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Persistent pain after a c-section: when is it muscle pain and what can you do?

I am really surprised by the number of hits I get from people trying to find out more about chronic pain post c-section. Although I suppose I shouldn’t be, because I see women with chronic pain every day and it takes years for most to get an answer (i.e. they don’t get an answer until they’ve been referred to me). It’s really so very sad, because many times the treatments are not very hard.

The two main causes of post c-section pain are nerve pain (covered here) and muscle pain. Muscle pain is actually the most common cause of chronic pain overall. Muscle pain can happen spontaneously; however, it can also be triggered by trauma (like surgery or childbirth). Throw in the hormonal changes of pregnancy and delivery as well as the lack of sleep and the stress of caring for a newborn and you have many of the ingredients for a chronic pain condition.

The formal medical term for this kind of muscle pain is myofascial pain syndrome, or MPS for short. It happens when (for whatever reason) a muscle tenses and contracts too much, forming tight bands (ever felt a knot of muscle in your neck? That is the kind of tight band or knot that happens with MPS, except with MPS the knot won’t go away). The spasms cause severe pain by reducing blood flow and squeezing nerves.

After a c-section, this kind of myofascial pain syndrome can affect the belly wall or it can affect the muscles of the pelvic floor (those are the muscles that you squeeze to stop your flow of urine and the muscles that contract during orgasm).

Muscle pain can be very severe and is often (but not always) worse with physical activity (including sex). Frequently I hear it described as the feeling of “a bowling ball” or a “fist” in the vagina.” I have also heard it described as “my insides are coming out.” Some women say it is a squeezing or a cramping sensation. Everyone has a unique pain experience, so descriptions certainly vary. Because these muscles surround the bladder and bowel, pelvic floor MPS can also cause the need to empty your bladder a lot and urgency (difficulty holding your urine) as well as pain with or after bowel movements.

There are no specific tests for muscle pain or MPS, it is diagnosed by exam. It can be hard for someone who isn’t used to diagnosing muscle pain to know if the pain is coming from the belly or the pelvic floor. However, if you lay flat on your back, press on your belly, and lift your head off the bed and your pain is worse, then the belly wall is probably involved (lifting your head flexes the belly muscles, and worsening of pain while the muscles are working can be a sign of MPS). Your doctor should also feel for specific tight bands in the muscle as well as specific points of pain called trigger points.

MPS of the pelvic floor requires a pelvic exam. The examiner will feel tight bands of muscle (like a violin string) and touching them will reproduce the pain. Many women feel as if their partner is hitting “a wall or blockage” during intercourse – that is actually contact with these tight bands of muscle.

The good news is once MPS is diagnosed most women respond to treatment. The first step is seeing a pelvic floor physical therapist. You can find one at in the International Pelvic Pain Society (enter your country, state and city and a list of providers will appear, you will be able to tell who is a physical therapist and who is not). The physical therapist will do manual therapy on the muscles and help release the tight bands (they may do other kinds of treatments as well). Other therapies may include some of the following:

