Rib Pain After Pregnancy
This case study is about a 27 year old female runner who was referred to me by her physician assistant for treatment of rib pain. Her pain was in the lower right front part of her rib cage. I have helped several runners with side aches but this situation was unique. She had been able to run 30 miles per week for the previous 2 years and then became pregnant. She ran until 7 months into the pregnancy and felt too awkward to continue running. She was able to train on an elliptical until a couple of weeks before delivery.
After delivery (no complications) she waited 6 weeks to begin running again. After about 10 minutes of running she began to experience severe lower right rib pain. The pain would even linger after the run if she reached overhead or reached behind her twisting to the right. She kept running but the pain got so bad that she could not run for more than one minute before having to stop. She decided to give running a rest and work out with a personal trainer.
One day her trainer had her perform abdominal exercises with an ab roller. Ab rollers are a wheel with handles on each side – you start from a kneeling position and with the handles in your hands roll forward trying to fully extend your body (a very challenging exercise). She was sore for an entire week after that exercise, at which time she was referred to see me.
When I evaluated her she had excellent biomechanics, running form, balance, flexibility and strength, with the exception of tightness with side bending to the left and fully extending her trunk in a standing position. Additionally, upper abdominal strength testing was painful in the area she was experiencing pain with running and ab roller training.
My impression was that during pregnancy junior may have had his foot in the lower right rib area and strained the area. After delivery this remained a weak area and may have developed some scar tissue (hence limiting her trunk motion). I have seen people with chronic side aches have a similar situation following various abdominal surgeries. So I showed her some specific stretching exercises to address the stiffness that had developed and started her on some upper abdominal strengthening exercises that were less straining.
We also talked about post pregnancy abdominal training. I am a firm believer that it is very important to regain abdominal / core strength following pregnancy. However, it takes a while for the hyper stretched tissue to be able to perform at previous levels. In one study of abdominal musculature during pregnancy they documented a splitting / hyper stretching of the muscles that lasted after 8 weeks following delivery.
In another study, women who performed daily abdominal exercise were tested 12 weeks following delivery and were found to not have more strength in the abdominal muscles than the group that did not exercise. However, the group that performed the abdominal training had significantly less back pain following delivery – possibly indicating that they had better abdominal function that didn’t show up in the way they tested the abdominals. So, the take home message is that the abdominal muscles get pretty beat up during pregnancy and delivery and will take a while to regain their previous strength level. It is safest not to perform aggressive abdominal exercises (ab roller, dynamic planks, reverse roman chair) for at least 3-6 months following delivery and then proceed cautiously.
After 2 weeks of performing the exercises I asked her to follow up with me and try to run just prior to our appointment. At our follow up appointment she was able to run 5 minutes before feeling some discomfort and then stopped. Her stretching exercises had improved her motion about 50%. We made a few modifications to the stretching and strengthening exercises and sent her off for another 2 weeks with instructions to gradually increase her running but stop as soon as symptoms began.
After 4 weeks of performing her rehab program the rib pain was gone and she was enjoying running again.
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Bryan Whitesides PT, OCS