Abstract
Pelvic floor assessment is probably the most important part of the physical examination in patients with chronic pelvic pain and this exam is best performed by a skilled pelvic floor physical therapist. Physicians who see a large number of patients with pelvic pain should probably partner with a physical therapist and refer those patients for assessment. Some of the red flags on the history part of the assessment for pelvic floor dysfunction are urinary hesitancy (delayed onset of urine flow when trying to urinate) and pain after intercourse, or pain with physical activity (post exertion muscle soreness). Patients with pelvic floor muscle spasms also often have discomfort and pain with use of tampons, vaginal probe ultrasound, and pelvic exam. On pelvic exam when palpating with one finger muscles may feel tight and tender, often to the point where the examiner is not able to insert one finger. The obturator internus muscle is best palpated during the pelvic exam in the lithotomy position with the patient pushing with her knee against the examiner’s external hand.
Editor’s Introduction
Pelvic floor assessment is probably the most important part of the physical examination in patients with chronic pelvic pain and this exam is best performed by a skilled pelvic floor physical therapist. Physicians who see a large number of patients with pelvic pain should probably partner with a physical therapist and refer those patients for assessment. Some of the red flags on the history part of the assessment for pelvic floor dysfunction are urinary hesitancy (delayed onset of urine flow when trying to urinate) and pain after intercourse, or pain with physical activity (post exertion muscle soreness). Patients with pelvic floor muscle spasms also often have discomfort and pain with use of tampons, vaginal probe ultrasound, and pelvic exam. On pelvic exam when palpating with one finger muscles may feel tight and tender, often to the point where the examiner is not able to insert one finger. The obturator internus muscle is best palpated during the pelvic exam in the lithotomy position with the patient pushing with her knee against the examiner’s external hand.
Introduction
Chronic pelvic pain (CPP) is a widespread disabling condition that is partly misunderstood because it is mostly a diagnosis of exclusion. In addition, viewing the problem as having a single etiology has created a dilemma regarding the assessment, classification, and management of CPP [1]. Most often a primary allopathic approach has excluded the possibility of the musculoskeletal/somatic and myofascial systems’ contribution to initiating or maintaining impairments that are found in patients with pelvic pain. In fact, the pathophysiology of chronic pelvic pain can arise from the pelvic viscera, peripheral or central nervous system, pelvic joints, muscles, and connective tissue. It is also evident that as the body attempts to manage a local disturbance there are interactions between the other systems that can further complicate the clinical picture.
To best understand the musculoskeletal system, we must start with some physical medicine tenets. The purpose of the musculoskeletal structures of the pelvis is for “form and function”: to house and protect the vital organs of the reproductive, gastrointestinal, and urological systems and thus allow for normal supportive and dynamically controlled (both reflexive and volitional) activities of evacuation, penetration, and pleasure to be achieved for the individual. Another tenet is that generally the musculoskeletal system responds to injury, trauma, or perceived threat in a predictable way [2, 3]. The final tenet is that the response of the musculoskeletal system is decided by the brain, which can not only modulate somatic activation and inhibition continuously but also interpret the function of the system based on the current context of the individual [4]. Because of these understandings, we recognize that while we must adequately assess local impairments and global relationships, we also have to understand the psychosocial implications of a history of pain or what pelvic pain means to the person’s role, vocation, and abilities.
According to Wall and DeLancey, pelvic floor dysfunction as it relates to pelvic pain is poorly addressed partly due to “professional compartmentalization of the pelvic floor” [5]. This again speaks to the importance of integrated and coordinated care among multiple providers as well as treatment planning that recognizes the pelvic floor as a dynamic system that interacts with the rest of the body. Pelvic health physical therapy has a role in the integrated care and effective treatment of musculoskeletal causes of pelvic pain [6–8].
In this chapter we will outline screening for myofascial and mechanical impairments and describe a complete pelvic physical therapy clinical evaluation associated with musculoskeletal involvement in women with CPP.
