S. Abbas Shobeiri, MD, FACOG, FACS

Physical Therapy for Pelvic Pain: Understanding the Musculoskeletal Connection

Julie Sarton, DPT

Pelvic pain has traditionally represented a complex diagnosis and management problem for the OB/GYN. Now, however, the emergence of a distinctly identifiable and treatable musculoskeletal condition holds the promise of relief for many of these women.

Pelvic pain is one of the most challenging medical conditions that OB/GYNs must treat. It is estimated that 40% of all laparoscopies are performed for pelvic pain.1 If endometriosis is found, only 33% of cases resolve with surgical intervention,1 with the cure rate rising to only 40% for adhesions.2 Chronic pelvic pain (CPP) can lead to symptom magnification, receptor-field expansion, and onset of new peripheral pain.3 This cascade can cause significant frustration and distress for both patient and practitioner. However, there is another, overlooked aspect of pelvic pain that is often treatable: a shortened, hypertonic pelvic floor.

The pelvic floor is the largest structure in the pelvis but it is seldom considered in the evaluation of pelvic pain. Nonetheless, this muscular group can be a significant source of pain and is easily palpated.æIf identified as a contributing factor in pelvic pain, pelvic-floor disorders may be amenable to physical therapy (PT) and referral to a specialist physical therapist can dramatically improve the patientÍs symptoms.

PELVIC FLOOR TENSION MYALGIA

The musculoskeletal system plays a large role in CPP.4-8 Indeed, myofascial pain is the most common somatic cause of CPP in patients with negative findings on laparoscopy.9  More specifically, pelvic floor tension myalgia (PFTM) has been linked to dyspareunia, urinary urgency/frequency, interstitial cystitis, vulvodynia, anismus, coccydynia, and generalized pelvic pain.

Pelvic floor tension myalgia is characterized by a shortened, hypertonic pelvic floor with myofascial trigger points throughout the musculature. These trigger points generally refer pain to the lower abdomen, suprapubic region, hips, perineum, tailbone, and/or lumbosacral region—leading to confusion as to the source of the pain.

Many musculoskeletal structures of the back, pelvis, and lower extremities share segmental innervation with urogenital structures and can mimic urogenital pain.10 Additionally, afferent nerves of the viscera and the pelvic-floor muscles are routed to the medial thalamus, and cannot localize noxious stimuli. Thus, patients with PFTM often cannot recognize the locus of their pain.11

Abnormal functioning of the lower urinary tract can also result from PFTM. Hypertonicity of the levator ani decreases its ability to lengthen and relax, resulting in inadequate or obstructive voiding.3,8æAdditionally, the levator may not adequately inhibit the detrusor during bladder filling, leading to urinary urgency and frequency.8æAs patients attempt to control this by contracting the pelvic muscles, the additional activity can further stimulate the trigger points and exacer- bate the pain.8æTable 1 summarizes the symptoms of PFTM, and Table 2 lists its most common causes.11,12

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PELVIC FLOOR PHYSICAL THERAPY

The success of pelvic floor PT in managing refractory CPP is well documented.7,13  The goals of PT for the patient with pelvic pain include:

• Eradication of external musculoskeletal factors perpetuating pelvic pain (eg, postural malalignment, skeletal asymmetry, faulty biomechanics, gait deviations, trigger points/muscle spasm, scar tissue, abnormal connective tissue/paniculosis)
• Decline in abnormal neural tension (particularly of the pudendal and sciatic nerves)
• Improvement of inflammation
• Normalization of pelvic-floor tone
• Eradication of internal trigger points
• Re-education of both internal and external lengthened muscles to fire with appropriate timing and force
• Instruction in efficient movement patterns
• Facilitation of patientÍs return to functional activity
• Establishment of home program consisting of self-treatment and exercise.

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EVALUATION

The urogynecologic physical therapist’s evaluation starts with a comprehensive history.  Understanding what contributes to the patient’s pain is crucial and will help to prevent return or exacerbation of symptoms after discharge. Table 3 outlines the essential questions to ask. Additional “red flags” for PFTM include:

• Negative findings on diagnostic laparoscopy
• Repeated treatment of culture-negative “urinary tract infections” or “yeast infections”
• Urinary retention (especially immediately postsurgery)
• No response to intervention focused on other systems.

