Pelvic Pain PT: The Role of Connective Tissue Manipulation

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connective tissue

You say “skin rolling.” I say “connective tissue manipulation.” Tomato…tomahto; semantics aside, let’s talk about what it is and what it has to do with pelvic pain.

“Skin rolling” or “connective tissue manipulation” as I’ll be referring to it throughout this post, is a major component of our pelvic pain treatment technique here at PHRC. That’s because in our experience treating pelvic pain patients—both male and female—more often than not, when there is pelvic pain, there will be some level of connective tissue restriction.

Before we delve into the connection (wink) between connective tissue restriction and pelvic pain, let’s first explore exactly what “connective tissue” is.

Connective tissue is one of the four general classes of biological tissues—the others being epithelial, muscular, and nervous tissues. The job of connective tissue is to support, connect, or separate different types of tissue and organs.

Bones, ligaments, tendons, and cartilage are all considered connective tissue. However, the type of connective tissue that we’re interested in in the context of pelvic pain is known as “loose connective tissue.”

Loose connective tissue is aptly named because its fibers are randomly arranged and there’s lots of space between the cells, which makes it THE ideal tissue for cushioning and protecting. Besides surrounding blood vessels and nerves, one of the biggest jobs of loose connective tissue in the body is to attach the skin to the muscles.

(For the sake of brevity, even though I’m referring specifically to “loose connective tissue,” going forward I’m going to use the term “connective tissue.”)

Connective tissue can become restricted as a result of dysfunction in underlying muscle, nerves, joints and organs. Reflexively, once connective tissue restrictions have developed there will be dysfunction in the area (locally) and in distant locations if not properly addressed by manual treatment.

When the connective tissue that attaches the skin to the muscle becomes restricted (think thickened or dense) it can and does cause pain. One reason is that restricted connective tissue impedes healthy blood flow to the area. Plus, research shows that connective tissue restrictions lead to local pain via the peripheral nervous system.

In addition, a strong association between active trigger points and connective tissue restriction exists. As a result, treating the connective tissue restriction can relieve trigger points activity and/or make trigger points more responsive to treatment. (How cool is that?!) On top of all of that, it’s hypothesized that restricted connective tissue can cause referred pain—including pain to organs (think bladder in the case of pelvic pain)— via the central nervous system.

For all of the above reasons, it’s important for pelvic floor PTs to treat connective tissue restrictions as part of a comprehensive treatment plan.

The manual test that’s used to determine if a patient has connective tissue restriction (a.k.a. “subcutaneous panniculosis”) is the “pinch-roll test.” When a PT carries out a pinch-roll test he or she will roll a fold of skin between his or her fingers, and note whether the tissue is thickened. This is painful to the patient. It should be noted that typically, there is only pain if the tissue is restricted. Healthy connective tissue does not produce pain in response to this test.

At PHRC, we refer to the treatment of connective tissue restriction as “connective tissue manipulation.” However, the common term used to describe connective tissue manipulation is “skin rolling.” The reason we prefer the former phrasing is that “skin rolling” doesn’t seem to do justice to what’s actually going on. After all, it’s the connective tissue, not the skin that’s being taken to task.

Semantics aside, to fully treat connective tissue restriction, a PT has to normalize its mobility, improve circulation to the area, reduce hypersensitivity, and minimize the negative reflexive effects on surrounding muscles, nerves, and organs. A tall order, I know. And that’s why it’s not unusual for us to devote half of an appointment time to connective tissue manipulation for our pelvic pain patients.

Patients with pelvic pain typically have connective tissue restrictions in the thighs, along the pelvis, in the glutes, and in the abdomen. For instance, patients with pain with sitting may have connective tissue restriction, particularly in the medial to ischial tuberosities, glutes and medial and post-thighs. And patients with perineal pain may have connective restriction along the pelvis, abdomen, and/or perineum.

When evaluating for connective restriction, a patient should be examined front and back from navel to knees. Once the restricted areas are isolated, connective tissue manipulation involves the therapist pinch-rolling the affected tissue below the skin and above the muscle between his/her thumb and four other fingers, with both hands. The therapist then palpates to feel where the tissue is thick and restricted and mobilizes the tissue using the thumb and four fingers to improve blood flow, decrease thickness, and restore mobility.

When tissue is restricted, manipulating it typically causes a sharp sensation and may cause tissue soreness in the days following treatment. If symptoms increase, or the patient cannot tolerate the technique, the therapist will postpone the treatment until it’s better tolerated. As the patient’s tissue normalizes over a series of treatments, connective tissue manipulation becomes less painful during and after treatment.

One final thing we’d like to mention about connective tissue manipulation is that it’s not a technique practiced by most pelvic floor PTs. The reason for this is that it’s very rarely taught in PT school or in post-graduate level pelvic floor PT classes. When we see patients who’ve not had success with PT in the past, it’s often due to this missing component.

At the end of the day, successful treatment outcomes are often dependent on including a connective tissue evaluation, and if dysfunctional tissue is found, including connective tissue manipulation in the treatment plan.

For more information about connective tissue manipulation, check out this presentation.