Function-Based Approach
When addressing CPP from a musculoskeletal standpoint, establishing the goal of the intervention is important. Many factors contribute to determine the ultimate prognosis for the individual but usually fall within curative (recovery), improvable (rehabilitative), and manageable (adaptive) outcomes. This is most easily understood when looking at typical neurological or orthopedic conditions [9]. When someone sustains a femur fracture he or she can recover completely with no limitations; require rehabilitation and have some form of persisting impairment like a limp or impaired endurance; or always require some adaptation, such as a cane, and have limitations to participation in some physical activities. Similarly, in patients with CPP, for functional limitations such as sitting intolerances, impaired participation in sexual activities, and interruptions in daily tasks, we have similar expectations. Setting a baseline to understand the current status requires information to be collected on the patient’s reported previous function. This must include assessment from the different roles the patient participates in. Patients with CPP can experience limitations in self-care, vocational, relational, and recreational domains [10]. While they are all important, patients’ value of each area determines how it affects their quality of life and what their priorities are for treatment. Often it is helpful for the clinician to guide the patient through the process of identifying the limitations and the physical therapist can further describe the physiological elements required to complete the activity, and those that may be rehabilitated or adapted. This approach is focused not on pain level, but on capability of doing the activity to satisfaction [11]. The principle is to encourage patients to use their ability as a guide to improvement and not be limited by what they think their pain will stop them from doing. In addition, physical therapists can guide patients in managing their pain symptoms by using graded exposure techniques and imagery where useful, and to identify where they can stretch their tolerances by doing edgework but minimizing “flare ups” of their pain with pacing activities [12]. By creating an initial biopsychosocial perspective with CPP, clinicians can help patients achieve their activity goals by introducing variety to previously challenging tasks, and not being limited to linear progression based on their pain score.
Subjective Intake
Chronic pain studies in the last few decades have been critical about measurement of more than just a single measure of the impact of pain on the individual [13]. Not only does it poorly correlate with their disability or their functional loss, but in chronic pain it does not serve as an adequate marker for systemwide improvements.
In addition, the style of a typical single-symptom/single-system–based assessment is often too narrow of a net to capture the complexities of the patient with chronic pelvic pain [14].
Patient intake can have several components. It is important that the patient be informed that to adequately assess her problem, you will need to look at it from many angles, and this requires a few forms asking different questions and time with you to go over her answers.
First, a collection of medical history can detail injuries, surgeries, and early diseases; ongoing chronic conditions; and former and current interventions. For women, include gestation and parity history as well as any specifics about delivery methods or complications. It is also important to note which conditions are now stable and to identify overlapping conditions. It is recommended that there be clear inclusion of lumbar spine and hip pain in the questionnaire [15, 16]. Next, it is important to clarify the patient’s primary complaint, which can be a single symptom, or many that limit participation in a particular function. A McGill Pain Questionnaire with body chart can be helpful in identifying where the patient localizes different pain complaints and descriptions and reminds the clinician to look for drivers or relationships outside the pelvis.
In addition to the completion of a pain questionnaire the patient should also complete the short screening for pain catastrophizing (PCS)[17], central sensitization (CSI)[18], and kinesiophobia (TSK)[19] (Table 5.1). This information is significant and is not easily ascertained by interview or even on follow-up visits, as it reflects the patient’s perceptions about her condition that can impact the magnitude of her pain experience and her rehabilitation and recovery, and highlights nonvisceral and nonsomatic sources of persistent pain that need to be addressed with a specific inclusive neuropathic approach.
