Even the most advanced skier, snowboarder, or ice skater will fall.

Many of these falls are on the sacrum and/or coccyx. Repetitive falls on the posterior pelvic girdle can result in sacroiliac joint and/or coccyx mal-alignment. Joint mal-alignments such as these will cause compensatory muscle activation which often leads to muscle hypertonus and myofascial trigger points.

These patients typically complain of tailbone pain, sacral pain, pain with sitting, pain transitioning from sitting to standing and vice versa, hip pain and low back pain.

In order to realign these joints, the muscular dysfunction must be eliminated as well as the joints adjusted. The physical therapists at the Pelvic Health and Rehabilitation Center specialize in treating the musculoskeletal dysfunctions related to coccyx and sacroiliac joint mal-alignment. The treatment programs include manual techniques to normalize muscle tone and motor control, eliminate myofascial trigger points, joint re-alignment, and a home exercise program.

Trigger points are tight spots within a muscle, often referred to as “knots”.

They occur when the muscle fibers in a small part of the muscle are contracted.  Often, muscle fibers will become taut in a small line, and the trigger point is a nodule on that line that is most involved.  When the fibers are contracted in this way, the blood flow to those fibers is restricted, like when a sponge is squeezed tight and cannot let in any more liquid.

Muscles that are tight and lacking blood flow are very tender, so putting pressure on a trigger point is painful and may feel like burning or pinching.  Trigger points can also refer pain to other parts of the body, and muscles with trigger points may be painful to contract or stretch.  The exact cause of a trigger point is unknown, but some things that may contribute to the formation of trigger points include trauma, repetitive movements, or recurrent postures that involve shortening the muscle.

To treat a trigger point, the fibers must be reorganized and released.  Physical therapists will release a trigger point by applying manual pressure directly to that location until the tissue begins to show improvement.  In some states, physical therapists, chiropractors, and acupuncturists may also choose to “dry needle” a trigger point.  Dry needling is when a solid acupuncture needle is passed through the tissue of the trigger point repeatedly to force the fibers to release.  Though both of these techniques can be uncomfortable, the release of trigger points can be essential in treating pain or muscle dysfunction.

Scars from trauma, surgery, or childbirth have the possibility to become adhered to nearby structures due to excessive amounts of disorganized collagen produced during the healing process.  These adhesions or masses of scar tissue can cause pain or restrict movement.  It is important to mobilize and stretch these scars to allow the skin, muscles, and other tissues of the body to move freely and without pain.  Scar mobilization promotes collagen remodeling to increase pliability of the tissues and reduce uncomfortable sensations, such as itching or sensitivity.  It is best to start scar mobilization early in the healing process, usually 6 to 8 weeks later, because the tissues will respond quickest during this period.  However, scar mobilization can help scar tissue and adhesions that are years old.  Scar mobilization can be performed on scars anywhere on the body including the abdomen, pelvis, and vagina.  It also desensitizes the area surrounding the scar, which may become extremely sensitive to touch after a surgery or laceration.  Physical therapists can perform scar mobilization and instruct you in ways to perform the mobilization at home.

Male sexual dysfunction includes erectile dysfunction as well as pain with an erection and post-ejaculatory pain. Erectile dysfunction can be the result of various diseases or conditions which can be successfully treated with pharmaceutical therapy. However, erectile dysfunction can also be due to musculoskeletal dysfunction. More specifically, hypertonus of or the presence of myofascial trigger points in the bulbospongiousus and/or ischiocavernosus muscles can result in difficulty getting or maintaining an erection and decreased ejaculatory flow. These men will typically fail pharmaceutical treatment and require a pelvic floor physical therapist to regain normal function. Pain with an erection or post-ejaculatory pain are common symptoms of male pelvic pain. These symptoms are the result of pelvic floor muscle hypertonus and myofascial trigger points in the urogential diaphragm. Both erectile dysfunction and pain with sexual activity secondary to musculoskeletal impairments can be successfully treated by a physical therapist specifically trained in the pelvic floor. The physical therapist will utilize manual techniques to normalize pelvic floor muscle tone and motor control and eliminate myofascial trigger points to eradicate the symptoms of dysfunction and pain.

