Why do expectant women experience so much leg cramping and achiness, hip pain, arm numbness, and neck discomfort, in addition to the more common complaint of back pain? Put simply, potent hormones and profound functional shifts affect every joint, muscle, ligament, and nerve in a woman’s body during pregnancy. Let’s take a look at the causes and some relevant guidelines for easing these discomforts, based on my three decades of maternity bodywork practice, study, teaching, and writing.

Endocrine and Functional Contributors
In the tale of prenatal musculoskeletal pain, the hormone relaxin stars as both heroine and villain. Depending on levels and overall joint integrity, elevated relaxin—in synergy with progesterone—softens all connective tissue and increases ligament laxity. This process helps accommodate the growing fetus; unfortunately, it can also compromise the expectant mother’s feet, knees, hips, and weight-bearing structures.
Try this exercise: Stand up and imagine you’re pregnant. Feel the weight of the imaginary baby you’re carrying. You might notice some characteristic shifts in your body. As the baby’s weight tips your pelvis forward, notice and exaggerate the similar cervical spine collapse. Jut your chin out well ahead of a vertical plumb-line standard. Feel the shortening and the deep tension of your posterior neck muscles, vertebrae, and especially your sternocleidomastoid and scalene muscles. Let your pectoral girdle anteriorly rotate, compressing and collapsing across your upper torso. For further realism, hyperventilate while pressing your fingers into your solar plexus to simulate maximum uterine growth.
Attend to your lower body now, noticing your need for knee hyperextension to keep from being pulled forward. Register that more weight is both toward your toes and on your medial arch, particularly after you make this next adaptation. For further stability, widen your stance beyond your shoulder width, and then externally rotate your femurs. Wander about for a moment, feeling the waddling, side-to-side gait you must use. Take note, and remember this significant functional adaptation of the movers of the hip joint, pelvic stabilizers, and many other muscles and joints when we discuss leg specifics later in the article. Go ahead and release yourself from this imaginary pregnancy and shake out where needed, as we examine how this posture contributes to the pains of pregnancy.

Headache Pain in Pregnancy
The upper body muscle shortening and strain you just felt as a pregnant woman often translates into tension headaches and trigger-point referrals. Elevated estrogen levels commonly result in sinus pressure and sinus headache pain. However, whether pregnancy worsens or lessens migraine headache frequency and intensity remains unclear.
What is more definitive is that headaches with migraine-like sensations are often associated with a dangerous physiological complication of pregnancy. If a pregnant client sees dark or flashing light, along with severe headache pain, you should be alert that she may have extremely high blood pressure, known as eclampsia of pregnancy. Although massage therapy might help counter stress contributors, women with this type of headache need their health-care provider’s immediate evaluation. Highly elevated blood pressure can put the mother’s life, and that of her unborn child, in jeopardy. This extreme hypertension is more likely in high-risk pregnancies.
Massage therapists tend to be effective at addressing a pregnant woman’s neck and head pain. When tension and postural distortions are the main causes, include somatic techniques that address the joints and ligaments, the muscles, and both the investing and superficial fascia (Image 1). Identify any relevant trigger points in these muscles, too, and extinguish them.
I find that mobilizing the spine longitudinally and horizontally, and freeing the mother’s pectoral girdle from the rib cage, is particularly effective. Use passive stretches, resisted stretches, and other forms of positional release. In the pregnant client’s body, it can be useful to diligently friction areas of adhesion and ligament distortion. While a side-lying position may initially seem odd for work in this area, I find the alternate access it provides to be quite effective.
Some prenatal teachers advocate having clients rotate at mid-back from side lying to turn their upper body to a more supine and accessible position for face work. I don’t like the sustained deep spinal rotation this creates; I prefer face work in either a semi-reclining or supine position. Even late in pregnancy, it is well within medical recommendations for most women with normal pregnancies to be supine for as long as 3–5 minutes without supine hypotension developing (reposition immediately if shortness of breath or dizziness develop). This brief face work is a great start or end to a session. If a more comprehensive facial or sinus sequence, or lots of deep-tissue work on the neck and upper torso, is needed, then semi-reclining is usually safest and most comfortable, especially after 22 weeks.
Address the client’s trapezius, levator scapula, and supraspinatus, precisely. Only use broad pressure when at the mid-point apex of the shoulder area, taking care to avoid deep, focused pressure to this point, as it holds the potential for uterine contraction if inappropriately and repeatedly contacted.