| Measure | Domain Assessed |
|---|---|
| Verbal Rating Scale (VRS) | Pain intensity using verbal descriptors (e.g., mild, moderate, severe) |
| Visual Analog Scale (VAS) | Pain intensity using a 10- or 100-mm line, anchored by no pain and worst possible pain |
| McGill Pain Scale | Pain quality, location, exacerbating and ameliorating factors |
| Pain Disability Index (PDI) | Pain disability and interference of pain in functional, family, and social domains |
| Pain Catastrophizing Scale (PCS) | Catastrophic thoughts related to pain |
| Tampa Kinesiophobia Scale (TKS) | Fear of movement or limited activity |
| Central Sensitization Inventory (CSI) | Measure of somatic and emotional symptoms of CS |
| Vulvar Questionnaire (VQ) | Questions regarding vulvar pain symptoms |
| Pain Urination and Frequency (PUF) | Questions regarding bladder symptoms |
| GI Symptom Rating Scale (GSRS-IBS) | Questions regarding abdominal/bowel symptoms |
| Marinoff Scale | Tolerance to sexual intercourse activity |
Finally, the patient’s demographic information is valuable to put together the lifestyle and functional demands of the individual. Clarification of support systems available with regard to their relationship to the patient, and who the patient lives with is important. Determine the patient’s job status, including the demands as well as the tasks and tolerances required. If the patient has been on leave from work, establish when she was placed on leave and for which condition and if she is scheduled to return. Information about the patient’s general health can be initially determined by self-report about diet, exercise, sleep, and stress control.
Once those forms are collected and scored, a patient-centered interview can begin [20]. First, the provider invites the patient to tell the purpose of her visit in her own words. The provider can practice reflective listening at moments in the patient’s story to clarify and direct the interview. Once the reason for the visit is established, the provider may want to clarify what the patient’s understanding is of the problem, what she believes is the etiology, and what she thinks will improve her condition. If it is clear what the patient’s belief system is concerning her problem, it will be easier to educate or motivate her for health behavior changes.
Next is a brief review of the medical history to clarify the timeline or any unclear information. In addition, a function-based review of systems includes questions about bowel regularity, continence, and consistency; bladder continence, frequency, voiding; and sexual function for pain report, impact on desire, arousal, and orgasm. Questions have been included in Table 5.2.
| Age: Gravida: Para: |
| Did you have any trouble with the deliveries? |
| Occupation and demands? |
| Live with? Stairs at home or work? |
| Any hip pain? Low back pain? |
| Difficulty standing? If so, how long? Difficulty sitting? If so, how long? Difficulty walking? If so, how long/far? |
| Do you have regular periods? Perimenopausal? Menopausal? |
| On birth control? If yes, method? |
| Any urine leaking? Any frequency of urine, needing to urinate more than every 2 hours? |
| Night waking to urinate? Any trouble emptying bladder? |
| Any bowel difficulty or pain on emptying? Bowel movement every 1–3 days? What is the consistency? |
| Pain symptoms found where: Location? |
| 24-Hour pattern? |
| If episodic how many a day/week? If constant what is range of pain experienced? |
| Easing factors? Aggravating factors? |
| Sleep disturbance? Falling asleep or waking with pain? |
| Takes medication for pain: if yes, how much and how often? What is its effect? |
| What home activity does this pain keep you from doing? |
| Does this activity keep you from work-related responsibilities? |
| Does this activity keep you from leisure or fitness activities? |
| If the pain score goes up by 2–3 points, what do you find you have difficulty doing? |
| If the pain score goes down by 2–3 points, what do you find you are able to do? |
| Do you have pain or discomfort or problems with sex? |
| If yes: When did sex pain start? |
| Was this the first sexual encounter? |
| Have you tried a lubricant? What kind? |
| Does it limit penetration completely? |
| Does it hurt at entry or deep? Does it change with certain positions? |
| Describe if it hurts at the beginning, all the way through, or is there pain afterwards? |
| Do you have trouble with the last vaginal exam by a physician or nurse? |
| Do you use tampons? If yes, are you still able to use them? |
| Since the pain problem, has desire for sexual activity changed to higher, lower, or stayed the same? |
| Since the pain problem, are you able to do other physically intimate things besides intercourse? |
| Is your partner aware of your pain and accommodating? |
When reviewing the reported pain, on either the VAS or McGill Pain Questionnaire, the provider should include follow-up questions about easing factors and aggravating factors. He or she should ask the patient to quantify pain at rest, average, and maximum on the VAS. It is important to determine if the pain has a pattern that is hormonally cyclic, episodic by physical activity, related to sleep/rest cycles, or to bowel and bladder activity. If the patient reports episodes of pain that are intermittent the provider can have her quantify how many she has had within a time period. If she reports constant pain, the provider can have her describe the daily range on the VAS. The Pain Disability index (PDI)[21] can be helpful for categorizing areas of impairment that affect the patient’s lifestyle and to what degree. For specific vulvovaginal pain the Vulvar Questionnaire (V-Q)[22] can be used, and for bladder-related symptoms as a primary tool the PUF[23] questionnaire, and Gastrointestinal Symptom Rating scale (GSRS-IBS)[24] for bowel-related pain. The Marinoff Scale is used to assess tolerance to sexual penetrative activities (Table 5.1).