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Objective Examination

In patients with pelvic pain only a skilled urogynecologic physical therapist can assess the biomechanics of the pelvis and lower kinetic chain and perform an internal pelvic-floor examination to properly assess the musculature and connective tissue.æA number of specific structures are routinely evaluated (Table 4).

Internal Examination

The internal examination should assess muscular hypertonicity, trigger points, reproduction of symptoms, and contraction/relaxation of the pelvic floor.æThe examination begins with single-digit palpation of the bulbospongiosus and pubococcygeus. If the patient is experiencing vulvar burning, a cotton-swab test should be performed to rule out vestibulodynia. Resting tone of the pubococcygeus is evaluated and, if excessive, the patient should be asked to bear down gently to eccentrically lengthen the muscle, facilitating finger insertion.10æA simple test for evaluating muscle awareness and strength involves asking the patient to ñsqueeze and relaxî the levator ani as the clinician observes strength of muscular recruitment, extent of relaxation, and the patientÍs proprioception. Next, each pelvic-floor muscle is systematically palpated—ie, the pubococcygeus, iliococcygeus, obturator internus, coccygeus, and piriformis (Figure 1).æStarting medially and sweeping laterally, active trigger points are identified by locating significantly tender areas that are often palpable as small, 3-to-6-mm nodules within a taut band that reproduce the patientÍs referral pattern and pain.3

The obturator internus can help to orient the clinician to the anatomy of the pelvic floor, as the muscle belly is easy to feel when contracted.æPalpating laterally, the clinician asks the patient to abduct the knee against resistance while the hip is flexed (Figure 2). The iliococcygeus covers the lower two-thirds of this muscle: following the obturator posteriorly leads to the ischial spine.æMoving the examining finger anteroinferiorly from here allows palpation over the pudendal nerve in AlcockÍs canal, which lies inferior to the arcus tendineus.8æPlacing the leg in internal rotation stretches the pudendal nerve, allowing the examiner to check for pain. Lastly, the posterior pelvic floor—ie, the coccygeus and piriformis—can be assessed vaginally or rectally; confirmation of the piriformis is attained by asking the patient to abduct the thigh against resistance. Findings indicative of PFTM include:

• Tender pelvic-floor muscles, especially at the insertion of the tendinous arch
• Poor proprioception with inability to relax/eccentrically lengthen the muscles
• Active trigger points reproducing the symptomatic pain and referral pattern.

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PHYSICAL THERAPY

Findings from the internal and external examinations dictate individual treatment.æTypically, treatment is aimed at correcting external musculoskeletal factors first as these dysfunctions frequently set the stage for PFTM.æAlthough biofeedback therapy has been widely publicized to treat pelvic pain, the origin of PFTM involves more than dysbehavior.3 Direct manual therapy is required to achieve somatic and visceral improvements via mechanical and reflexive actions of the nervous system.3,7,8,10,14

A variety of manual techniques can be used transvaginally for internal treatment of the pelvic floor, including trigger-point release, myofascial release, proprioceptive neuromuscular facilitation, and strain/count-erstrain. These treatment approaches can be combined with others such as contract/relax, in which the patient is asked to isotonically contract the muscle against the resistance of the therapistÍs finger.14æAs each patient is unique in her presentation, there is no standardized protocol for treating this population, and the physical therapist will determine the most appropriate interventions.

Prescriptive exercise is also an essential component of the management plan. Regarding pelvic pain, the evidence supports addressing deficits in motor control rather than focusing on the strength of the individual muscle.15æThe goal is to correct dysfunctional patterns of muscle activation by teaching new movement patterns/stability strategies so that the load is optimized through all joints of the kinetic chain.15

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CONCLUSION

Pelvic floor tension myalgia, an often overlooked musculoskeletal component of pelvic pain, can be easily identifiable and treated. In addition, PT represents a conservative option to try for patients with suspected PFTM before resorting to surgery or other invasive interventions. A working understanding of appropriate evaluation techniques and a relationship with a good pelvic floor physical therapist will facilitate the successful management of this challenging medical condition.

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Julie Sarton, DPT, is assistant clinical professor, Department of Obstetrics and Gynecology, Division of Urogynecology; and director, WomenÍs Healthcare Physical Therapy Program, University of California, Irvine.

References

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