Statistics state that as many as 1 in 5 Americans of every age suffer from some type of pelvic floor dysfunction during their life time (Stein 2010). When counseling a client with chronic, non-specific low back pain, groin pain, hip/pelvic pain after injury, surgery or athletic participation practitioners address the spine, hips and surrounding musculature omitting the base of support for all these structures – the pelvic floor. It’s proximity to the sex organs and impact on bodily functions makes it embarrassing for clients to discuss. However, it’s location in the lower bowl of the abdomen makes it an essential member of the core stabilizing lumbopelvic cylinder. Failure to address pelvic floor dysfunction after injury, surgery or repetitive athletic participation can result in continued spine and hip instability causing chronic back and pelvic pain and predisposition to additional spine, hip, neck, shoulder and lower limb injuries as well as impaired breathing and disruption of organ function.
The anatomy of the lumbopelvic cylinder consists of muscles and bones. It begins just below the lungs with the diaphragm. It descends along the front and side of the torso with the transversus abdominis supported by segmental attachments to the psoas and abdominal muscles. It descends along the back of the torso with the spinal column supported by the segmental attachments of the lumbar multifidus. It ends in the bowl of the pelvis with the pelvic floor (Chaitow & Lovegrove 2012).
Abnormal pelvic floor function negatively impacts spinal stability, intra-abdominal pressure, respiration, sexual function, continence and pelvic organ support (Chaitow & Lovegrove 2012) resulting in global instability, chronic joint pain and predisposition to injury. The pelvic floor as the most essential arch in the body providing the base of stability for all lower limb and foot joints (Dalcourt 2012). Integrity of the trunk is essential to maintain joint position, respond to perturbations, avoid low back pain/injury, insure proper proprioception, and develop power and strength (Landow 2010).
Pelvic floor dysfunction (PFD) occurs after injury, sports participation or surgery. Examples of injury include a hard fall or blow to the sacrum or tail bone as in falling on ice or off a horse or telescoping femoral injuries when landing on the feet after a long fall as in sky diving. Sports associated with PFD also report frequent groin injuries from kicking, quick multi-directional lateral changes or pelvic rotation during axial loading as in soccer, running, golf, ice hockey, figure skating, football, baseball, ballet, martial arts and gymnastics (Chaitow & Jones 2012). The reported incidence of groin pain and injury as a result of sports participation is as follows: cycling – 22 to 91%, running – 70%, football – 22% and ice hockey 13 to 30% (Chaitow 2012). Any lower abdominal surgery may result in the abnormal pinning of deep fascia to muscle (Dalton & Hedley 2012) causing PFD.
Additional causes of PFD include hernia, infection, cancer or sexually transmitted disease. Special considerations for women include endometriosis, pregnancy (large baby, twins), difficult delivery or cesarean and multiple pregnancies. Sexual violence is another cause with greater physical and psychological implications. Treatment of the victims of sexual violence should include other medical professionals to ensure a successful outcome.
The pelvic floor identifies a consortium of muscles. The deepest muscle, the levator ani, is often referred to as the pelvic diaphragm and is divided into two parts – the pubovisceral and iliococcygeal muscles. The superficial muscle, the pereneal membrane or urogenital diaphragm, sits above the levator ani (Chaitow & Jones 2012). These muscles consist of both smooth and striated muscles of which approximately two thirds are type 1 and innervated by the pudenal nerve through direct branches from sacral nerves S3-S4. The pelvic floor contracts or relaxes as a whole but may also contract or relax in segments (Chaithow & Jones 2012).
The pelvic floor, like all muscles, can become hypotonic or hypertonic after injury, sports participation or child birth. Corrective exercises specific to strengthening a hypotonic pelvic floor include Kegels (pelvic contractions stopping and restarting urination). Kegel exercises, in the absence of proper breathing and appropriate deep abdominal wall activation and strength, cannot resolve lumbopelvic cylinder dysfunction, gait abnormalities and trunk instability. To ensure a full recovery from a hypotonic pelvic floor the practitioner should evaluate the strength and function of the entire lumbopelvic cylinder and instruct the client in proper breathing techniques and appropriate core/limb coordination exercise.