  • A TENS unit. A small device that sends an electic impulse to the muscles of the belly wall. This should be set up by a physical therapist (there are specific settings). A TENS can be very helpful for belly wall pain.
  • Trigger point injections. Using a needle to mechanically break down the bands and knots in the muscle. Some local anesthetic is given to make this less painful (it sounds worse than it is). Trigger point injections are not stand alone treatment, they work in conjunction with physical therapy
  • Ibuprofen or other anti-inflammatory pain relievers. If there are no contraindications, a 10-14 day course of prescription strength ibuprofen every 8 hours may help reduce inflammation and break the cycle of pain
  • Nerve pain medications. When pain has been going on for several months the signalling in the nervous system starts to change and this can amplify pain (think of it as the volume being turned up too loud in the nervous system). Nerve pain medications, such as nortriptyline or gabapentin, can help reverse or dampen these changes. The medications don’t have to be permanent. Many times reducing the pain helps the nervous system get re-organized and the medications can be stopped with time. Nortriptyline can be used during breastfeeding if needed.
  • Botox injections. Yes, you read that correctly. When physical therapy has been ineffective at relieving muscle spasm, Botox injections are a highly effective way to break the cycle of muscle spasm. They only work for about 12 weeks and have to be combined with physical therapy. Once the cycle of spasm is disrupted, the physical therapist can help you re-educate the muscles so the effect becomes long-lasting. Botox can’t be used while breastfeeding.
  • Weight loss. The mechanical strain of extra weight (not uncommon after having a baby) makes muscle pain worse. In addition, belly fat churns out inflammatory chemicals that can make pain worse.
  • Physical activity. Even though it might be painful, muscles are meant to be worked. The less they are used, the less blood flow and the worse the pain will become. Muscles also shorten over time when you don’t move. Some tips for getting started are walking in a pool (the water helps to carry your body weight, putting less strain on the muscles), walking around the block, or a gentle yoga class. When first starting it is important to only exercise every other day to give the muscles time to recuperate.
  • Managing constipation. Straining will over work the pelvic floor muscles. Talk with your health care provider about the best way to manage your constipation. Fiber supplements or changing your diet (we need 25 g of fiber a day) is a good place to start.

If your doctor has never heard about muscle pain, print this page out and give it to them and point them to this article in UpToDate. In my experience, myofascial pain is the most common cause of post c-section pain. If your doctor is unsure, they can easily have you see a pelvic floor physical therapist who can be invaluable in confirming the diagnosis (as well as starting treatment).

Remember, this post does not represent medical advice.

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Discussion

26 thoughts on “Persistent pain after a c-section: when is it muscle pain and what can you do?

  1. I would also suggest someone who specializes in visceral massage, and/or acupuncture.

    Posted by boulderacupuncture | May 10, 2012, 11:05 pm
    • Well yes, of course you would.

      However, science-based medicine can provide real solutions to pain, as opposed to flaky rituals intended to induce a placebo effect.

      Posted by boostick | May 12, 2012, 12:30 pm
      • You are allllmost not worthy of a reply.
        1. Define “science based” proof or evidence. 2,000+ years of holistic health care (placebo or not) might be more proof than FDA lab scientific proven rushed through or paid off to pass in 3 months, which is many and plenty of drugs prescribed by your MD.
        2. How many people are sicker and worse off, trading one bad ailment for a side effect or dying on these meds?
        3. How many get better on placebo….JUST like they arguably do with ANY other modality? Be it supplements, herbs. acupuncture or pharmaceuticals? Therefor…what’s it matter? I would opt for the lesser side effects, more tried and true avenue.
        4. WHO, and NIH, and insurance companies are now backing holistic health care. There are plenty of “science” based studies and research now supporting and yielding a better understanding for how something like acupunk works, blurring the boundary of what “science” is in health care. Just because YOU don’t understand how something might work (which stands for THOUSANDS of big pharma drugs and their off label uses) does not qualify it to be more or less scientific.

        Western med is great. It’s there when you NEED it. You my dear should never ever shun something just b/c you don’t understand it. Once upon a time, we thought the Earth was flat.

        Your hostility and close-mindedness may benefit from one of the above.

        Posted by s | July 30, 2012, 9:53 am
  2. Another reason for pain could be diastasis recti, a split in your abdominal muscles; many pregnant women get this and a c-section can make it a lot worse.

    http://fit2b.us/how-to-check-for-diastasis-hd/

    Posted by Oubli | May 14, 2012, 11:59 am
  3. For me, trigger point injections really were that bad! The problem is, the exact place you need the needle is where it already hurts the most, so it’s very different from a normal shot. That said, the were effective, and I went back for several rounds of them. Some were just just anesthetic, others also had a steroid (similar to a cortisone injection as far as I understand). If you need them, the doctor should be able to apply a topical lidocaine gel transvaginally that will make the needle much less painful. Sadly, they didn’t wise up to that until my last set! So I would ask even if they don’t offer. However, as I said, these were very helpful and allowed my pelvic floor PT to make more progress. So even though they’re difficult it’s worth considering them if your doctor or PT recommends it.