Initiating a musculoskeletal assessment includes gathering information about many systems that interact with muscles, ligaments and bones. It is also important for the provider to clarify the patient’s primary concern, how she is currently functioning or her limits of function, to direct the next part of the evaluation, the physical assessment.
Objective Assessment
Clinical Anatomy Overview
The pelvic floor is made up of superficial and deep muscles that contribute to numerous systems throughout the body including musculoskeletal, respiratory, reproductive, lymphatic, gastrointestinal, and urological. They function to provide sphincter control and support to maintain continence and prevent prolapse of pelvic organs [25]. By way of their connections to the pelvis, hips, and other abdominal and back musculature, they help stabilize the sacroiliac (SI) joints, lumbar spine, sacrococcygeal joint, pubic symphysis, and hips to allow for load transfer from the lower extremities to the pelvis and postural stability during functional tasks and movements. They are synchronized with the deep core musculature to allow for appropriate intraabdominal pressure fluctuations and optimal respiratory function [26]. Through appropriate contraction and relaxation of the pelvic floor muscles, they allow for optimal sexual function [27]. Additionally, similar to the calf muscles in the lower extremities, they contribute to the flow and return of blood and lymphatic fluid to prevent congestion.
More specifically, the pelvic floor is composed of three layers: superficial, intermediate, and deep. The superficial muscles of the pelvic floor consist of the bulbocavernosus, ischiocavernosus, superficial transverse perineal, and external anal sphincter. The intermediate or second layer includes the deep transverse perineal, sphincter urethrovaginalis, compressor urethra, and external urethral sphincter. The third and deepest layer includes the levator ani group (puborectalis, pubococcygeus, and iliococcygeus) and coccygeus. The third layer is connected to the obturator internus muscle through the arcus tendinous levator ani (ATLA), a fascial band formed by the obturator internus and extending from the ischial spine to the posterior pubic symphysis. The piriformis muscle, along with the obturator internus, are hip muscles that attach within the pelvis and contribute to the musculature of the posterior and lateral pelvic walls respectively. All these muscles are housed within the boundaries of the pubic bone anteriorly, ischiopubic ramus and ilium laterally, and the sacrum and coccyx posteriorly.
Because of the anatomical relationships between intrapelvic and extrapelvic muscles, biomechanical dysfunctions and imbalances can result in pain and impairments throughout the entire pelvic girdle. Overactive pelvic floor muscles can be the causative agent in musculoskeletal conditions due to anatomical and functional relationships related to the respiratory diaphragm, abdomen, spine, sacrum, coccyx, and hips. Alternatively, malalignment; impaired biomechanics; or injury and pain in the trunk, pelvis, or lower quarter can impact the pelvic floor due to faulty load transfer, gait dysfunctions, and other suboptimal movement patterns causing overuse and overactivity in the pelvic floor muscles [28]. Musculoskeletal structures of the low back, abdomen, pelvis, and hips are also neurologically connected to the pelvic floor through shared innervation. Studies show that in patients with pelvic floor muscle pain or abnormality it is common to find tender points or abnormality in the obturator internus, iliopsoas, gluteus, quadratus lumborum, and piriformis muscles [29]. Abnormal musculoskeletal findings were found in patients with chronic pelvic pain 37% of the time compared to controls without pelvic pain only 5% of the time [30].
