Hip Dysfunction: Is Your Pelvic Floor the Missing Link?
Hip structure and function directly impact the pelvic floor. Based on proximity alone, the pelvis and hips are closely related. Their muscle groups are interconnected and overflow into each other. Hip dysfunction can contribute to pelvic floor dysfunction and vice versa. Pelvic floor muscles are smaller, serve to promote continence, and support our internal organs. Hip muscles are larger and help us produce movement to ambulate throughout our life. If hip muscles are underactive, they can cause the pelvic floor to become overactive by not providing the stability it needs.
Hip strength is vital for pelvic floor function.Hip range of motion is also important to pelvic floor function. Hip flexibility is a good indicator of pelvic floor muscle activity and continence. If hip flexibility is decreased, pelvic floor muscles will not be working in their fullest capacity. In pelvic floor physical therapy, we work to assess what contributions are occurring from the joint above (low back) and below (hips). Someone who experiences pelvic floor dysfunction likely have some dysfunction in the low back or hips.
Conversely, someone who experiences back pain or hip problems will likely have an underlying pelvic floor dysfunction based on the proximity of these regions. Patients with hip problems (or those post-hip replacement) may report a deep, aching hip pain that does not resolve with only external treatments. This is pain potentially stemming from hip muscles that can be accessed within the pelvic floor. If we neglect pelvic floor contributions to hip pain, how would we expect our patients to get back to 100%?
Pelvic floor physical therapy can resolve hip-related dysfunctions by assessing the pelvic floor, hips, and low back to determine the best plan of care for a patient. We address hip mobility and strength, core strength, pelvic floor muscle tone and coordination, and pain management strategies to give you a holistic treatment method. Physical therapy can be considered a conservative treatment for those who may need a hip replacement. Reach out to us if you have any questions regarding treatments and approaches to the pelvic floor. Pelvic floor physical therapy may be the missing link to you living a pain-free life.
Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine (Phila Pa 1976). 1998;23(9):1009-1015. doi:10.1097/00007632-199805010-00009
Ike, Hiroyuki MD; Dorr, Lawrence D. MD; Trasolini, Nicholas MD; Stefl, Michael MD; McKnight, Braden MD; Heckmann, Nathanael MD Spine-Pelvis-Hip Relationship in the Functioning of a Total Hip Replacement, The Journal of Bone and Joint Surgery: September 19, 2018 – Volume 100 – Issue 18 – p 1606-1615 doi: 10.2106/JBJS.17.00403
Reiman MP, Matheson JW. Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. Int J Sports Phys Ther. 2013;8(5):729-740.
Endometriosis is a condition where the endometrial tissue (lining of the uterus) exits the uterus and enters the body and blood stream. Endometrial tissue is expelled from the uterus during menstruation through the fallopian tubes. Endometrial tissue is healthy and normal within the uterus. Endometrial tissue, outside of the uterus, is harmful. Endometrial tissue can travel through the bloodstream and relocate to other areas of the body (studies have found endometrial tissue as far as the eyes and brain). When endometrial tissue exists outside of the uterus, it proliferates scar tissue. See, our organs like movement, and they are designed to slide and glide against each other. When scar tissue builds between organs, our bodies cannot move as well. Organs can become tethered together. The bladder can bind to the uterus, uterus to colon, colon to colon, and so on and so forth. This can affect our digestion, reproductive abilities, excretion of waste products, and overall comfort. Endometriosis can contribute to pelvic pain and dysfunction.
What can pelvic floor physical therapy do to address endometriosis?
Pelvic floor physical therapy cannot cure or treat the cause of endometriosis. However, pelvic floor PT can address symptoms associated with endometriosis. We can determine a plan of care that is individualized to each patient regarding their symptoms. About half of patients with endometriosis experience chronic pelvic pain in some way, shape, or form. This could be through pelvic pain during menstruation, sexual intercourse, or digestion. Other symptoms include constipation, decreased organ motility, and joint pain. Endometriosis can even have injurious effects of posture. Pelvic floor physical therapy can help with symptom management and promote organ motility. There are a variety of techniques we incorporate including soft tissue mobilization, visceral mobilization, promotion of movement, pelvic floor relaxation, recommendations for behavioral modifications, and so on.
Endometriosis is a distressing condition for those who experience it and their loved ones. With pelvic floor physical therapy, we can improve your quality of life with symptom management. If you struggle with endometriosis, reach out to us, and see what we can do for you!
