Beyond Muscles: The Bone Driving Postpartum Pelvic Pain

Are you considering the bone itself (and not just the muscles) when postpartum patients come to you with persistent pelvic pain, adductor tightness, or tailbone symptoms? In today’s podcast episode, Lynn Schulte, PT introduces the concept of osseous lesions in the pelvis, subtle hardening of pelvic bones that can occur during childbirth and continue to drive soft tissue tension long after delivery. She explains how birth mechanics, baby positioning, and prolonged pushing can create trauma in key pelvic structures – and how skilled palpation can help clinicians identify the difference between healthy bone and hardened bone. 

This conversation opens the door to a frequently overlooked contributor to postpartum dysfunction. If you treat postpartum women, this conversation can help enhance your assessment of the pelvis.

✨ Key Takeaways for Practitioners

• Osseous lesions are areas of hardened bone created by trauma or compression during birth, often affecting surrounding muscles, ligaments, and tendons.
• The most common pelvic locations include the lower sacrum (S3–S4), coccyx, pubic rami, and medial ischial tuberosities.
• Persistent muscle tightness - like recurrent adductor tension - may actually be a reaction to a bone lesion rather than a primary soft-tissue problem.
• Skilled palpation can help clinicians differentiate normal bone mobility (“tree”) from hardened bone (“telephone pole”).
• Gentle compression techniques may help restore softness and mobility to affected bone and improve symptoms.

This episode will challenge practitioners to start listening to the bones, not just the muscles, when evaluating postpartum pelvic dysfunction.

Have a comment or question about today’s episode? Message Lynn on Instagram or Facebook, or Email Lynn.

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Transcript

Hello, everybody, and welcome to this episode. Today, I want to talk to you about osseous lesions. And osseous lesions in birth, or from birth, actually.

Hello, everybody, and welcome to this episode. Today, want to talk to you about osseous lesions from birth. An osseous lesion is an injury to the bone, and it, to me, shows up in my hands as a hardened bone.

So the bone is meant to have a little bit of give, a little bit of softness to it. It's a firm structure, but it does have a little bit of a bend.

If you compress it a little bit, and when it has been injured or traumatized or impacted in any way, it can develop a hardness to it.

So that's what I'm calling an osseous lesion is when the bone feels hard and it's lacking that bend. It's lacking that softness to it.

What the analogy I'd like to think about is a sponge. A dry, hard sponge is an osseous lesion. That's hardened bone, but a wet sponge actually gives and can compress the difference that you'll feel in the bone and what it does to the tissues.

My experience is that when a hardened bone is, we have that osseous lesion, things that attach to that bone can get activated.

The tendons, the ligaments, the muscles that attach in can get activated. So one of the most. There's three, four different bones that can be impacted from birth, and I want to talk about those today.

And when those bones are activated, they're hardened, there's an osseous lesion there, you will find that whatever's attaching to it might be impacted.

So I want you to start looking for this and feeling for it. One of the big things that I like to make sure that all the students who come to my live courses know and can appreciate the difference between hardened bone and normal bone, okay?

Because that is, I think, such an important skill to have in your hands to be able to distinguish between the two.

So let's talk about what bones are, what parts of the pelvic bones are really impacted from a baby's passage through it.

And it really does depend on the baby's position as it's going through that pelvis, so babies that had... are a little bit asynclitic or crooked as they're coming through.

They're going to create more of this osseous lesion, this tension in the bone. OP babies can also cause this.

But babies that are in a good position and the flow of the birth tends to be uninterrupted, like there's not a big stuck point as baby's trying to come through that pelvis, then we may not have as much.

of an osseous lesion. And, you know, we do know that there are studies out there. They've done MRI studies of postpartum pelvises, and they have seen higher water content in the bone, in the joints.

They have noticed separations. They have seen fractures. We know that tailbones fracture, sacrums can fracture, symphysis pubis can disrupt, and they are seeing the micro tears and the trauma to the side.

So there's a lot that happens in this pelvic space and to the pelvic tissues as a baby comes through and us recognizing and being able to determine what is it in a lesion or osseous lesion versus normal tissue, abnormal tissue versus normal tissue is really important for us as we're helping our clients recover from childbirth.

So there's several different points of the pelvis that stand out to me as carrying more of these osseous lesions than others.

And the first one I want to talk about is the sacrum. And it really does depend on the curve of the sacrum.

If you've taken any of my courses, I have a beautiful slide that one of my students actually gave to me.

And it's just a picture of all these different sacrums and how curved some are and how straight others are.

And you Every sacrum is different, but the more curved the sacrum is, and especially if that person is on their back and giving birth, the curved part, the lower part of the sacrum is what usually curves.

And if the baby's head gets stuck, you can so feel the impact in the lower third of the sacrum.

If you're watching this on video, I'm showing you a little pelvis and where I feel the greatest amount of trauma to the sacrum is in the S3-4 area of the sacrum.

And I like to just slide my hand underneath someone while they're laying in supine, and sometimes you can just feel the hardness in that lower sacrum.

