Part one of a two part series on pelvic pain and exercise.
Exercise is a major topic that comes up in the treatment room with our patients.
The two questions surrounding the exercise conversation are:
1. Are there any exercises that I can do that will help treat my pain?
Most folks are familiar with PT for other parts of the body and those who have had PT before for orthopedic rehab recall that they were given certain exercises to help with their healing. So naturally, they want to know if this will also be the case for their pelvic pain PT.
2. As far as my general fitness routine, are there any exercises that I shouldn’t do that may exacerbate my symptoms? And are there exercises that you specifically recommend for me based on my findings?
Our patients are typically very active and when pelvic pain enters the picture, oftentimes, exercising for fitness can cause a flare-up of symptoms such as urgency/frequency, vulvar or anal itching, or perineal burning, just to name a few. Therefore, it’s important for us PTs to help our patients develop a fitness routine that works for them while not exacerbating their symptoms.
In a two-part post, I’m going to cover both of those issues. This first of the two-parter, will tackle the question:
What exercises can patients do to help treat pelvic pain?
When it comes to therapeutic exercises for pelvic pain, let me first say that my view is that any outlet that provides a generalized list of stretches and strengthening exercises for pelvic pain patients is doing a disservice.
I’m going to explain why I believe this to be the case using an example.
Two women both suffer from daily vulvar burning. It is determined by their PT evaluations that both women have tight hamstrings and tight hip external rotators (the six small muscles of the hip that rotate the femur in the hip joint). Even though both women have tight hamstrings and hip external rotators, having both women do exercises to stretch their hamstrings and hip external rotators would be a mistake.
Here’s why: The PT evaluations also reveal that the first woman also has trigger points in her hamstring muscles as well as irritation of her posterior femoral cutaneous nerve (a nerve distributed to the skin of the perineum and the back surface of the thigh and leg), whereas the evaluation of the second woman reveals trigger points in her obturator internus muscle, a pelvic floor muscle that is often involved in pelvic pain. In fact, many patients with pelvic pain have trigger points in this muscle, which causes symptoms. Therefore, the first woman should not stretch her hamstrings due to the trigger points. That’s because stretching muscles with trigger points can cause them to become activated thus causing both local and referred pain. In addition, hamstring stretches can further irritate her posterior femoral cutaneous nerve. However, she can stretch her hypertonic (too tight) hip external rotators.
As for the second woman, she can stretch her tight hamstrings, but stretching her hip external rotators is not yet recommended because doing so can activate the trigger points in her obturator internus muscles.
So even though their symptoms are the same, the reasons for their pain is different, and therefore their home programs, including what therapeutic exercises they’re should be as well.
As another example, a lot of patients with pelvic pain also may have low back pain and one of the standard exercises given for low back pain is a so-called “clamshell” where the patient is lying on his or her side with the knees bent while lifting his or her leg up and down. This movement is aimed at strengthening the core muscles, which should help protect the back. The problem is that it’s a movement that directly contracts the obturator internus muscle, which remember, often has trigger points in patients with pelvic pain that can cause symptoms of pain at the “sits bones” or urinary frequency or burning.
The good news is there are many alternative exercises that can be used to strengthen the core, which don’t directly influence the impairments that contribute to the patient’s symptoms. It is important when trying to treat two issues, such as back pain and pelvic pain, to choose exercises that are therapeutic but do not exacerbate other symptom-causing structures. This is completely doable with critical thinking and a little creativity.
With all that said, there are two therapeutic exercises that we recommend across the board to our pelvic pain patients: pelvic floor drops and diaphragmatic breathing.
Pelvic Floor Drops
It is now common knowledge that people with pelvic pain usually have too tight or what we PTs refer to as “high tone” pelvic floor muscles. A great exercise that helps patients decrease this high tone is called a “pelvic floor drop”.
Often patients cannot simply “think about it” and let their muscles relax because the muscles have physiologically shortened. So, this exercise uses neuromuscular patterns to “turn off” the pelvic floor muscles until patients can do this on their own.
For instructions on how to do a pelvic floor drop, please click on our YouTube video here.
Or watch below:
With a pelvic floor drop what’s happening is you’re using a contraction of antagonistic muscles (in this case your hip flexors, abductors, and external rotators,) to make the pelvic floor turn off, or inhibit muscle activity thereby decreasing tone.
There are three positions that can be used to do drops: the squatting position, flat on the back and in the child’s pose.
The squat drop has the added benefit of using gravity and a person’s bodyweight to lengthen the pelvic floor muscles. However, not all patients can do a squat because of limitations, such as hip or sacroiliac joint problems or pudendal nerve irritation. For these patients, “the flat on back drop” or doing drops in child’s pose is the best alternative.
Below is a photo of a squat drop:
Below is a photo of the flat back drop:
Initially, trying to do a pelvic floor drop can be frustrating and challenging for the patient, which is why positioning and reflexive inhibition can help. The pelvic floor drop can be a first step toward teaching a person how to relax the pelvic floor. Ultimately, we want patients to be able to drop the pelvic floor without having to lie on the ground, squat, or use isometric contractions to “turn it off”.
When I ask my patients to do a pelvic floor drop I instruct them to hold the position for five seconds on, five seconds off.
Diaphragmatic breathing is another exercise that may help decrease pain, and the reason for this is two-fold. The pelvic floor muscles move with movement of the diaphragm, which can help relax the muscles with gentle movement. This exercise has also been shown to decrease adrenaline and cortisol, two hormones that are often elevated in people with pain and stress. Both of these benefits may lead to reduced pain.
In addition pelvic floor drops and diaphragmatic breathing, there are other exercises that can be therapeutic for the impairments associated with pelvic pain, but as I explained above these exercises should be prescribed by a PT on a case-by-case basis.
For example, if a PT identifies a muscle as tight or weak, the PT can recommend specific exercises to help strengthen or lengthen the muscle. For instance, many of our male patients have tight hamstring muscles (in fact, male hamstrings are 15% tighter than those of females), and this can affect how they sit, which can in turn cause or exacerbate their pelvic pain symptoms. So once it is determined that the hamstring muscles are free of trigger points, hamstring stretches may be appropriate for the patient.
Other tight external muscles that contribute to pelvic pain, such as the gluteal muscles and inner thighs can also be treated with a foam roller if they are free of trigger points.
So while there are therapeutic exercises that can be done at home to help during the treatment process, my advice is because the source of patients pain is so varied, it’s always best to talk to your PT to determine which stretching or strengthening exercises can help with healing.
Please stay tuned for next week’s blog when we’ll be delving into the second issue surrounding pelvic pain and exercise: exercising to stay fit, while not interfering with the healing process.
All my best,