This post comes from a friend and physical therapy colleague, Dr. Laura Ross, PT, DPT, PRPC. Dr. Ross is an orthopedic physical therapist who is specially trained in Pelvic Health Therapy. This is such an important topic and one that I have written guest posts on as relates to Running athletes and Cycling athletes.
Enjoy this post from Dr. Ross!
At the beginning of my physical therapy (PT) career, I worked in an Orthopedic clinic treating a mix of general orthopedic clients and pelvic health clients. I treated my pelvic clients in one of two private rooms. For my fellow orthopedic PTs, and some of their clients, Pelvic Health PT was something mysterious that happened behind closed doors.
Pelvic Health Therapy (inclusive of Physical Therapy and Occupational Therapy) is its own specialty with unique skills that requires ongoing additional training over many years. Trained Pelvic Health Therapists have insights into orthopedic injuries from the perspective of appreciating the connections between the pelvis and disparate areas of the body. Distinct from orthopedic training, we can directly examine the perineum, pelvic floor, and external genitals. It’s important for Pelvic Therapists and Orthopedic PTs to work together. I’d like to make the case for why a good Pelvic Therapist can be an Orthopedic PT’s “secret weapon,” in producing excellent clinical results for clients.
The Pelvic Floor is Connected to the hip, low back, and “groin.”
Have you ever worked with a client with hip, back, or “groin” pain that didn’t resolve no matter what you threw at it? In these cases, you may want to consider a consultation with a Pelvic Therapist to assess the role of the pelvic floor as a potential contributor to the client’s persisting pain.
The core is not just a muscle or group of muscles. It is actually a system comprising the diaphragm, pelvic floor, abdominals and multifidi muscles and functions kind of like a canister. The core and all of its elements work together to manage pressure, support posture, support organs, bowel and bladder continence, sexual function and more. If one part of the system isn’t functioning optimally, it can lead to issues elsewhere. The pelvic floor muscles also have fascial and kinetic chain relationships with the adductors, glutes, hip rotators, abdominals, jaw, and feet. When appreciating these various connections one can recognize the importance of a pelvic health assessment for many clients with musculoskeletal pain concerns.
For example, it is common for folks with hip labral pathology or Femor-actetabular Impingement (FAI) to also have pelvic floor issues.(1,2 ) This can lead to pain that doesn’t resolve after a course of standard Orthopedic PT. It is also common for folks with low back pain to have some pelvic floor dysfunction, incontinence, or pelvic pain. (3,4,5) “Groin” strains also have a pelvic component. It’s important to be specific about distinguishing whether this is an adductor or inguinal strain, but in both cases Pelvic Therapy can directly assess related structures (i.e., testicles, spermatic cord, inguinal canal, pelvic floor muscles, abdominal muscles) and help connect them in the larger kinetic chain for optimal rehabilitation.
Why It is Important to Screen Your Clients for Pelvic PT Needs
Many conditions or history of past incidents that can respond well to Pelvic Therapy are common but may not seem connected to a client who comes into your clinic with other issues. These can include: urinary or fecal incontinence, pregnancy-related pain, and pelvic or genital pain.
Urinary incontinence is more common in folks who have not had children than you might think.(6) Have you ever asked a high school volleyball or basketball player or maybe a gymnast if they leak urine while jumping and landing? This is surprisingly common and often not addressed until after these folks are older. It doesn’t have to be this way! These folks may also report urinary urgency/frequency, painful tampon insertion or GYN exam and/or urinary leakage while laughing. Send them to a Pelvic Therapist and you’ll win some points for helping their overall quality of life. Often urinary issues and pelvic pain are normalized in young female athletes. It may feel uncomfortable to ask some of these questions, but it is well within our scope to be asking and we have the time to do so as PTs. If you are worried about asking private questions in an open area there are also screening tools for pelvic health concerns like the Cozean Screening Tool.(7) Help support these clients to know that leakage and pain may be common, but there are ways to help. If you treat folks who engage in heavy weightlifting you can also screen for urinary incontinence, bowel incontinence (including flatus), testicular pain or rectal prolapse. While these may not be the reasons that someone is in your clinic, you may be the first person to ask some of these questions. It is sometimes celebrated or normalized for women or people assigned female at birth to leak urine in a heavy deadlift or final attempt at a max effort squat or deadlift.(8) This is not always a problem, but if it happens habitually it is worth checking out. Men or those assigned male at birth can develop testicular pain or bowel issues due to faulty belting or bracing strategies. If a lifter commonly passes gas when they don’t want to at the bottom of a squat, it might be an indicator of bracing issues. When left untreated, incorrect bracing mechanics can lead to things like erectile dysfunction or rectal prolapse in heavy weightlifters. Pelvic Therapy is well-placed to address these concerns in conjunction with a Sports PT or weightlifting coach.
