Chapter 15
Prevention and Management of
Common Musculoskeletal Injuries
Incurred through Exercise during
Pregnancy
Mimi Zumwalt, MD
Learning Objectives
• Understand the anatomy involved with
pregnancy and associated structures affected
• Learn about the physiological/systemic
changes of pregnancy and their effects on
exercising
• Delineate the anatomic/structural issues
affecting types of exercise while pregnant
• Comprehend different prevention measures
and methods of management of pregnantrelated musculoskeletal conditions
Introduction
• Pregnant state w/anatomical, structural,
physiological, & systemic changes
• Hormonal/biochemical; musculoskeletal
• Unique orthopaedic injuries/conditions
• Must protect fetus from physical harm
• Modify exercises/choose carefully
Anatomical & Structural
Considerations in the Pregnant
Female
• Involved anatomy
• Uterus in pelvis - ilium/pubis, ischium, &
sacrum/coccyx w/pubic symphysis &
sacroiliac joints, ligaments, muscles/fascia
• Mammary glands against thoracic cage
• Surrounding supporting structures
• Spinal & abdominal musculature
Physiological & Systemic Changes
Affecting Exercise in Pregnancy
• Hormonal chain – HCGrelaxin
• Estrogen & progesterone
• Prolactin, insulin, cortisol, para/thyroid
• Fetal-maternal metabolism
• Anabolic”accelerated starvation”
• General/dependent edema
• Inflammatory response/nerve entrapment
Anatomical Structures Affecting
Exercise Capability in Pregnant
Athletes
• Anterior/inferior center of gravity shift
• Roundback/swayback
• LBP, pelvic girdle & SI joint pain,
widened pubic symphysis
• XS increased hip & knee joint forces
• Elevated pressure of pelvic floor muscles,
tight/short chest, low back, hip, & thigh m,
slack in rectus abdominus & gluteals
Prevention of Musculoskeletal
Injuries in Pregnant Female Athletes
• LBP, pelvic girdle, pubic symphysis, SI joint
pain, PFPS, ankle sprains; leg cramps,
diastasis recti, meralgia paresthetica, CTS &
other compression neuropathy, de Quervain’s
• Beware of potential hip & other sites of
osteoporotic fx
• Core conditioning, spinal stabilization, hip
balancing exercises (Swiss Pilates)
• Avoid xs repetitive usage/loading
Prevention of Musculoskeletal
Injuries in Pregnant Female Athletes
• ACOG/ACSM/CDC exercise guidelines
• 30-45min most days of the week
• Resistance & endurance training
• Avoid prolonged supine position or
motionless standing or impact activity
• Avoid xs height or deep water or team/
contact & other high risk sports
• Avoid Valsalva maneuver w/wt lifting
• Borg’s RPE scale
Management of Orthopaedic
Conditions in Pregnant Athletes
• Avoidance of aggravating positions/activities
• Physical therapy for postural control, core
conditioning, & spinal stabilization
• Abdominal, low back, pelvic floor, hip/
gluteal strengthening
• Aquatic > ground exercises
• Acupuncture, lumbosacral corset
• Limited steroid injections, NO NSAIDs, local
modalities or spinal traction
Conclusion
• Increased body weight, morphologic &
physiologic changes challenging
• Working out beneficial for mother & baby
• Modify activities/maneuvers
• Avoid certain positions/sports/conditions
• Minimize injury risk since limited options
for orthopaedic treatment of injuries
Case Study
• You are a family practice physician working in a small town where the
closest major medical center is a couple of hours away. An emergency room
is available near by, but medical resources are scarce. You have been the
“family doctor” for a few decades in the community. In fact, you have made
“house calls” in the middle of the night to tend to extremely ill patients or to
deliver an unexpected baby! Currently you have five different women who
are in various stages of pregnancy, three of whom are fairly healthy and all
desire an exercise program. One woman, unfortunately, has gestational
diabetes along with being extremely overweight. In fact, she has already
gained over 60 pounds nearing the end of her second trimester. She has been
giving in to her “food cravings” and wants to start exercising to lose as much
weight as possible. The second woman just found out she is pregnant and
has been working out for several years along with competing in triathlons.
She wants to keep up with her training and competitions plus is very afraid
of “putting on weight”. The third woman is near the end of the first
trimester, is gaining weight appropriately, and has begun a workout program.
She needs to know whether she can continue to exercise and when she
should stop working out. The fourth mother to be, although she has been
involved with a training regimen for a few years, is so afraid that she’ll
damage the fetus since it’s her first baby, so she decides that she needs to quit
exercising all together. The fifth female patient is complaining of low back
spasms and abdominal cramping when she attempts to work out, especially
lower extremity exercises but she does not want to slow down.