A hypertonic pelvic floor restricts the ability of the diaphragm to expand and transversus abdominis to contract during respiration. This leads to hyperventilation syndrome (HS) and altered breathing pattern disorders (BPD) (Chaitow 2004). Over time HS and BPD alters mood (constant fight/flight breathing), changes body chemistry (respiratory alkalosis), and hypercapnoea (increased levels of CO2) which compromises key core stabilizer by reducing or eliminating the postural (tonic) and phasic contractions of muscles necessary for spinal stability (Chaitow, Breathing Pattern Disorders, motor control and low back pain, Journal of Osteopathic Medicine, 2004; 7(1): 34-41).
The hypertonic pelvic floor does not respond to Kegel exercises but does respond to trigger point therapy. In a study of 56 continent physiotherapists (51 women and 5 men age 23 to 56) all tested positive for a hypertonic pelvic floor with some of the cases demonstrating clear differences in tonicity from one side to the other. Trigger point therapy was administered and tonicity returned and pain resolved after approximately two to five breaths (Carrire & Feldt 2006).
Individuals can administer their own trigger point therapy by sitting on a tennis ball placed between the coccyx and vaginal opening or just inside the coccyx and breathing deeply (Chaitow 2008). More sensitive or difficult cases may require clinical instruction on Thiele Massage. Again, to ensure a full recovery from a hypertonic pelvic floor the practitioner should evaluate the strength and function of the entire lumbopelvic cylinder and instruct the client in proper breathing techniques and appropriate core/limb coordination exercise.
Chronic PFD as a result of injury, sports participation or child birth may result in the presence of altered concomitant muscle contractions and scar tissue extending from the pelvic floor to other pelvic muscles. The opposite also holds true and an injury to another pelvic muscle may result in scar tissue that extends to and entraps the pelvic floor. Susceptible muscles include but are not limited to: psoas major, iliacus, tensor fasciae latae, pectinius, gracilis, and adductor magnus, brevis, longus (Chaitow 2012). Symptoms of this disordered relationship include repeat groin strains, non-specific hip or pelvic pain, lower limb and low back pain that does not respond to traditional manual therapies, stretching of the susceptible muscles or core conditioning. Normal hip and spine range of motion may exist despite this disordered relationship.
Susceptible muscles resulting in posterior pelvic tilt attach to the sacrum and coccyx pulling it forward (Weiss 2012). These muscles include piriformis, quadrates femoris, and gluteus maximus. Symptoms of this disordered relationship include restricted sacral counternutation, chronic L5/S1 strain, deep pelvic and sacral pain, lower limb and low back pain that does not respond to traditional manual therapies, stretching of the susceptible muscles or core conditioning. Abnormal hip and spine range of motion usually accompanies this disordered relationship.
Chronic PFD, groin strains and low back pain does not respond to traditional manual therapies for a variety of reasons. Therapists specializing in PFD only treat the pelvic floor and frequently do not address the disordered breathing or lack of core conditioning and faulty muscle patterns. For manual therapists and exercise specialists the pelvic floor sits in the industry ‘no fly’ zone where touch is forbidden at best and a law suit at worst. Additionally, the client may be reluctant to discuss the other symptoms of PFD including urinary incontinence, drip or leakage after urination, genital pain, pain during and after sex, pain during orgasm, complete avoidance of sex, hemorrhoids and bowel incontinence. The client also might not connect these symptoms to their injury and PFD.
