Table 2. Musculoskeletal Protocol for Pregnancy through Return to Sport.^7,31,34,36.

Stage	Focus	Recommendations
First Trimester	Cardiovascular activity	Light-moderate activities kept at a conversational pace (RPE 1-4), occasional bursts of RPE range 5-7 (<10 minutes) Modify interventions based on daily symptoms 150 minutes of moderate activity each week over a minimum of 3 days/week but preferred daily Variety of physical activities to include aerobic, strength training, and mobility work Awareness of appropriate warm up and cool down (5-10 minutes of gentle activity prior to and after completion of exercise routine)
	Neuromuscular activity	Education on diastasis recti Eliminate and/or modify exercises creating coning Coordination of diaphragmatic breathing (exhale with pelvic floor contraction, inhale with pelvic floor relaxation)
	Strength Training	At least 2 days of resistance training/week with selection of desired exercises by the individual patient and provider within surrounding limitations. Strength training should incorporate full body focus
	Pelvic floor	Internal muscle exam typically deferred
	Modifications for this phase	Work around varying symptoms including fatigue, nausea, and discomfort
Second Trimester	Cardiovascular activity	Light-moderate activities kept at a conversational pace (RPE 1-4), occasional bursts of RPE range 5-7 (<10 minutes) Running may continue but athlete should consider more interval training to assist with musculoskeletal demand of the pelvic floor as baby grows Cross training (biking, swimming) should be encouraged
	Neuromuscular activity	Same as first trimester with continued focus on appropriate loading of transversus abdominis, linea alba
	Pelvic Floor	If agreed upon with the athlete’s medical providers, internal muscle exam may be performed if desired by patient to determine baseline pelvic floor function and address range of motion and strength/endurance deficits External muscle exam may also be performed to limit risk of infection associated with internal muscle examination
	Strength Training	At least 2 days of resistance training/week with selection of desired exercises by the individual patient and provider within surrounding limitations. Strength training should incorporate full body focus
	Modifications for this phase	Heavier focus on anti- core movements to encourage stability Eliminate/modify tasks that require power movement of barbell over abdomen Limit/modify supine activity if patient is symptomatic
Third Trimester	Cardiovascular activity	Light-moderate activities kept at a conversational pace (RPE 1-4) Running may continue but athlete should consider more interval training and more frequent rest to assist with musculoskeletal demand of the pelvic floor as baby grows Heavier focus on cross training (biking, swimming) should be encouraged as opposed to running
	Neuromuscular activity	Increase focus on down-training techniques to assist with delivery Increase focus on postural endurance as center of gravity shifts forward
	Strength Training	At least 2 days of resistance training/week with selection of desired exercises by the individual patient and provider within surrounding limitations. Strength training should incorporate full body focus
	Pelvic Floor	Perineal massage may be discussed to begin around 34 weeks gestation Discussion of appropriate birthing positions for pelvic mobility and opening of pelvic outlet Heavy focus on down-training/relaxation of pelvic floor musculature and breath techniques to assist with delivery
	Modifications for this phase	All previous modifications maintained Impact work (jump/run) may be continued if asymptomatic for short bouts and increased rest time
Postpartum Weeks 0-2	Cardiovascular activity	Minimize musculoskeletal stress to allow healing Household ambulation in small bouts Education related to nutrition (within scope of the provider) to ensure appropriate intake to accommodate for nursing and exercise
	Neuromuscular activity	Diaphragmatic breathing, pelvic mobility as tolerated Gentle and pain free mobility/postural work Education regarding proper body mechanics for handling of newborn infant i.e. lifting, carrying, and holding
	Pelvic Floor	Light transverse abdominis/pelvic floor contract/relax – defer if symptomatic
Postpartum Weeks 3-4	Cardiovascular activity	Walking program with shorter duration (<10-15 minutes), frequency may increase as tolerated
	Neuromuscular activity	Increase focus on transversus abdominis coordination – supine, side-lying, and quadruped
	Pelvic Floor	Pelvic floor contract/relax with focus on short holds (5 seconds) Continue to defer if symptomatic
Postpartum Weeks 5-6	Cardiovascular activity	Walking program may slowly increase in duration (<20-30 minutes) Speed may gradually increase, but should be kept below jogging
	Neuromuscular activity	Postural strength and endurance to include thoracic and cervical spine Coordination of transversus abdominis in more functional movements such as sitting/standing
	Pelvic Floor/Strength	Open kinetic chain hip strength in combination with appropriate pelvic floor contract/relax Pelvic floor contract/relax with focus on long holds (10 seconds) Light functional movements (sit to stand, step ups)
Postpartum Weeks 7-⁠12	Cardiovascular activity	Slow increase in duration of walking program with gradual speed increases Short <60s bouts of jogging may be appropriate at the 8 week or beyond mark (dependent on response to impact readiness tasks) Recovery intervals should be 2x that of work phase in jogging (ie 60s jog:120s recovery) Work phases should be kept conversational with RPE <6
	Neuromuscular activity	Awareness/improvement of postural changes that often persist postpartum Thoracic rotation/extension, improving excessive pelvic tilting (anterior or posterior) should be addressed Horizontal impact work (ie table plank position – mountain climbers) may be slowly progressed to begin force absorption focus until patient is ready to tolerate this in an upright position
	Pelvic Floor	Internal muscle exam performed if desired by patient to determine baseline function Focus should be both on appropriate contract/relax as well as strength/endurance to determine individual need for up vs. down-training
	Strength	Closed kinetic strength tasks beginning with slow performance and increasing speed of movement as tolerated Progression from double to single leg weight bearing tasks
	Impact-Specific Markers for Readiness for Progression	Double leg jump downs, heel raises with bounce, forward/lateral/reverse lunging performed rapidly, kettle bell swing variations to include the sagittal, transverse, and frontal planes
	Functional Testing Options	Musculoskeletal pain or pelvic symptoms with loading and impact25 Run Readiness Scale36
Postpartum Weeks 13+	Cardiovascular activity	Slow increase in mileage and speed with walking/jogging/rest throughout run as needed 2D running assessment may be performed to limit likelihood of injury
	Strength/Power	Impact work may be better tolerated from a pelvic floor perspective on an incline Incline may be slowly lowered until tolerating impact performance on flat surface Full clearance for return to running/sport should be assessed weekly as training volume increases per ACSM guidelines (2-10%/week)