Awad E, Ahmed HAH, Yousef A, Abbas R. Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design. J Phys Ther Sci. 2017;29(12):2112-2115. doi:10.1589/jpts.29.2112
By Natalie Sterner, PT, DPT
Running is a common activity that many women and men enjoy daily. Frequent runners typically have a pre and post workout regime consisting of stretching for hip and knee musculature, foam rolling, and even icing in order to reduce pain and inflammation in various joints or muscles. One thing that is often left out of these routines is the pelvic floor – a vital component in core stabilization and injury prevention with exercise, particularly running. Many runners will seek out treatment for common orthopedic issues – plantar fasciitis, hip pain, ITBand dysfunction – which may be stemming from the pelvic floor and will not see complete results with therapy due to only being given “core” exercises without addressing the pelvic floor as well. Statistics show that at least 1 out of 4 women report having one or more pelvic floor related disorders such as urinary/fecal incontinence, pelvic pain, and pelvic organ prolapse (POP). A study by Thyssen in 2002 found 44% of young female athletes leaked during sports.
The pelvic floor is just as important as our other external musculature in proper running mechanics. The pelvic floor is part of the deep core muscles which are our anticipatory muscles. They stabilize our body by contracting prior to movement. Other muscles in this group are the transverse abdominus, multifidi, and diaphragm. The pelvic floor works during both phases of running. During the flight phase it works eccentrically or lengthens. During heel strike of the stance phase the pelvic floor and deep core muscles work concentrically meaning they shorten to allow for stability. Thus we need the full range of the pelvic floor for optimal mechanics during running.
Pelvic floor dysfunction can present in various signs/symptoms. Some common dysfunctions found in athletes/runners are listed below:
- Urinary/fecal urgency: This symptom is often caused by myofascial trigger points within the pelvic floor muscles which triggers neurogenic bladder symptoms. These trigger points can become active during running and lead to the feeling of immediate voiding! This can be extremely frustrating for runner who may limit their paths or routes to make sure a bathroom is close by or even needing to stop mid-run to not lose urine or feces.
- Urinary/fecal incontinence: Urinary or fecal leaking can be a very common occurrence with runners. In a study by Leitner in 2016, it was found that 41% of female athletes have experienced urinary leaking with running. This can range from a small dribble to fully soaking through leggings and running down legs. Running is very stressful on the pelvic floor muscles that work to support all the pelvic organs while maintaining continence. If leaking occurs, the pelvic floor is not able to tolerate this pressure. This could be caused by myofascial trigger points, muscle weakness, and/or decreased coordination.
- Pain: The pelvic floor muscles work just like any other muscles – they contract and relax and can become tight or weaken. Pelvic floor muscle trigger points can develop as well if not allowing lengthening to occur in the muscle. Common pain referrals from the pelvic floor are the lower abdomen, hip, buttock, posterior thigh. Pain may also be coming from external hip muscles as well. The adductors, our inner thigh muscles, can also refer pain to the pelvis. It is important to have both strength and flexibility in all of these muscle groups.
- Heaviness or pressure: This can be a potential sign of pelvic organ prolapse (POP) which is the downward descent of the pelvic organs. This can involve the uterus, bladder, and/or rectum. The pelvic floor muscles need to provide enough support with the increase of intra-abdominal pressure that occurs during running. If there is weakness and not enough support, this can lead to pulling on the ligaments and connective tissue leading to possible prolapse.
What can we do to ensure that the pelvic floor is working appropriately to reduce the risk of these symptoms? Breathing is the first step. When exercising we want to ensure that the diaphragm is moving properly. When we inhale the diaphragm should move down into our abdominal cavity allowing the rib cage to open and the belly to expand rather than just breathing using our chest. This will allow the pelvic floor and transverse abdominus muscles to lengthen. During our exhalation the diaphragm moves upward as the pelvic floor and transverse abdominus return to their prior position. The diaphragm and pelvic floor muscles move in tandem like a piston and generate good tension in the trunk which creates more stability while we run. Coordination of this is important.
Try not to hold/grip the abdominals or pelvic floor. This will limit trunk rotation and the ability to use the abdominals effectively. Same with the pelvic floor – there needs to be some absorption of pressure and holding can lead to overactivity of the muscles. We want all of the deep core muscles to work together in balance.
Posture is important for running as well. Proper running posture consists of leaning over so that your rib cage is on top of your pelvis in order to keep your head looking forward. This will allow better mobility through the hips and will keep your body over your heel as you land reducing the pressure through the body. Increasing your cadence, the number of steps you take per minute, can also decrease the forces through your body leading to less impact through the pelvic floor as well.
Making sure that your body is taken care of while doing what you love to do is important so that you can keep doing it! The demands of running are intensive and repetitive. It is important to specifically train the pelvic floor to meet these demands just as you would strengthen your back, hip and knees for fitness. If you feel you are having any of these issues the pelvic health therapists at Pelvic Health Solutions can assess you individually and work with you to continue with the sport that you love to do!
