Manual therapy for postpartum symphysis pubis diastasis: a case report

Introduction

Symphysis pubis diastasis (SPD) is an infrequent complication of labor that can impair women’s general health due to the failure of the passive stability of the pelvic girdle (1). During labor, factors contributing to the dilation of the birth canal may lead to the total or partial separation of the pubic symphysis, defined as a diastasis of 10 mm or more, accompanied by associated symptoms (2). Characteristic symptoms include pain localized in the pubic bone area, which worsens with activities such as walking, lifting heavy objects, or climbing stairs. Epidemiological studies estimate that SPD occurs in approximately 2.8% of women during or after labor (3). The exact cause of SPD remains unclear, but potential contributing factors are broadly categorized into metabolic and mechanical causes (4,5). Mechanical factors may include fetal macrosomia (a larger fetal size relative to the maternal pelvic dimensions), fetal position, rapid or strong labor contractions, a prolonged second stage of labor, the use of forceps during delivery, or a history of pelvic trauma (6).

Treatment for SPD is often long-lasting and aims to restore pelvic stability. Initial management typically involves non-surgical approaches, such as bed rest, pain management, and physical therapy (7). Conservative treatments, including Tuina reduction, three-dimensional bracing under continuous traction, pelvic girdle fixation, and exercise therapy, have shown satisfactory clinical outcomes in postpartum cases. However, if conservative measures fail, surgical intervention may be considered. Indications for surgery include chronic pain, failure to reduce the symphysis separation, or recurrence of separation after removal of the pelvic belt (8). It is important to note that surgical treatment carries risks such as infection, bleeding, and recurrence.

In traditional Chinese medicine (TCM), SPD is categorized into three patterns: dual deficiency of qi and blood, exterior cold pattern, and qi stagnation with blood stasis. TCM treatment is based on syndrome differentiation, including oral herbal medicine, fumigation and washing, Tuina (Chinese therapeutic massage), acupuncture and cupping. Manual reduction is considered a key component of TCM treatment for SPD. These methods can be used individually or in combination, often complemented by daily nursing and care. TCM offers a diverse range of therapeutic approaches with proven efficacy, making it a valuable option for managing SPD. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-189/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Basic information about the patient

A 32-year-old primigravida (G1P1A0L1) at 40 weeks of gestation with no significant medical history was admitted to the hospital in labor on November 25, 2024. Her labor progressed slowly, resulting in the delivery of a 3.9 kg baby via normal vaginal delivery without complications. During childbirth, the fetal head was impacted in the pelvis for approximately one hour. The first stage of labor lasted 5 hours, and the second stage lasted 18 minutes, followed by an uneventful immediate postpartum period. The following day, the patient reported bilateral hip pain that worsened with movement, along with difficulty walking and urinating. She sought medical attention at Foshan Hospital of TCM. An orthopedic consultation was obtained, and an anteroposterior pelvic X-ray revealed a 25 mm gap between the pubic bones, confirming a diagnosis of SPD (Figure 1). Initial treatment included exercise therapy and analgesics, but the pain persisted. On December 7, 2024, the patient visited our rehabilitation clinic for further treatment. After evaluating her condition, we recommended TCM as a conservative treatment option, considering the risks associated with surgical intervention. The patient agreed to proceed with TCM.

Figure 1 Anteroposterior radiograph of the pelvis abnormal widening of the symphysis pubis to a maximal transverse measurement of 25 mm.

TCM treatment and improvement of condition

During the initial visit on December 7, 2024, the patient described a constant dull ache in the pelvic area, which occasionally felt crushing. She rated the pain 8/10 visual analog scale (VAS). She reported pain in the pubic and sacroiliac areas on both sides. The pain worsened when standing, climbing stairs, lifting heavy objects, and even while walking. She experienced instability while standing and a sensation of weakness. On examination, severe tenderness was noted over the pubic symphysis, and she had difficulty raising her legs with restricted hip joint movement. The patient exhibited a waddling gait, and her pelvic separation and compression test was positive. The TCM diagnosis was postpartum physical pain, characterized by qi stagnation and blood stasis. According to TCM theory, after childbirth, there is often a deficiency of qi and blood, and the meridians become empty. This leads to insufficient nourishment of the limbs, bones, and meridians, disrupting normal circulation and causing blood stasis to block the uterine cavity, resulting in pain due to obstruction.