If you have any questions about any of the points covered in this post, please don’t hesitate to leave them in the comment section below!

All my best,

Stephanie

 


37 thoughts on “Pelvic Pain PT: The Role of Connective Tissue Manipulation

  1. Great blog post – saves me from writing one on this topic!

    I totally understand how hard it is to write what we do as PT’s…the only things I would add are:
    1. If you have allodynia, it might be painful even if the tissues are healthy
    2. I would examine at least up to the shoulder and thorax because the muscles that attach to the pelvis extend up there and restrictions there can affect the pelvis.
    3. If the symptoms don’t get better or they get worse, it says to me that the tissue restriction/muscle spasm might be protective of some other dysfunction and taking it apart might not be helpful. I would actually look for another dysfunction somewhere else and assess the effect of those on the pelvic pain and tissue symptoms.

    Obviously, it is hard to write down everything that we do and I have no doubt that you instinctively do these things. I will be reblogging and sharing this post…I hope some of my posts might be useful to you at http://www.physiodetective.com – thanks again!

  2. Love this post Stephanie! We are always looking for great information to educate out patients better on why we do what we do, and this will definitely become one of those handouts! Thanks for the continued great info you all provide–looking forward to seeing you at IPPS!

  3. I just found this site. I have been dealing with chronic pain in my perineum, hips, and thighs for almost 2 years. I have seen urologists, physical therapists, pain specialists, tried oral meds, spinal injections and am just about to have a site injection. This is the first time I have ever heard my exact symptoms explained and the practitioner I have seen who accepted my explanation that the pain seemed to be coming from the connective tissue was a PT. Unfortunately, when we concentrated on connective tissue massage for several weeks, the intensity of the pain kept increasing to the point that the PT and I thought we were making it worse. Did we stop too soon? Is there a way that I can find a local PT or massage therapist through this web site?

  4. Hi Stephanie,
    Great article! My yoga therapist talks a lot about fascia. I’ve always assumed connective tissue was same thing. ???

  5. Great post! Thanks so much for writing it. About how long should tissue in a single area be manipulated for during each treatment?

  6. Hi,
    Thanks so much for sharing this info and presentation!
    I have been treating pelvic pain patients for a while and am familiar with the connective tissue manipulation however I am not sure about the last slide in the presentation showing the picture of a squat as a home exericse – is this because doing deep squats as shown can result in reciprocal inhibition of the PFmms?

    • Dear Kimberly,

      The squat exercise is a home exercise to self mobilize the pudendal nerve via hip flexion or it could also be used as a position to facilitate pelvic floor muscle relaxation (pelvic floor drops) if there is no pudendal nerve involvement. It is not a home exercise to improve connective tissue mobility.

      All my best,
      Liz

  7. Stephanie,
    Thanks for another great article.
    The manipulation of connective tissue is so very important. This when done properly helps tremendously . I had the PN nerve decompression/ transposition surgery done in May of 2002 in Nantes France.
    I saw you many times a year or two later. You have to date been the best PT I have ever worked with.
    I have a good one now, after many many searches and trials.
    Doing the connective tissue manipulation is so important in having successful relief for pelvic floor pain.
    I will be forwarding the PDF about “How to” properly do this to my PT.. Everyone seems to do it a bit different, but you dear have been the best.
    I can do it myself in some area’s just because I have seen it done and know how it’s suppose to feel when done the right way.
    I wish I lived closer.
    You and your staff are the best. Thanks for all you do.

  8. I am so glad you all address and see the mistake of not including connective tissue restrictions in the pelvic and adjacent areas. I would invite you to look further afield-especially below the knees above the pelvis to be included in your inquiry because of the kinetic chain aspects of force transmission through the pelvis an upwards. I know that is not how we are trained, but have found over the years our clients are indeed whole people, connected to all their parts.

    I have been dismayed that only trigger point work seems to be taught for the pelvic floor. I am so glad that you work on the CT and do spend time on releasing these restrictions as this will make your progress swift and permanent.

    As far as tolerance to the “technique” on how it may not be tolerated, I find that there are few techniques that would be tolerated well in such delicate areas.

    I would love to suggest a form of connective tissue release that is ever so delicate, effective within a few moves per restriction, integrative and extremely well tolerated by clients, even those in pain or very restricted. In my opinion, anyone doing such important and delicate work should know this technique. It has detailed assessment components as well as integrative movement techniques to balance the whole body. Please consider looking into Aston Kinetics-your clients will love you for it. http://www.AstonKinetics.com

