelvic pain (pelvic girdle pain)

Pelvic changes begin during pregnancy and while these changes resolve uneventfully in some women, others develop chronicity due to persistent symptoms, which may last for several months to years.

New mothers with posterior pelvic pain experience a continuous, dull pain in the lower back. Some women have more intense symptoms, such as sharp and stabbing pain.

Bruising, fracture, or dislocation of the coccyx

Coccydynia, the medical term for tailbone pain, is a condition that may affect women who have a difficult vaginal delivery due to a large newborn, excessive weight gained during pregnancy, or an instrumental delivery.

The coccygeal segment forms the bottommost part of the spine, and this segment may be forced backward beyond its normal range of motion during childbirth. While this condition is self-limiting and resolves itself in a few weeks or months, the symptoms can be debilitating.

Coccydynia causes severe pain at the very bottom of the spine and makes activities such as getting up from a chair or bed painful.

Sacral stress fracture

Similar to tailbone trauma, the fused vertebrae of the sacral spine in the pelvic region may undergo stress fracture during childbirth. In addition to the risk factors for coccydynia mentioned above, a sacral stress fracture may also occur due to increased curvature in the lower back, the use of blood-thinning agents, such as heparin, or osteoporosis of pregnancy.8

Sacral stress fractures cause severe pain in the rear pelvic region and make weight-bearing in this region painful.For example, sitting may be notably uncomfortable.

 

When to See a Doctor

Back pain that does not subside with rest or home treatments, such as a massage, heat therapy, or gentle stretching and exercise, and/or pain that progresses over time may require medical attention. As a general rule, troubling symptoms, such as newly occurring numbness or weakness in the leg(s) or worsening of previous leg pain and numbness symptoms, must be reported to a doctor.

A doctor can accurately diagnose the underlying cause of the pain and formulate a treatment plan. For breastfeeding mothers, it is advisable to consult a doctor before taking any pain-relieving medication. The type and dosage of pain-relieving medications vary, and not all over-the-counter medications are safe while breastfeeding.

Postpartum back pain may be a continuing symptom of pregnancy or develop as a new symptom after labor and delivery. Failure to adequately treat the symptoms may lead to chronic pain, affect daily functioning, and reduce the overall quality of life. Women are encouraged to seek medical attention to relieve the symptoms and address the underlying problem. Having a pain-free back after labor and delivery will help new mothers care for their newborn more effectively and enjoy the early phases of motherhood.