In the case of chronic PFD as a result of a hypertonic pelvic floor the client demonstrates core development to a point and no further or returns to instability randomly despite lengthy and otherwise proper training. A hypertonic floor increases the pressure in the lumbopelvic cylinder which then increases the pressure on the internal organs. The body resists any further organ compression by reducing the range of motion in the diaphragm and transversus abdominis. When contracting a fully functioning diaphragm and transversus abdominis the body responds by destabilizing or moving the spine, intermittently shutting down the transversus abdominis, and reducing or eliminating the breath.
Individuals can administer their own trigger point therapy using a tennis ball or OPTP “little pinky” ball in the bikini or ‘tighty whitey’ area. This region encompasses the lower abdomen, gluteals, intersection of the ilotibial band/TFL/Glute med-min and the pelvic floor – basically any area a bikini bottom or brief underwear covers. Place special emphasis on incision scars and take care to avoid sensitive nerves. The femoral nerve sits outside the bikini area and should be avoided. Pressure should be tolerable, mildly uncomfortable, and held until the trigger point becomes comfortable (approximately 2 to 5 relaxing breaths) before moving on to the next trigger point. Breathing should remain consistent and relatively deep throughout. Rib or shallow breathing, as in mild hyperventilation, indicate the pressure is too deep and should be adjusted downward until breathing returns to normal.
Individuals unable to perform the trigger point release may relax the pelvic muscles by lying face down on a rolled bath towel. Place the towel on the lower abdomen below the navel, above the pubic bone and inside the hips. The towel should be a comfortable height and allow deep and relaxing breathing. Place the head/neck in a comfortable position as well. Remain until fully relaxed and then roll off the side of the towel and onto the back.
Successful stretching for PFD occurs along the deep front line (Myers, p. 192) in a closed chain and includes the torso muscles. Lateral lunges with opposite arm reach over head and multidirectional lunges with opposite arm reach over head stretch this line as an entire, functional complex (aka the “Saturday Night Fever” stretch). Minimal discomfort should occur as the client holds the stretch for 2 to 5 easy breaths. Again, breathing should remain consistent and relatively deep throughout. Rib or shallow breathing, as in mild hyperventilation, indicate the stretch is too deep and the range of motion should be adjusted downward until breathing returns to normal.
Returning to optimal performance begins with the health of the lumbopelvic cylinder and the pelvic floor. Its location in the ‘no fly’ zone and embarrassing symptoms make it difficult to discuss and treat. Its contribution to chronic groin, low back and lower limb injuries make it essential to address. Kegel exercises strengthen a hypotonic pelvic floor while trigger point therapy and deep front line stretching releases a hypertonic floor. Successful results occur in the presence of a normal breathing pattern and fully functioning transversus abdominis. Strength, power and performance improve only when the lumbopelvic cylinder functions.
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Stein, Amy, MPT. Pelvic Floor Dysfunction & Pelvic Pain, 2010, www.beyondbasicphysicaltherapy.com
Chaitow, Leon and Jones, Ruth Lovegrove 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 34.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 33.
Dalcourt, Michol, 2012. Footwear and Function – Views on Barefoot Training, 1/11/12, NSCA webinar.
Landow, Loren 2010. Trunk Training for Performance. 9/15/10, NSCA webinar.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 101.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 115-120.
Dalton, Eric et al 2012. Dynamic Body. USA, Freedom From Pain Institute, p. 69.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 34.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 41.
Chaitow, L. 2004. Breathing pattern disorders, motor control, and low back pain. Journal of Osteopathic Medicine, 2004; 7(1): 34-41, p. 36.
Carriere, Beate, Feldt, Cynthia Markel 2006. The Pelvic Floor. New York, Thieme, p. 107.
Chaitow, L. 2008. The Pelvic Floor Paradox. Naturpathy Digest. www.naturpathydigest.com.
Chaitow, L. and Jones, R. L. 2012. Chronic Pelvic Pain and Dysfunction. England, Churchill Livingstone, p. 102.
Weiss, David 2012. Prostatitis or Pelvic Myoneuropathy. http://www.chronicprostatitis.com.