    • Dear Kim,

      We do not know of a PT in your area. Below is a list of all the PTs in CA that have taken our class. Perhaps one of them is close to you. All my best, Liz
      De La O Melissa PT Santa Barbara CA
      Palandrani Allison San Francisco CA
      Guthrie Julie Los Angeles CA
      Hickenbotham Natalie Santa Barbara CA
      Hickman Debbie Redlands CA
      Horn Laura Los Angeles CA
      Lombardo Kathleen Newport Beach CA
      Machado Dorothy Los Angeles CA
      Moody Holly Camarillo CA
      Rubino Angela Thousand Oaks CA
      Sarton Julie Tustin CA
      Sheaffer Egan Becky Santa Cruz CA
      Tanaka Julie PT Monterrey CA
      Shiozaki Eltheia CA
      Solanki Dhara Santa Barbara CA
      Soroudi Rhonda Agoura CA
      Spruill Angela Thousand Oaks CA
      Steele Joyce San Diego CA
      Wright Kevin Orange CA
      Hernandez Heidi PT Merced CA
      Hopps Trisha PT Paradise CA
      Pier Virginia PT Sacramento CA
      MacDonald Risa PT Sacramento CA
      Worman Rachel PT Folsom CA
      Goodrich Tanya DPT San Francisco CA
      Hoyer-Fisher Giorgia PT Danville CA
      Moffatt Brande MPT Redding CA
      Monteil Diane LAC Mill Valley CA
      Sahi Sanya PT Kentfield CA
      Detwiler Kristin DPT Torrance CA
      Kirages Daniel PT Los Angeles CA
      Landau Lois PT Chico CA
      Kurtovich Karen PT Rohnert Park CA
      Furey Cindy PT San Diego CA
      Jeffcoat Heather DPT Encino CA

  9. Hi! I’ve had chronic burning, raw feeling, stabbing pains in my Vulva after 4 months of several bacterial and yeast infections. I live in Pittsburgh, pa. Can you recommend any PT’s?

    • Hi Diane,

      We don’t know of any PTs in Conn or RI; however below are to PTs we refer to in Mass; All my best, Liz

      Wade Marie PT Framingham MA (207) 779-2256 Franklin Memorial Hospital

      Lewis Elizabeth PT Gloucester MA (978) 761-3149 Elizabeth.L.Lewis@lahey.org Lewis Physical Therapy and Lahey Clinic

  10. I have just come across this blog and a surprised by the information. I live near Grand Rapids Michigan and am a very competitive 55 y/o triathlete. For the past 2 years I have been tackling a urinary urgency problem. I have had internal treatments and light work on my abs. No other connective tissue has been addressed. More recently, starting last summer) I have had pain in the perineum, numbness in the perineum and genitals. Last fall I had pudendal nerve blocks. My pain is less and intermittent, except for when I sit for long periods, but urgency continues. Should I talk about more complete connective tissue work with my PT? Any suggestions.

    • Hello Eric,

      Is your therapist a pelvic floor specialist? I certainly advise that you communicate with your therapist, and suggest connective tissue release. We consider this an essential part of treatment for our patients. I would also suggest that you introduce your therapist to our blog and website for more information.

      Best,

      Stephanie

  11. Stephanie,

    I just ran across your blog on the internet. I’ve had chronic pain syndrome for almost 20 years. Typically, the urine samples are negative. My pain is on the left side and prevents me from sitting for too long and forget the bicycle. I’ve had 3 TURPs and bladder cancer (surgery and chemo) and last year underwent 44 direct beam radiation treatments for prostate cancer. Can you provide the name of an expert in southern New Jersey (or Philadelphia) who can lead me through the exercises? Thanks for writing the blog. Now, I know there’s hope.

  12. I suspect I have pelvic floor dysfunction but have not had specific tests performed to verify. I was being treated by a women’s certified pt for pelvic pain and was actually feeling better. My pt referral ended two weeks ago and I am doing home exercises to relax the pelvic floor muscles but am now getting worse. I live near St. Louis, MO and am looking for a doctor to perform the correct tests to confirm my condition.

    • Dear Kathy,

      There is no definitive test to confirm pelvic floor dysfunction. If you were making progress in PT, I would suggest that you return, even if that means paying out of pocket.

      All my best,
      Stephanie

  13. Pingback:Why Some Men Taint Feelin’ Good (a pun on “ain’t” – get it?) | Blog About Pelvic Pain

  14. I was wondering if anyone knew of any PT’s in the Altoona or Pittsburgh, PA. area that treat males for this. I saw some posted earlier in the thread, but I wasn’t sure if they were still current or not. Also, would I need a referral of some kind to see them? Thank you in advance.

    • Hi Gary,

      Below is the list of therapists we recommend in Pittsburgh, PA. Yes, a referral from a physician will be necessary in order for you to receive treatment.

      Best,

      Stephanie

      Christine Woods, PT
      Pittsburgh, PA
      (412) 967-9229
      Fox Chapel Physical Therapy

      Janice Bryant, PT
      Pittsburgh, PA
      (412) 422-4775
      UPMC Centers for Rehab Service

  15. Hi Stephanie-I have been reading your blogs for several years. Thank you for the great information. I have had pelvic pain for ten years, and I have been through the usual list of doctors, and several pt’s here. The usual manipulations and dry needling have not worked for me. I don’t think I have had the connective tissue skin rolling applied to my painful area. Can you recommend a pt in atlanta who has had this training?

    • Hi Grace,

      Pelvic Health and Rehabilitation Center has an office located in West Los Angeles, please call 424-293-2305 and I would be happy to assist you.

      Regards,
      Admin

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