The bony structure of the pelvic girdle is formed by the ilium, ischium, and pubis, which fuse to form the innominate bones. The pelvic girdle is a supportive yet dynamic link between the thorax, spine, and lower extremities [28]. The two sides of the bony pelvis are joined through the connection between the ilia and sacrum posteriorly and the superior pubic rami forming the fibrocartilaginous pubic symphysis joint anteriorly. In optimal pelvic movement, the motion of the sacrum is correlated and synchronized with motion at the sacrococcygeal and lumbosacral joints. As the sacrum extends, the apex of the coccyx flexes and as the sacrum flexes, the apex of the coccyx extends. Lastly, the femoral head articulates with the acetabulum of the innominate bones and couples with ilium movement. As the hip flexes, the ilium rotates posteriorly, and as the hip extends the ilium rotates anteriorly. Through these various joints, connections, and the synchronization of movement, one can appreciate how optimal or suboptimal movement at the spine, sacrum, coccyx, and hips can influence the pelvis and its musculature [28].
Sacroiliac Joint
The main function of the pelvic girdle joints is to provide stability and transfer forces to the lower extremities. Ligamentous support to the SI joint is provided by some of the strongest ligaments in the body. The anterior or ventral sacroiliac ligament is a thickening of the fibrous capsule of the SI joint and is the weakest of the supports. The interosseus sacroiliac ligament forms the major connection between the sacrum and innominate and is the strongest of the ligamentous group spanning from the lateral sacral crest to the iliac tuberosity. It resists anterior and inferior movement of the sacrum. The long dorsal sacroiliac ligament connects the posterior superior iliac spine (PSIS) with the lateral aspect of the third and fourth segments of the sacrum. Nutation, or anterior motion of the sacrum, places slack on the ligament. This ligament can be palpated directly below the PSIS, felt as a thick band, and can often be a source of pain or reproduce SI joint pain. The long dorsal ligament is connected to the gluteus maximus muscle through shared fascia, and connections have been found to the multifidi muscles as well. The sacrotuberous ligament is formed by lateral, medial, and superior bands. The superior fibers combine with the long dorsal ligament. The lateral band connects the ischial tuberosity and posterior inferior iliac spine and receives some fibers from the piriformis. The medial fibers span from the lateral lower sacrum and coccyx and run toward the ischial tuberosity. Muscular attachments from the gluteus maximus muscle also insert onto the sacrotuberous ligament, therefore increasing tension during muscular contraction. The sacrotuberous ligament stabilizes against nutation of the sacrum. The perforating cutaneous nerve travels through the sacrotuberous ligament to supply the skin covering the inferior and medial aspects of the buttocks. Lastly, the sacrospinous ligament spans from the lateral part of the sacrum and coccyx and onward to the ischial spine and is connected to the coccygeus muscle. SI joint disorders can be a common finding in patients with pelvic floor muscle dysfunction, with concomitant observation or history reporting including faulty biomechanics, degenerative changes, habitual postures, and pregnancy-related SI joint pain. SI joint pain is typically noted with palpation over the SI joint as well as possible referral of pain into the iliac crest, low back, groin, buttocks, and down the back of the thigh. Compression of the SI joints due to increased tension into the pelvic floor can lead to poor motor control; impaired lumbopelvic stabilization; posturing into a posterior pelvic tilt; hip restrictions into flexion, adduction, and internal rotation; and tender point in the obturator internus, piriformis, and coccygeus [31]. Patients may report pain with palpation of the posterior superior iliac spine (PSIS) that is worsened with prolonged sitting, standing, walking, or lying down and walking up hills or stairs, radiating pain into the buttocks with some alleviation of pain in side-lying.
