“Pelvic floor issues…those are just if you’ve had babies, or for old ladies, right?” Not so fast, young ladies (and everyone else). The following story comes from ardent Share MayFlowers supporter and all-around pelvic floor advocate – physical therapist, Jessica Powley, of Proaxis Therapy (South Carolina). Unprompted by me, she uses a version of my all-time favorite phrase: “The pelvic floor muscles do not work in isolation.”
Case Study: 18-year old female with chronic pelvic pain after…knee injury
Note: This case study was selected as it demonstrates the synergy within the body. Our bodies are meant to function in unity with each joint, muscle and ligament doing its part. When one structure does not function optimally, the entire person is impacted and often other structures will have to “pick up the slack.” This can create pain, instability and a loss of function. Treating the pain means treating the person—finding the weakened structure and helping the entire person regain the synergy they need to fully support their bodies.
Subjective History: Mary* was referred to physical therapy by a local Urogynecology team for chronic pelvic pain which had been occurring for the past year, slowly worsening over time. She reported that pain caused frequent nausea and impacted her ability to participate in athletic activities. Prior to the onset of pain, she was active in athletics at her high school, playing soccer, volleyball and ice hockey. She had no complaints of changes in urinary function, but noted occasional constipation. She was not currently having sexual intercourse, but reported some pain with sexual stimulation. She had been seeing multiple different physicians before being referred to the Urogynecology team.
With further questioning, Mary reported that she experienced a fracture of the tibia (at the knee) 1 year ago while playing soccer. She was immobilized in a brace for 1 month, but did not have physical therapy after her injury.
Pertinent Objective Findings (for all non-clinical types out there, you’ll find parenthetical comments to ‘sum up’) :
Gait: Pt demonstrates R hip circumduction during swing phase of gait and decreased R knee extension (changes in normal patterns of walking with respect to how her right hip and knee are moving)
Manual Muscle Testing:
- Knee Extension: 5/5 L, 3/5 R (weakness on the right side in the muscles than straighten the knee)
- Knee Flexion: 5/5 L, 4/5 R (weakness on the right side in the muscles than bend the knee)
Knee ROM: Within normal limits bilaterally (her knee straightens and bends as much as is normal)
Abdominal Wall Examination: Tender with palpation of rectus abdominus muscle along lateral borders bilaterally. (her ‘6-pack’ muscle is tender to the touch on both sides)
Hip Examination: Tenderness and moderate trigger points noted in L iliopsoas muscle and L adductor muscle group. No other significant findings. Normal ROM with no pain noted. (she has painful areas in her left hip muscles, but otherwise her hip motion and muscles on both sides are normal)
Pelvic Floor Muscle Assessment: Tenderness noted externally with tenderness at STP. Internal palpation demonstrates severe tenderness throughout all layers of pelvic floor muscles which caused wincing and withdrawal. Pt was only able to perform small flicker contraction of 1/5 with poor relaxation. (she has small to large amounts of tenderness and pain in muscles in her pelvis when examined externally and internally – through a vaginal muscle assessment. Her pelvic floor muscle contraction is very weak and uncoordinated.)
Mary demonstrated decreased strength in L quadriceps muscle group causing compensatory changes in gait and resulting spasm of R pelvic floor muscle group and associated hip musculature. Her pelvic floor muscle tenderness and trigger points were causing the referred pelvic pain, constipation and pain with sexual stimulation.
Day 1: Mary was instructed in performing “pelvic floor drops” to promote relaxation of the pelvic floor, quad sets to promote knee strength as well as in correct methods of walking to decrease pain levels.
Progression/Outcomes: Mary was treated with manual therapy to address her pelvic floor muscle tenderness and hip muscle trigger points for 6 visits with complete resolution of her pelvic pain and constipation. She was also instructed in knee strengthening exercises as well as core stabilization exercises over 2 additional visits, and was treated concurrently by a physical therapist specializing in orthopedics. We also recommended that she see an Orthopedic physician who was in agreement with our plan. After a few months, Mary ended up having surgery to correct a meniscus injury (an injury to tissue in her knee), and is currently doing well finishing physical therapy for her knee. She has been able to return to her previous athletic activities without difficulty.
Mary’s case demonstrates the significant role the pelvis plays in stability of both of the lower extremities. Physical therapists are taught to see the whole person—to recognize that a problem with the ankle could be a problem with the hip which could be a problem with the low back—and this should also be the case while treating the pelvis. The pelvic floor muscles do not work in isolation. They are part of a larger system that is working constantly to maintain the stability of the body. If one part of that system (in Mary’s case, the knee) fails, the pelvic floor will often have to work much harder and will often become weakened and irritated in the process. An optimal approach from any healthcare provider will examine the person—not just the problem area—to really determine the source of the pain and treat the person to promote optimal function and recovery.
*name changed for case study purposes