For this treatment, we used the TCM spinal correction technique, which focuses on promoting qi circulation, improving blood flow, relaxing tendons, and activating collaterals. The specific procedure was as follows: the patient first lay on her back in a supine position, and the doctor used a plucking technique to relax the bilateral inguinal regions for 3 to 5 minutes, followed by kneading and massaging the acupoints GB27 and GB28 for 1 minute. Due to severe pubic pain, the patient was then placed in a lateral position, and the erector spinae muscles in the bilateral lumbar regions were plucked alternately for 3 to 5 minutes. Next, the acupoints BL23, BL24, BL25, BL26, BL27, BL28, BL29, BL30, BL53, and BL54 were kneaded and massaged for a total of 5 minutes. After completely relaxing the muscles, the doctor performed oblique lumbar traction manipulation: Position the patient in a lateral decubitus position with the affected side uppermost. The lower leg remains naturally extended, while the upper leg is flexed at both the hip and knee. Considering the patient’s pathology is located in the pelvis, the patient’s upper body should be positioned with significant flexion. Stand facing the patient. Place one hand on the anterior aspect of the patient’s shoulder. Flex the elbow of the other arm and use its medial aspect to brace against the patient’s hip, with the thumb positioned over the previously identified affected segment. Apply gentle, slow force with both hands in opposite directions. When lumbar rotation reaches its restrictive barrier, the affected segment becomes the fulcrum for the manipulation. Apply a brief, precise thrust at this point. An audible click from the joint is often heard. Some patients may not exhibit an audible click; if the practitioner perceives movement of the posterior joint, this also confirms a successful adjustment.

Instruct the patient to assume a supine position. The practitioner stands on the patient’s affected side. Support the patient’s knee with one hand and grasp the ankle with the other. Perform hip flexion, knee flexion, internal rotation, and traction on the affected limb. The objective is to elongate muscle fibers and release tension in the gluteal and posterior thigh muscle groups. Sustain each stretch for one minute and repeat the procedure three times.

After the treatment, the patient reported significant relief in groin and lower back pain and was able to walk slowly on her own. Pain was reduced from 8/10 VAS at the first visit to 4/10. The doctor advised her to rest and avoid strenuous activities.

Changes in the overall physical condition

On December 30, 2024, the patient walked to our outpatient department for a follow-up visit. She reported that her pain had significantly improved after the first treatment, with a noticeable reduction in discomfort during daily activities such as walking and standing. She requested to continue treatment and have her pelvic condition re-evaluated. After the second treatment on that day, we performed a computed tomography scan, which showed SPD with a width of approximately 10 millimeters. The patient experienced immediate pain relief after the initial treatment, with pain levels further reducing to 2/10 on the VAS scale following the second session. The bilateral hip joint space was normal, the bone joint surfaces were smooth, and the joint alignment relationship was normal (Figure 2). The patient exhibited new vitality and happiness, expressing gratitude for the improvement in her condition.

Figure 2 A pelvic CT showing a 10 mm separation of the pubic symphysis. CT, computed tomography.

During the follow-up one month later, the patient reported that the pain had completely disappeared, and she was able to resume her daily activities without any discomfort. She was advised to continue light exercises and avoid strenuous activities to ensure full recovery. The complete timeline of the patient’s course of illness is recorded in Table 1.

Discussion

The pubic symphysis is a non-synovial joint (a type of joint where bones are connected by fibrous tissue or cartilage, allowing limited movement) that connects the right and left superior pubic rami, with a normal radiographic separation width of four to five mm. During pregnancy, hormonal changes and physiological adaptations can increase this gap by two to three mm, a condition known as physiological SPD, which may persist after delivery. In rare cases, vaginal delivery can lead to joint widening exceeding 10 mm, defined as pathological SPD. Risk factors for this condition include multiparity, cephalopelvic disproportion, precipitate labor, difficult labor, difficult forceps delivery, and pre-existing pelvic bone pathology (9).

In Western medicine, treatment primarily involves conservative treatment such as oral analgesics, pelvic binders, and local steroid injections, general improvement should occur within 6 weeks (10). Pelvic binders or braces provide external stability and support to the pelvic girdle, alleviating pain and promoting mobility (11). Physical therapy aimed at strengthening the pelvic floor and core muscles enhances stability and facilitates functional recovery. Non-steroidal anti-inflammatory drugs and acetaminophen may help reduce inflammation and relieve pain (12). However, conservative treatment may result in persistent pain for several months and interfere with breastfeeding due to analgesics, antibiotics, and thromboembolic prophylaxis (13).