Women who exercise safely during pregnancy experience numerous benefits for
themselves and their babies. Mothers who exercise during their pregnancy gain less
weight and are less likely to retain weight after delivery. Exercising mothers also have
improved cardiovascular benefits, decreased muscle pain and cramping, less swelling,
more stable moods, and improved self image. Continuing to exercising after delivery
reduces fatigue and depression, and children of parents who exercise are more likely to
become physically active themselves. Exercising during pregnancy can help prevent
gestational hypertension and preeclampsia, which may have potentially life-threatening
complications if not treated. Women who participate in regular stair-climbing were 44-
69% less likely to experience preeclampsia. Additionally, women who are physically
active during the first trimester reduce the risk for gestational diabetes by 51%.

The American College of Obstetricians and Gynecologists recommend that women
without complications accumulate 30 minutes or more of moderate intensity exercise
on most days of the week. Exercise that raises the mother’s heart rate above 90% of
her maximum, increases her risk of falling, may lead to abdominal trauma, is done at
altitude, or is performed lying on one’s back after the first trimester should be avoided.
Resuming exercise after pregnancy should also be gradual due to deconditioning and
other changes in the body. A physical therapist can create an appropriate exercise
program for pregnancy and post-partum to benefit you and your baby.

With Valentine’s Day just around the corner, sex may be on our minds a little more than usual.  Dyspareunia, or pain with intercourse, is a common symptom among women that suffer from pelvic pain. Unfortunately, one in four women will suffer from pelvic pain at some point in their life. Dyspareunia can be a symptom of several pelvic pain syndromes. Most women with vulvodynia will have dyspareunia due to pelvic floor muscle hypertonus and/or myofasical trigger points and tissue hypersensitivity. In addition, some women will experience dyspareunia after gynecological surgical procedures such as a hysterectomy or laparoscopy or after child birth. Post-operative or post vaginal delivery can result in tissue hypersensitivity around the incision or episiotomy scars as well as create myofascial trigger points in traumatized muscle in and around the pelvis. A specialized physical therapist can normalize pelvic floor muscle tone, eliminate myofascial trigger points and decrease tissue hypersensitivity with manual techniques that can successfully resolve dyspareunia.

Coccygodynia is defined as pain in or around the coccyx. Patients with coccyx pain often have increased pain during sitting, transitioning from sitting to standing, and sometimes during a bowel movement. The most common cause of coccygodynia is a fall on the tailbone. It is commonly thought that manipulation of the coccyx or sacro-coccygeal joint is the appropriate treatment, however, it may only be one component of a successful treatment plan. When the coccyx is injured, not only can it become stiff or immobile, but the muscles attaching to it can also become impaired. Several pelvic floor muscles attach to the coccyx including the pubococcygeus, the iliococcygeus, and the coccygeus. Injury to these muscles can cause them to become hypertonic or develop myofascial trigger points which can cause pain in and around the coccyx as well as refer pain to the rest of the pelvis. To successfully treat coccygodynia, both the coccyx and the surrounding muscles must be evaluated and treated. This can only be done by a pelvic floor physical therapy specialist with an internal exam. The therapists at the Pelvic Health and Rehabilitation Center successfully treat coccygodynia with manual techniques to regain normal mobility of the coccyx and the sacro-coccygeal joint, normalize muscle tone, and eliminate myofascial trigger points.

In 1995, the NIH recognized the term ‘chronic nonbacterial prostatitis’ does not explain nor is even related to the symptoms these patients suffer from and adopted the term ‘chronic pelvic pain syndrome’ (CPPS). Symptoms of CPPS can include dysuria, hesitancy, frequency, penile and/or scrotal and/or rectal pain, bowel dysfunction, and sexual dysfunction. Unfortunately, it is estimated that 50% of all men will suffer from this at some point in their life. The majority of men with CPPS have failed trials of antibiotics because they do not have an actual infection. Musculoskeletal impairments such as hypertonic levator ani muscles, connective tissue restrictions, pudendal nerve irritation, and myofascial trigger points commonly cause the symptoms of CPPS. The physical therapists at PHRC are specially trained to evaluate and treat these impairments, providing successful outcomes and restoration of quality of life. Treatment is typically one hour per week for several weeks. Our physical therapists use manual therapy techniques to eradicate the musculoskeletal impairments as well as provide a home exercise program for the patient. The majority of men will benefit from physical therapy, resulting in normal urinary, bowel, and sexual functioning and an elimination of pelvic pain.