Hand and Arm Pain
Even at 15 weeks, the weight of the breasts begins rotating the expectant mother’s pectoral girdle anteriorly. By the final 10 weeks, the mother’s superior rib cage will often shift too far posteriorly, while the inferior section juts forward. This alignment tends to create a blockage of fluid return from the hands, as well as pressure on the brachial plexus. The resulting carpal tunnel and thoracic outlet symptoms involve pain, tingling, numbness, and sometimes arm and hand weakness and dysfunction.
Women with these symptoms sometimes are surprised. They might have expected backache with their pregnancy, but what’s up with their hands? These women often are in their third trimester when the effects of forward abdominal weight are most pronounced. Most women escape debilitating hand pain prenatally, but many develop this condition postpartum as a result of nursing and other repetitive childcare tasks.
Relieving thoracic outlet arm and hand numbness is about freeing the brachial plexus from compression. Try direct techniques to relieve her pain, such as deep tissue and friction, especially to the pectoralis major, minor, and the scalenes. Relax tight muscles and stretch ligaments with all types of mobilizations, stretching, positional releases, and other more indirect techniques. The side-lying position provides spectacular access and options for freeing the pectoral girdle and rib cage (Image 2).
With increased fluid volumes in the mother’s body, edema in the arm and hand can result, particularly if there is mechanical restriction from poor torso and pectoral girdle alignment. If unrelieved, the median nerve can have little space in the carpal tunnel, and pain, numbness, burning, or weakness can develop in the thumb and fingers. Carpal tunnel syndrome is more common in women who have smaller bone structure or who repetitively use or misalign the wrist and hand. It is also associated with systemic edema.
Does that raise a red flag for you? It should. Remember that systemic edema is one of the signs of eclampsi—gestational hypertension. Be sure to evaluate if any hand swelling is pitting. If it is, it is likely gestational hypertension’s lymphodynamic edema, which requires further medical assessment. Also, look for some of the other signs of eclampsia listed in the sidebar below.
Work with your client’s prenatal carpal tunnel symptoms first by draining excess fluid. Starting in the axillary region, work systematically through the upper arm and then the lower arm. Remember that this type of fluid moves most readily with superficial work. After thoroughly working down to the hands to reduce fluid pressure on the nerve, I look to address overuse, tension, and trigger-point components. I find wrist and hand ligament work improves mobility and reduces adhesions, and I relax hand flexors with deep tissue and other deep Swedish techniques. Of course, there are other types of hand pain, but these two are the most likely to develop prenatally.
Before we leave the hand, locate the junction of your thumb and index finger on the dorsal surface. Press in with your opposite thumb at another of those points that are traditionally needled by an acupuncturist to promote uterine contractions, among other effects. This is where you want to avoid pointed pressure on the client. Notice that I didn’t caution you to not touch here; it takes repeated, focused, and energetically potent pressure to potentially elicit a uterine response with manual pressure. There is no need to be fearful of these points, just respectful.