Assessment of the SI joint can include posterior palpation of the long dorsal SI ligament (or Fortin’s finger sign). There are passive and active tests that demonstrate SI dysfunction. If the patient is standing a single limb stance can elicit pain on the ipsilateral SI joint, as well as demonstrate weakness or impaired ligamentous integrity. Supine the examiner is standing at the side of the patient. The examiner crosses his or her arms and places them at the medial aspects of the patient’s anterior superior iliac spines. A gapping pressure is applied in an outward direction bilaterally and simultaneously. The examiner then uncrosses his or her arms and places his or her hands on the iliac crests to apply an inward/downward force. Pain indicates a positive test. While the patient is in the supine position one can add the posterior provocation test, bringing the ipsilateral knee up to the patient’s chest and crossing midline and applying a long axis compression into the femur. Hip pain may be present but is positive for SI dysfunction if the posterior pelvic girdle pain is elicited.
Pubic Symphysis
Pain and dysfunction into the anterior bony pelvis can also contribute to overall pelvic pain. Dysfunction into the pubic symphysis can refer pain into the low abdomen and groin that can be mistaken for bladder or other visceral pain. Osteitis pubis is characterized by a sharp or aching anterior pelvic pain over the pubic symphysis, lower abdominal muscles, or perineum due to infection, inflammation, trauma during contact sports, or repetitive trauma due to increased shearing such as during pregnancy as a result of ligamentous laxity. The pain may also radiate into the adductors, leading to spasm in these muscles [32]. Muscle dysfunctions and imbalances between the hip adductors, abdominals, and pelvic floor can also cause excessive or inappropriate shearing of the pubic symphysis, leading to pain symptoms [33]. Osteitis pubis has also been reported to complicate a variety of pelvic surgeries including abdominoperineal resection, inguinal herniorrhaphy, anterior colporrhaphy, retropubic urethropexy, and periurethral collagen injection. Patients may report pain that worsens with running, climbing stairs, transitional movements such as sit to stand, rolling in bed, or getting out of the car. Although pubic symphysis pain disorders can refer to the pelvic girdle, labia, and perineum, often the pelvic floor muscles are overlooked as possible contributors to the pain, particularly the superficial layer of the pelvic floor. The bulbocavernosus and ischiocavernosus muscles directly attach to the pubic symphysis, as does the deeper anterior aspect of the pubococcygeus, and these should be assessed for pain reproduction during palpation, particularly for unilateral tension. Diagnosis can be based on radiological examination including x-rays; palpation that would include pain at the pubic symphysis; and likely observation of difficulty during gait including a waddling gait, hip stiffness, and pain with transitional movements.
A lateral compression test can be performed with the patient side-lying while applying a downward force at the lateral iliac crest and considered positive with reproduction of pain in the pubic symphysis area. The symphysis gap test is also performed and includes having the patient supine with bilateral hips and knees flexed to 90 degrees, legs supported by the examiner. The patient then performs an isometric adductor contraction against the fist of the examiner placed between the knees. A painful isometric muscle contraction with pain into the pubic symphysis is considered positive.
Coccyx
The coccyx can also be a location of pain and dysfunction in combination with pelvic floor muscle hyperactivity. The coccyx is stabilized through the sacrotuberous, sacrospinous, and long dorsal ligaments which can all be concomitant pain referral areas in conjunction with coccyx pain. The coccyx also acts as an insertion site for the deep pelvic floor muscles (pubococcygeus, iliococcygeus, and coccygeus), and gluteus maximus and contraction or relaxation of these muscles can influence coccygeal movement [28]. Coccyx pain can be the result of direct injury to the coccyx including a fall or during childbirth, repetitive compression or poor posturing of the coccyx such as in cycling and horseback riding, or pelvic malalignments due to leg length discrepancy or indirectly through pelvic floor muscle tension or surgery involving the sacrospinous ligaments. The subjective interview might include symptoms such as pain during/after sitting with the length of sitting being a factor; acute spike of pain during transitional movements such as sit to stand; greater difficulty sitting on soft surfaces than on firm; pain with bowel movements; and possible referral of pain into the sacrum, low back, rectum, and lower extremities.
