At first glance, you might reason that a college soccer player recovering from an ACL reconstruction has nothing in common with a mom recovering from childbirth. I would disagree. In fact, I think they have strikingly similar rehabilitation goals.
I became an orthopedic specialist in 2007. At that time, protocols for ACL rehab were shaking things up. We learned that the quicker our patients started their rehab, the sooner they could return to their sport. They also had less pain, atrophy, and dysfunction which contributed to improved long term outcomes.
I didn’t consider the recovery process that a mom might need until I had my own babies. I didn’t value that expertise, until I was the one lost and confused with a mild prolapse, a large diastasis, and an umbilical hernia. Then, it got my attention.
Here are three reasons I believe every mom should have prehab and rehab just like an athlete:
1. Prehab and Rehab
Prior to having an ACL reconstruction, athletes will typically have a few pre-hab visits to optimize recovery and to discuss guidelines and expectations for return to sport and activity. Their post op physical therapy visit will be in place so that he/she can have physical therapy right away. What if we treated every mom like the soccer player? What if she had formal education prior to vaginal delivery or cesarean surgery… prehab if you will? What if the injuries and strains and stitching to the muscles in her pelvic floor or abdomen were considered an impairment requiring physical therapy. My post op athlete has an incision, swelling, atrophy, loss of range of motion, weakness, and pain. She is sent for PT the following day of her surgery. What happens to the mom who has an episiotomy, a cesarean surgery, weakness, or pain in her pelvis following labor and delivery? Could we prevent further dysfunction of c-section scar adhesions, diastasis, or prolapse if she were also offered prehab and post op physical therapy. I think the answer is yes.
I’ve had three babies, so I understand the blur of life that happens when you go home with a newborn. I also know that so much attention is on those sweet babies and moms are often lost in the gap. By six weeks, a lot has happened. I think we can do better.
2. Clear Guidelines and Protocols for Postpartum Rehabilitation
My desire is to see every mom formally educated on prenatal exercise and modifications to prevent injuries to their abdominal wall and pelvic floor. I also think early intervention by a pelvic floor therapist and/or a postpartum physical therapist is essential for full recovery. Why are we expecting moms to go home and lift toddlers and strollers and laundry without straining their back or developing a prolapse? Why do we think strained muscles in the core and pelvic girdle accompanied my connective tissue laxity and weakness shouldn’t be rehabbed?
I would never teach my post op ACL patient quad sets to do at home, and expect that in six weeks, she could return to her sport. She would need to work on strengthening her whole body as well as improving her motor control and balance. I would challenge her ability to jump and work on strength in different planes of motion. Likewise, I would never teach my postpartum patient to go home and do kegals for six weeks, and expect her body to fully heal and be ready for fitness. How could I expect her pelvic floor and core muscle groups to be prepared for running, doing a HIIT bootcamp, or playing hopscotch with her children.
3. A Better Bridge to Fitness:
Often, moms return for their six week follow up visit and are briefly assessed and affirmed that they are all healed and can return to working out. Unfortunately, that is not always the case. What if that mom is breastfeeding and plans to return to CrossFit with high intensity training? What if she is a runner who signed up for her first half marathon as motivation to get her baby weight off ? What if she starts jumping in a few weeks and her group fitness instructor encourages her to keep attending class because that’s completely normal after having kids? The female body changes drastically with pregnancy, childbirth, and breastfeeding and moms would greatly benefit from better guidance when it relates to getting back into fitness.
Some of the many changes the body goes through with orthopedic implications:
The Rib Cage Expands 2-4 inches throughout pregnancy
Body Composition changes occur as a result of hormone changes and demands of pregnancy
The pelvic joints and ligaments stretch and expand in preparation for delivery
The pelvis becomes anteriorly rotated and the lumbar spine increases in lordosis
The Q Angle increases at the knee as a result of the hips widening
Connective Tissue of the abdominal wall stretches and adapts for the growing uterus
Decreased balance and proprioception of the whole body as pregnancy progresses
Decreased core breathing efficiency as the diaphragm and pelvic floor muscles adapt and accommodate the demands of pregnancy
Pelvic floor weakness and lack of motor control due to demands of pregnancy as well as labor and birth
Abdominal weakness and lack of motor control due to excessive stretching
Potential for scar adhesions or hypersensitivity following a cesarean surgery
Potential for persistent weakness, lack of motor control, scar tissue, and dysfunction of the pelvic floor muscle groups following episiotomy or repair
The female athlete should be be considered as we educate her on the demand of her sport and her recovering body. I often find that higher level postpartum athletes are told they can continue to participate in whatever type of fitness they were doing prior to pregnancy and that at six weeks, they can jump back in. Unfortunately, this is outdated advice in my opinion. I’ve also seen the far end of the spectrum where postpartum athletes are advised against their sport and develop fear and depression as they adjust to their postpartum body. As a physical therapist and postpartum athlete, my heart is to help the female athlete safely continue in her sport with modifications during pregnancy and breastfeeding. Every mom should be treated as an individual case when it comes to prenatal fitness and return to postpartum athleticism. Based on prior level of fitness, hormone changes, connective tissue adaptations, body composition changes, and weakness of the core and pelvic floor, we can not treat every mom exactly the same. Women carry their babies differently and experience different changes based on their individualized response to pregnancy and birth. They should be treated individually as they return to high level exercise as well.
You see, the post op athlete and the postpartum mom actually have a lot in common. The patient who has formal education to explain expectations and individual considerations for recovery and return to fitness and sport will have better outcomes. The patient who has immediate access to physical therapy will have less pain, atrophy, dysfunction, and loss of motor control. The patient who is treated as an individual with a customized plan of care will return to her sport quicker and with less anxiety and confusion surrounding her recovery. I hope we will continue to see positive changes in women’s health that reflect more referrals to physical therapy and better education on prenatal and postpartum fitness modifications for every mom.