Urinary incontinence is any involuntary leakage of urine.  Stress urinary incontinence is the leakage of urine associated with activities that put extra stress on the muscles of the pelvic floor, such as sneezing, coughing, laughing, running, or jumping.  Incontinence occurs in men and women, though it is more common in women.  Incontinence may result after trauma to the pelvis, such as childbirth, prostatectomy, or chronic coughing and may also result for normal, age-related tissue changes.  Women may experience leaking after giving birth, but any incontinence that lasts beyond a few weeks postpartum is a sign of possible pelvic floor dysfunction, and should be evaluated. Women of all ages may experience incontinence and unfortunately they commonly do not discuss it with their physician, and they think it is ‘normal’.  Physical therapists can treat patients with incontinence by evaluating muscle dysfunction and creating a personalized treatment plan to correct these impairments.

The most commonly discussed treatment for incontinence is pelvic floor strengthening, or Kegel exercises. Pelvic floor muscles may become weak or deconditioned after events such as pregnancy or over time with age. If this is the case, Kegel exercises, prescribed by a physical therapist, can strengthen these muscles, train them how to contract appropriately, and eliminate incontinence.

Not every person with incontinence needs to do Kegel exercises.  Sometimes a person’s pelvic floor muscles can become contracted or tight.  This can occur when a person, often unconsciously, clenches these muscles to substitute for another muscle group, to guard against discomfort, or in response to other physical or emotional stressors.  In this case, the muscles are strong and always active therefore they need to be reminded how to relax and lengthen.  A physical therapist can help reduce the tension in these muscles through manual techniques and other exercises to stop incontinence.

Pudendal Neuralgia can be a debilitating condition that may cause urinary, bowel, sexual dysfunction and pelvic pain. The pudendal nerve is a mixed nerve containing autonomic, sensory and motor fibers arising from S2-S4. It follows a tortuous course through the pelvis to innervate the majority of the pelvic floor muscles, the urethral and anal sphincters, portions of the distal urethra and anal canal, and the skin of the clitoris and lower 2/3 of the labia in women, the dorsum of the penis and scrotum in men, and the skin of the perineum and anus in both sexes.

 Pudendal Nerve Sensory Distribution: male and female

The pudendal nerve is anatomically vulnerable to compression and tension as it travels through the pelvic floor, the space between the sacrospinous and sacroutuberous ligaments, Alcock’s Canal (formed by fascia and the Obturator Internus muscle), and around unyielding interfaces such as the ischial spine. The pudendal nerve has three primary branches: the perineal branch, the dorsal penile or clitoral branch, and the inferior rectal branch.

Pudendal Nerve, Alcock’s Canal, Obturator Internus

If a person describes pain in any of the above-mentioned areas that is sharp/stabbing/shooting their symptoms fit the description of Pudendal Neuralgia (PN). Pudendal Neuralgia may be classified as a myofascial pelvic pain syndrome, thereby explaining it’s associated with numerous other symptoms. In addition to the pain that is often worsened with sitting and may be (but not always) alleviated by standing, patients suffer a myriad of other symptoms. The pudendal nerve is intimately related to the pelvic floor and even more closely related to the Obturator Internus muscle. These muscles are almost always tender, hypertonic, and have trigger points in patients with PN. This muscular dysfunction can create symptoms of urinary frequency, urgency, hesitancy, and burning, constipation, pain with intercourse, aorgasmia, pain with orgasm, and as already mentions, pain anywhere in the territory of the nerve.

It is not uncommon for patients to suffer from additional symptoms such as sciatica, sacro-iliac joint and low pain, lower extremity heaviness and tightness and pain in their feet. The pelvic region may be hypersensitive, making underwear and clothing seem unbearable.

Pudendal, Posterior Femoral Cutaneous, and Sciatic nerves

Finally, the pudendal nerve is unusual because it not only has sensory fibers (to innervate the skin) and motor fibers (that innervate the muscles) but also autonomic fibers. The Autonomic Nervous System is responsible for controlling functions such as heart rate, blood pressure, goose bumps, and the flight-or-fight response. When the PN is involved, unfortunately patients may experience symptoms of a racing heart, anxiety, and temperature deregulation. They often feel like they are going crazy and they most certainly are not crazy. The symptoms are caused by the physiology of this complicated nerve.