When non-surgical treatments fail, surgical options such as open reduction and internal fixation, anterior plate fixation, or external fixation may be considered. The use of plates and screws to stabilize the pubic symphysis is generally associated with good pain relief and functional recovery (14-16). Wakefield et al. (17) reported a case of anterior-posterior compression type I injury in which the patient developed chronic pubic symphysis pain after conservative treatment, significantly impacting quality of life. The condition improved following pubic symphysis bone grafting fusion with plate fixation combined with posterior pelvic ring stabilization using sacroiliac screws. It is important to note that surgical interventions carry certain risks, including potential invasion of the hip joint and damage to the lateral femoral cutaneous nerve during the placement of external fixation frames (18). Beder et al. (19) utilized transpubic parallel screw fixation through plates to treat SPD. The results demonstrated that the use of longer cross screws significantly enhanced local biomechanical stability, with patients achieving favorable functional recovery postoperatively. However, the technique presented challenges including intraoperative drill bit fracture due to excessive angulation causing collision with the plate, as well as surgical site infections associated with the open surgical approach.

Given the limitations and risks associated with surgical treatments, alternative approaches such as TCM spinal correction technique have gained attention. With its long history and rich clinical experience, TCM spinal correction technique has shown promise as a safe and effective approach, particularly in treating postpartum SPD. Research findings indicate that satisfactory clinical outcomes can be achieved in treating postpartum SPD through therapies such as manipulative reduction, three-dimensional repositioning under continuous traction, pelvic girdle fixation, and exercise therapy (20-22).

Beyond the traditional TCM concepts of qi and meridians, modern translational research provides potential scientific explanations for the efficacy of manual therapy in SPD. A study suggests that manual techniques may modulate the neuroimmune response by reducing pro-inflammatory cytokines such as TNF-α, IL-1β, and IL-6, which are known to contribute to mechanical allodynia and hyperalgesia in pelvic pain conditions (23). This method utilizes manual techniques to improve patients’ overall health, accelerate tissue recovery, and enhance the mechanical properties and microcirculation of local muscles and ligaments. A study on analgesia (24) has confirmed that manual therapy can significantly improve the inflammatory response to pain in local tissues of the body by reducing the levels of inflammatory cytokines. Furthermore, manual therapy has been shown to promote the release of endogenous neurotransmitters including serotonin, dopamine, and oxytocin, which are involved in pain modulation and emotional regulation (25). Biomechanically, these techniques may facilitate realignment of the pubic symphysis by relaxing hypertonic muscles and ligaments, thereby restoring normal joint kinematics and load distribution. Such multimodal actions—anti-inflammatory, neuromodulatory, and biomechanical—collectively support the clinical benefits observed in this case.

In this case, the patient was a primigravida with an athletic build and a prolonged labor. Based on her specific condition, we developed a personalized treatment plan. Through manual adjustments, we facilitated the natural realignment of the pubic symphysis, alleviated her pain, and improved her quality of life. The treatment involved two main steps: first, relaxing the locally tense soft tissues to reduce inflammation and promote repair, followed by osteopathic realignment to restore the displaced joint anatomy and ensure the smooth flow of qi, blood, and meridians. TCM emphasizes the role of acupressure in harmonizing qi and blood and unblocking meridians. By stimulating specific acupoints, we combined the effects of different meridians to address local qi stagnation before performing orthopedic restoration. TCM spinal correction technique leverages the characteristics of pubic separation, guiding patients to maintain a reasonable position while applying external force to narrow the pubic space. This approach not only corrects misaligned joints but also clears meridians, promotes blood circulation, removes blood stasis, and strengthens muscles and bones, significantly alleviating symptoms such as local pain and limited lower limb movement.

The findings from this case report suggest that TCM spinal correction techniques may provide rapid symptom relief and shorter treatment cycles for postpartum SPD. These techniques appeared to effectively alleviate pain and improve quality of life in this case, indicating their potential as an option for clinical application. However, it is important to note that most current studies on this approach are limited by low quality and small sample sizes. Therefore, further research with larger sample sizes and controlled study designs is essential to validate these preliminary observations and better understand the mechanisms underlying their potential efficacy.

Conclusions

SPD is a common injury associated with pelvic fractures. Clinicians should carefully evaluate surgical indications and tailor treatment plans to individual patients. The primary goal is to restore pelvic stability and integrity, thereby improving the patient’s prognosis. TCM spinal correction is a time-honored therapeutic approach with a history of application in managing soft tissue injuries, dislocations, fractures, and chronic conditions. Its use in addressing SPD represents a combination of traditional Chinese and Western medical principles and an application of traditional orthopedic practices.

In this case, TCM spinal correction techniques were used to relax tense soft tissues, potentially reduce inflammation, and restore joint alignment. The patient reported that this approach was effective in reducing pain associated with SPD and contributed to overall recovery and improved quality of life during this treatment period. While conceding that it remains unascertainable whether specific therapeutic interventions, if any, facilitated clinical recovery, or whether the observed reductions in pain and SPD reflected the natural disease trajectory, the potential for long-term pain and disability and the scarcity of existing literature indicate the need for further investigation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-189/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-189/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-189/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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