Prenatal Leg Pain
Relieving prenatal extremity pain requires understanding all of the possible sources and then using a variety of techniques to address them. Many women’s discomforts in these areas are inconvenient and uncomfortable; others have considerable pain and movement restriction resulting in other negative consequences from inactivity.
All of a woman’s hip joint structures absorb the compression of pregnancy’s extra weight, particularly the ligaments and bursa. Excessive femoral external rotation will stretch her anterior structures and shorten her posterior ones. With a waddling gait, hip joints and movers function differently. With the leg externally rotated, the iliopsoas cannot properly stabilize or flex the pelvis or the thigh. Instead, the gluteus medius must abduct the leg to initiate each step. This overuses and tires the gluteus medius, spawning trigger points here and sometimes in other hip movers. Localized and referred pelvic and leg pain results.
Another factor in leg pain is referral from uterine ligaments. Strain to the round ligaments can contribute to anterior thigh pain. Broad ligament strain mimics sciatica and piriformis syndrome (Image 3).
As abdominal weight rests more on the inguinal ligament, significant fascial restriction develops there and in the surrounding fascia. Hormonal changes, gravitational effects, and restrictions often produce swelling in the lower extremities, contributing to leg and foot pain. In addition to the normal fluid and femoral venous pressure buildup, this also puts pressure on many nerves of the lumbosacral plexus, creating further hip and leg pain. Other nerves become irritated by entrapment in the piriformis/sciatic notch or the inguinal ligament/anterior pelvis, for example. Of those most affected perinatally, the two commonly problematic and most readily addressed through bodywork are the sciatic nerve and the lateral femoral cutaneous nerve.
The lateral femoral cutaneous nerve supplies the skin of the lateral thigh. It may become compressed by the gravid uterus and by traversing through a tense iliopsoas. If the nerve gets pinched near the anterior superior iliac spine (ASIS) by inguinal fascial restriction, then there’s a painful, burning sensation in the anteriolateral thigh. Its superior neighbor, the ilioinguinal nerve, is actually carried in the inguinal ligament fascia. It is also sometimes compressed by the baby’s weight, creating inguinal pain.
Entrapment of the sciatic nerve, secondary to increased tone and shortening of the piriformis, is common prenatally due to the tendency toward a wider, externally rotated stance. As the fetus nestles down into the relaxin-softened pelvis and pelvic floor, its head can further compress both the mother’s sciatic nerve and obturator nerves running through another external rotator of the femur—the obturator. The fetus will also compress many of the mother’s other pelvic nerves.
Most MTs recognize that sciatic nerve compression creates numbness and burning pain in the buttocks. It refers down the posterior leg and can travel as far as the calf. What else might cause similar sensations in these areas prenatally? Referred pain from the uterine broad ligament, trigger-point referrals, tension in the hamstrings, and blood clots are other possibilities. Remember these contributors as we discuss choices about leg techniques.
Other pelvic nerves of relevance include the genitofemoral, femoral, and saphenous nerves that also emerge deep to the inguinal ligament. Each of these may provoke pain in the genital region and legs through their respective dermatomes. For women who have previously given birth, stretch and trauma injuries occurring in labor—especially from improper positioning or a particularly difficult labor—can leave lingering pain. The fetal head may have compressed the pelvic nerves, including the pudendal nerves, during earlier births. As they begin to regenerate, the nerve endings are exceptionally sensitive to stimuli, and women may have pain from these nerves in subsequent pregnancies. Other causes of nerve pain here are pelvic surgeries, automobile or other accidents, sexual abuse, or occupational repetitive actions.

