©2014. Ginger Garner. All rights reserved.
I remember the exact moment of excruciating pain when the well-meaning L&D nurse cranked back on my leg. I told her it hurt worse, but she misunderstood me. And she kept cranking. The pain was unbearable. And I was in too much agony to be able to voice any protest. So I kept pushing. My baby was crowning. I was about to meet him. I pushed through the pain.
The nurse thought I was just talking about my son’s crowning, which was true, it DID hurt far worse than my first two. But the reason it hurt so much more – was because it was also severely damaging my hip, not to mention increasing pelvic floor tension and closing down the pelvic outlet.
It was excruciating, and I’ll never forget it. My now reconstructed hip won’t let me. It’s a constant reminder of a catastrophic injury and over 3 years of chronic, debilitating pain – that was entirely avoidable. I don’t wish that kind of pain or disability on anyone, and this post is one of many dedicated to helping other women avoid the injury I experienced.
The take home message is, leave her legs alone.
During birth you are at risk for hip labral tears, especially if someone is is manipulating your legs. So labor and delivery (L&D) nurses, birth partners, and other staff, keep your hands off a mom’s legs.
No pushing the legs back during birth, no grabbing the foot or leg and pushing. It not only increases the risk of hip damage. It also closes down the pelvic outlet (contrary to popular belief that it opens the outlet) and increases perineal tension, which exponentially raises the risk of tearing.
If you want to learn the hard science on better birth positions, read this post from Evidence-Based Birth: Birth Positions: The Evidence.
In a previous post, I also discuss The Importance of Early Intervention in Labral Tears.
There are plenty of birth positions that are helpful to mother, but lithotomy and supine (flat on your back) positions are among the highest risk and most painful.
©2019. Ginger Garner. All rights reserved.
Pregnancy brings with it a bevy of physiological and hormonal changes. They greatly influence orthopaedic health, not to mention psychoemotional well-being. However, what has historically been overlooked is the risk at which the acetabular hip labrum and related structures are placed during pregnancy, labor, delivery, and the postpartum. Hip labral tears are debilitating and painful, preventing normal ambulation, ADL completion, or participation in any recreational activity, including sex. Tears can also lead or contribute to pelvic pain, with the average time of injury to diagnosis being an average of 2.5 years. This delay in diagnosis can put mothers at high risk for developing chronic pelvic pain, and yes, put them at higher risk for a labral tear, among other serious disability.
Several theories have been posited as to why pregnancy and being a new mom brings a higher risk of hip labral tears. Increased joint laxity (hyper mobile joints) has been widely debated but is generally accepted as a plausible mechanism in back pain, sacroiliac joint dysfunction, pubic symphysis dysfunction, or related pain. Increased (axial) loading through the joint combined with joint laxity are thought to be compounding factors. These changes alone could explain the presence of a prenatal tear, says researchers Brooks et al (2012).
Unavoidable changes in joint structure and function during labor and delivery also place mothers at higher risk. This means screening for hip joint intra-articular pathology is vital in the clinical setting. Further, forces applied externally during labor can be responsible for hip labral tears. Brooks et al (2012) found 4 of 10 women (all with labral tears) reported a specific incidence during labor, such as a pop, twist, or sudden sharp pain in the hip, that led to their diagnosis of hip labral tear. The range of motion that is most often forced in the hip during labor is flexion and internal or external rotation, combined with abduction. This looks like pushing the legs out to the side and up to the chest. This is commonly done in the delivery room and it should be stopped. It applies torque at the hip joint and can commonly be done by a birth assistant (husband, relative, or health care professional).
©2019. Ginger Garner. All rights reserved.
What Can We Do?
This problem raises the importance of interdisciplinary interaction in maternal health care since “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.” The cost that these injuries exact on the healthcare system is ENTIRELY AVOIDABLE, if we would consider these solutions:
- Hand’s off a mom’s legs during delivery. No touch unless she asks for your help. And when she does, do NOT push back or pull her legs out to the side or up to her chest.
- Prenatal and postpartum pelvic physical therapy should become the norm during pregnancy and postpartum. It should be offered to every mother without charge in order to address pain and identify any issues that can cause bigger problems down the road. Pre-existing conditions of the hip and pelvis, such as femoral torsion, femoracetabular impingement (FAI), hip dysplasia, shallow acetabulum, and lumbopelvic instability or failed load transfer can all contribute to the incidence of, and increased risk for, hip labral tears. These could be addressed during pelvic physical therapy, which would offer a great cost savings down the road.
- Screening mothers at highest risk for hip joint pathology and special tests to target the hip labrum and related structures should be considered a regular part of prenatal and postpartum care. Hunt et al (2007).
Since over 80% of women give birth in the United States during their lifetime, the vast majority of women are at risk for hip labral tears. Universal screening and education for hip joint preservation should be made available, through women’s health PT, as part of national agenda to improve birth and maternal health. This would be an excellent start to stem avoidable and preventable pain, injury, and disability for women worldwide.