Resources:
Leitner M, Moser H, Eichelberger P, Kuhn A, Radlinger L. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurology and Urodynamics. 2016;36(6): 1570-1576. Doi:10.1002/nau.23151
Thyssen HH, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J Pelvic Floor Dysfunction. 2002;13(1):15-7.
By Natalie Sterner, PT, DPT
Interstitial cystitis (IC) is a chronic pain condition that affects more than 12 million Americans. It is typically 2-3 times more common in women than in men and research has shown the risk of IC increased with age. IC is characterized by both pelvic pain and urinary symptoms. Patients will experience sensations of pain and pressure in the bladder area as well as lower urinary tract symptoms. It is typically diagnosed by unexplained pain and ruling out other health conditions that may cause similar symptoms. 85% of people with IC also have pelvic floor dysfunction.
Pain is often the most common sign along with pressure of the bladder. The bladder pain may increase as the bladder fills. Pain may also be experienced in other areas of the pelvic region and low back. The muscles of the pelvic floor attach to the front (pubic bone), back (tailbone), and sides of the pelvis and help to support all of the pelvic organs as well as coordinate between contraction and relaxation to allow for proper bladder and bowel function. Often times with IC, these muscles are tight or in spasm which causes trigger points to develop. Inflammation will arise and persist due to the chronic nature of IC. Muscle tightness, trigger points, and inflammation can irritate the nerves that run through the pelvis and refer pain to other areas such as pelvis, thighs, buttocks, lower abdomen, and perineal area.
Frequency of urination is also a common symptom with IC. Typical daily voiding ranges between 5-7 times a day with no night time voiding. A patient with IC will go the bathroom to urinate more often during the day as well as at night. This can also lead to urinary urgency. Some patients will feel the urge to urinate that does not even go away after they have voided. Other symptoms that may occur with IC include burning with urination, pain with intercourse, difficulty starting/maintaining urine stream, and constipation. Symptoms may be exacerbated by various reasons. Certain foods or drinks, such as spicy foods or caffeine, may be more irritating to the bladder. Stress both physical and mental can be an irritating factor. Some women may notice symptoms vary around their period as well.
Only a fraction of patients with the key symptoms of IC (urinary frequency, urgency, and pelvic pain) have ulcers within the bladder (Hunner lesions) and many are found to not have any sort of bladder pathology at all. Thus the muscles of the pelvic floor as well as external hip/pelvic musculature are important to assess as they may aide with decreasing and managing symptoms related to IC. The American Urological Association has given pelvic floor physical therapy a grade “A” and is recommended as the first line of medical treatment for IC. Other bladder treatments and oral medication are often needed to be continued indefinitely to provide benefits if they work. Physical therapy can provide lifestyle changes and techniques for sustained relief. One study in 2013 showed that 63% of patients had significant pain improvement with pelvic floor physical therapy.
As always, a thorough initial evaluation would be completed prior to beginning treatment as everyone is individual. This would include both an external assessment of the hip/pelvic/back muscles and an internal assessment of the pelvic floor muscles. The goal of physical therapy is to restore normal function of the muscles, prevent irritation of the nerves that cause pain, and clearing inflammation from the system. Release of trigger points in the tightened muscles helps to clear inflammation in the fascia which can restore better blood flow and reduce reoccurrence of trigger points. This can help with disrupting the nervous system’s pain feedback loop. Other treatments include relaxation of the pelvic floor and hip muscles and education for self-care at home such as deep breathing, stretching and self-release of pelvic floor muscles.
Our skilled therapists at Pelvic Health Solutions can evaluate and provide individualized treatment plans for patients with IC. For more information on chronic pelvic pain or other pelvic dysfunctions, call us at (561)899-7747.
Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med 2013; 58: 504–510.
By Katie Usher, DPT
Diastasis Recti is a term used to describe separation of the abdominal wall muscles that typically occurs during pregnancy. Abdominal muscles are made up of 4 muscle groups. From superficial to deep, they are named rectus abdominis, external obliques, internal obliques, and transverse abdominis. These muscles, under normal circumstances, meet in your midline called your linea alba. During pregnancy, these muscles are stretched laterally as the belly grows to make room for baby, which is completely normal. In fact, there is recent research that sites that 100% of women will have some sort of diastasis by 36 weeks of pregnancy. This separation can become problematic on the postpartum side if the tissue doesn’t heal appropriately and continues to stay separated.