Informed Prenatal Leg Work
Lateral recumbent (side-lying) positioning of the pregnant client provides superior access to relieve hip and some thigh pain. Small amplitude, rhythmic passive movements are favorite techniques of mine. Not only do they induce profoundly relaxing effects, these undulatory movements help me to assess client mobility and integration, showing me soft-tissue restrictions that I need to work into more precisely. Along with myofascial release and deep-tissue techniques, rhythmic passive movements can ease hip joint structures and compression on nerves. All types of movement modalities that work indirectly, including stretching, resisted stretching, positional release, and muscle energy, are especially effective in this area, particularly if spider veins in the region, or high thrombi risks, make direct pressure questionable.
Any stretching or joint movements need to stay well within each structure’s normal range of motion. Pushing beyond that risks overstretching relaxin-softened connective tissue. Take additional caution and make further adaptations if there is stabbing, central pelvic pain, which is characteristic of symphysis pubis instability.
If there are no spider veins to consider, you may safely work deep, melting away gluteal tension (Image 4). Deep pressure and friction to the posterior hip ligaments, myofascial spreading throughout the lateral and posterior pelvis and the anteriolateral thigh, and extinguishing any relevant trigger points are beneficial. Be sure to keep this deeper work from being alarmingly painful; pleasure on the borderline of pain is best.
As weight settles into a pregnant woman’s legs and fluid buildup increases, generalized achiness and local areas of pain may develop. Numbness around the medial malleolus and medial plantar foot can occur if edema compresses the tibial nerve in the tarsal tunnel. Cramping in both the gastrocnemius/soleus group and the peroneals torments some women’s sleep, as do the vibrations and irritated feeling of “restless legs.” Relaxin-softened ligaments in the feet, weight imbalance toward the toes and medial arch, and edema make feet achy, too.
These complaints usually benefit most from the same type of superficial, rhythmic, and repetitive draining actions similar to those described earlier for edema-related pain in the upper extremities.
With massage therapy to the leg, there are critical precautions involving blood clots to remember. Let’s take a quick review of the physiology involved: hormonally induced circulatory system changes, uterine compression, and activity levels all create an environment more or less conducive to thrombi formation. Where pooling of blood occurs, especially where valves in the femoral veins collapse, varicose veins and blood clots are more likely. Because of the many contributing factors, you should always consider that clots might be the cause—or part of the cause—of leg pain, especially in the calves, and particularly if unilateral.
Though thrombi may exist where no symptoms are present, these are common signs to look for: edema, especially more in one leg than the other; heat and redness; achiness, worsened with activity; palpable ropy or hard linear tissues; and other less-obvious signs including the dilation of superficial veins, cyanosis in the nail beds or skin, or a low-grade fever of unknown origin.
As you ease edema or perform any leg work, remember the precautions for working on the legs, as summarized in Image 5. Understand these precautions to prevent possible thromboembolism, a blood clot that circulates to the lungs. This is the most likely and most serious negative consequence of ill-informed or careless massage therapy and bodywork.
My understanding of obstetrical physiology and the inconclusive evidence of circulatory effects of many massage therapy techniques leads me to less conservative leg massage guidelines than some instructors, and more precautions than others. Because the most likely veins harboring thrombi—the iliac, femoral, and saphenous veins—traverse the medial thigh and leg, greatest caution seems prudent there. Additionally, leg precautions need to be most restrictive and conservative with those women who have a greater risk of thromboembolism. The more inactive she is, the higher her likelihood for more, and larger, clots. This is particularly true of those women on extended or total bed rest ordered by their doctor or midwife to treat a medical complication. That said, physicians whose patients I’ve cared for sometimes have requested significant leg massage; however, safety precautions should only be eased under direct medical supervision. These high-risk, medically complicated pregnancies are safer in the hands of a prenatal massage therapy specialist, so pursue further education if needed.
Remember to take care as you work on the calves and feet to avoid specific deep thumb or digital pressure to certain points believed to stimulate labor or strengthen weak labor contractions. There are varying opinions on these points’ potency. With little to no real data to convincingly confirm or dismiss them, I suggest avoiding ischemic compression or bone-to-bone pressure on, and superior of, the calcaneus, between the big and second toe, and four finger-widths superior of the medial malleoli. I am particularly cautious during the first trimester and when risks of miscarriage or prematurity are higher.
Other types of contact are both safe and certainly appreciated. One of the most persistent and misleading myths about prenatal massage is that one should never massage the lower legs or feet of a pregnant woman. This is an exaggerated precaution, but, conveniently, if you are following the clot precautions about medial leg pressure (Image 5), you won’t contact most of these points deeply anyway.
Women who have calf cramps will especially appreciate learning daily preventive resisted stretching techniques to reduce the torturous frequency of nighttime cramps. A simple pelvic flexion and leg swing repeated daily have been shown to reduce round ligament pain common in the medial thigh, mostly in the second trimester. These are just two examples of educational activities to possibly share, if they are within your scope of practice. Observing, guiding, and informing your client about how she can maintain a more vertical, organized structure is essential to reducing almost all prenatal achiness.