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About the Author
Ginger has spent 20+ years helping people (mostly moms!) with chronic pain as a physical therapist, athletic trainer, and professional yoga therapist. Ginger is the author of Medical Therapeutic Yoga, now in its 4th foreign translation, founder of ProYogaTherapy Institute, codirector of Living Well Yoga in Healthcare, and most recently ran for State Senate in NC.
Hi Dr. G.,
I am ten months postpartum and have confirmed by a recent MRI and injection into the hip joint that the groin pain I have been experiencing since having a baby is from a labral tear. Hip arthroscopy has been recommended. I am concerned about the fact that I would like to have another baby in the near future. My ob/gyn has suggested that the pain from the tear would likely increase while pregnant and suggested undergoing the surgery before becoming pregnant again. How long after the surgery should I wait until becoming pregnant? Or, should I wait until I am finished having children before undergoing the arthroscopy? Also, what should expect with regard to recovery and the ability to care for my child(ren)? Thank you so much for your time!
Hello Allison,
Apologies for the long delay in response, but you caught us right as we were leaving for the Christmas and New Year Holiday.
But to answer your questions:
First, I am so sorry you have a confirmed tear, but I do understand the trauma and it’s cause. I suffered a birth injury that led to my eventual hip surgery, which was more than a 5 year journey in all. The good news – I emerged from it all greatly improved and able to return to activities I had long abandoned and thought were no longer possible.
Second, your ob-gyn is correct, the pain could increase. However, I would not focus on that, lest it become a self-fulfilling prophecy. Rather, I would focus on pain-free function, strength, and endurance. A PT that specializes in hip labral tears/FAI can help you optimize your hip outcomes there.
Third, if you wait until after your pregnancy to have surgery – I cannot predict what will happen. No one can. To have surgery before becoming pregnant could be prudent, however, it is a long recovery, and your success depends on the quality of your surgeon, the surgery, your hip (no arthritis or any other major chrondral/bony deficits is best), and finally – your physical therapy. A great surgery can be undone by poor rehabilitation, just like a poor surgery cannot be fixed by excellent physical therapy. You need both to have the best outcome. It could take as little as 4 months (See my blog on this as 4 months is rarely possible except for young, elite athletes – the rest of us need a more realistic, “we live in the real world” time frame) http://www.gingergarner.com/2015/02/12/hip-labral-qa-long-recovery-take-surgery/) or like me, as much as 18-24 months.
Lastly, so far as care of your children – I would seek out maximal support and take the most time off of work that you can. I did not, but quickly resolved the issue with support from colleagues and family. I now think that getting more support was the BEST thing I could have done – short of finding the best colleagues possible to do the surgery and help me carry out the rehab – to assure the BEST outcome for the surgery.
I hope this has helped – and if I did not answer all your questions – don’t hesitate to respond to this reply.
Best wishes for you and your full recovery and plans!
Dr. G
Hi Dr. G! I am 38 years old and a year out from giving birth. In the past few months I have been experiencing hip pain with external rotation, abduction, such as Indian style sitting. I also get pain if I lie on the affected side and occasionally if I lie on the opposite side. Getting out of the car is painful. I was forced on my back during the birth of my son and my leg was forced into flexion, abduction, and external rotation. When I had a moment of sanity during pushing, I asked the student nurse to adjust the position of my leg because it was hurting. I am making an appointment with the family doctor this week. I’m hoping therapy will help.
Hello Stacey,
I am glad you found my blog helpful to your situation. Your situation sounds all too familiar – as the positioning described during birth would be a typical mechanism of injury for the hip. Not to say that the birth or leg positioning caused the injury – but it could be related to your unique structural makeup and morphology of the hip. However, the recommendation I always give L&D nurses and birth attendants is, if they haven’t had their hips screened by an orthopaedic PT or surgeon, who can tell them what their structural mobility limits are, then the best approach to assisting during birth is hands-off. Allowing the mom to move her legs freely – and not pinning them into a position – such as the most common one you describe. It increases of injury. That said, I would highly recommend seeing a pelvic/hip PT who specializes in hip conditions in order to get a thorough assessment of the hip. The family physician could possibly provide this referral, but will be unable to make specific recommendations or assessment or treatment, due to the generalist training. Diagnostic testing can also prove unreliable, but plain film x-rays can be good to provide a baseline and foundational measurements that help determine presence of structural anomalies in the hip and/or pelvis. I wish you the best of luck – and if you would like to provide your location – I can see if I know a pelvic/hip PT in your region to refer you to.
Thank you for taking the time to comment!
Hope this helps!
Dr. G
Thanks for taking the time to reply. I do need a referral from my primary care physician to see a therapist. I am currently a missionary and full time mom in Cabo Rojo, Puerto Rico. I am a physical therapist assistant, but have not practiced for over 5 years as I am raising my children.