Assessment would include palpation of the coccyx in standing as well as while prone to determine available movement, pain reproduction, or deviation laterally as well as palpation of the ligamentous and muscular attachments that influence the coccyx as described earlier. The movement of the coccyx may be better appreciated through rectal examination if this seems to be a large source of the patient’s pain.
Lumbar Spine
The lumbar spine can also influence, and be influenced by, the pelvic floor muscles. As discussed earlier, the lumbar spine is connected via muscular and ligamentous attachments to the pelvic girdle, and the transfer of loads from the lower extremities to the spine is routed through the pelvic girdle. Lumbopelvic posturing into either excessive lumbar lordosis or lumbar flexion can impact recruitment and coordination of abdominal as well as pelvic floor muscles, impacting resting tone of the pelvic floor and maintenance of continence [34]. Pelvic floor muscle hyperactivity can refer pain into the low back area and can be a source of impairment related to spinal stability and mobility through connections between the gluteal muscles, transversus abdominis, and psoas. Low back pain has also been found to alter the anticipatory recruitment of the transversus abdominis muscle, therefore altering the synchronization of the deep core muscles including the pelvic floor muscles. The deep core feedforward impairments related to low back pain are shown to persist even once pain is resolved [35]. Muscle imbalances or dysfunctions can lead to compression and irritation of nerves exiting the lumbar spine, therefore contributing to radiating symptoms into the pelvis and lower extremities. This can include compression on the iliohypogastric (T12–L1), ilioinguinal (L1), lateral femoral cutaneous (L2–L3), femoral (L2–L4), genitofemoral (L1–L2), and obturator (L2–L4) nerves. These nerves innervate areas including the mons pubis, inguinal regions, groin, medial and anterior thighs, and genitals [36]. Studies have shown significant correlations between low back pain and pelvic floor issues, with up to 95.3% of participants in one study with low back pain found to have some form of pelvic floor dysfunction and 71% of those demonstrating hypertonicity or tenderness of the pelvic floor muscles [15].
If a patient reports pain or genital/sexual dysfunction a screening of S2–S4 be included to rule out impairment from the lumbosacral nerves that control pelvic floor sensory and motor functions.
Assessment of the involvement of the lumbar spine includes standing passive flexion and extension of the trunk as well as side bending and rotation. Pain elicited that reproduces radicular pain into the pelvis or lower extremity and pain that occurs at spine with specific motions should be further assessed with a spinal accessory motion exam and evaluation of neural system.
Transverse Abdominus
The pelvic floor is also intimately linked to what is referred to as the deep core. The deep core is thought of as a canister that includes the pelvic floor muscles at the base, respiratory diaphragm at the top, transversus abdominals in the front, and multifidi spinal stabilizers in the back. This deep core canister provides proximal stability upon which more distal mobility can occur and helps to prepare the body for load transfer [28]. Research shows this group of locally functioning deep core muscles activate as a unit and have anticipatory function in that they fire prior to initiation of movement [37]. The more globally functioning superficial abdominal muscles include the rectus abdominis, obliques, and erector spinae muscles. Patients with pelvic pain may tend to overuse these global stabilizers due to dysfunction with the synchronization pattern with the deep core stabilizers because of weakness and/or overactivity in the pelvic floor muscles. When this occurs, faulty movement patterns and suboptimal muscle activation ensues that, over time, likely contribute to a patient’s continued pain. Research has found that increased activation of the deep muscles and/or decreased activity in the global muscles during movement tasks can help to improve movement patterns and decrease patient symptoms [38].
Assessment of the transverse abdominus is typically with ability to draw in the navel but also for endurance in tonic postures such as ability to maintain neutral thoracolumbar and lumbopelvic spine with demands such as a plank start position for a push up. Activation can also be assessed with dynamic rehabilitative ultrasound.