Positioning Considerations
The side-lying position’s primary advantage when working with pregnant clients is the ideal access it offers to the most needy structures. Some women’s left shoulders and hips are achy from lying primarily on their left sides. This restriction is necessary only if a midwife or doctor recommends it (another example of fear-based and limited pregnancy understanding, so common in our culture). Encourage all others to switch sleeping sides, and be sure to work both during your sessions. If either side is more problematic, spend more time with that side up.
There’s more stability and joint protection when your client extends the table-side leg, and you place bolsters and/or pillows beneath the flexed ceiling-side leg. Align her hip, knee, and foot horizontally with supports of sufficient size and density. This level alignment of the torso and lower extremity will also reduce her tendency to roll forward with deep gluteal work and otherwise prevent rotational strain and pull to the hip, pelvic, and lumbar joints (Image 6). If she has sharp anterior pelvic pain from symphysis pubis instability, she will likely want supports between her legs, forgoing stability for comfort. As softer supports compress over time, add additional pillows to maintain optimal leg alignment as your session progresses.
Add cushioning if either the hip or shoulder joint compresses the table’s foam down to its plywood base.  Certain products, such as Oakworks’ Side Lying Positioning System and the bodyCushion, usually provide more shoulder joint space and prevent these discomforts. Sometimes a flat pillow placed across the table gives a bit more shoulder room, but much less ideally than either system’s comfort. Having sufficient and firm head height protects the shoulder and the cervical spine, too, but avoid extensive side-bending. If the client’s hip joint is off the torso cushion, insert a small wedge under her hip. Place a higher pillow under the arm to help fluid drainage; elevating it to face level often helps ease carpal tunnel symptoms by allowing further mechanical drainage.
Semi-reclining or supported supine positions usually give the best access to the inguinal area and thigh. Remember to avoid inguinal and medial deep pressure, but the anterio-lateral rectus femoris, vastus lateralis, and iliotibial tract may safely benefit if there are no vascular issues evident. The more dangerous veins are medial, with the femur between them and your pressure—that is, as long as your vector is not directed to those veins.
Finding the Way
With so many hormonal, structural, and emotional changes to adapt to, women live with many common discomforts throughout their pregnancy. Your job as a massage therapist is to understand these changes, discern what you can do to help your client, and educate yourself on the protocols that can safely assist her along her journey.

A Pregnancy Leg Protocol
With all of the described precautions actively in mind, here’s a sampler of the leg work I offer pregnant clients:
• Resisted and passive stretches of all the hip movers;
• Friction, deep tissue, and stretching of the peroneals, all beautifully served up for ease of access in a side-lying position;
• Foot massage that is generous in mobilizing and stretching each joint.
I also work with reflex zones from the woman’s feet to other areas of discomfort in her body. This is another great way to begin or end a session. When edema relief is paramount, I open the abdominal and inguinal areas with specific, targeted myofascial and joint mobilization techniques, followed by light lymphatic drainage-type strokes, instead of the deeper work described.

Warning Signs of Eclampsia
Although eclampsia can spike rapidly, especially in the final weeks of gestation, it usually develops gradually and shows the following escalating signs:
• Protein in urine
• Systemic, pitting, lymphodynamic edema
• Rapid weight gain
• Shortness of breath
• Severe mid-back to shoulder pain, especially on and near the kidneys
• Pain mimicking heartburn
• Violent headaches accompanied with vomiting and/or visual disturbances
• Convulsions, especially with pressure readings in excess of 160/110

Carole Osborne is an author and instructor of pre- and perinatal massage therapy and other somatic arts and sciences. See her workshop and mentor group schedules at www.bodytherapyeducation.com. Contact her at carole@bodytherapyeducation.com or via Facebook at Carole Osborne’s Prenatal and Deep Tissue Massage Training.
Find an expanded discussion of this topic, including specific techniques in her book, Pre- and Perinatal Massage Therapy, 2nd ed. Free videos are available at www.bodytherapyeducation.com.

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