I would pursue the referral then, absolutely.
Dear Dr Garner,
My wife had for her two hips an arthroscopy which were successfull for both. The first was done four years ago and the last now 1.5 years ago. Now, she is pregnant and the birth is predicted for June. Her surgeon suggests a caesarian to avoid any new labra tear. He says that the risks is too high. We asked another Physician and the gynecologist of my wife and they both say that there are no risk to achieve the labour by the natural way.
What is your point of view ?
After 7months of pregnancy she do not suffer from the first hip and has small pain in the second.
We know that the position for the labour would be very important and maybe be the key to avoid any further disease.
Our limits for the final choice (caesarian / natural way) is the expected weight of the baby, its position before labour and the pain before the birth.
Looking forward to your answer and hope that you have experiences about that. It’s difficult to find any statistics or topics on the web.
Best regards,
Nicolas
Hello Nicolas,
Thank you for your question – and thanks for stopping in to read – I am glad you’ve found the blog helpful.
To address your question, I have seen no reports of increased risk of labral tear as a result of birth. The risk comes with pregnancy alone, which can mostly be attributed to carrying the additional pregnancy weight plus baby.
I will say that the risk of labral tear in birth WILL increase IF labor attendants try to force the laboring mom’s legs back into flexion, abduction, and external rotation (FABER). This is a position that some women may not anatomically or structurally have available, and this is where the labral tear occurs. It doesn’t occur from giving birth alone.
I tend to agree with the second ob/gyn, which is that there is no posed increased risk for labral tear during birth. The caveat is to make it clear that the nurses are not to touch or manipulate your wife’s legs in any way during birth, especially for the FABER position I mentioned. There is no way of knowing what the morphology of her hip is – without a full physical exam and possibly diagnostic testing. The easiest way to prevent a labral tear during birth is to err on the side of caution and avoid FABER during delivery. I would make sure you are there to see that this (FABER) isn’t used. Gently assistance of leg holding is fine – but no FABER. It is not helpful in any way, not for crowning or delivery.
All the best, and I hope this helps –
Dr. G
Hi Dr. Garner,
First let me thank you for your blog, although labrum tears during delivery are common finding information online is not.
I am a 40 year old woman and 21 months ago I gave birth to a beautiful, healthy baby boy. I had a natural vaginal delivery without an epidural as I did with my first child 19 years earlier. After I delivered my first child I was up and moving around within a few hours unfortunately after I delivered my son not only was it extremely painful to get myself out of bed (this lasted for many months) but once standing I was only able to move my toes, when I did manage to walk or move in bed I could feel the bones in my pelvic area making noise I knew at that moment something was wrong; my OB/GYN attributed my pain to a pulled muscle. I am very athletic working out at least 3 times a week and an avid salsa dancer, I knew this was not a pulled muscle. Looking back I should have stood up for myself and voiced what I was feeling but I did not and almost a year later I found out I had a torn labrum through an MRI. I opted to do PT and although my pain has never disappeared I did get some relief so I figured that if I worked out and strengthen my muscles I would be able to live without surgery. Then my husband and I got pregnant again. I am 4 months into my pregnancy and am so scared of delivering my baby because of what might happen. Is there anything I can do to prepare my body for delivery? Should I do some PT and if so could you recommend someone in the Miami/Ft. Lauderdale area? Should I do yoga? My last PT told me I should stay away from it because it will add more elasticity to the area which could make the pain worse. Also from your previous comments my understanding is that a vaginal delivery should not make my injury worse or create a new one so long as I keep an eye on my leg position. Is this correct?
I look forward to hearing from you.
Thank you Thank you Thank you!
Hello Mercy,
I am so glad you found my website – and that this post was helpful! I started this blogs for moms and other women just like you! Certainly there are men with hip issues as well, but by and large, women suffer inordinately. First, congratulations on your pregnancy! Second, there is no reason to believe you cannot progress through and deliver without any further injury, or even pain. I would *strongly* suggest you find a pelvic PT in the Ft. Lauderdale area who can help you throughout the remainder of your pregnancy. She will be able to suggest activity restriction and movement or manual therapies that will help maintain your hip health as best as possible. I would avoid group yoga classes, unless you know a teacher who is equipped to handle not only prenatal yoga but also someone with an active hip labral tear. I would seek out a PT who has experience in yoga, you may be able to find someone I have trained here: https://proyogatherapy.org/for-patients/find-a-therapist/. I would also invite you to join my group on FB, there are over 1200 members: https://www.facebook.com/groups/HIPLABRALPHYSICALTHERAPY/?ref=br_rs
To answer your last question, so long as you keep an eye on leg position, correct, there is not likely to be any change in your current hip condition. Good luck, and please reach out again if you have more questions!
All the best,
Dr. G