Pregnancy and Post-Partum
Pelvic Therapy is likely most well-known for helping those in the perinatal period. If you are seeing a birthing person for PT in this perinatal period and they have pain that you can’t quite touch and does not fit a standard orthopedic diagnosis, send them to a Pelvic Therapist. Depending on the driver, manual therapy to the pelvis and pelvic floor can also help alleviate some pelvic pain in pregnancy. Pelvic Therapists will also provide prenatal education on what to expect, positioning, early post-delivery tips and more. Pelvic Therapy can help to prevent perineal trauma(9) and lower grades of perineal trauma are key to preventing urinary or fecal incontinence. According to the American College of Obstetrics and Gynecology it is, “standard of care,” to have Pelvic Therapy in the 4th Trimester.(10) This doesn’t necessarily mean that every person needs 8-12 visits postnatally, but a pelvic floor checkup and ways to get moving in the right direction back to activity are helpful for all clients after giving birth.
Why I like to know good Orthopedic PTs
The Orthopedic-Pelvic collaboration goes both ways! I love to have good Orthopedic PTs that I can refer to in order to address TMJ, cervical, shoulder, thoracic, knee or foot issues that present in my clients in a more complex way. These areas can affect the pelvic floor function and I do include them in part of regular treatment. This is far from my specialty, however, so I like to be able to refer to a colleague for additional work. I also love a good Sports PT to help my clients return to high level sport or activity after injury or after giving birth. I have a basic knowledge of most sports and activities, but having an expert in a given sport is an asset to the recovery and success of my clients.
Not all Pelvic Therapists are created equal
I would recommend networking and getting to know your local Pelvic Therapists. Just like Orthopedic PTs, some specialize in treating certain populations and some have very little experience with others. Some may not have expertise in athletic populations, treatment of cisgender men or folks assigned male at birth, or in loading clients with appropriate strength training. Knowing to whom you can refer your clients for a best fit will make this collaboration a success. Thanks for reading and for all you Orthopedic PTs: I hope you reap the benefits of this new “Secret Weapon” in your toolbox!
Dr. Laura Ross, PT, DPT, PRPC
You can find Laura at:
Instagram: @drlauraross.
References:
1. Navot S, Kalichman L. Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization. Prevention and Rehabilitation: Case Report. 20(3), 604-609 (2016) https://doi.org/10.1016/j.jbmt.2016.04.005
2.Coady, Deborah MD1; Futterman, Stacey PT, MPT, WCS, BCB−PMD2; Harris, Dena MD1; Coleman, Struan H. MD, PhD3. Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-up After Hip Arthroscopy. Journal of Lower Genital Tract Disease 19(3):p 253-256, July 2015. | DOI: 10.1097/LGT.0000000000000108
3. Dune, T.J., Griffin, A., Hoffman, E.G. et al. Importance of internal vaginal pelvic floor muscle exams for women with external lumbar/hip/pelvic girdle pain. Int Urogynecol J 34, 1471–1476 (2023). https://doi.org/10.1007/s00192-022-05390-4
4. Dufour: Dufour, S., Vandyken, B., Forget, M. J., & Vandyken, C. (2018). Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice, 34, 47- 53. https://doi.org/10.1016/j.msksp.2017.12.001
5. Eliasson, K., Elfving, B., Nordgren, B., & Mattsson, E. (2008). Urinary incontinence in women with low back pain. Manual therapy, 13(3), 206-212. https://doi.org/10.1016/j.math.2006.12.006
6.Gan ZS, Smith AL. Urinary Incontinence in Elite Female Athletes. Curr Urol Rep. 2023 Feb;24(2):51-58. doi: 10.1007/s11934-022-01133-6. Epub 2022 Nov 24. PMID: 36418531.
7. https://www.pelvicsanity.com/post/screening
8.Wikander L, Kirshbaum MN, Waheed N, Gahreman DE. Urinary Incontinence in Competitive Women Powerlifters: A Cross-Sectional Survey. Sports Med Open. 2021 Dec 7;7(1):89. doi: 10.1186/s40798-021-00387-7. PMID: 34874496; PMCID: PMC8651931.
9. Leon-Larios F, Corrales-Gutierrez I, Casado-Mejía R, Suarez-Serrano C. Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery. 2017 Jul;50:72-77. doi: 10.1016/j.midw.2017.03.015. Epub 2017 Mar 27. PMID: 28391147.
10. Optimizing postpartum care. ACOG Committee Opinion no. 736. American College of Obstetricians and Gynecologists. Obsetet Gynecol 2018; 131:e140-150.
sapiens movēs 