Our abdominal wall functions to hold in intestinal contents and stabilize the body during movement. It is also part of our core, along with our diaphragm, pelvic floor and back muscles. If there is dysfunction in the abdominal wall, it can lead to problems such as umbilical hernias, pelvic floor dysfunction, breathing problems and poor movement strategies.
When a health professional assesses for diastasis, they will ask the person to do a partial curl up off the surface. The practitioner is looking for any doming or dipping through that midline tissue called the linea alba. They measure the width and the depth of the tissue using their fingers to assess the severity of the separation. Typically, they will then ask the patient to engage through their transverse abdominis and retest to see how well the abdominal wall can produce tension.
If there is a diastasis present, physical therapy is typically indicated. Therapy options include manual therapy to promote bringing the tissue back towards midline, education on proper engagement of core muscles, education on proper breathing mechanics, and instructing the patient how to properly recruit the muscles during functional movement. We also provide education on exercises and movements to avoid that may increase the intra-abdominal pressure and strain through the abdominal tissue. The biggest indicator for improvement is the ability to correctly produce tension through the core, as the tissue will often remain separated. In some rare and severe cases, surgery may be indicated.
If you feel you have a diastasis recti, you should be evaluated by an appropriate health care provider. It is important to know there is something you can do to help yourself. Our experienced and well trained pelvic health physical therapists here at Pelvic Health Solutions are available to treat any issues with diastasis recti.
By Gail O’Neill
Our pelvic organs (bladder, vagina, uterus and rectum), are supported by our pelvic floor muscles (PFM) and endopelvic fascia which is a sheet of connective tissue that covers the internal organs. When there is a loss of support within this system one or more of our pelvic organs can descend or prolapse into, and in some cases, out of the vagina. This usually occurs with older women. However, it can happen with women of any age. Some causes may include: childbirth, aging, decrease in estrogen, prior surgery, regular heavy lifting, exercise overload, connective tissue injury, obesity, injury to Levator Ani muscle (PFM) and chronic straining which occurs with constipation.
There are certain types of prolapse. The most common is bladder prolapse or Cystocele. This is a result of the bladder moving to the front of the wall of the vagina (anterior). If severe, the front wall of the vagina may bulge out of the opening of the vagina and may actually be visible at the vaginal opening.
A Rectocele is when the lower part of the bowel or rectum moves forward into the back wall of the vagina. This is known as a posterior vaginal wall prolapse. This may be more evident during and after straining when having a bowel movement.
Uterine prolapse occurs when the uterus and the cervix drop into the vagina from their normal position. If a woman has undergone a hysterectomy, the upper part of the vagina can move downward. This is referred to as a vaginal vault.
A Rectal prolapse is a condition that is confused with a pelvic organ prolapse (rectocele). This involves only the rectum- not the vagina. This prolapse affects the lower part of the bowel or rectum moving down or out of the anus. A rectal prolapse is most often cause by weakening of the supportive tissues holding the rectum in position. This weakness may be in the Pelvic Floor muscles which includes the external anal sphincter.
Some symptoms associated with POP may vary and do not always correlate with the severity of the prolapse. They generally are worse with prolonged upright postures such as standing and relieved when lying down. Some common complaints may include: vaginal bulging, heaviness or pressure within the pelvis, lower back pain, lower abdominal pain and/or pressure, difficulty emptying bladder, difficulty evacuating bowels, manually repositioning the prolapse in order to effectively void.
If left untreated, a POP will not heal or disappear on its own. Given that a prolapse occurs due to tissue being stretched beyond its limits, once over stretched, the tissues are not able to return to their former length. Some mild to moderate grades of prolapse can improve with pelvic floor rehabilitation.
A Gynecologist, Uro-Gynecologist or pelvic floor physical therapist are trained to assess the severity of a prolapse. It is measured in stages using a calculation referred to as the POP-Q. This system measures the amount of downward displacement of the affected organ in relation to distinct landmarks within the vagina. The prolapse is graded from Stage 0 (no prolapse) to Stage IV (complete protrusion through the opening of the vagina).
Addressing pelvic organ prolapse may include strengthening of the pelvic floor muscles, pessary inserts and behavioral modification in order to educate patients how to avoid worsening their prolapse. These may include avoiding activities which increase intra-abdominal pressure which can occur with both heavy lifting as well as straining with constipation. Pessaries (supportive devices that are custom fitted and inserted into the vagina) act as a sling to help support and keep the organ elevated.
If you feel that you have an organ prolapse, you should be evaluated by an appropriate health care provider. Our experienced and well trained pelvic health physical therapists here at Pelvic Health Solutions are available to treat any issues with pelvic organ prolapse.
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