It may also be because the sacrum is stuck in sacral flexion and it's pressing more into your hand. So I want you to become aware of differentiating between position of the bone.

And hardness of the bone. Okay. Because the, if the sacrum is stuck in flexion, which the majority of our postpartum clients, sacrums are stuck in flexion.

Um, and there is, you know, it will press more into your hand, but if you really tune into this lower third of the sacrum, you will appreciate maybe a hardness in that bone.

And, um, you can press up with your palm and just see how that bone feels as you do that and see if it has a softness or a give to it, or if it just feels like cement in your hands.

Cement is that hardened bone. It's that osseous lesion that can happen. So we can get that happening in the lower third of the sacrum that usually what you'll find is moms are pushing for greater than two hours.

Baby got stuck. It wasn't flowing through and you can just feel that that baby's head was just hammered. So hammering into that lower third of the sacrum for a long time, okay?

The other bone that can have an osseous lesion is the tailbone. The tailbone can definitely, depending on where it was positioned prior to birth, nobody's checking this, guys.

Unless they're coming to see you, hopefully you will be. But seeing where that tailbone is pre-labor and then also sensing and feeling into it after labor.

So you may want to do this more in prone and just have, you know, if you put your palm in the midline of the sacrum, your middle finger should curl under and find that tailbone.

And there should be a gentle give to that bone. And if it's really hard, that can be an osseous lesion in the tailbone.

And making sure if we have any tailbone issues, that we make sure that the sacrum gets out of flexion to help decrease the strain on.

I did another podcast on the tug of war on the tailbone, sacral flexion is one part of it, the anococcygeal raffia is the other part of it.

We need to release both of those to help the tailbone be happy along with the coccygeuses on either side.

So the tailbone is another area that we could have an osseous lesion in the pelvis. And then the other is the pubic bone and the pubic rami and how the baby's head comes into the pelvic inlet.

And when it goes to rotate posteriorly towards the sacrum, it can put a lot of increased pressure on this pubic bone and pubic rami.

I tend to find because I'm mainly working with postpartum women, I'm able to discover all these different patterns. And of my clients, of the thousands of clients I've seen, the majority of them have this hardness on the left side.

Occasionally you find it on the right. Focus. But I'm just giving you the percentage of like, okay, the majority of the most common pattern is on the left, that the left side will be more hard and more containing that osseous lesion in it.

And because of what attaches to this pubic rami bone, the adductors can get very activated with the lesion in the rami bone.

And I've had clients come in and tell me that they have worked with a massage therapist, their adductors are just really tight and there's a lot of tension in them, they'll go see a massage therapist, it's better for a day, but then it comes back.

And if you hear that from your clients, please look at the rami bone, the muscles are reacting to the bone, because that's where it attaches into when you release the bone, then the muscles able to maintain its relaxed state.

Okay, so that is the pubic bone, pubic rami. And then the other place we need to look at... That the medial aspect of the ischial tuberosities.

So those ischial tuberosities can contain some osseous lesions in them depending on the position you were in or your client was in when the baby came out.

It may put more pressure on one side versus the other, and you will just feel a hardness, a difference in the hardness from one ischial tuberosity to the other.

And usually that hardened side will lack any medial mobility, and that's what we want to encourage the softening of the ischium and the medial compression.

I teach it in Suprine and Prone, but it's also very easy to do it in sideline to help decrease the, or to help increase the medial splay or to help get it to go medially.

Um, you can do, you can treat in sideline as well. So, um, those are the areas of the pelvis.

Bones that can get impacted from birth and those are the the most typical ones that I find in my practice and so I just invite you to start paying attention to the bones and most PT and OT curriculum is not giving you ways to help approach the bones and so if you are unfamiliar with that please check Any of my courses treating the postpartum pelvis is just the four patterns that you find in the pelvis that's all it focuses on and or if you want all the patterns take my holistic treatment of the postpartum body course okay so thank you for listening in and I hope that you will have a greater awareness greater ability to tune in and start appreciating the hardness in the bone to identify these osseous lesions in the pelvis and and and and and

And just remember that all hardened bone loves compression. So if you can figure out a way to offer compression to that hardened bone, that can help soften it again.

The analogy my friend Heather Hannum talks about with osseous lesions and bones is telephone pole is the hardened osseous lesion bone and a tree that bends and gives in the wind.

That's a normal healthy bone. So tree versus telephone pole is the difference that we're looking for when we go to evaluate these bones anywhere in the body.

Okay, so please keep that in mind. You can do this with a break in any bone. You could do this after a knee surgery, total knee replacement, help that bone that that new device is now attached to the bone.

That bone is so hard after total knee replacement. man. Figure out a way to offer compression to that femoral head, to that tibial plateau, and just help soften the bone after they've recovered from that total knee replacement.

It is huge for helping that area to feel better after the surgery. So keep that in mind, everybody, and thank you for listening, and we will see you all in the next episode.

Please share this with any of your colleagues, whether they're in pelvic health or not, because the bones of the body are so important.

And I think it's a missing piece to a lot of our work in the body. All right. Thanks, everybody.

Take care. We'll see you on the next episode. Bye-bye.