    Posted by Cat | May 26, 2012, 5:48 pm
  4. Muscle pain can be best remedied through the use of OTC pain killers like ibuprofen and paracetamol.,;,;.

    With appreciation http://www.foodsupplementdigest.com/chia-seeds-side-effects/

    Posted by Bradley Mellow | August 22, 2012, 11:20 pm
    • I do not understand your post. You are recommending long-term use of drugs for muscle pain, it seems, which will lead to pathologies in other systems. Why not address an underlying cause of the pain rather than masking the symptoms with a pain-reducer?

      Posted by Danielle Spath | February 6, 2014, 1:47 pm
      • A nerve pain medication does not mask pain, but treats the disturbances in the nervous system that produce and result from chronic pain.

        The post actually advocates a multidisciplinary approach.

        Posted by Dr. Jen Gunter | February 7, 2014, 6:35 am
      • That is actually not what the post says. There are several effective therapies for chronic pain listed. Medications that are typically called nerve pain medications are called adjuvant medications and those treat/address the underlying disorder in the nervous system that falsely amplifies pain signals (this is the hallmark of chronic pain). Opioid medications are a band-aid and can cause more harm than good and I am not advocating those for long term use.

        Posted by Dr. Jen Gunter | February 13, 2014, 6:27 am
  5. it has being almost 3 years since my c-section and I still have so much pain on one site of teh scar..I can not do exjercises and even getting up from bed is painfull, and to tp this up I have a overlaping belly on it as teh cust is deep. is this possible to have tis for so long?

    Posted by corina | September 24, 2012, 5:08 am
  6. i really like to sculp my abdominal muscles through lots of crunches and weight training. love to have those 6 packs. `:,:”

    Our own blog site
    http://www.caramoantravel.com

    Posted by Donnell Kristofferson | October 6, 2012, 11:33 pm
  7. 6 months post c-section (witn uterine infection during delivery and also incision infection afterwards which required wet to dry packing for 2 months) and I have a burning pain across my incision after I have sat or laid still for an hour or more and then stand up. Off the top of your head does it sound more like nerve pain or muscle? If I had to give my uneducated guess- it seems like maybe I have scar tissue that needs to “loosen up” once I start moving?!

    Posted by Julie | October 30, 2012, 2:50 pm
  8. I had my last c-section 5 years ago. In the past year once or twice month I get really sore stomach muscles, like I’ve been doing situps and worked my muscles really hard. I was wondering if this could be MPS? My stomach is also very tender to touch.

    Posted by Jo | January 17, 2013, 1:06 pm
  9. Thank you sooo much for this information! It has answered many questions and calmed some troubling concerns! I greatly appreciate it!

    Posted by Danielle | April 16, 2013, 10:35 pm
  10. what would cause pain and tenderness at a scar after 12 years? it’s actually been occurring for a few years.

    Posted by carly welch | May 12, 2013, 1:12 pm
  11. Hi I had my baby8 wks ago it is my 5th chikd yes 5th lol n my 4th csection but I am geting very bad tenderness when touching stomache still.also sharp pains on occasions on right side of stomacge but not in scar infact scar very nice from begining.I had a long bleed aftef birth whichb is also unusual for me and even after tgat 5wks occasionaly I get a bloody jelly loss. You wpukd ghink I woukd have t answers after 5 children but it doesnt work like that .

    Posted by amanda | August 16, 2013, 1:14 pm
  12. This has helped me so much. I am so glad I found this article. I had my fourth section 2 years ago and I still have pain. I feel like a small object is stuck above the incision. I have been complaint dice the first week. I’ve been with my doctor for 18 years. She examined me again! Nothing she can find. Sent me to pain management but I couldn’t stand being there. I don’t want to be medicated. I want to live! I was an aerobics instructor. Now when I do abs it sets me back for days! Belts hurt the area. Sex can hurt the area. Cat scan shows nothing. Really!???? I wish you were in South Carolina. Desperate to fix this. I just want my body back. I want to run races again pain free.

