Pelvic Pain and Exercise: What Exercises can help Treat my Pain?

Share the KnowledgeShare on Facebook56Share on Google+2Tweet about this on Twitter0Share on Reddit0Share on LinkedIn1Print this page

images

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:

squat-I-150x150

Below is a photo of the flat back drop:

PNF-D2-ant-view-II-150x150

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

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,

Stephanie


42 thoughts on “Pelvic Pain and Exercise: What Exercises can help Treat my Pain?

  1. Thank you as always for your informative blog. You all are my go to source when I need more information. Wish you were closer as always but, glad to know such thorough caregivers exist. Thanks!

  2. Do u treat men for pudendal nerve entrapment
    Does it always have to be internal PT to get at the
    Pudendal nerve

  3. Thanks, as ever, for a very informative article. I just wish there were enough expert PTs out there to actually make such evaluations -in my experience, there simply aren’t.
    Could you please explain the ‘child’s pose’ and diaphragmatic breathing? Many thanks.

  4. I was so excited when I saw this weeks topic. This is an issue that I am currently struggling with in my treatment plan. I discovered the exercises I was doing prior to starting pt about a year ago were actually making my symptoms worse, not better like I had thought. Now, my pt is slowly adding exercises and this series will be very helpful! I am greatly looking forward to next weeks post.

  5. I purchased a book that was supposed to heal pelvic pain through a series of daily stretches. After doing the stretches 2-3 times per day for 1 month I now have the burning and stinging in my inner thighs. Do you think that the stretches could have activated the trigger points in my leg muscles? I wish I would have known this information before I purchased the book!!!!

    • Many times, the squat drop and/or any kind of drop or squat is an issue. For some pelvic pain this works well, but other types of pelvic pain issues it can aggravate the issues.
      The rule is to typically NOT do any exercise or stretch that aggravates symptoms either at the time of the exercise or even a day later (may take some trial and error).

  6. Steph, thanks for the insight. I’m a personal trainer who developed pelvic pain in Dec 2013….have not weight trained at all, and have abdominal pain and perineal pain….I’m looking for Europe based therapists to do internal work, but my question is, in your experience, Willa return to weight training of any sort be possible?? Interestingly, a blood test showed I was 100% zinc deficient…..

  7. Thank you so much for all your informative articles. I’m sure there are a lot of us pelvic pain sufferers who don’t have time to comment but really appreciate this info. How I wish I lived in S.F. So I could get treated by you and your staff!

    Much thanks again

  8. i have had pelvic pain with SITTING for two years this month! To add to it now, rectocele! I am in Rochester, NY and was diagnosed with Pudendal Neuralsia by Dr. Foster. (Howards office) On Lyrica, did 3 pudendal nerve blocks, yoga,meditation, minimal exercise plan from specialty PT. Symptoms the same….the same… Waiting to ride bike on the Erie Canal with husband. We would like to come in by train for a consultation, treatment plan. Or is this PNE with a different treatment plan? i bought your book a few weeks back. i shared with PT and don’t get much specific feedback. i get nothing in writing. appointments are all but 15 minutes. I was thinking of coming to conference but i feel i need a more thorough exam /consultation to confirm my diagnosis and then do the plan. What a distracting life. When i was diagnosed from Dr. Foster he did tell me to go to New York! i had no idea i would be at this for another year! When is your next availability???
    looking forward to hearing from you with some dates.Anne Cliby

    • Hello Anne,

      We recommend Stacey Futterman in NY. Her contact information is located below. If you would like to consider our out of town program for our Los Angeles office, I suggest you contact our office. 9415) 440-7600.

      Regards,

      Casie

  9. Hi there,
    When I try to do exercises to strengthen my gluts (very basic and trying not to over recruit) I am irritating obturator Internus. Do I just avoid glut strengthening? My legs are really not getting to do much as walking and any repetitive hip flexion, sit to stand or standing trunk flexion is hugely irritating 🙁
    Once my Obturator Internus is irritated I get referred adductor pain as well. Should I avoid stretching both my gluts and my adductors?
    Any ideas as to why repetitive hip flexion (active or passive) irritates me so much? and any exercise ideas for my gluts/legs?
    Thank you in advance!
    Emma

    • Hello Emma,

      Without evaluating you it is difficult to know for sure. Please contact a local pelvic therapist to receive an assessment. He or she will be able to provide a specific treatment plan for you, and advise whether or not stretching certain muscles should be avoided.

      All my best,

      Stephanie

    • Hello O Huante,

      It is important to first receive an evaluation from a pelvic floor therapist before beginning a general exercise program. Please consult with a local therapist to get started.

      All my best,

      Stephanie

  10. Do you recommend contacting therapists on your list, within the region, to potentially help me find a physio in my part of the state? I can’t locate any in my town through an internet search.
    Thanks.

    • Hello Ted,

      We do not have a therapist recommendation in Wilmington, but can offer you a referral for Raleigh and Greensboro. Their information is below.

      Young Wilda PT Greensboro NC (336) 275-6380 wildayoung@gmail.com
      Talley Sarah DPT Raleigh NC (919) 571-9912 Carolina Pelvic Health Center
      Wegmann Emily PT Raleigh NC (919) 571-9912 emily@carolinapelvichealth.com Carolina Pelvic Health Center

      Best,

      Stephanie

  11. Ted-I live in Wilmington NC and had a great experience with InnerStrength PT. They do treat males-internally to my knowledge.

    For some alternative options-Beth Ventre is great with external muscle release and Mindy Trotten does wonderful CranioSacral treatments.

    Best to you-

  12. I am suffering from this dysfunction as well. Do you have a PT recommendation in Huntsville, AL or surrounding areas? Thank you so much!

    • Hello Dee,

      I apologize for the delayed response! I am familiar with Rachel Butler in the AL area, however our practice is not affiliated with Birmingham PT. Below is their contact information:

      Butler, Rachel Birmingham AL (205) 298-9101 Birmingham PT

      Best,

      Stephanie

  13. Pingback:Relax Your Pelvic Floor Some More – Blog About Pelvic Pain

  14. I have been given this site by my consultant .I have tenesmus surgically induced by child birth.Will any of this help me.I don’t know what my problem is but have had 6 operations to help last op.being a colostomy.Urge still persists.please advise .ams I using the right site.
    Am I on the right site for my condition.

  15. Pingback:pelvic muscle exercise male – Muscle and Abs

  16. Are there any personal trainers you would recommend in Kansas City area that have knowledge of pelvic floor tension?. I have worked succesfully with a PT to mitigate pain, but the only exercise I’ve had luck with is walking. Tennis, and other cardio seem to trigger. Can’t stand being so out of shape!

Leave a Reply

Your email address will not be published. Required fields are marked *