Piriformis Muscle
The piriformis muscle connects to the pelvic girdle through its attachment to the anterior surface of the sacrum and inserts onto the greater trochanter of the hip with additional attachments to the sacrotuberous ligament. The tendon of the piriformis then joins with other hip rotator tendons including the superior and inferior gemelli and obturator internus and externus tendons. The function of the piriformis muscle is to extend, abduct, and externally rotate the hip; stabilize the SI joint; and control innominate anterior rotation. Tenderness and pain into the piriformis can be a common symptom for patients with pelvic floor muscle hyperactivity because of these connections and the resultant muscle imbalances that can occur due to dysfunction and/or upregulation of muscles surrounding the pelvic floor muscles by way of fascial, neural, and anatomical connections [28]. Piriformis syndrome refers to pain and/or numbness in the buttock caused by spasm and therefore compression of the sciatic nerve, which runs beneath the piriformis muscle referring symptoms into the ipsilateral posterior thigh and possibly foot. The pudendal nerve can also become compressed as it exits the medial inferior surface of the piriformis. Spasm of the piriformis and sacral dysfunction can place tension on the sacrotuberous ligament with resultant compression on the pudendal nerve as well leading to neuralgia symptoms into the vulvar area. The patient with piriformis spasm may demonstrate increased external rotation of the ipsilateral hip noted as increased turning out at the foot during gait [39].
During assessment, the patient rests supine with the testing hip in external rotation. The clinician asks the patient to bring the hip into internal rotation and a positive test elicits pain in the buttock/piriformis area. Pain can also be felt during passive internal rotation into the buttock area knows as the Freiberg sign.
Hip Joint
Due to the connection between the femoral head and acetabulum of the pelvis, hip impingement syndromes can occur as a result of pelvic girdle dysfunction. Abnormal contact between the femoral head and acetabulum can be due to increased tension or weakness within hip flexors, extensors, and deep rotators including the psoas, obturator internus/externus, piriformis, and gluteus maximus/medius misaligning the femoroacetabular junction. Patients may describe symptoms including groin, anterior or medial thigh pain, deep hip pain, and sensations of locking within the joint. Pain may be reproduced during turning or pivoting motions and/or passive, active, or resisted movement into hip flexion, adduction, or internal rotation. Restrictions are typically seen within the iliopsoas, quadriceps, tensor fascia lata, and external hip rotators in the form of decreased passive range of motion into hip extension, knee flexion, hip adduction, and hip internal rotation respectively [40].
If the femur continues to be malpositioned within the acetabulum, labral injuries can occur, although most labral tears are due to repetitive sports injuries that involve frequent pivoting or cutting type maneuvers. The most common patient complaint with labral tears is pain in the anterior hip or groin, less common into lateral and deep posterior buttock, lower abdominal quadrant, and knee. The pain may be described as a sharp or dull pain. Pain reports are often accompanied by mechanical complaints of clicking/catching or giving way. Development of labral tears is possible during twisting/pivoting injuries, posterior hip dislocations, hyperflexion or hyperextension movements, or idiopathically. Along with pain complaints, patients with hip labral tears may report decreased hip mobility and pain with prolonged sitting. Studies have shown a relationship between hip function and pelvic floor muscle function including a case series of patients with labral tears as a comorbidity of low back and pelvic girdle pain [41]. Labral tears in the hip have also been linked to vulvar pain syndromes such as vulvodynia and resultant hyperactive pelvic floor muscles [16].
Assessment should include performance of the anterior hip impingement test, which is performed with the patient supine and the hip and knee at 90 degrees flexion. The hip is internally rotated while an adduction force is applied through the femur. A positive test would produce pain in the anterolateral hip or groin. McCarthy’s sign is another test involving bilateral hip flexion, bringing the patient’s knees to chest passively followed by extension with internal rotation of the affected hip and again extension with external rotation. Impingement testing includes passively taking the hip into flexion, adduction, and internal rotation. A positive test would be reproduction of pain or a clicking sensation. A labral tear can also be confirmed through MRI, MRA, or arthroscopy.
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