    Posted by Krista Collins | January 30, 2014, 7:26 pm
  13. Thank u so much for this article! At last I know what the pain is I’ve been getting! Thank u thank u thank u!

    Posted by Suzy | May 27, 2014, 1:53 pm
  14. I had 2 c-sections, my last being almost 3.5 years ago and for the last year and a half I have had a lot of pelvic pain, which my OBGYN had summed up as ‘extensive scar tissue’ after having a laparoscopy in January. He suggested getting a hysterectomy in hoping to get rid of some scar tissue, and some pain. That was 4 months ago, and I am still currently waiting on an appointment to have this done. After reading a couple of these articles, I am now wondering if I have nerve pain or muscle pain and would even having a hysterectomy cure my pain?! I am in eastern Canada, and find it very difficult to get any answers here regarding my pelvic pain. It’s very depressing…do you currently practice in Canada or the US? If you have any leads on any good pelvic floor PT or OBGYN in eastern Canada, please let me know! I’m glad I came across your blog! Thank you so much!

    Posted by Sarah P | July 8, 2014, 5:02 pm
    • I had my first C Section in late 2011 and my second in early 2013. I feel like I healed about 70% and whatever pain was there when my youngest child was a few months old is still there to this day and now he’s 1.5 yrs old. I have spoken to several doctors, in Eastern Canada and Western Canada, over the course of 2.5 years. All of them shrugged me off, feeling the incision and saying “You healed really well!” ……. Yeah Doc, I healed excellent! That’s why I’m in pain all the time, hurts to piss, really hurts to have sex, hurts/burns to do sit-ups and almost daily sharp, shooting pains. I can’t even touch my lower abdomen, it’s so sore. At this point, although I’m a much bigger fan of any natural approach to fixing a heath issue than I am of pharmaceuticals, I’d be happy to take pain killers at this point for a little while, if that is the only way they would help me. I want to go to my homeopathic clinic about it but my insurance don’t cover it and since having my kids, I haven’t been financially able to. I like the options described in this article but in order to get any of that, doctors would have to take me seriously, which I don’t have any hope for anymore. Sometimes I wonder if it’s because I’m only in my early 20’s. I just wish I could live pain free.

      Posted by Nikki | August 6, 2014, 6:16 am
    • Sarah, if you’re in your 20’s like me, don’t get a hystorectomy!! I have the exact problems of you and had endometriosis. So we did a hysto and I regret it!! I’m miserable. My ob says see a pain mgmt doc, my pain mgmt doc says see an obgyn. It’s a vicious cycle that I have no clue what to do. I’m in pain with a young son, so this is ruining our lives!!

      Posted by lacey | October 22, 2014, 1:29 pm
  15. @ SARAH P ..your doctor is mad! some women have gotten pudendal neuralgia from hysterectomies! your pain will turn into eternal chronic pain !!

    Posted by mary jane | July 22, 2014, 4:51 am
  16. One of the actions you can do to help relieve back pain is to strengthen your core.
    Make sure the chair has good lumbar support, arms rest and a firm cushion. Incidences of the problem seem to increase with age-up to the
    middle or late forties.

    Posted by ปวดหลัง | August 28, 2014, 12:37 am
  17. Sometimes, the relaxin hormone leads to abnormal motion in various
    new joints of your body, thus leading to swelling and pain. Muscle strains are the most common cause of low back pain. You should also know
    the type of back pain you are suffering.

    Posted by ปวดหลัง | August 30, 2014, 7:02 pm
  18. Im..an egyptian physical therapist
    This great artical
    thanks from egypt

    Posted by dr ashraf | October 21, 2014, 1:11 pm

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  1. Pingback: Pain Management – surgery is not the first choice – Stephen S. Rodrigues, MD « Earl's View - June 13, 2012

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